by Alwyn Cohall, M.D., John Nelson, Ph.D., C.P.N.P., and Christel Hyden, M.S., C.H.E.S. of the Harlem Health Promotion Center

Jessica is an 18 year old female living with HIV who is away at college. She is coming home for vacation and wants to schedule a monitoring visit appointment. She calls her provider but does not reach him directly, and leaves a message on voicemail. Later that day, the provider calls back, but Jessica is in class, and he reaches her voicemail instead. This game of “tag” continues for several days until a mutually satisfactory appointment date has been scheduled.

This scenario, as it applies to scheduling appointments, requests for medication refills, queries about minor complaints and other assorted issues, is played out multiple times daily in clinics and health providers offices across the country resulting in frustration, inefficiency and potential lapses in patient care continuity.

Adolescent/young-adult patients tend to be “now” oriented. Delays in providing responses and services may subsequently result in patients dropping out of care. This is of particular concern for youth living with HIV/AIDS, where close follow-up is extremely important. Text messaging may be an important tool to enhance linkages between providers and youth living with HIV/AIDS (YLWHA). This article will provide a brief review of the various ways in which text messaging has enhanced communications between providers and YLWHA involved with Project STAY, a program based at New York Presbyterian Hospital and the Columbia University Mailman School of Public Health which provides medical and psychosocial services to both high-risk youth and YLWHA. The program is funded by the New York State Department of Health's AIDS Institute and the Robin Hood Foundation.

TM – also known as SMS messaging – involves sending a short message (limited to 160 characters) to a cell phone number, or short code (i.e. a five or six digit number used for convenience instead of a ten digit phone number). Compared to phone calls and voicemail, TM has many advantages. Text messages reach their destination instantly, never get cut off or misunderstood because of bad reception, and can be easily accessed even in noisy, crowded places. TM is well-suited for sending simple instructions and directions.

Text messaging has become one of the most important functions used by cell phone users. 41 million Americans send text messages “almost every day”, and young people 18-29 are most-active users. As a communication format between provider and patient, TM can provide a win/win situation. Health providers and patients receive information quickly without the inconvenience of playing phone tag. While TM is not meant to replace traditional means of communication, it may represent an important new adjunct to enhance provider-patient communication.

Up to this point, the majority of the innovations in electronic messaging have involved secure e-mail systems. However, many patients do not have the online access necessary to use e-mail regularly. By comparison, cell phone access is virtually universal, and usage frequent. In a pilot survey done among Project STAY patients, 90% had cell phones with texting capabilities. Additionally, 90% said they would be interested in getting appointment reminders via text, and 85% liked the idea of getting health promotion messages using this format.

Potential clinical applications for text messaging include the following:

Appointments: As noted above, making appointments can be a frustrating experience for both patients and providers. Some hospitals and clinics use text messaging to let patients schedule and reschedule appointments, often with time and money saving results. Text message reminders have improved attendance rates and cost about 35-50% less than telephone reminders. Project STAY uses text messaging to remind patients about upcoming appointments, and to provide information about clinic location and hours. It has also been used as an outreach tool to engage patients who been missed several appointments.

Medication Reminders: Text message reminders can be extremely useful both for short-term medication regimes to assist the patient in integrating the medication into their daily schedule, and for chronic conditions in which “pill fatigue” can lead to decreased adherence over time. Personalized text messages have been shown effective in improving insulin adherence among diabetics, and contraceptive pill utilization among adolescents.  Similar potential may hold true for YLWHA with respect to ARV. For patients starting ARV or contra-ceptive regimens, Project STAY providers send out periodic text messages to enhance adherence.

Case management: YLWHA have complex psychosocial needs in addition their ongoing health issues. Text messaging between client and social worker has been used by Project STAY to remind clients about upcoming appointments with entitlements programs like Medicaid or HASA.

Patient Initiated Communication: From the patient point of view, text messaging can be an easier way for youth to let their provider know that they have a question or concern. Project STAY providers frequently field queries from youth regarding contraceptive methods, ARV treatment, and minor health complaints. For more in-depth or urgent concerns, youth are instructed to call providers directly or to come in for an evaluation.

Health promotion messages: As noted above, youth are interested in receiving health promotion messages which can be crafted to enhance safer-sex practices. With support from the DHHS Office of Minority Health, and in collaboration with the Hetrick-Martin Institute, Project STAY is developing an initiative to use texting to disseminate health promotion messages to high-risk youth.

New Developments: Previously, text messaging communication between Project STAY providers and youth for appointments, medication reminders and health promotion messages were initiated and disseminated by individual providers – a laborious task. In the near future, Project STAY will be using a third-party vendor which will send out customized messages at predetermined times to selected patients. This will improve time savings and increase the number of youth that can be reached quickly.

Efficiency and convenience, coupled with the ability to manage simple problems and provide useful information quickly, makes text messaging an important way for patients and providers to communicate. While text messaging and other forms of electronic communication are not a substitute for face-to-face clinical evaluation, evidence suggests that these resources have the potential to contribute to substantial time and cost savings while increasing compliance and access to care. With support from the New York State Department of Health, Project STAY will be developing a study to measure improvements in appointment-keeping and medication adherence using text-messaging.

The authors are staff members of the Harlem Health Promotion Center. Alwyn Cohall, M.D., is Principal Investigator and Project Director; John A. Nelson, Ph.D.,C.P.N.P., is Coordinator of Clinical Services, Specialized Care Center, Project STAY; and Christel Hyden, M.S., C.H.E.S., is Coordinator of Technology and New Media Ventures. Dr. Cohall can be reached at atc1@columbia.edu; the Project Stay website is www.projectstay.net.