Texting with patients poses challenges and opportunities

July 10, 2016

Physicians may have an opportunity to engage with patients via text messaging as smartphones become ubiquitous.

In an era dominated by mobile devices, it has become apparent that many consumers-especially young people-are not interested in visiting web portals and don’t use email much or at all. Instead, they are use texting for most communications. 

So if doctors and/or practices want to communicate with their patients between visits, they might consider texting them, at least as a supplementary channel to secure messaging on web portals. There are workflow and security challenges, and fee-for-service doctors still aren’t being reimbursed for non-visit care, but texting has become so dominant in our culture that healthcare can’t escape it for long. Here’s how some doctors deal with texting today and what experts say about it.

Seth Eaton, MD, an internist and
pediatrician in Laurel, Maryland, is part of an eight-provider practice that has used a patient portal since 2006. “We routinely send out messages on the portal,” he says. “But we feel the portal has lost functionality because people prefer text messages. So we text message everybody.”

The practice uses a texting platform within its eClinicalWorks EHR to text patients to call back for more information, to make appointments and to tell them lab results are normal. “We know most people don’t remember their portal password, so we don’t rely on it at this point. When we’re trying to reach people, we text them to call back, and they call back,” Eaton says.

Rob Lamberts, MD, an internist and
pediatrician in Augusta, Georgia, has been texting his patients since he launched his solo concierge practice a few years ago. Lamberts uses a secure texting application called Twistle that enables patients to send him texts without using his personal mobile number. The app copies his two nurses on all texts sent to him so they can deal with the routine ones. 

Lamberts, who has about 700 patients, says that texting has become his main method of communicating with patients. “I prefer this mode of communication by far over others,” he says. Texting allows him to reply to messages at his convenience, to respond to each message in less than a minute, and to document the interaction automatically, he notes.

Eaton and Lamberts are ahead of most of their peers in their adoption of text messaging. And despite the skepticism or unawareness of many doctors about the potential of this technology, some experts believe it represents the future. 

“I think we’re moving to a world where there’s more acknowledgment that consumers are in the driver’s seat,” says Michelle Holmes, MBA, a principal with ECG Management Consultants in Seattle. “We need to start modifying how we engage with consumers and interact with them using their preferred communication methods, if we’re going to have behavior changes and if people are going to be compliant.”

 

 

Reliable contact method

One reason Eaton texts some patients is to make sure he reaches them, and sending messages via his portal doesn’t offer that assurance. His EHR provides a mobile app that automatically texts people who have messages waiting on the portal if they choose the texting option for notifications. But few patients have downloaded the app, he says.

Both the eClinicalWorks and athenahealth EHRs include a link in their automated texts that will take patients right to the portal, Holmes says. But people still have to enroll in the portal beforehand, she adds.

When texting is used for routine tasks such as sending lab results to patients, it can be more efficient than phone calls, Holmes says. “That may take up less staff time if it’s a routine question and you know you can script or create protocols for the responses.”

Lamberts personally texts four to six sets of lab results a day, along with personal notes to patients. Sometimes he’ll include additional information that tells patients how to take care of themselves. All together, this task takes him approximately 10 minutes daily, he says. 

Lamberts receives 15 to 20 texts a day, on average, and handles about half of them himself. Some patients ask him drug-related questions, such as whether they should take an over-the-counter remedy like ibuprofen when they’re on a certain prescription medication. One patient with sciatica recently texted Lamberts he’d gotten tremendous relief from an injection. A woman whom he’d sent to the emergency department texted him when she was about to be discharged inappropriately, and he texted the woman some information to show to the ED doctor who admitted her.

Lamberts also has patients text him photos of their pink eye, poison ivy or other physical symptoms to aid him in his diagnoses and recommendations.

Despite his initial worry that he’d be overwhelmed by texts, that hasn’t happened, he says. Because his patients text many elements of their history between visits, he can spend less time with them in the office. That opens up his schedule for same-day appointments, making him more accessible to his patients.

Joseph Scherger, MD, a family physician in Rancho Mirage, California, who is also vice president of primary care and academic affairs at Eisenhower Medical Center, texts with some of his patients, and he believes that it has been beneficial to patient care. He cites the example of an 85-year-old woman who has shingles.

“She texted me [recently] about her pain and her progress with her shingles,” he says. “Then I got a second text asking for a refill of the antiviral medication, to which I responded.”

Scherger, a member of the Medical Economics editorial advisory board, views texting, in certain circumstances, as a good alternative to email because both communication methods are “asynchronous”-that is, they permit either party to respond when it’s convenient for them. Observing that it is often difficult to get in touch with physicians by phone, he says, “You can greatly improve relationship-centered care by improving communication options.”

Similarly, Lamberts feels that texting has enhanced his patient relationships. In fact, he says, the availability of texting has attracted patients to his practice, which charges $30-$60 a month for primary care and doesn’t accept insurance. “People brag about it all the time. They say, ‘do you know what I can do with my doctor?’”

 

Improves chronic care

Some studies indicate that texted alerts can improve outcomes by reminding patients with certain chronic conditions to follow their doctors’ instructions.

A 2015 randomized controlled study of patients with coronary heart disease, for example, showed that a six-month text messaging intervention was correlated with significant reductions in cholesterol, blood pressure, and weight.

A randomized controlled trial of the free Text4Baby app showed that participants were more likely than control subjects to agree that it was important to take prenatal vitamins, avoid alcohol, and visit healthcare providers. And a 2015 review article in the Annual Review of Public Health found that the majority of text message interventions for diabetes self-management, weight loss, physical activity, smoking cessation and medication adherence were effective.

