Text messages: The workhorse of mobile health?

At times, text messages seem to be the uncelebrated workhorse of mobile health, especially when
you compare SMS to health apps in terms of the amount of attention each gets.
While the potential for smartphone apps is still great, adoption across all mobile phone users in the
US for apps has remained flat at about 10 percent for the past three years. Once these apps find
tighter integration with hospital IT systems, more clinician champions, fine-tuned behavior change
tactics, a clearer FDA regulatory framework, and (in some cases) companion peripheral medical
devices, they will likely become more of a mainstay.
For years now, text message-based initiatives have seemed to be eating health apps lunch.
[MobiHealthNews is hosting a webinar focused on Texting in Healthcare this Thursday,
December 13th at 2PM ET. Be sure to sign up for your complimentary registration right
here! We'll cover both provider-to-patient and provider-to-provider secure messaging,
too.]
In an interview with MobiHealthNews in 2009, Partners HealthCares Center for Connected Health
Director Dr. Joe Kvedar explained why his team had focused on text message programs instead of
apps: We have been very fond of text messaging because it enables us to reach the broadest
number of users. If you start out having to narrow your sample size because you are treating
people with a certain illness or a certain level of engagement with the system already, then
demanding that they have a specific phone or carrier, that can really, really dull the impact of your
intervention, he said. We have been more excited about text messaging and have used it as a
reminder tool for the most part.
In 2009 PriceWaterhouseCoopers published results from its Consumer Access Survey thatfound
about 21 percent were willing to receive healthcare information via text messages as an
alternative way to access health information. Back then, some 55 percent of those surveyed said
they were unlikely to use text messaging for health messages. While that many consumers were
willing, a Microsoft survey conducted by Kelton Research around the same time (mid 2009) found
that about 10 percent of consumers believed text messaging was the best way to receive health
information from their insurer.
While the potential for SMS-based health programs has been a ripe one for years, adoption today
surprisingly is actually about the same for both health apps and health-related text
messaging services.

The most recent data from Pew found that while 80 percent of adult mobile phone owners in the
US use text messaging, only about 9 percent used text messaging to receive health or medical
information. Adoption was strongest among women, African Americans, and those between the
ages of 30 and 49 years of age, according to Pew.
Over the years MobiHealthNews has tracked a number of patient- and consumer-facing text
message-based health initiatives and trends. Below is the beginnings of a comprehensive roundup
for SMS in healthcare.
Appointment Reminders
Perhaps more than any other text messaging service that healthcare providers offer their patients,
appointment reminders are the most widely available. In late 2009 Kaiser Permanente rolled out
its text message appointment reminder service for its patients. The integrated health systems
launched the service following a pilot study that determined the reminders reduced costs and
made it easier for patients to make it to office appointments. The system, which was developed by
MobileStorm, also included treatment reminders and lab result alerts. While KP may have helped
to put the SMS-powered appointment reminder opportunity on the map, such services have been
around since the early days of text messaging. Companies like Smile Reminder, which was founded
around 2000, now serve tens of millions of patients appointment reminders.
Lab Results Available
While the specific results from labs should not be sent via regular old SMS because of privacy
concerns, the fact that lab results are in is another low hanging fruit for text-enabled health
services. Often a physicians office will text a patient to call in when a lab result has come in. In
2009 Massachusetts General Hospital (MGH) said it was developing an ATM-like kiosk for health,
sort of like what Healthspot offers now, that performs a variety of diagnostic tests and then texts
the patient their results later.
Prescription Refills, Ready for Pickup
An Accenture survey that was announced at the AHIP conference this year found that most
patients surveyed (73 percent) would rather use their mobile phone to request prescription refills.
Retail pharmacies have been quick to offer such services, too. In 2010 Walgreens launched its
Prescription Text Alerts service, which lets customers know when medications are ready for pickup
or if there are any status changes to the prescription. Rite Aid has also offered text, email and
phone alerts for its Rx Reminders service for years now. Pharmacies use services like SMS-enabled
prescription refills to help bring down abandonment rates for prescriptions, which currently hover
around 25 percent for first fill prescriptions.

