Text Messaging Can Lower Costs For Patient Outreach and Improve Appointment Adherence

The Perelman School of Medicine at the University of Pennsylvania conducted a study that showed sending patients automated text messages is the next best means of communication next to receiving telephone calls. It saves you money and your staff’s time while you expand your outreach to patients with limited access to the Internet and emails.

Save Money and Staff Time

To encourage patients to get Covid-19 vaccinations, researchers hypothesized that reaching more patients is possible with text messaging than telephone calls. The response rate of both methods resulted in about 3% of patient outreach. The study indicated that text messaging is an alternative and inexpensive tool compared to outbound telephone calls. However, this needs additional effort when it comes to improving the vaccine uptake, according to Shivan Mehta, lead author of the study and Penn Medicine’s associate chief innovation officer.

In a news release, Mehta stated that the takeaway is the comparison of the text arms and the phone-only arm. Text messaging is less intensive with resources because a live call center talks only to interested patients instead of cold calling everyone listed.

The trial also found that Black patients with lower income and Medicaid have higher response rates than White patients with higher income and commercial insurance. Mehta suspected the reason for this response rate could be directed at earlier efforts via email or through a patient portal logging more responses on White patients. 

Improve Equity in Response Rates

The study occurred from April 29 to July 6, 2021, in Philadelphia, Pennsylvania, among 16,045 patients. It took place at a time when the enthusiasm for the vaccines for Covid-19 started to subside. This led to the aim of Penn Medicine to read a wide range of patient populations and improve equity with telephone calls.

Colleen Mallozzi is the study’s co-author and an associate clinical informatics officer at Penn Medicine. She said that this approach addressed some concerns about equity citing how answering the phone is not often effective for patients.

Three groups divide the patients in the healthcare system when scheduling vaccine appointments. The healthcare system sends the following to receive the vaccines:

  • Automated texts and follow-up phone calls – 3.1%
  • Just phone calls – 3.6%
  • Only automated texts – 3.3%

Mehta suggested applying the lessons for patient outreach to other healthcare areas while Learning to apply the same lessons to breast cancer screening, flu vaccines, and colorectal cancer screening. 

Using tools like phone and text messaging improves equity in response rates to preventive outreach in healthcare, especially for older patients and minorities. These efforts prove to be more promising as automated text messaging is more efficient than cold calls, which can consume plenty of staff time.     

Provide Patient Education

Before procedure and appointment adherence, patient education is critical to achieving good outcomes. Designed to support these outcomes,  text message tools for patient outreach may not be a cure-all.

The Perelman School of Medicine at the University of Pennsylvania has researchers focused on colonoscopies for colorectal cancer screenings. They ensure the importance of patients in procedural preparation and adherence to screening schedules.

In the US, the second leading cause of death related to cancer is colorectal cancer. Ensuring early detection and better outcomes is through regular colonoscopies. According to the researchers in JAMA Network Open, the process of colonoscopy is complex for patients and involves the following:

  • Obtaining and purchasing bowel preparation
  • Identifying an escort
  • Taking a work day off
  • Completing the recommended preparation
  • Adhering to a clear liquid diet

These challenges make non-attendance and cancellation rates high and preparation quality poor. Both will limit the benefits for patients and the population. 

A market for interventions based on technology opened due to the imperative of patient education and appointment adherence. These interventions included text message patient outreach. Different IT developers in healthcare created tools based on the text that provides information about colonoscopy and its patient’s preparations.

Adopting these tools showed the intention of a healthcare organization to increase patient education regarding colonoscopy and to improve patient engagement using preventive procedures. 

The technology reinforces pre-care instructions and helps improve practice management. Despite the hectic workflow of nurses and other medical professionals, it saves them time as the calls don’t have to be made by them.

Can Text Message Help Improve Appointment Adherence?

The control trial was random and compared reminders from phone calls and text messages. But its difference is negligible between usual care and adding text messages. The control group consisted of 386 enrolled patients who received one phone call from the nurse along with written instructions.

About half of those who went to their appointment made preparations at optimum. The same goes for the intervention group. A week before their appointments and usual care, they received nine patient education and text messages that serve as a reminder. The secondary outcome doesn’t differ much on the following:

  • Last-minute cancellations
  • Appointment non-attendance
  • Attendance with poor procedure preparation
  • Appointment rescheduling

In other words, the technology added for the text message patient outreach did not show any difference in improving the results. Some patients were observed to have the ability to access the text message intervention more than others. 

