Abstract
BackgroundText messaging is an affordable, ubiquitous, and expanding mobile communication technology. However, safety net health systems in the United States that provide more care to uninsured and low-income patients may face additional financial and infrastructural challenges in utilizing this technology. Formative evaluations of texting implementation experiences are limited. We interviewed safety net health systems piloting texting initiatives to study facilitators and barriers to real-world implementation.MethodsWe conducted telephone interviews with various stakeholders who volunteered from each of the eight California-based safety net systems that received external funding to pilot a texting-based program of their choosing to serve a primary care need. We developed a semi-structured interview guide based partly on the Consolidated Framework for Implementation Research (CFIR), which encompasses several domains: the intervention, individuals involved, contextual factors, and implementation process. We inductively and deductively (using CFIR) coded transcripts, and categorized themes into facilitators and barriers.ResultsWe performed eight interviews (one interview per pilot site). Five sites had no prior texting experience. Sites applied texting for programs related to medication adherence and monitoring, appointment reminders, care coordination, and health education and promotion. No site texted patient-identifying health information, and most sites manually obtained informed consent from each participating patient. Facilitators of implementation included perceived enthusiasm from patients, staff and management belief that texting is patient-centered, and the early identification of potential barriers through peer collaboration among grantees. Navigating government regulations that protect patient privacy and guide the handling of protected health information emerged as a crucial barrier. A related technical challenge in five sites was the labor-intensive tracking and documenting of texting communications due to an inability to integrate texting platforms with electronic health records.ConclusionsDespite enthusiasm for the texting programs from the involved individuals and organizations, inadequate data management capabilities and unclear privacy and security regulations for mobile health technology slowed the initial implementation and limited the clinical use of texting in the safety net and scope of pilots. Future implementation work and research should investigate how different texting platform and intervention designs affect efficacy, as well as explore issues that may affect sustainability and the scalability.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0258-7) contains supplementary material, which is available to authorized users.
Highlights
Text messaging is an affordable, ubiquitous, and expanding mobile communication technology
All safety net health systems (n = 8) completed an hourlong interview with research study staff, representing 17 volunteer interviewees across all the sites with a wide variety of roles in the organization (Table 1)
Two sites were delayed in beginning their pilots: 1) Site C was still waiting for administrative approvals despite a completed platform and design, and 2) Site A was still waiting for their vendor to complete a customized platform
Summary
Text messaging is an affordable, ubiquitous, and expanding mobile communication technology. Safety net health systems in the United States that provide more care to uninsured and low-income patients may face additional financial and infrastructural challenges in utilizing this technology. Health systems are exploring digital communication solutions, many of which require the Internet or sophisticated health information technology (IT) capabilities [2]. Developing and implementing these solutions may be more challenging for ‘safety net’ health systems, defined by the Institute of Medicine as health systems in the United States (US) that deliver a significant level of healthcare to uninsured, low-income, and other vulnerable patients either by legal mandate or because these patients represent a substantial portion of the patient mix [3]. It is not surprising that a majority of safety net patients have expressed a willingness to use text messages to communicate with their healthcare providers [8,9,10]
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