Weight Loss, Nutrition, Exercising

In 2011 researchers at the University of Michigan published a study that found tailored text
messages could help teens adopt healthier lifestyle changes. Four focus groups consisting of 24
male and female teens in weight management programs were sent six different message types:
testimonials, meal and recipe ideas, targeted tips, reflective questions, feedback questions and
tailored messages. The teens responded well to instructional messages from peers, including
recipes and testimonials about weight-loss strategies. Positive messages were also well-received,
including exclamations and emoticons, but colloquialisms like LOL were not.
Earlier this year Pennsylvania-based health insurance provider Highmark offered up a text
message-based health service, called Encouraging Words of Wisdom, for its members who are
enrolled in its personal nutrition coaching program. The free program has individuals meet with a
registered dietician up to seven times per year and the SMS component aims to help users stay
motivated. The messages are not personalized for the individual members.
More recently Rock Health alum Sessions has been offering a text message-powered coaching
platform that aims to help people stay motivated to exercise whether by going to the gym,
exercising at home, or just walking regularly. The program includes texts from a coach throughout
the week to check compliance with a workout schedule that the user and coach agree upon at the
start of each week.
Food Allergy Alerts
In early 2010 Irelands national Food Safety Authority launched an email and text messaging
service that aimed to inform food allergy sufferers about foods that have not appropriately labeled
their products for the presence of common allergens. Once the authority establishes that a food
product is missing the allergy information, the alerts go out to those consumers who subscribe to
the service via the authoritys website the agency also notifies enforcement officers and the
offending food businesses.
Medicaid Enrollment
In February the Centers for Medicaid and Medicare (CMS) announced plans to leverage the
Text4Baby SMS-based initiative to increase enrollment in Medicaid and the Childrens Health
Insurance Program (CHIP). Text4Baby participants will receive texts and information about
pregnancy and infant care, along with texts about no-cost health insurance coverage available via
Medicaid and CHIP. Specifically, the new texts included an InsureKidsNow phone number and
website for users to visit to sign up for coverage. About 184,000 current Text4baby users were
expected to receive the new messages.

Smoking Cessation
Text message powered services that help people quit smoking have been among the most popular
behavior change efforts in recent years. A meta-study of efficacy studies over the years found
that, based on five studies, with a total of more than 9,000 participants, smokers who used mobile
messaging interventions were twice as likely to make it six months without smoking than those
who didnt. There are a number of smoking cessation programs available in the market today that
leveraged SMS. In September 2011 The U.S. Department of Health and Human Services (HHS)
announced the launch of new SMS smoking cessation programs, QuitNowTXT and SmokeFreeTXT,
as part of its Text4Health initiative. The programs, a collaboration with the National Cancer
Institute, are aimed separately at adults, and teens/young adults, respectively. Around the same
time Alere announced that it had inked an exclusive deal with Voxiva, which powers Text4Baby, for
its smoking cessation program, Text2Quit.
Disaster Response, Emergency Alerts and Tips
Text messaging has been leveraged for disaster response around the globe in almost every recent
major natural disaster. For example, following the earthquake in Haiti in 2010 the Red Cross sent
public health text message tips to help Haitians in areas affected by a cholera outbreak to treat
their symptoms. The service also instructed those in areas not yet hit by cholera to take
preventative measures. The US government has recognized the critical role that text messages
play in such instances so much so that it has created an SMS toolkit for disaster response, which it
made available in June 2011. In 2009 the Centers for Disease Control and Prevention began a pilot
that leverages text messaging to send information about the H1N1 (swine flu) and other health
topics. The pilot is a three month long study that will also include feedback surveys from users to
help the CDC better use the platform moving forward.
Mental Health, Especially for Teens
In 2009 a crisis telephone helpline for people with mental health problems in Surrey, UKbegan
allowing callers to send text messages instead: While the functionality is intended for people who
are deaf or hard of hearing, anyone who prefers to text may. The user can text a brief message
that indicates the nature of the crisis and receive response via text, too. In 2009 Kaiser
Permanente touted a text message-powered service, called Happy Factor, which is had no hand in
developing, that helped users track their moods and general happiness by answering quick surveys
over text. That same year a Robert Wood Johnson Foundation funded startup, called Living
Profiles, mined the text messages of teenage boys and girls who had chronic diseases to passively
determine their mental state. The group tracked and categorized the words that the teens used

