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Friday 30 September 2016
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Textual healing: SMS patient messaging systems in surgeries

Systems & Information

Judith Harvey

DPhil BM BCh DRCOG
General Practitioner

A late entrant to medicine, Judith has tackled everything from teaching in a comprehensive school in Liverpool to running a volunteer programme in Papua New Guinea before she trained in medicine. She was a partner in a semirural Home Counties practice for 10 years and has been a sessional GP in inner London since 2001. Judith has contributed to the Handbook of Practice Management since 2001, and is also involved in working to help clinicians and nonclinicians find ways of involving patients that benefit both sides

ru txtng yr pts?
Probably not, but the chances are that your patients are receiving textmessage reminders about their outpatient appointments from a hospital near you.

Last year, patients failed to keep more than 16 million general practice appointments, according to Developing Patient Partnerships.1 Usually it's because they forget or because they can't get through to cancel the appointment. Research suggests texting could reduce the number of UK general practice appointments missed by 26–39%, corresponding to cost savings of £9,483–£20,991 per GP practice per annum.(2)

Hospitals that use SMS (short message service), otherwise known as texting, to remind patients about outpatient appointments are seeing a gratifying drop in DNA rates.

It works like this. When patients book their appointments they are offered a text reminder, and a computer entry is made. If necessary a consent form is generated. From this point the process is automated. The messages go out a few days before the appointment and tell patients to text or phone if they can't keep it.

Some units are going much further. Patients with kidney failure may receive information about their renal function by SMS. Text messages can be used to manage appointment systems, reducing the time both patients and receptionists spend hanging on the phone trying to find a free slot. Health advice can be texted to target groups.

Would it work in primary care? The potential is obvious: reducing DNAs; calling patients with chronic diseases for checks; inviting patients for flu jabs; reminding parents about childhood immunisations. Good for patient health, good for practice Quality and Outcomes Framework (QOF) targets. And enterprising techies will spot plenty more opportunities.

Y nt txt?

We in general practice have been slow to grasp the opportunities. The cost of a GP appointment is estimated at about £18, compared with £65 for a hospital appointment, so there is less to lose. And because we see 80% of our patients every year, we can give verbal reminders and do opportunistic checkups. But practices do contact patients to remind them about flu jabs, and in March receptionists will ring round to get patients in for checks before the QOF deadline. However, letters and phone calls are expensive and the results often disappointing. Why not text?

Some primary care organisations (PCOs) have taken the plunge. Two practices  from Ealing PCT piloted the use of text messaging software that allows them to send appointment reminders to patients. This went well enough for them to have rolled out the opportunity to 22 practices.

Receptionists booking appointments are prompted to check the patient's mobile telephone number and ask them if they would like a text reminder. Practices can choose whether to include the practice name and the doctor's name in the text and, if they do, the patient is advised of this.

The software system then generates the messages via the mobile phone network, and patients can respond by text or phone. Texted responses are then forwarded to an email address designated by the practice, providing a validated audit trail.

Dus it wrk ok?

The effect on the DNA rate obviously depends on the percentage of patients whose mobile numbers are on the database. But Hillview Surgery, one of Ealing PCT's pilot sites, is finding that patients who are texted are less likely to miss their appointments.

Their patients say they like being reminded. Very few actively decline or choose to unsubscribe. And SMS is a much easier trick for the elderly to grasp than, say, email. Most organisations send out reminders three days in advance, but we don't yet know what advance notice is the most effective; some are experimenting with times varying from a week in advance to the night before.

More than 70% of us have a mobile phone, and that includes the socially excluded. Asylum seekers, refugees, the homeless, all are much more likely to have a mobile phone than a fixed address. A text is much more likely than a letter to reach these patients.

Some mobile communications solutions offer a multilingual facility, so SMS offers a tool for improving access to healthcare for groups whose health is known to be well below average. And very few people fail to respond to a ringtone. Ninety-eight percent of us read our text messages, while "snail mail" these days is as compelling as a pizza parlour flyer.

Texting is cheaper. The software and support cost a lot less than a typist or a receptionist – compare a 6p text with a 24p second-class stamp or a phone call. It is possible to offset the cost of texting by incorporating advertising. Most hospital appointment cards carry ads for local care homes and therapy services, so adding a plug for a health drink to a text would be an easy step. However, general practices and their patients are likely to be less keen on this idea.

