Engaging Patients, One Text at a Time
Written by John S. Misa, MD, Chief of Primary Care, Park Nicollet Health Services | December 13, 2013
How Park Nicollet uses (not so) new technology to personalize the experience of care
One recent morning a patient in his early 20s arrived on time for an exam at the Park Nicollet Clinic in Champlin, Minn., a northwest suburb of Minneapolis. He thanked the nurse for the text message that had reminded him of his appointment time and location. "I would have never made it without it," he said. "It's just so much easier reading a text than listening to a voicemail."
The clinic, which opened in January 2013, is brimming with high-tech, patient-friendly touches. It provides urgent care, diagnostic imaging and labs. A comfortably furnished waiting area includes features such as touch screens with educational content on a variety of health topics. In each of the 14 exam rooms, physicians can swivel the desk around to share the medical record side by side with the patient.
Following his time with his physician, the young man met with the staff care coordinator, who answered questions on follow-up treatment and encouraged him to sign up for the online patient portal MyChart. On his way out, he scheduled a follow-up visit, and asked, "Will I be getting another text reminder?" He was assured he would. In fact, just a few hours later, he received a text asking him to rate his overall experience during his visit.
This is healthcare post-reform. With patient volumes falling nationally and patients on the hook for ever more of the cost of care, growth is not just about expanding your geographic footprint or building new facilities; it's also about finding new ways to bring healthcare to patients, whenever and wherever it's needed. Technology such as text messaging, touchscreens and portals isn't the only solution, but it is an incredibly effective tool for enriching the connection with patients.
My organization, Park Nicollet Health Services, has more than 800 physicians, 22 primary care clinics and eight urgent care locations. We're focused on the triple aim of higher quality, lower costs and improved patient experience. As both a Medicare Pioneer accountable care organization and a patient-centered medical home, Park Nicollet is responsible for all of our patients' care, whether or not they're coming to us. For population health management to become a reality, you need engaged patients. For us, patient experience equals patient engagement. If a patient has a poor experience, there is little hope of improving the quality of their care, their health or our financial footing.
The problem has been how to find out if we are delivering a good experience and how to act on that information. Traditional survey vendors provide an avalanche of data, but it's easy to lose the big picture. With so many survey questions, you wonder which responses are most important to focus on. A bigger problem is the timeliness of the data: The surveys are sent out weeks after a care encounter, and it takes weeks more to crunch the numbers, so the data are months old by the time we get a report. Any sense of immediacy is lost, and along with it the chance for meaningful service recovery.
Trust me, we get a lot of feedback. Minnesota is the epicenter of measuring and reporting of data on quality, outcomes and the patient experience. This is the home of Minnesota Community Measures, a nationally recognized program through which providers voluntarily report all of their quality metrics around a number of different quality conditions. It's also the home of the Institute of Clinical Systems Improvement, which supports process and quality improvement using evidence-based expertise. Healthcare in our state is all about transparency and sharing of best practices, and it started long before government regulations such as the Consumer Assesment of Healthcare Providers and Systems program made it mandatory.
The truth is that Park Nicollet's sense of urgency on improving patient experience did not arise from the need to report or score well on government measures. It came from our realization a couple of years ago that despite all this data and analysis, we were still not anywhere near where we wanted to be. We had a lot of clinicians who wanted more real-time data. There was even talk about physicians going back to doing their own surveys.
Then, in January 2012, we heard about a Minneapolis-based startup called CareWire. Its solution — encounter-specific, precisely timed and personalized SMS text messages to patients with instructions, arrival information and a patient experience survey tool — addressed our instinctual needs.
Patients get a series of messages leading up to the appointment. They are reminded to come early for first visits and to fill out and bring forms with them. "This has been really valuable with our well-child screening forms that we use," says Glen Carlson, MD, an internist and pediatrician at Champlin. "It really saves us time if the parents are filling them out in the waiting room, as some forms can be quite lengthy."
A particularly valuable use of the messaging is for diabetes patients, who get additional prompts to bring in medication lists and blood sugar logs, Dr. Carlson said.
After a brief pilot, CareWire has been rolled out to all of our primary care clinics, and we are looking at other uses as well. One key addition since the pilot phase has been courtesy messaging, which we first tested at Champlin. We can alert patients when the physician is running late or called in sick. It's the kind of message that would not reach them in time via email or even by phone. This is also the level of service we have come to expect in other industries, but our expectations of the healthcare system are so low in terms of customer service that we could quickly and easily reset the bar.
