Problem Addressed

• Significant staff time, mostly on negative results: Staff in clinics that provide testing for STIs often spend a significant amount of time communicating the results to patients via telephone or inperson consultations. For example, staff in the typical sexual health clinic in the UK spent 120 hours per month on these activities,¹ roughly equivalent to three-fourths of a full-time equivalent (FTE) staff member. The vast majority of these test results are negative² and thus require no additional followup with the patient. Before implementation of this program at the three Chelsea and Westminster Hospital clinics, several staff spent 4 hours a day responding to patients who called a special telephone line to receive results. In addition, patients often spent a long time on hold before being able to speak to someone to learn the results.
• Treatment delays: Problems reaching patients by telephone and/or setting up inperson appointments can delay communication of positive test results, which, in turn, delays treatment. In some cases (particularly with men), extended delays reduce the likelihood of the patient showing up for treatment.³ In addition, staff time spent communicating negative results to patients can limit the capacity of the clinic to schedule treatment for those testing positive, thus creating further delays.
• Increased risk of complications and spread: Delays in treatment increase the risk of complications and exacerbate the degree to which an infected individual spreads the infection. Typically, the longer the infection goes untreated, the more secondary individuals will be infected.⁴
• Unrealized potential of text messaging: The vast majority of patients have a cell phone capable of receiving text messages, yet very few health care providers give them the option to receive test results in this manner. For example, at the John Hunter Clinic (one of the three implementing this program), 98 percent of patients had a mobile phone, even more than the 68 percent who had an e-mail address.⁵

Description of the Innovative Activity

• Wide variety of tests covered: The program covers a variety of tests commonly conducted in the clinics, including those related to diagnosing chlamydia, gonorrhea, syphilis, hepatitis, and herpes. Patients being tested for human immunodeficiency virus (HIV) can receive negative laboratory results by text, but only if they have also received other tests (and hence get those results by text as well). At present, 90 to 95 percent of all initial contacts related to test results are communicated via text message, with each clinic typically sending between 1,000 and 1,500 messages a month.
• Confirming patient agreement to receive text message: At the end of each visit in which testing has occurred, clinicians inform the patient that the clinic's standard practice is to communicate test results via text message. The clinician confirms that the patient agrees to this approach (which the overwhelming majority do). If the patient has not previously provided his or her cell phone number for texting, the clinician records this information on a specially designed card that also lists the tests provided during the visit. For those who previously provided a cell phone number, the clinician confirms the number and records the test(s) on the card. The clinician informs the patient that the text message should come within 5 to 7 days, and to call the clinic if it has not arrived in 10 days. All cards from a given day are placed into a box.
• Daily health adviser review: Each morning, a health adviser collects the box containing the cards of patients receiving tests 1 week earlier. (The 1-week delay helps to ensure that results will be back.) The adviser gathers and reviews available test results for each patient from the clinic's electronic systems (all results come in electronically). For those with missing results, the adviser places the card in the next day's box to ensure that results can be checked as part of that day's batch.
• Daily text messaging: Using a computer with specialized text-messaging software, the health adviser chooses the appropriate message to be sent to each patient from 1 of 30 "prepackaged" messages developed to cover virtually any situation. If more than one patient needs to receive the same message, the adviser can set up the system to deliver the message to multiple telephone numbers. The texts go out around 9 a.m., thus giving those who need to call the clinic ample opportunity during the day to do so. The texts follow Caldecott guidelines related to patient privacy and confidentiality, which all providers in the UK must follow. Because these guidelines generally prohibit providing specific results data or naming an infection (with the exception of referring to hepatitis B vaccination status), the wording tends to be generic while still providing the necessary information to the patient, as outlined below:
  • For negative results: The message typically states that all results are negative. For example, texts might read as follows:
    • "All your results are negative. This means there are no problems. Thank you."
    • "Your followup results are fine. Thank you."
    • "The doctor is happy with all your results. Thank you."
  • For "expected" positive results: For those with expected positive results who require no further treatment (e.g., for a suspected case of urinary infection or chlamydia in which the patient received both testing and treatment at the initial visit), the text confirms the expected results and notes that no further action is necessary. For example, the text might read as follows: "You were treated appropriately. All other results are negative. Any queries, phone the health advisers at XXXX XXX XXXX."
  • For patients in need of followup: Texts to those with positive results who need additional treatment urge the patient to call or come into the clinic, without providing any specific details on the results. (The only exception is for those testing positive for HIV, who are contacted by telephone and only receive a text if they cannot be reached and the clinic does not have permission to leave a message to call back.) Sample text messages to those in need of followup include the following:
    • "Please make an appointment to return to clinic for followup after treatment if you have not already done so."
    • "You are now due for followup after treatment. To make a nurse's appointment, call XXXX XXX XXXX."
    • "Please phone the result line at XXXX XXX XXXX on Monday, Tuesday, Thursday, or Friday, 10 a.m. to 11 a.m. Thank you."
    • "Please make an appointment for a review of your results. XXXX XXX XXXX."
    • "You require treatment. Please phone to make a health adviser appointment at XXXX XXX XXXX. To discuss this, call XXXX XXX XXXX."
    • "Please phone the health advisers at XXXX XXX XXXX for followup. Thank you."
    • "Your results are now ready to pick up from the clinic. Thank you."
  • For communicating hepatitis B status: Caldecott guidelines permit naming hepatitis B in relation to vaccination status. Consequently, texts related to hepatitis B status include the following:
    • "Your results show hepatitis b immunity. Thank you."
    • "Your result shows no hepatitis B immunity. To obtain protection against the virus, continue with your vaccination course or start one."
    • "You need to return for your hep B vaccination if you have not already done so. Thank you."
    • "You are now due to return for a test to check your protection against the hepatitis B virus. Thank you."
• Followup with those who do not respond: The health adviser keeps a hard copy "diary" for any patient who requires additional followup. The adviser sends a second text to those who have not responded within 1 week of the first message. Those who still do not respond receive a telephone call, followed by a letter, and, potentially, a house visit in serious, time-sensitive cases. Typically, only about one patient per month consistently fails to respond to these followup efforts.

