Short Message Service as A Support Tool In Medication Adherence And Chronic Disease Management

Abstract
Short Message Service (SMS) or text messaging is an aspect of mobile telephone technology which will be the subject of a pilot programme involving patients in a District Health Board in Auckland, New Zealand. Anticipated outcomes include increasing adherence to medication regimen by mental health patients, whose motivational and cognitive impairments play a significant role in medication non-adherence and poor self management, and also the attendance at clinic outpatient appointments by diabetic and cardiology outpatients, who are known to have some of the highest rates of missed clinic appointments. Factors critical to the successful rollout of this technology include: the successful development of a technical application which meets the identified need; patients’ access to, and sufficient cognitive ability to, operate a mobile phone; and the successful management of the medicolegal aspects of utilising a medium for which there are no clear definitions or rules of ownership for patient information transmitted in this way. This pilot project will test the concept of using technology as a support tool to change patients’ behaviour. At time of publication a User Requirements (detailing the identified need) and a Functional Application (detailing the proposed application to address the need) had been developed.

Introduction
SMS (Short Message Service) is an aspect of mobile technology that has been embraced world-wide and involves sending a text message, usually from mobile telephone to mobile telephone. Recent technological advances have allowed telecommunication companies to automatically send out mass text messages to people with mobile telephones.

The health needs of the city of Auckland, New Zealand, are serviced by three District Health Boards (DHBs),^{[ a ]} each with their own population of care within a defined geographical area. Waitemata DHB has developed a plan, with the intention of now undertaking a pilot project, involving sending text messages to their patients reminding them of upcoming clinic appointments (specifically, Cardiology patients and Diabetes patients) or to take their medication (specifically, Mental Health patients). The idea is to use the text message as both a reminder and a support tool to encourage individual patients to take a more active involvement in their health management.

Successful treatment and management of chronic illness is characterised by the patient’s ability to instigate a change into their lifestyle, by adhering to a regulated medication regimen or by attending routine follow-up visits with their physician.^{[ 1 ]} Medication regimens are usually determined through consultation between physician and patient. Outpatient appointments are visits made to an outpatient clinic to receive an assessment before surgery, as a follow-up after an inpatient stay or, in the case of chronic illness, to routinely monitor the patient’s self-management of their disease.

Consequences of missed medication or hospital appointments are issues that face the entire community. A patient’s adherence to a medication regimen (ie, how closely they follow a prescribed treatment regimen) decreases the chance of their readmission into hospital^{[ 2 ]}. It is thought that an increased rate of adherence will have a greater positive effect on health outcome than any further developments in traditional biomedical interventions.^{[ 2 ]} Attending outpatient appointments ensures clinic time slots are fully utilised and that the patient is provided with up-to-date tools to help them manage their chronic illness: medication, advice, changes in disease management plans or provision of/alert to available community resource.

The degree to which a patient is able to successfully change their behaviour is dependent on their willingness to accept and adapt to their illness and the degree to which they are motivated to become involved in their care.^{[ 1 ]} Traditional methods to help patients become involved include patient incentives, reminders and education, however, patient education on its own (leaflets, videos, etc) has not proven to be not as effective as once thought.^{[ 3 ]} A collaborative partnership model is emerging^{[ 4 ]} in which people with chronic conditions are their own principal caregiver and health professionals act as consultants supporting them in this role.^{[ 2 ]} Supporting this model is the discussion in recent telemedicine literature^[5-8] on the application of information technology in reminding patients to take medication and/or to attend clinic appointments. Text message reminders would support the empowerment of the patient to take an active and integral role in the care and management of their own illness.

Organisations like the National Health Service (NHS) and primary care practices in the United Kingdom, have recently piloted projects utilising text messaging for these purposes. The pilots have been applied in both clinical and administrative contexts, with automated, specific, text messages sent to patients, acting as a reminder to take their medication at specific intervals^[5,9] and also to attend their planned outpatient appointments with their physician.^{[ 6 ]} The pilot projects involved patients with chronic diseases including diabetes and patients with planned clinic appointments.^{[ 6, 10]}

In New Zealand, The University of Auckland recently completed a the first New Zealand study to use text messaging as a support aid – to assist patients to stop smoking. The programme sent participants text messages to support and motivate them into reaching their goal – quitting smoking.^{[ 7 ]} A paper on the findings will be published in the near future, but early results indicate that the text messaging was successful as a support tool.