and then gave them updates that help the teens understand changes in their moods month-overmonth.
Pregnancy and Maternal Health
Of course, some of the most high profile SMS-enabled public health campaigns from recent years
have focused on healthy pregnancies and maternal health. In February 2012 then White
House CTO Aneesh Chopra announced the launch of Text4Baby, a free mHealth service that
provides timely and expert health information through SMS text messages to pregnant women
and new moms through their babies first year. Later that year, the Washington Post reported on
the launch of a similar service in Ghana developed in partnership with mobile operator Grameen:
In the past two months, Grameen has registered 500 expectant parents in the Kassena-Nankana
area of Ghana, near the border with Burkina Faso, to receive free, regular phone calls and text
messages guiding them through pregnancy. At week seven in the pregnancy, a parent receives a
text reminder to take a malaria vaccination. At week 37, the parent is told that contrary to myth,
eating fruits such as mango and proteins such as eggs is nutritious and wont harm the fetus. Not
all pregnancy related text programs are for moms mobile health company Rip Road offers a text
message-based service for expectant fathers called Duty Calls.
Asthma
In 2002 the medical journal BMJ published a small study that found daily text message reminders
helps people with asthma better manage their condition. From the abstract summary: We set up
a mobile phone text message service consisting of daily reminders to use an inhaler, health
education tips, and safety messages. We streamed these into a supply of lifestyle related text
messages about sport, celebrity gossip, and horoscopes; they were all written in contemporary
text jargon and sent by a virtual friend with asthma called Max. Thirty two young people with
asthma from Tayside, Scotland, were recruited through local radio to take part in a study to assess
the safety, reliability, acceptability, and effectiveness of the service. An even smaller 2011 study
of seven children found that text message reminders did not help them better manage their
condition. There are a number of SMS-based services for asthma available today. For example,
Asthma Signals, a health program from Quvium, leverages text messages to alert families when
the air contains certain asthma triggers in their area.
Sexual Health
In recent years public health groups have recognized that the convenience and privacy of text
messaging makes it a good channel for getting the word out about sexually transmitted diseases.
In 2010 The Minnesota Family Planning and STD Hotline announced plans to improve its website
begin providing updated services including Web chat and text messaging, in addition to its toll-free

hot line. The group provides confidential health education and by offering personalized text
messaging and Web chat options, users are now able to access information in the format that is
most convenient. In 2009 The New York Times published a feature on a service in North Carolina
called the Birds and the Bees Text Line, which is not automated, but staffed by nine professional
texters with public health backgrounds. According to the report, many epidemiologists and public
health experts believe sex education in the classroom is either ineffective or insufficient.
Diabetes
In 2010 endocrinologist and future entrepreneur Dr. Jennifer Shine Dyer made headlines for
leveraging text messages to better engage some of her Type 1 patients. Dyer found that her
weekly, customized text messages to remind adolescent diabetes patients about their personal
treatment activities increased overall treatment adherence and improved blood glucose levels. In
May 2011 Aetna launched an SMS-powered diabetes management service for members with help
from partner Silverlink Communications in 2011. Washington, DC-based Medicaid managed care
organization, D.C. Chartered Health Plan, announced plans toroll out a pilot text messaging
program for members with diabetes earlier this year. Arogya World, a US-based non-profit,
announced a collaboration with Nokia at the 2011 Clinton Global Initiative (CGI) Annual Meeting on
an SMS-based diabetes prevention program in India. CareSpeak Communications announced a
deal with UnitedHealth Group in 2011 to bring the health plans members two-way mobile text
messaging services focused on improving adherence to treatment regimens.
Birth control
The prospect of helping women remember to take birth control via text message reminders got a
bad rap in 2010 when a high profile study found that such reminders did not change adherence to
a birth control regimen. The study tracked adherence based on when a pillbox was opened not
self reports. The patients in the study, however, were aware that their pill boxes had the tracking
device installed. In the control group women were encouraged to use their own tricks to remember
to take their pill, and these included taking it as the same time as a vitamin or using their mobile
phone alarm, which may explain why reminders via text didnt improve adherence rates the
control group also likely had devised similar reminders on their own.
Blood donations
In 2009 The Red Cross announced that it would begin offering real-time alerts about critical blood
inventories and tips for successful blood donations through text messages. Users opt-in to the
program and can then choose to give blood when and where it is needed. The text even includes a
click to call feature that allows the user to book an appointment right away.

