Introduction
Why text messaging?
Potential uses of text messaging in healthcare
Risks
Final impact
References
Further reading
Text messages refer to the messages sent via cell phones or computers, comprising up to 140 or 160 characters, over wireless messages, to other mobile devices. Trillions of text messages are sent in the USA alone each year.
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Text messaging has become the norm in many areas of healthcare. This includes messaging applications like Short Message Service (SMS) and Multimedia Message Service (MMS).
Why text messaging?
Text messaging is probably the most widely used method of communication today. In addition to the extensive coverage of this method, it lends itself to health messaging because of its scalability at a low cost. The messages can be customized to each person or group. Interactive communication is possible, as well as personalized messaging.
The ability to repeat the messages as often as required lends itself to reinforcing the content. And finally, scientists note, “Text messages appeal to users’ addiction-like desire to receive messages and the unconscious pleasure of the dopamine release associated with this reward (45). As a result, it has been found that 99% of received mobile text messages are opened, and 90% of all mobile text messages are read within three minutes of being received.”
Potential uses of text messaging in healthcare
Text messaging is part of a mobile health strategy to enhance public health interventions and improve health care.
The use of such methods to communicate health-related data may represent an excellent and inexpensive manner of helping patients take better care of themselves by sending reminders about medication use, appointment dates, and general information about their illness and its management.
Healthcare facilities send reminders to patients ahead of their appointments, reducing the number of cancellations and absentees. Potential delays are notified ahead of time, allowing patients to show up later and thus prevent their having to wait too long.
Texting is used to send prescription reminders to maximize the number of prescriptions collected. In chronic conditions, messaging is used to help the patient self-manage the illness to reduce the impact of the condition by appropriate adjustments to medication, treatment, or behavior, respectively. Such self-efficacy could include reminders, feedback, support network creation and maintenance, and thus better self-management.
The same is also true of communicable diseases and health promotion programs such as “Quit Smoking” campaigns. Young people who are notorious for their hesitance to approach the formal healthcare system can remotely avail themselves of healthcare services. Mental health services are another potential area of utility.
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Healthcare professionals can hand over patient information to each other to reduce the chance of errors in management and save time in communicating by phone. This time can be spent treating patients themselves. This is also an inexpensive option and improves patient and staff satisfaction.
The advantages include the speed, efficiency, and convenience of communication via text messaging. These messages can be sent from almost anywhere, including both audio and video files and file attachments.
Risks
The lack of end-to-end encryption on many text messaging platforms leaves them open to the danger of interception. Recipients are not verified, allowing for the possibility of private and/or important messages going to the wrong recipients.
Messages could also be deleted with the important information they convey. If they remain on the mobile device, others could retrieve the information, as often happens without a regular clean-up. This risk is higher if the mobile devices happen to be lost or stolen.
The use of text messaging could, however, convey wrong information or mislead the patient via misunderstanding or misinterpretation of the content or because of the limited ability of the patient to read or decipher the messages. Providers may forget the essentially supportive role of such communication and stop with sending messages, disregarding the need for follow-up. The lack of verbal and non-verbal cues may also lead to different interpretations of the messages compared to their delivery in person.
HIPAA and text messaging
Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that protects sensitive patient health information from unauthorized disclosure by mandating national standards for the communication of such information.
Scientists have noted, “Even after implementation of steps to mitigate risk, no communication method is 100% secure, and text messaging is no different. Ultimately, the decision to send text messages with PHI is a policy decision in which the risks and the benefits are weighed by decision-makers.”
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HIPAA allows text messages to be extensively used in healthcare between providers, support staff, and patients but insists that the requirements be satisfied before sending such information electronically. The requirements include access controls to prevent unauthorized access to electronic patient health information, together with data encryption and other safeguards to prevent accidental alteration or deletion of such messages.
One important way to accomplish this is by maintaining an audit trail and monitoring the activity of those with authorized entry into the system. However, the typical text messaging system does not have any of these features. The lack of encryption and long-term storage on the servers of the service providers means that almost anyone can read the messages.
Even the customer-level instant messaging platforms with end-to-end encryption may not be HIPAA compliant. The latter requires the presence of safeguards that maintain the confidentiality, integrity, and availability of patient health information communicated electronically via closed platforms that allow entry only to authorized persons. Messages are encrypted end-to-end, and if the mobile device should be lost or stolen, access to the messages is cut off from unauthorized persons because of the login credentials required.
Privacy, confidentiality, secure storage, and accurate contact information are all requirements of a good text messaging system. Some researchers point out that alternatives to encryption must be developed and guidance provided on them since encryption is not feasible for most health departments.
Final impact
The technology is available for text messaging in healthcare. Still, the evidence available so far is inadequate to allow conclusions to be drawn about the best design or strategy or the effectiveness of specific design features such as the optimal frequency, timing, duration, and interactive nature of the messaging, and how the addition or integration of other features adds to the intervention.
Cost-benefit analyses are almost completely missing. For instance, personalization of text messages as well as tailoring them to the specific condition of interest, as well as changing the frequency of delivery of the messages could improve the effectiveness of the intervention but at a higher cost. The inadvertent consequences of text messaging also need to be considered and identified before this strategy can be widely recommended, as at present.
With the rise of smartphones, text messaging will probably be replaced with combinations of web-based and mobile phone messaging technologies, which will require further extensive research on the benefits and effectiveness of this platform.
References
Further Reading
Enhancing the adoption of pragmatic clinical trial results in healthcare systems