References/Related Articles

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Results

• Quicker diagnosis and treatment: In a 6-month pilot test involving 28 patients testing positive for chlamydia who received text messages, the average (mean) time between the test and the patient receiving the diagnosis was 7.9 days, well below the 12.5-day average in a comparable group of 21 patients receiving results via telephone or in person. Quicker diagnosis translated into faster treatment, with the average (median) time from test to treatment being 9 days in the text-message group, compared with 15 days in the standard group.⁵ Program leaders have not evaluated the time to diagnosis or treatment since this initial pilot, but they firmly believe that the program has continued to speed up the time to treatment as it expanded to cover virtually all clinic patients.
• Less staff time to communicate results: Communicating a single test result in person takes roughly 12 minutes of staff time and doing so over the telephone takes about 4 minutes. By contrast, the texting service takes roughly 1.5 minutes of staff time per patient. During the last month of the 6-month trial described above, 285 of 841 results (roughly 34 percent) occurred via text message, with the remaining results being communicated via telephone (43 percent) or in person (23 percent). Consequently, during this month, clinic staff spent 40.4 percent less time communicating test results as a result of the text messaging service. At an average nurse salary of 13 British pounds per hour, the clinic "saved" 609 British pounds that month as a result of the service (although in reality the "savings" did not come in the form of money, but in freed-up staff time to perform other needed duties).⁵ Since the initial trial, the amount of staff time saved has increased significantly, as now 90 to 95 percent of patients receive results via text message.
• Freed-up capacity to serve new cases: In 2004 (before implementation of this program), roughly 61 percent of patient visits at the three clinics involved either a new patient or a new episode for an existing patient, with the remaining 39 percent being followup on a specific episode with existing patients. By 2007 (when roughly 4 in 10 patients received results via text), 81 percent of visits involved either new patients or new episodes for existing patients. At present, this figure is likely even higher because use of texting has become nearly universal. (Program leaders believe that texting accounts for the lion's share of the freed-up capacity, with one additional change—allowing patients to treat warts at home using cream instead of freezing them in the office—accounting for the remainder.)
• High patient satisfaction: In surveys, patients have consistently expressed very high levels of satisfaction with the program. Only one patient has ever refused to receive results via text message, and only one has ever complained about receiving a text message after the fact.