Experts believe that texting could support population health management. For example, Holmes points out, practices could set up automated text campaigns to alert patients with diabetes to get HbA1c tests, women in certain age groups to get mammograms or older people to get flu shots. 

“You don’t have to dig in and evaluate what the message should be for each individual patient, but you can customize it, based on the subpopulation that the patient is in, to do more targeted alerts and reminders,” she says. 

Derek Kosiorek, CPHIT, a principal in the Medical Group Management Association’s Healthcare Consulting Group in Englewood, Colorado, agrees that texting can be used for preventive and chronic care reminders. 

“It would be easier and probably preferable to patients than robocalls,” he says, and it would also be more effective than sending emails. But they need to be able to opt out if they don’t want to receive texts, he adds.

Reimbursement barrier

Kosiorek doesn’t believe that most physicians are ready to text directly with patients. “I can’t imagine doctors buying into this anytime soon,” he says. “For most physicians, it’s not even on the radar.”

 

A significant obstacle to texting is reimbursement, he notes. With 95% of office visits still reimbursed on a fee-for-service basis, according to a March study in Health Affairs, it’s difficult for doctors to block out time to deal with text messaging, for which they are not reimbursed, Kosiorek points out. And to the extent that texting reduces the number of visits from patients, they would be earning less.

Mark Novotny, MD, a part-time hospitalist and consultant and the former chief medical officer of Cooley Dickinson Hospital in Northampton, Massachusetts, thinks texting might distract physicians, just as pagers do, and reduce their productivity. While it would increase the efficiency of treatment for patients, caring for them via text messaging would require the same amount of work as an office visit, he says.

“That’s the struggle for doctors,” he says, “They’d like to meet a patient’s need, but it has to also reduce their work or at least not reduce the number of patients they see.”

Physicians who have concierge practices or who belong to groups that take financial risk in value-based payment models are in a better position to adopt texting, notes Scherger. He is part of an advanced primary care practice that charges $400-$600 a year for unlimited email communication and 24/7 care. 

Scherger, who has emailed with patients since the late 1990s, thinks that doctors can handle texting with panels of up to 600-800 patients. (He has 500 patients.) But in a busy traditional practice, where each doctor sees 30 patients a day, this would be impossible unless the care team fielded most texts.

Workflow and security

Another barrier to texting is that it is not usually part of a physician’s workflow. If the doctor wishes to exchange secure messages with patients, she can use her patient portal to initiate or respond to a patient email. Since the portal is attached to her EHR, she doesn’t have to leave her workflow to send or receive a message, and the email exchange is automatically documented in the EHR.

 

In contrast, texts are usually exchanged outside of the EHR, in which case they’re not documented automatically. Lamberts has his nurses cut and paste texts into his EHR.

“I don’t know why doctors would want to open this door,” Kosiorek says, regarding texting versus secure messaging. EHRs contain “self-contained messaging systems,” he notes, referring to patient portals. “That’s the main conduit of communication between physician teams and patients, and that’s what doctors are going to use.”

Some EHR vendors have begun to include texting capability, Holmes notes. Besides the aforementioned alerts about portal messages, she points out, athenahealth’s EHR permits practices to use texting for appointment reminders, notifications that lab results are available and some health maintenance alerts. Patients can decide whether they want to receive communications via email, phone or text.

Although athenahealth doesn’t charge extra for this kind of texting, eClinicalWorks does, according to Medhavi Jogi, MD, a Houston-based endocrinologist. He has to pay 10 cents per text to alert patients about messages on the portal, so he’d rather have his nurses call patients who don’t pick up important messages, he says.

Jogi, who does virtual visits with some patients, would rather not text directly with them. “If we text with somebody, we need a platform to receive the text. And if it’s not within the EHR and something that’s bidirectional, I’m not going to do it from my phone. There are some secure services like TigerText that are used between doctors, but I’m not going to pay extra for that,” he says. 

At this point, EHR vendors do not offer secure texting; in fact, athenahealth states that none of its texts include protected health information (PHI). Some providers are using TigerText to send lab results securely, Holmes says.

Imprivata spokesman John Hallock says that his firm’s secure texting service is
being used in follow-ups to primary care visits and in post-discharge care, as well as for appointment reminders. 

Lamberts uses secure texting. Patients who want to text with him and his staff must download the Twistle app to their mobile devices. If he wants to look up the record of a text exchange between him and a patient, he can quickly find it on Twistle, he adds.

Looking ahead

The business case for texting is still hard for most physicians to make. But value-based reimbursement will make non-visit care essential, and texting could be an important part of that equation. Meanwhile, observers say, it will probably be limited mostly to concierge and advanced practices that charge patients extra for enhanced communications with providers.

In some respects, email is still better than texting for patient communications, Scherger points out. For instance, he notes, there is still no way to document texts in an EHR note, so physicians have to communicate with patients outside of the medical record. 

Most likely, however, vendors will figure out how to resolve the workflow and security issues. Meanwhile, consumers will continue to demand that physicians meet them where they are-on their mobile phones. “This has become the most common way in which many people communicate, so it would in some cases be inappropriate for us not to make sure that our technologies and our operational workflows are accommodating that,” says Holmes.

Novotny thinks that consumers will lead the way in this area. “A lot of these disruptive innovations are going to have to come from patients,” he says.  “Physicians are kind of stuck on a treadmill that goes ever faster. But if patients create the consumer demand for some of this stuff, the healthcare industry will adjust.”