1. Randomized Clinical Trial of Bidirectional Text Messaging to Improve Adherence to Recommended Lipid Testing Laura-Mae Baldwin, MD, MPH Caitlin Morrison, MPH Nick Anderson, PhD Kelly Edwards, PhD, MA Jeff Green Jonathan Griffin, MD, MHA William Reiter, MD, FACP Cleary Waldren, MS A collaboration between the University of Washington Department of Family Medicine, the Institute of Translational Health Sciences, Northwest EHR Collaborative (Anaconda, MT), and a multidisciplinary group practice In rural MT.

2. Acknowledgements Chris Miller, Lalitha Ramesh – IT Support Anthony Beaver, Brenda Benefiet, Mitchell Marrujo - Patient Contact

3. Acknowledgements This research was funded by the Office of the National Coordinator for Health Information Technology (Award Number 10775336) and by the Northwest EHR Collaborative. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Office of the National Coordinator for Health Information Technology.

4. Background Increasing alliance of technology and health care EHR most prevalent technology that is increasing the ability to record and monitor care

5. Background Patients simultaneously are adopting technologies that may have health applications Mobile phone saturation is one of the most dramatic – 85% of adults have a cell phone * – 95% ages 18-34 – 92% ages 35-46 – 86% ages 47-56 – 84% ages 57-65 – 68% ages 66-74 – 48% ages 75+ *Source: Zickuhr, Kathryn. Generations and their gadgets. Pew Internet & American Life Project, February 3, 2011, http://pewinternet.org/Reports/2011/Generations-and-gadgets.aspxaccessed on June 5, 2013. http://pewinternet.org/Reports/2011/Generations-and-gadgets.aspx

6. Study Questions Can patient text messaging reminders improve adherence to recommended care? Will patients participate in bidirectional patient- provider text messaging? How do patients feel about bidirectional text messaging with their medical providers?

7. Recommended Care: Lipid Testing Lipid testing among patients who require ongoing monitoring: –Diabetes Mellitus –Ischemic Vascular Disease –Coronary Artery Disease –Hyperlipidemia PQRS and NCQA measure important to the medical group

8. Research Clinical Care Organizational Structure NWEHR Medical Group UW Research UW Informatics BAA IRB

9. Methods Pilot randomized controlled trial Identified study population Randomized to intervention and control groups Applied intervention for specified time Compared study groups

10. Study Population 18 to 75 years old and assigned to one of two physicians’ practices At least one face to face visit with a medical provider (MD, DO, NP, PA) in the Medical Group in the prior 12 months. Diagnosis of Diabetes Mellitus (DM), Ischemic Vascular Disease (IVD), Coronary Artery Disease (CAD) Diagnosis of Hyperlipidemia (HLD) and no DM, IVD, CAD

11. Eligible for Reminder Text Message IF: No LDL in the past 12 months OR No LDL in the past 3 months AND: –The latest LDL between 3 and 12 months prior is >100 for patients with a diagnosis of DM, IVD, or CAD. –The latest LDL between 3 and 12 months prior is >130 for patients with a diagnosis of HLD.

12. Methods Called eligible patients to determine whether they had a cell phone, and were willing to accept text messaging from the practice. At the call, recorded current cell phone number. Randomized half of group to receive text message reminders about lipid testing Sent up to 3 text message reminders 30 days apart Interviewed intervention group on experience with text messaging after 2 nd text message reminder sent

13. Text Message “You are due for a cholesterol test. Reply 1 for YES, I will go to ’s lab this week, open 7:30-6 M-F. Reply 2 for NO. Fasting not needed. ”

14. Project Timeline Text #1 – April 1, 2013 Text #2 – April 29, 2013 Research interviews conducted Text #3 – May 28, 2013 End of observation period –June 25, 2013

15. Outcomes of Interest 1.Adherence to recommended testing 2.Patient response to text messages 3. Patient experience of text messaging as a method for screening reminders

16. Enrollment Chart 248 Overdue for LDL based on EHR data 248 Overdue for LDL based on EHR data 71 Ineligible or declined 71 Ineligible or declined 112 Not reached after 3 recruitment calls 112 Not reached after 3 recruitment calls 65 Eligible – had cell phone, willing to participate 65 Eligible – had cell phone, willing to participate 4 Received LDL prior to intervention 4 Received LDL prior to intervention 61 Eligible – and randomized 61 Eligible – and randomized 26 Refused 26 Refused 45 Ineligible (no cell phone, no text plan, different primary physician) 45 Ineligible (no cell phone, no text plan, different primary physician)

17. Study Groups 28 Received up to 3 text messages 28 Received up to 3 text messages 61 Eligible and randomized 61 Eligible and randomized 31 Randomized to text message group 31 Randomized to text message group 30 Randomized to control group 30 Randomized to control group 1 Refused after first text message 1 Refused after first text message 2 Duplicate phone number –only one text message 2 Duplicate phone number –only one text message 3 Duplicate phone number – only one text message 3 Duplicate phone number – only one text message