Wait times at doctors office, emergency room

Earlier this year several walk-in clinics in Montreal, Canada started sparing patients endless waits
by sending a text or an automated voice message when its almost their turn to see the doctor.
The problem of long waiting times is particularly acute in the Montreal area, where, according to
local reports, 300,000 people do not have a regular family physician. In 2010Bostons MetroWest
Medical Center launched a texting program that enables people to find out emergency room wait
times. In 2010 The Wall Street Journal reported on the launch of MedWaitTime in Chicago a Web
and mobile service that aims to help patients determine if their doctor is running late for an
appointment. An orthopedic surgeon, launched the service with 10 Chicago-area doctors.
Sobriety support
Text messages can also help people recovering from alcoholism. For example, one of the many
SMS services provided by HealthCrowd is an intervention for recovering alcoholics that involves
texting a persons friends to remind them to congratulate him on a sobriety birthday.
Drug Authentication
In some developing countries knowing whether the medication you have purchased is fake or not
is a rampant problem. Since the adoption of mobile phones has ramped up, a number of
companies now offer SMS-based drug authentication services in those markets. One such company
is Sproxil. In August Sproxil signed a deal with Indian telecommunications company Bharti
Airtel for the latter to offer its subscribers in 17 African countries free texting for drug verification.
Sproxils Mobile Product Authentication service includes a scratch-off label affixed to drug
packaging. Consumers scratch off the label to reveal a unique code when they buy a medication or
pick up a prescription, then text the code to a Sproxil SMS short code. A return text message
reports whether the drug is real or counterfeit.
Clinical trials
When it comes to successfully completing clinical studies, keeping patients enrolled is crucial.
Lengthy trials pose a significant risk of patients dropping out, especially if invasive procedures are
involved. In studies that include add-on trials, every patients continued participation grows even
more valuable. In addition, making sure patients stay on course with all study requirements adds
to this burden. While the need for effective retention and compliance measures is clear, they must
be targeted to do the job. Thats where mobile technologies, especially text message can play an
effective role. Many companies are now looking at ways to leverage texting and other mobile
technologies to improve clinical trials.

Dont forget the sun screen

One of the earliest studies that Kvedars group at the Center for Connected Health did thatused
text message reminders to put on sun screen. Kvedar is, after all, a dermatologist. We did one
study that was exciting where we compared a group of individuals who didnt get daily reminders
with a group that did. The goal of the intervention was to remind people to put on sun screen We
had a device that we could use that could measure whether people were actually putting sun
screen on or not. Both groups had that same device. Every time they opened the tube to put on
sun screen, it was a measured event that we could track. The intervention group had a daily text
message that shared with them a weather report and reminded them to use their sun screen. That
group had twice the level of adherence to the care plan as the control group. It was quite dramatic
and statistically significant.
What are other patient-facing use cases for text messaging in healthcare?