Concerns about confidentiality centre on the involvement of companies outside the NHS and the breach of the nhs.net firewall. But in practice, messaging has proved safe. Patients are asked for their consent, and the messaging system is run in conjunction with, or by, the practice clinical software. Even if a system like that used by the Ealing PCT practices is adopted, no confidential data goes outside the practice.

Wot u say?
Messages can be as simple as: "You have an appointment with the doctor at 10.30am on Monday 25 July", although it is possible to include more information. SMS is much less likely to lead to confidentiality problems than email, and is much more widely accessed by patients. The General Practitioner Committee's Consulting in the Modern World provides guidance on e-consulting but does not mention texting.(3) However, the Medical Defence Union advises that all texts should be included in the patient notes.(4)

Staff may be concerned at having to operate yet another piece of software, but patient care messaging systems have been designed to integrate into existing clinical systems, and in future are likely to be an integral part of them.

Appointment reminders are automatic; once the system is set up, no further staff input is required. When using SMS to inform patients about flu jabs, the process is a little more complicated, as a search has to be done to identify the target group. A text to patients about flu jabs can also ask them to text back if they don't want one.

Similarly, texting patients with chronic diseases not only encourages them to attend for checks, but also provides evidence that the practice has offered appointments to nonresponders. Even practices that hit their QOF targets will find that texting saves time and money reaching poor attenders. Young people are the SMS wizards, and experience suggests that they respond well to texts to remind them to come for asthma checks or depot contraception repeats.

No fags 4 u
Some practices have gone further. A surgery in north London is finding that texting smokers who want to give up is much more effective than phone calls or letters. At another London practice, North End Medical Centre, GP Paul Ferguson and his wife designed a program to provide patients with test results.

The program includes rules that enable nurses who are looking at results to decide whether to send a message – for instance, results of pregnancy and HIV tests are not texted. The program provides a range of standard messages that can be sent; nurses can decide whether to choose one of these messages, or send a bespoke message. Twenty percent of patients opt to receive their results by email, 80% by SMS. Such applications require some work from staff, but they can save work and improve patient care. For IT-literate GPs and managers, the opportunities for developing new uses are wide open.

More 2 come?
Some mobile communications providers have developed messaging programs that sit with several of the popular clinical software systems. They have proved to be secure and simple to use. However, some clinical systems can already send texts without requiring extra software.

Meanwhile, IT specialists are developing systems for managing communications involving pagers, mobile phones, smartphones and VoIP (Voice over Internet Protocol). Essentially, communication made via a phone or computer (whether written or verbal) will go through the internet and may be received as a text, fax, verbal phone message or email, and the cost may be as little as nothing depending on the system and the internet pathway.

In the future, and not far ahead, a few systems will emerge as market leaders and the bewildering range of options and acronyms will simplify – or not, as technology never stays still. But the nhs.net now has a free SMS service, which provides a secure pathway with receipt of delivery/nondelivery, and nontechies will find that the technology is mostly unobtrusive and the results impressive.

GPs are not always as comfortable with IT as their practice managers. Some doctors' fears that texting will appear unprofessional have been proved unfounded but, for others, eliminating DNAs is a threat – how will they run to time if all the patients keep their appointments? The answer is to timetable breathing spaces: better-planned breaks, rather than unplanned ones.

There is now enough experience of messaging in primary care to show that many concerns are unfounded. Others can be managed. Now is a good time for practices to be thinking about how modern communications can work for them and their patients.

References
1. Developing Patient Partnerships. Missed appointments increasing despite same day appointments. August 2006. Available from: http://www.dpp.org.uk/en/1/pr2006kioci. qxml
2. Atun RA, Sittampalam SR. A review of the characteristics and benefits of SMS in delivering healthcare. In: The role of mobile phones in increasing accessibility and efficiency in healthcare. Vodafone Policy Paper Series Number 4. 2006. p. 18-28. Available from: http://www.vodafone.com/ etc/medialib/attachments/cr_downloads. Par.43742.File.dat/vodafone_policy_paper_ 4_march06.pdf
3. British Medical Association. Consulting in
the modern world. London: BMA; 2001.
4. Norwell N, medicolegal advisor to the Medical Defence Union. Letter. BMJ 2003;326:1148.