In his continuing series on the use of technology in primary care, Harry Brown looks at the potential value of text messaging.
In this modern era of hyperconnectivity, it’s often hard to appreciate how far we have come so quickly. SMS (short message service) – or text messaging (texting to you and me) – has only been around for a relatively short period of time. Incredibly, the first ever text message was sent in the UK in December 1992 (the message was “Merry Christmas”). 1
SMS messaging has been defined as “the act of typing and sending a brief, electronic message between two or more mobile phones or fixed or portable devices over a phone network”.2
Almost every mobile phone (although not necessarily the user) can send and receive texts, and due to the widespread use of mobile phones and texting, it has become a mainstream form of communication, particularly among – but certainly not restricted to – young people. Approximately eight trillion (yes you read this right) texts are sent every year.3
Use in primary care
Healthcare relies heavily on communications across a number of parties, and primary care is no exception. We have to be in touch with patients to communicate all sorts of information, such as results and appointment reminders, and encourage them to attend, for example for smears, ’flu vaccinations or other health promoting activities.
There’s nothing wrong in using traditional methods, such as writing to patients, phoning them, or having a real-time conversation or opportunistic contact while they are attending in person for another healthcare-related activity. But to become more efficient we have to embrace modern technology, and SMS messaging, particularly bulk texting, is one way to achieve this.
For some time, genitourinary clinics have typically transmitted their results to patients by text, and now many GP surgeries also use text messages to remind patients of their appointments as well as to encourage them to attend for ’flu jabs and other services. However, there is little room to put in a standard text message detailed highly customised information; it is best for general comments or simple reminders. The use of text messaging should therefore be just one part of a number of communications strategies.
Of course, the critical element here is that you should have an up-to-date mobile phone number for the patient which is definitely their personal number. This should be confirmed regularly, as people do change their mobile phones.
Also, it is not unheard of for people to pass and share around mobile phones to friends and family, so one mobile could have multiple different users. You should also have the consent of the patient to communicate with them in this format. 4
Bulk texting to patients
One huge advantage of texting is that large numbers of people can easily be contacted within a relatively short timeframe. You don’t need to be fiddling with a mobile phone sending out one text at time; technology offers a simple solution for inexpensive bulk texting to a large pre-defined audience. Some practices use an nhs.net email address to distribute the texts to specific groups of patients, and if an individual patient replies, it goes back to that specific address. Even better, this method is free. There are also plenty of commercial services (for example http://www.textmarketer.co.uk) that offer impressive sounding bulk texting services, although of course that will cost money (for example look at costs for bulk testing at http://www.textmarketer.co.uk/bulk- sms-prices).
There is of course a limit to what you can achieve with bulk texting to specific groups of patients. You may have consent of the patient and the correct telephone number of their mobile, but will the recipient read it? According to http://www.pure360.com:“90% of all text messages are read in three seconds” Another thing to consider is that texting is not so good for a two way conversation, such as diagnosing a condition or advising a patient. Compared to a text conversation, a two-way live phone (or video) call will probably be more efficient and achieve its objective more quickly.
Because text messaging has become a commonly used medium, the possibilities are almost endless. Couple this with the ability to reach out to such a large population relatively cheaply and easily and it seems a great addition to patient communication and support plan. According to a recent news item published in the British Medical Journal ,5 a recent study conducted in India found that “A mobile phone text messaging intervention can help prevent type 2 diabetes by promoting lifestyle modification in at-risk individuals”. Of course, other chronic disorders, such as hypertension and obesity, could benefit from this type of approach. Or a similar system could be utilised to encourage compliance with a drug regime.
Evidence of value Like all high-tech breakthroughs (though there is the argument that text messaging is no longer considered high tech), it is easy to get carried away and make claims for its success when there is no, or sparse, evidence to support this. Just like any medical intervention, we have to establish its true effectiveness in an evidence-based manner. A recent Cochrane review6 that looked at mobile phone messaging and its role in the management of chronic illness noted: “We found some, albeit very limited, indications that in certain cases mobile phone messaging interventions may provide benefit in supporting the self-management of long-term llnesses. However, there are significant information gaps regarding the long-term effects, acceptability, costs, and risks of such interventions”.
As with any intervention, there are downsides. As mentioned earlier, it is easy for the text message to go to the wrong person, and this could lead to a potential breach of confidentiality. This highlights the importance of regularly checking that the clinical unit has the up-to-date, current personal mobile phone number and the patient still consents to receiving these health related texts. Also, if there are too many texts, they may lose their effectiveness as the user becomes overloaded. Equally, any message must be clear, concise and designed to make a specific point (best to be a single item, such as an appointment). And don’t forget to make it clear who the message originated from.
The immediacy of texting and the sound of the alert can be distracting, especially when the recipient is engaged in another activity and may feel the need to check their phone. A good example is vehicle driving, where texting has been implicated as a significant crash risk. 7,8
If the potential power of text messaging can be harnessed properly, it can be a useful communication resource for public health promotion. 9 Of course it has to be secure, the sender should have the consent of the recipient and it should be relevant. The short size of a text message imposes the sense of brevity to the healthcare sender, resulting in a more focused communication.
Put very succinctly according to one paper: “A key theme of the texting for health literature is that text messages are valued when they are perceived as highly relevant, customised, and simple”. 9 Sticking to that simple rule should result in maximum effectiveness for text messaging as a healthcare communication tool to a substantial group of patients, particularly in primary care.
1. http://en.wikipedia.org/wiki/Short_Message_ Service
3. http://www.businessweek.com/ videos/2012-12-03/how-many-text-messages- are-sent-each-year
4. http://www.medicalprotection.org/mps- communicating-with-patients-by-text- factsheet.pdf
5. http://www.bmj.com/content/347/bmj. f5750?sso=
6. http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD007459.pub2/ abstract 7. http://www.fcc.gov/guides/texting-while-driving
8. http://www.cdc.gov/motorvehiclesafety/ distracted_driving/