Following an appointment, the patient receives another text message asking him or her to rate the overall satisfaction with the visit from one (unhappy) to 10 (total satisfaction). There is space to enter free text, and the patient can give permission to get a callback. The response allows us to know all the details about the person’s appointment, including which provider was seen. A clinic manager can follow up with patients who report problems with their visit.
"I love the immediacy of the response, and most of it is positive," says Sue Coller, the Champlin Clinic manager. "I always call those who rate us a six or below. Many of the ones and zeros we get turn out to be mistakes, as the patient meant to enter a 10 on their phone."
In fact, it's rare to have a patient say something negative, Ms. Coller says. Occasionally someone will say they don’t want to receive a text. In aggregate, though the clinic's approval scores of seven or above amount to more than 95 percent of responses. The dashboard records all patient messages and responses in real time, allowing us to intervene if we see a patient response suggesting a significant issue.
The other advantage of the service is in reducing no-shows and last-minute cancellations, which amounted to more than 8 percent of all appointments and are very expensive for organizations like ours. Healthcare in general has a very large fixed overhead, and you need to run your operations very hot. Telephone reminders and postcards never made much of a dent on no-shows.
Results of Text Messaging at Park Nicollet Primary Care Clinics
1.3 million messages sent to date (touching over 500 thousand patients)
Appointment cancellations reduced by 5% and no-shows by 22%
Average arrival time improvement prior to scheduled encounter: > 10 minutes
Pediatric forms completion rate improvement: > 10%
Patient satisfaction survey response rate: > 28%
Patient overall rating: 96% a 7 or above (out of 10)
"Through the dashboard, we know if patients have received the text message or opted out of receiving messages, so we can follow up with a phone call," says Coral Sandstrom, a patient-care assistant at Champlin. "It is very rare for patients to opt out. Most people actually prefer texting these days to phone calls or emails."
Through this new service, no-show rates throughout our primary care clinics have fallen by more than 20 percent.
The notion of using text messaging to patients brings up a number of questions worth consideration.
- Is this a privacy worry in the age of HIPAA and embarrassing disclosures of personal health information through lost laptops, etc.? In this case, no. Despite the fact that the messages are tailored to each patien'’s individual care, the content does not include personal health information, so privacy is protected. Every day we send the vendor a flat file transmission via encrypted transfer protocol. The vendor automatically identifies and verifies mobile numbers and matches patients to the appropriate message sequences.
- Isn't texting for the young and techie? Data from the Pew Research Center's Internet and American Life Project show that 91 percent of American adults have a cell phone, and 81 percent of cell phone users send and receive texts. Almost all texts are opened within 15 minutes of receipt. About 35 percent of people over age 65 text, but that number is already a year old and we are seeing huge increases year over year. In fact, there has been a far higher adoption rate in our senior patient population. Research shows that the adoption of mobile technology is happening faster than the spread of any technology in human history.
- Do you have to cajole patients to give up their mobile numbers? Actually, we have had absolutely no workflow changes to get cell numbers from almost all of our patients. We already asked on our intake forms for home, work and cell numbers. CareWire runs all the numbers through a program that identifies whether the home or work numbers we have are in fact mobile numbers. Many are, and studies show that is rising astronomically with each passing year.
- Don't many people just dislike texting? It is true that texting is not for everyone – yet. We opt in everyone automatically, and about 10 percent have opted out. Some people don't have a texting plan, and a few people have let us know they are just not texters, but we are seeing fewer and fewer of them.
The truth is that we're just scratching the surface of the potential for this technology. Just think of this: The average patient with chronic conditions comes in to our facilities two to three times a year, which amounts to just 40-60 minutes of their lives annually that they spend face to face with a clinician. And yet under accountable care, we are still responsible for their health, which is dependent on all those things that happen the rest of the year. So anything we can do to reach out to them to improve their health outcomes is important. Mobile texting is one important tool for that outreach.
We have done some pilots in specialty care, such as for colonoscopy patients and those coming in for stress tests. There is a significant opportunity in taking advantage of existing functionality in this technology to ensure patients follow orders on fasting, caffeine and early arrival time. We have tested using texts to lead patients to links for educational resources. We may also text to prompt them to take their meds.
When you look at what is going on in mobile technology in other countries and how businesses have adopted it, the opportunities are tantalizing. Yes, we are in an era of big data, but it means little without the ability to use that information to effectively influence individual behavior through personalized communication. In medicine we have to standardize to the science, but ultimately we must also customize to the patient. We have a whole new world out there; we’re just beginning to explore it.
John S. Misa, MD, is chief of primary care at Minneapolis-based Park Nicollet Health Services.
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