Patients who have higher literacy in digital health may get more out of the technology. This approach suggested that it targets driving better results. At the same time, researchers are prudent in comparing usual care like phone calls from nurses and written materials to only tools for text message outreach.

The study showed that those who received text messages also received nurse phone calls. This indicates that none of the researchers can determine if text messages can replace, not just supplement, but provide care for colonoscopy as well.

The team mentioned that future research on this should be considered. A study on text message patient outreach tools  also determined the following:

  • Saving clinician’s valuable time
  • Streamlining clinic operations
  • Potentially cutting costs

The research team also stated that nursing telephone calls represent a process that consumes time and can be labor-intensive. By contrast, automated scheduled text messages don’t interfere with patients because it does not require staffing overhead and works with minimal cost.

Mitigating patient call volume is significant for healthcare organizations to work. Text messages and chatbots are automated tools that offer some opportunities for a streamlined workflow. Contradicting results of this study show anecdotal evidence of how automated communication based on technology can work.

A good example is NYC Health + Hospitals which offers text message patient outreach to organizational leaders. They helped them fully understand the reasons behind patient no-shows.

In an interview last January 2020, Kaushal Challa, NYC Health + Hospitals senior assistant vice president of Ambulatory Care Services mentioned how they used text message patient outreach by asking patients to confirm their scheduled appointments and state their reasons if they couldn’t make it on time. This allowed NYC Health + Hospitals to detect the patient’s health social determinants as well as other barriers keeping them from getting enough healthcare.

Challa gave credit to call centers and electronic health record (EHR) integration because of the tool’s success. NYC Health + Hospitals noticed that the patient no-show rate in Coney Island showed 21%  in 2019. It is also essential that all patients have access to the tool even if they speak in different languages.

Challa also said that the move partly responds to the population of their patients to provide an enhanced solution through text messaging capabilities.

Since the majority of people have cell phones, the rate of patients relying on their cell phones is higher than the average. Challa continued that there’s a misperception recorded in history that the population of patients belonging to a poorer sector is not tech-savvy.

The truth lies on the opposite where their patients are almost exclusively relying on mobile phones.

Is Text Messaging the Best Tool for Covid-19 Vaccines?

When patients seek out the Covid-19 vaccine, the effectiveness of text messaging in patient outreach was the same as direct phone calls but is likely the best option. Put into consideration that most organizations have limited resources.

Even if public healthcare efforts are enough to increase the rates of Covid-19 vaccination, there is a continuous sparse uptake, especially for minorities. The Kaiser Family Foundation conducted the data on April 5 about Black people receiving vaccines, and only 57 percent across the country got at least one vaccine shot.

The researchers said that the minority populations have lower rates of vaccination with seemingly even further disparities in pandemic outcomes. Because certain populations have low uptake of Covid-19 vaccines, they also hypothesized that communicating with people is more likely by text than by phoning them for Covid-19 vaccination.

Researchers stated that patients can take advantage of text messaging since it costs low and makes outreach more efficient to those interested in vaccines. To get the perspective of equity, patients who have no access to email or the internet can only use the option of text messaging or outbound telephone calls.

 For patients who received the text messages, the content randomly assigned by the researchers is different:

  • A standard messaging
  • Using language from behavioral science principles

Even if the groups’ achieved results were not significant, messages emphasizing endorsements and endowment of clinicians responded higher than the usual text for outreach. The researchers also noticed that the same population had no equal accessibility to all outreach methods.

Mehta stated that finding the difference has no significance relative to outbound phone calls and texts because of sociodemographic variables. But the trial showed a higher response rate in patients who are Black, have lower income, and with Medicaid insurance, compared with Whites, with commercial insurance and higher income. More response shows in the latter group towards the efforts on email or patient portal. The response rate for Black patients is 5.6 percent and 1.9 percent for Whites.

Response from Black, Medicaid, and lower-income patients indicates that engagement in messages through texts and phone calls is effective in certain groups.


Final Thoughts
Even if text messaging showed some benefits, patients tend to unsubscribe to overutilize the technology. Medical providers that send out many automated messages to their patients received opt-out messages from those patients who no longer want to receive messages in the future.


Phoenix Virtual Solutions is an offshore outsourcing company based in the Philippines with HIPAA-trained virtual medical assistants that ensure each patient in your medical practice achieve effective telehealth and optimal virtual healthcare. Contact Phoenix today to let your patients sense their importance and value. Remember that patients prefer more personalized messages than those that read like a marketing blast. 

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