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Why not just text them?

September 8, 2016

I want to acknowledge the contributions my colleague Kamal Jethwani and his team made to this post.

The business value of medication adherence tools is coming into focus.  For years, I remarked that, while we could create a case for why adherence was the right thing to do, we had great difficulty creating the right financial incentives to move these programs from curiosity to scale.  That is changing now with the collision in the marketplace of new payment models and exorbitantly priced pharmaceutical products.

The poster child for this phenomenon is the drug Sovaldi, which represents a miracle cure for Hepatitis C infection but costs $84,000 for a course of therapy.  But if the patient doesn’t finish the entire course, the money is largely wasted.  In that context, the price of any adherence solution is small compared to the cost of a failed treatment.

Today, there are a large number of adherence solutions on the market.  Two years ago, we found more than 100 companies offering products in the space.  A more recent report lists 5 categories for addressing adherence:  predictive modeling solutions, communication and education, smart pill bottles, smart tablets and apps.

In conversation with an influential senior executive at my organization — who I’d consider to be a connected health enthusiast but a realist — we debated the pros and cons of a simple text messaging solution versus one or more of these other approaches.  I thought I’d share the highlights of our discussion in this post.

Text messaging has become easy to scale.  We can now do it directly through our EMR, so the incremental cost of sending a reminder message is nil.  We can reach hundreds of thousands of people easily using this approach.

The downsides are important to mention as well.

  1. Onboarding: The FCC mandates two levels of consent from patients. First, when patients share their cell phone number, they are required to consent to receiving text messages from our organization; and second, the first text message sent should always be an ‘opt-in’ message that the patient has to reply to, in order to initiate the messaging campaign. In previous studies, we have seen a 30% drop off rate at this second step.
  1. Regulatory considerations: Text messages need to be ‘HIPAA compliant,’ which means we cannot send anything that could possibly reveal personal health information, including the patients’ condition, should others have access to their phone/messages.
  1. Reminders only: Text messages are usually prompts that ask a patient to remember something, or take a certain action. In several cases, the barrier to taking action is a patient’s lack of information/knowledge/understanding, making it difficult to predict which individuals will fall into this category. The limited number of characters (140) can also render the text prompt futile.
  1. Message Fatigue: It is well documented that, over time, people will pay less and less attention to timed, similar messages.
  1. Other considerations include the cost an individual may incur per message received, as well as oft-changing phone numbers, common in certain patient demographics.

Mobile apps overcome most of these problems.  Once you download the app, it is much easier to manage communication with you via notifications, and it’s also easier to secure the transmission of personal health information.  Engagement is multifactorial in the app environment: we can remind but also educate and interact with the patient. Finally, apps can be free to download.

Of course apps are not a panacea.  Patients sometimes have difficulty with the download process itself.  Just as messages can cost users, use of apps can affect data plan expenses.  Estimates of smart phone ownership vary, with most urban markets coming in around 80%.  That leaves 20% of any given sample as unable to use an app.

So what is the best course of action?

Based on our experience and research with both texting and mobile apps, we recommend texting for simple, one-time interventions such as medical appointments, annual screenings, medication refills and flu shots. Text reminders can also be good for short-term campaigns for patients taking infrequent meds, de-addiction or rehabilitation programs, or for patients who do not own a smart phone.

However, for more complex treatment regimens or challenging patient populations, we believe, and have proven the effectiveness of mobile apps when sustained, long term patient engagement is required.  There are a few examples that come immediately to mind, including programs that use sensors or collect patient reported outcome measures (PROMs), highly dynamic medical conditions that require just-in-time care, or programs targeting sensitive conditions such as HIV or STIs. Further, mobile apps can play an important role in patient education, improving patient-provider communication and passive data collection.

There is also a place for mobile apps in medication adherence, in cases when poor adherence is the result of factors other than forgetfulness. This may seem to be impractical advice, but I’m hopeful that as we continue to develop predictive algorithms, we will be able to better segment individuals to create more robust and effective engagement.

But for healthcare providers and executives, like my colleague, who are in need of immediate, cost-effective solutions to address critical healthcare needs, text messaging appears to be the answer. Our research and experience tells us that is not always the case.

What are your thoughts?

14 Comments leave one →
  1. September 8, 2016 10:15 am

    After wondering whether I’d taken my thyroid medication for the umpteenth time, it made me consider how a elderly patient handles all the medication that most are taking. I’m only 56 and have only one medication to take daily. Half the time, I truly can not remember whether I’ve taken it. Therefore, I might be taking two at a time.

    I’m thinking there should be a compliance app, much like LoseIt where you log whether you’ve taken a medication after you’ve done so. My method of simply moving the medication from one side of the sink to the other is not working.

    • September 8, 2016 4:04 pm

      I tried to make the case that apps are more flexible, so we are in agreement.

  2. September 14, 2016 11:54 am

    A lot of texting solutions go around HIPAA issue by never using patient’s name in the text. So instead of saying “Joe, take your blood thinner” they say “Take your blood thinner”. I am not sure if others having access to patient’s phone is a HIPAA issue. Every time you fill a prescription, the bottle has your name and other details and it ends up in bathroom closet where “others” (your guests, handman, etc) may see the info. In the end, the bottle ends up in trash and gets out in the open. I have not heard a pharmacy getting accused for HIPAA violation in such circumstances.

  3. September 17, 2016 1:00 am


  4. September 27, 2016 10:03 am

    When patients take multiple medications-15% of Americans now on 5 or more-texting or reminding pillboxes cannot assure the correct drugs at accurate doses will be taken. In a published study with Connected Health with cameras in a weekly dispenser, 62% of the time the box was misloaded. The sickest 5% of patients-virtually all on polypharmacy,-account for 50% of health costs. In MedSentry’s ongoing demonstrations with Connected Health, we port the MD regimen to a computerized tool in the pharmacy that loads a cartridge loaded into a monitored home dispenser. Based on the earlier study-showing a 5 fold reduction in rehospitalations-this is a powerful approach. Less costly mobile applications of this technology for patients at lower risk are available based on the MedSentry fill and verification tool in the pharmacy.

  5. September 27, 2016 4:18 pm

    You are correct about the need to be HIPAA compliant. However, you can be HIPAA compliant and still send protected health information (PHI) in a text message. The key is that the patient has to give you permission to do so. If they give you permission, then it’s not a violation of HIPAA.

    • September 27, 2016 5:29 pm

      well stated. During this back and forth process we find we lose lots and lots of patients.

      but you are correct.

      • John Silva permalink
        November 3, 2017 12:02 pm

        I understand this thread is a little dated but I it’s important to clarify a couple of points. First, the patient providing you their phone number gives you the required consent and second, you are not required to use the opt-in strategy as long as they have the ability to opt-out at any point.

  6. September 28, 2016 8:16 am

    Reblogged this on Jon Michaeli’s Blog.

  7. September 28, 2016 8:53 am

    Great piece. Thank you for posting. Another argument for apps is that apps enable people to record each dose and see their history. Addressing forgetfulness isn’t just reminding people when it’s time to take their meds but also visual confirmation when they’ve already taken them so they don’t take a second dose.


  1. Round up – Medical professionalism stories from across the internet this week – Good doctors
  2. Barriers To Using Texting To Motivate Compliance |

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