It is important to recognise that there is no inherent meaning in the data being sent using this technology. It is the transformation of data into information and the application of meaning and purpose to this information that allows the process to contribute to management of knowledge.^{[ 11 ]} A mobile technological application will use this data and, consequently, will change the way health care is delivered. It will also change the model of communication and accordingly communication between physician and patient is being demonstrated in a variety of health care settings. The Internet has been used to develop successful “cyberclinics” for advice for chronic disease patients^{[ 12 ]} and email has also been used to help facilitate communication between doctor and patient.^[13-14] Recent literature has highlighted the application of text messaging technology in clinical, supportive and administrative contexts. Pilot projects, particularly in the UK and also in South Africa have used text messaging to remind patients to take their medication^[5,9] or to communicate the results of lab tests,^{[ 15 ]} to act as a medium to offer support between appointments^{[ 7 ]} and to remind patients to attend their next clinic visit.^{[ 6 ]}

The application of text messaging technology to patients with chronic disease or mental illness is believed to be effective in increasing their medication adherence and attendance at clinic appointments. Mental health patients’ motivational and cognitive impairments, resulting from their illnesses play a significant role in medication non-adherence and poor self-management.^{[ 16 ]} It is also known that cardiology and diabetes patients have some of the highest rates of missed clinic appointments and a large proportion of these could be attributed to simple forgetfulness. Using text messages to remind mental health patients that their medication is due to be taken or cardiology or diabetes patients that their appointment is coming up would be an effective support tool in their self-management and care.

The successful adoption of this innovation by a select group would be influenced by various factors. Failure to fully comprehend many of these underlying relationships between these factors could mean that the uptake would be less successful.^{[ 17 ]} Such factors include the socioeconomic status (SES) of the patient; there are arguments in the literature both for and against the accessibility of mobile telephone technology to low SES groups.^{[ 18 ]} Pilot projects utilising this technology have to date been directed at a young, possibly more technically-savvy, population with positive results including increased adherence to insulin injections and also attendance at annual check ups.^[5-8] General population statistics for the proposed pilot region show an older demographic in some parts of the region and lower SES in other parts than within New Zealand. The implication is that much of the population that could possibly be involved in the pilot project could be significantly older and less familiar with mobile telephone technology.

Successful adoption is also driven by the fact that, using text messaging to communicate with patients in a clinical context about lab results, for example,^{[ 15 ]} raises medicolegal issues with regard to the ability of the patient to comprehend the intended message correctly and to understand the implications of such messages from their doctor. The content of a text message containing lab results and/or information regarding any intervention needed may require more consideration than is needed for a message containing a reminder about a clinic appointment.

Methodology

Background
The text messaging technology would be used with a group of patients using the services of Waitemata DHB in Auckland, New Zealand. The pilot project would initially use text messaging as a support tool, reminding patients from Mental Health to take their medication, and patients from Cardiology and Diabetes services to attend clinic outpatient appointments. Suitable technology would be developed by an external company specialising in advanced uses of mobile phone technology and would use existing hospital patient-management infrastructure and data.

The pilot project would encompass two work streams and, as a result, two different sets of functional needs and outcomes (refer table: Work Stream Outcomes). The text messaging to be used would accompany (not supersede) all existing patient reminder business processes including clinic letters and phone calls. Only Cardiology and Diabetes patients with existing mobile phone numbers in the patient management system could be included in the pilot project. Privacy issues like the transfer of patient information from the DHB to the off-site application are still being addressed by the Waitemata’s security officers.

Work Stream Outcomes

Project Path
The project team produced a User Requirements document detailing the DHB’s identified need – what the technological method/s developed would have to support to achieve what the DHB wanted. The document also detailed the existing data that would be utilised in the messages and current business processes in terms of reminders and booking outpatient appointments. In consultation with the application provider these User Requirements formed the basis for the development of a high level functional specification (the solution meeting those requirements) and initial system architecture (breaking down the required hardware and flow of data between systems). The Technical Solution proposes a web-based approach with relevant patient data being communicated to the messaging application via a gateway administered by the application provider.

Waitemata DHB uses a computerised patient management system (PMS) to perform administrative patient functions. The User Requirements document discussed above scoped the necessary data fields from the PMS, using these to indicate message recipients or type and the information they should receive. These particular data fields would be extracted from the PMS tables into a view and include demographic fields such as the National Health Index (NHI) number, name and mobile phone number and administrative fields including clinic time, place and clinician. Medication information will be sourced from a comparative repository and linked back by NHI number to the PMS.

Functionality
The proposed application would enable the project’s administrator, via a web-based user interface, to set up message templates specifically designed for communication to different groups of patients. The administrator would develop the template by creating a "blank" message and inserting nominated symbols into this text indicating where each specific data field should be inserted including: Name, Clinic Time and Place. These templates would then sit in the web-based user interface and at the specified times of delivery the application technology application would extract the specified data from the view and insert it into this message (based on the template) each time the messages are delivered to the patients.