18. Patient Characteristics n = 61 % age 55 and older49.2% % female32.8% % with a Wellness Visit in the last 12 months 24.6% Mean (SD) # ambulatory visits in previous year 4.0 (2.8)

19. Chronic Disease Status

20. Adherence to Recommended Testing Persons who came in for LDL testing Month #1 % Month #2 % Month #3 % Total Overall % Interventio n (N=31) 7 (n=31) 22.6% 2 (n=24) 8.3% 2 (n=22) 9.1%1135.4% Control (N=30) 2 (n=30) 6.7% 4 (n=28) 14.3% 3 (n=24) 12.5%930.0% Adjusted Relative Risk (CIs) 4.96 (1.08- 11.35) 1.42, (0.61- 2.39 )

21. Response Rate to Text Messages Responded to messagesParticipants (n=28)Percent Never responded 9 32.1% Ever responded 19 67.9% First only 8 28.6% Second only 1 3.6% Third only 2 7.1% First and second only 4 14.3% First and third only 2 7.1% Second and third only 1 3.6% All messages 1 3.6%

22. How Patients Responded to Text Messages Response Type by MessagePersons who respondedPercent of responses Message 1 N = 15 Yes 640.0% No 640.0% Other 320.0% Message 2 N = 7 Yes 342.9% No 228.6% Other 228.6% Message 3 N = 6 Yes 116.7% No 583.3% Other 00.0%

23. “Other” responses Who is this for? I already had the above test done prior to seeing Dr. XXXXX in early March of this year. I also need to get a PSA test for {another provider}. I will waite and coordinate into one lab visit. Already had one!.

24. “Yes” / “No” with more information 2. I will use the state clinic for lab tests. 1 / … Not sure who is requesting or if you are meaninh / 2 i will call you

25. Patient Experience with Text Messaging Invited the 28 individuals who received text message reminders to participate in a brief interview about their experience $10 incentive for participating 11/28 agreed to participate 8/11 were reached for the interview

26. Patient Experience with Text Messaging is trying to find ways that help people get the health care they need. A little over 5 weeks ago, sent you the first text message with a reminder to get a cholesterol test. Do you remember getting this text message? What did you think about getting a reminder like this via text message? 7 of 8 thought text messaging was a positive experience 1 of 8 remembered receiving the message, but did not regularly text, so did not successfully retrieve the message

27. Patient Comments about Text Messaging “Text is an easy way to communicate and can also be automated.” “I think it’s a good idea, people make appointments and it helps to recall when to do….It would be helpful if there are extenuating circumstances, like mine, to include a phone number.”

28. Patient Experience with Text Messaging Of the 7 interviewees who received the text message: – 3 came in for testing 2 noted that the second message prompted them to come in – The 4 who did not come had the test done with another doctor (n=1), were waiting to test at their annual appointment (n=1), or did not think they were due (n=2)

29. Patient Experience with Text Messaging How concerned are you, if at all, about the privacy of your health information in text messages? – 5 did not want actual health information communicated in accessible formats – 1 had no concern – 1 person was very concerned – 1 person did not know

30. There are many ways to get health reminders like this – phone, text message, postal mail, email. What do you think about getting a health reminder via text message compared to these other ways? Method Preferred Participants (n=8) Text 2 Email 2 Text or email 1 Text, email or phone 1 Mail 1 Phone 1

31. Main Findings A first text message reminder significantly increased LDL testing among rural patients overdue for this test. After three months, patients with no text message reminders nearly “caught up” with LDL testing compared with patient who had received reminders. This pilot study had a small sample size, so a larger study is needed.

32. Main Findings A majority of patients engaged in text messaging with their provider (67.9%) The minority of those who text messaged back said they would be coming in for their LDL tests – 40% after message 1 – 42.9% after message 2 – 16.7% after message 3

33. Main Findings Most patients had a positive experience with text message reminders, but did not want health information transmitted by text message. Half of those interviewed rated text messaging as a preferred method for getting health reminders, others preferred other methods (e- mail, phone, postal mail)

34. Limitations Excluded adults over 75 years of age Small sample size Special procedures gathered cell phone numbers – not always available

35. Conclusions Text message reminders may result in clinically meaningful improvements in adherence to recommended laboratory monitoring

36. Conclusions In this study, the greatest testing effect was after the first text message. Some of those who came in for LDL testing after the first text message may have been tested within a few months anyway. Though not statistically significant, more individuals who received text messages did get LDL testing after 3 months.

37. Conclusions Given this study’s findings, among 1000 patients needing an LDL test, the number tested within 3 months would be: – 354 if reminded by text message – 300 if not reminded Over 50 more patients would come in for testing.

38. Conclusions Patients have a positive experience with text messaging Patients will use text messaging to relay additional information

39. Next Steps Testing text message reminders in a larger study population Better understanding of patient concerns and limits regarding health care applications that use mobile technology

40. For more information, contact: Laura-Mae Baldwin lmb@uw.edu Caitlin Morrison cm46@uw.edu