The powers and limits of texting for medical adherence

15 September 2016
Joseph Kvedar, MD, writes about some business cases in his blogpost on Chealthblog.  ‘For years, 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.’

At the center of this change is the drug Sovaldi. It represents a miracle cure for Hepatitis C infection but costs $84,000 for a course of therapy.  If the patient doesn’t finish the entire course, the money is largely wasted.  This makes the price of any adherence solution is small compared to the cost of a failed treatment.

Kvedar points out the large number of adherence solutions on the market these days.  ‘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.’

Texting versus mobile app

In his blog Kvedar looks at the pro’s and con’s of using a simple text message to remind people to take there medicine, and at the use of a mobile app to overcome some of the con’s.

A big pro:
‘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.’

There are downsides as well:
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 the organization using the Phone number. 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, a 30% drop off rate was seen at this second step.

Regulatory considerations: Text messages need to be ‘HIPAA compliant,’ which means nothing can be sent that could possibly reveal personal health information, including the patients’ condition, should others have access to their phone/messages.

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. A limited number of characters availablecan also render the text prompt futile.

Message Fatigue: It is well documented that, over time, people will pay less and less attention to timed, similar messages.

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 the problems mentioned.  Once the app is donwloaded, it is much easier to manage communication with a patient via notifications. It’s also easier to secure the transmission of personal health information.  Engagement is multifactorial in the app environment: reminding is one option, but also education and interaction with the patient. Finally, apps can be free to download.

Apps no panacea

Apps are not a panacea, Kvedar states.  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.

The best course of action? Kvedar recommends  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.

For more complex treatment regimens or challenging patient populations, the effectiveness of mobile apps had been proven 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.