The processing of the messages would be done on the other side of a firewall on servers housed with the application provider. Message content would be processed according to rules defined by the project and dispersed to recipients or responses collected.

Functionality required within the Cardiology and Diabetes work stream would allow mass messages to be sent or not sent based upon certain factors including NHI number, which identifies which patients have opted in and out of the programme, clinic type, clinician or time, or to be scheduled to be sent upon a change in clinic time, clinician or place.

The Mental Health work stream requires a patient-specific reminder message and the ability to send different messages to individual patients with message content relevant to that patient’s medication regimen.

In the Cardiology and Diabetes work stream the main desired outcome of the pilot project is to reduce non-attendance at clinic appointments. It would be expected to encompass both the messaging technology and functions such as system generated advice of failed messages, decline responses and non-responses.

Messages that could not be delivered would be highlighted in a system generated exception report, which appointment consultants would follow up. Delivery failure could be for a number of reasons including inactive mobile number, inactive mobile phone or lack of reception. All instances of a patient’s response message being anything other than "Yes" (they will be attending) would be dumped by the system into a report which could then be followed up by an appointment consultant. Scheduling a new clinic time for patient’s cancelling and filling in the vacated clinic time slots obviously utilises resources more efficiently, thus, reducing non-attendance and also associated costs including clinic, clinician and administrative time. Lack of response by the recipient in any capacity would raise a flag and insert the message into another exception report and an intervention could be made at this time.

Discussion
This DHB has engaged a application provider in conjunction with one of New Zealand’s mobile technology service providers to enable the development of a functional specification of the proposed application. The application is to form the basis of the technology aspect of this pilot, the means by which the Mental Health and Hospital services in this DHB will be able to instantly send messages to a specific population reminding them of upcoming clinic appointments or to a specific patient reminding them that they are due to take their medication.

Global Indications
The majority of recent text messaging initiatives undertaken in the United Kingdom have been directed at young patients in an effort to marry their frequent use and uptake of text messaging with their need to control and self-manage their chronic disease. The initiatives have been trialled with chronic diseases such as diabetes and asthma. This differs fundamentally from the proposed population to be included in the Auckland pilot project. Inherently, cardiovascular problems tend to affect an older population while diabetes and mental health problems affect both young and old. The project region has a statistically significant older population.

Critical Success Factors
There are a number of common critical success factors (CSFs) underpinning all text messaging projects, like those undertaken in the UK and the proposed Auckland pilot project.

1. Where required, the development of an effective technological application to manage the dispersion of the messages to different populations.
2. Patients involved in the pilot project must reside in an area with adequate mobile telephone coverage is provided by the mobile service provider. 
3. There are a number of cognitive factors involved, including the ability of the patients in the pilot to use mobile phones and understand the technology, or at least have openness to learn. Comprehension also plays an important role in understanding the intended content of the message because the lack of intonation and expression in a text message eliminates cues that would normally assist in interpreting such information. On the other hand, the formulation of an effective message that minimises ambiguity is also important.
4. Successful management of all the medicolegal issues including message ambiguity, phone ownership and ownership of information in the message. Ambiguous messages will confuse the patient and potentially have an adverse effect on medication types/amounts or interpretation of results.

Auckland Pilot Project Implications
The CSFs detailed above highlight areas to be addressed by the pilot, in an effort to try and minimise the effects of any potential barriers to success. The clear definition of user requirements will ensure that technically, the proposed application meets the needs of the pilot by administratively managing the message content and recipients of different content effectively.

The Mental Health pilot population cannot be assumed to be fully cognisant with both mobile phones and the accompanying text technology both because they may not have used mobile phones before and the nature of their illness may make it difficult. As a result, core training in the technology will be considered for the entire pilot group and the mobile telephones to be used within the Mental Health work stream will be basic and easy to use. For cardiovascular and diabetic patients, the functional knowledge to operate mobile and message technology will be assumed to exist. There is an inherent risk in this but the size of the pilot means that the project is unable to assume otherwise.

Future Considerations
This paper has described a project that will use text messaging technology to increase adherence to specified medication and clinic outpatient appointment times. It has presented an overview of the associated literature both at a national and international level and discussed the components of the application that has been proposed to deliver and manage the text messaging for the pilot project.

As the pilot project is in its developmental stage, the paper has outlined the critical factors that will determine the degree of successfulness. Future papers may describe the project rollout and how well the critical factors were addressed; whether they contributed to the success or failure of the pilot.

After the pilot project is completed, other ideas about the influence that factors like support networks, social groups and family have in helping patients cognitively change and self-manage their disease could be investigated. The concept of a response text where, for example, a diabetic patient contributing to their own electronic health record with information such as their daily blood glucose should be researched as an exciting possibility for the future.

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