Friday, February 20, 2015

How "Texting" Would Work in a Real World Disease Management Program: How Many Nurses Do You Need To Hire? Can Physicians Deal With the Data Glut?

"My glucose is 149"
As population health providers such as care management vendors, home health agencies, medical homes, accountable care organizations and pharmacy benefit managers strive to increase both the quantity and quality of interactions with their patients, one thing is certain: traditional snail mail and phone calls are no longer equal to the task.

E-mail is an option (even as the lawyers worry about HIPAA and the CIO insists that it happens in a "walled garden") and then there's the emerging potential of social media (precontemplation in 140 characters or less?).

But how about cell phone texting?

The Disease Management Care Blog thought it would have been more common in population health settings, but it's not too sure. A quick literature search revealed some research on adolescent asthma care, diabetes, and lupus.  There's even this glowing review of the topic that describes multiple prospective studies in multiple countries that show that texting can have a positive impact on behavior change.

But before you run out and establish a texting option for your patients, you may want to read this hot-off-the-presses American Journal of Managed Care article first. Henry Fischer and colleagues from Denver Health recruited 47 persons with diabetes who were receiving their primary care in a Denver federally qualified community health center. The study subjects went through a short (3 month) pre-post study that piloted the impact of three-times-week text inquiries about blood glucoses plus reminders about upcoming appointments. If patients mistyped their answers, they were called by a nurse.

There are no data on the impact on blood glucose control, but that's OK. The DMCB learned some other useful stuff:

1. The Digital Divide: Cell phones are often the sole means of communication for patients who cannot otherwise afford a landline, internet access or a computer. If you're serving a socioeconomically disadvantaged population, texting may not be just the best option (because you need to get past caller ID), it's the only option

2. Ageism? Don't believe that this can only be used in adolescents. Nine of the persons in this pilot were between the ages of 60 and 69.

3. The Silent Treatment: The DMCB occasionally texts its spawn and, like many of the parents reading this post, gets ignored. But now you know that you are not alone because about a third (32% of the 1585 messages in this trial to be exact) will be ignored by patients.

4. Fat fingers? Nope. 99% of the texts were formatted correctly.

5. Oh, those pesky full time equivalents: Of course the only reason any health system CFO will OK the budget for a texting service is so you don't have to hire anybody and hopefully even "downsize." The bad news is that someone needs to monitor things: this study describes a "0.2" FTE nurse. The DMCB guesstimates thats one nurse for every 250 persons in a high volume (three times a week) texting-only care management program. Cutting the volume of messages to once a week may mean one nurse for every 750 participants. You get the picture.

6. The physicians?  You guessed it, the busy physicians were unable to get to the text message result a whopping 88% of the time.  A classic example of electronic data glut.  Better to let non-physicians manage this, says the DMCB, even if the CFO doesn't like it.

The DMCB Bottom Line: As far as the research goes, we already knew that texting can lead to behavior change.  This AJMC article was more of a real world effectiveness study that yielded some important insights on the target population, response rates, staff support ratios and the risks of burdening physicians with information overload.

Image from Wikipedia

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