Evidence Rating (What is this?)

• Pre- and post-implementation comparisons of the average time from test to diagnosis and test to treatment in 28 patients receiving text messages and 21 comparable patients receiving results by traditional means.
• Estimates of staff time savings based on assumptions about the time required to communicate results via text, telephone, and in person.
• Pre- and post-implementation comparisons of the percent of total clinic visits accounted for by new patients, new episodes for existing patients, and followup care for existing patients.
• Post-implementation patient satisfaction survey results.

Context of the Innovation

Planning and Development Process

• Choosing software: A clinic leader read about an appointment reminder text-messaging system offered by Mikkom, Ltd. and then contacted the organization to see if the same type of application could be created for text messaging of results. Company leaders embraced the idea and worked with the clinics to create the software. The company provided the software free of charge, with the understanding that the clinic would pay a per-text fee to Mikkom.
• Training health advisers: Mikkom trained the first health adviser on how the system works. Over time, this individual created a formal set of standard operating procedures that have been distributed to other health advisers.
• Creating a menu of standardized texts: The program began with a set of three standardized messages designed to cover only a narrow set of patient circumstances. Over time, the main health adviser responsible for the texting worked with clinic leaders to develop new standardized messages designed to cover additional patient circumstances. At one point, the full menu included 65 different messages, but has since been pared back to 30 messages that cover the vast majority of cases.
• Training frontline clinicians: Existing staff received a brief introduction to the system, along with scripts that lay out how to present the idea of receiving results via text message to patients. New staff receive the same brief training when they begin working in the clinics.
• Conducting initial small-scale test: Leaders at one of the clinics (The John Hunter Clinic) ran a small-scale test of the program over 6 months with patients undergoing testing for chlamydia. As described earlier, their evaluation demonstrated that the program led to faster diagnosis and treatment, with no "missed" results (i.e., cases in which patients did not receive notification) and high levels of patient satisfaction with little or no pushback.
• Expanding program: Based on the success of the pilot, leaders in the other two clinics introduced the program, and all three clinics began expanding it to cover an ever-larger array of patient circumstances.

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as the health adviser (typically a nurse's aide or medical assistant) sends the text messages as part of his or her regular administrative duties. The texting process takes about 1 hour of the adviser's time each day. As noted, the program reduces overall staffing demands, thus freeing up time to engage in other activities.
• Costs: The program required no upfront development costs. Program operating costs consist of a per-text payment made by the clinics to Mikkom. The per-text price has fallen as the volume of text messages increased. These costs, moreover, have been more than offset by the value of the freed-up staff time. Would-be adopters may be able to find ways to offer the service without paying a per-text fee.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Begin with small-scale test: As noted, leaders at one clinic ran a small-scale test that clearly demonstrated the program's effectiveness in enhancing access to treatment and keeping patients happy. These results made it relatively easy to "sell" the program throughout the organization.
• Train staff: All staff need to understand how the program operates so that they can clearly explain to the patient when and what to expect in terms of communication of test results.
• Consider integration into electronic systems: Although the Chelsea and Westminster Hospital program relies primarily on a paper-based approach (using cards that go into a box each day), some organizations may be able to integrate the program into an existing electronic medical record, thus reducing the risk of paper being lost. Program leaders have been working with information technology staff in hopes of achieving such integration but have not yet been successful in doing so.
• Create audit trail: The system needs to record precisely when and where messages have been sent. These auditing capabilities can be helpful in situations in which patients do not receive (or claim not to have received) messages. In one instance, this function helped to discover that a text message had been sent to a recently changed—and hence outdated—phone number.

Sustaining This Innovation

• Monitor and follow up with nonresponders: The person sending the messages should regularly check to ensure that patients in need of additional care have contacted the clinic to schedule an appointment. For those who do not, additional followup should occur (e.g., second text message, telephone call, home visit), with the intensity of the effort being driven by the urgency and severity of the situation.
• Remind clinicians to fill out information: The program cannot work effectively unless frontline clinicians accurately and completely document the relevant information related to the tests performed on every patient at each visit.

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