August 2014

Texting Program Provides Bump to Prenatal Care
By Joseph C. Kvedar, MD
For The Record
Vol. 26 No. 8 P. 26

The evidence that smartphones have become ubiquitous is overwhelming. According to a Kleiner-Perkins industry report, Americans look at their smartphones an average of 150 times per day, including 23 times for messaging, 22 times for voice calls, and 18 times to check the time.

One of the smartphone’s most dominant and popular features is its ability to send text messages. Besides being a tool for ordinary chit-chat, this inexpensive and portable form of communication has the potential to provide health information at the fingertips of a diverse and large audience. Even in underserved patient populations, smartphone adoption is staggering. For example, in Boston, 65% of underserved patients own the devices, based on an informal survey conducted at Massachusetts General Hospital’s community health center.

Prenatal Texting Program
Prior research suggests that using text messaging may be an efficient and effective tool to reach English- and Spanish-speaking pregnant women. The messages can offer support by providing general announcements, education, and appointment reminders during prenatal and postpartum care. This is significant because extensive literature suggests that little or no prenatal care contributes to poor maternal and child health outcomes, including neonatal and infant mortality, prematurity, and low birth weight.

Text messaging presents an opportunity to provide easily deliverable low-cost, multilingual communication between doctor’s visits. With this in mind, a text messaging pilot was developed by the Lynn Community Health Center, a comprehensive facility outside of Boston and home to many new immigrants and a large minority population, and the Center for Connected Health and Partners Community Health, which carries out Partners HealthCare’s commitment to improve the health and well-being of low-income and vulnerable consumers.

Partners Community Health funds and operates programs to increase access to health care, enhance economic opportunities, and achieve community health improvements. The hope was that by providing support and education resources via text messaging, patients would become more engaged with their care plan, feel better connected to their obstetrics team, and ultimately help ensure that young, at-risk pregnant women received adequate prenatal care.

The obstetrics team, including clinical staff and administrators, created the text campaign’s content. The messages were designed to be outbound only, with the goal of helping patients stay connected to their clinical team through educational tips, reminders, and motivational support. Examples of messages include the following:

• Your OB team wants to remind u that u can call us anytime @ (XXX) XXX-XXXX. Stay on the line and don’t forget to tell us you’re pregnant.

• Hi, it’s your OB team. We want to make sure u have a plan to get to the birth place. Let us know if we can help.

The messages, which were limited to no more than three in a given week, were personalized to each patient based on enrollment date, language preference (English or Spanish), and last menstrual period. The messages, some of which were repeated over time while others were delivered only once, focused on the baby’s development, birth preparation, and newborn and postpartum care.

Obstetrics case managers enrolled 25 patients aged 14 to 32 (average age of 22). Ninety-six percent of the patients enrolled during their first or second trimester. Patients were surveyed after six months and at the end of the study to determine satisfaction and gain general perceptions. A total of 19 surveys were completed. Feedback, which was positive, included the following findings:

• Ninety-five percent of participants found the program helpful.

• One hundred percent read most or all of the messages.

• Seventy-five percent thought the number of messages was just right.

• Eighty-four percent said the program helped them learn to take care of themselves and their babies.

• One hundred percent would recommend the program to other pregnant patients.

Keys to Success
The pilot program afforded several important learning opportunities. For example, enlisting the participation of the obstetrics team was deemed essential for the pilot’s design and message development, and it helped ensure that the content was correctly targeted to their patients. Combining the clinic’s deep knowledge of its patients with the health center’s “voice” led to the creation of engaging and relevant content.

It was important that the program was designed to give the obstetrics team the capability to make changes to patient status. As a result, it was possible for the care team to enroll or remove patients directly via the clinic’s website, which allowed the program to be more easily integrated into the workflow.

The content and frequency of the text messages play important roles in whether patients accept and engage in the program. Text messages must be personalized in terms of care (ie, trimester-specific educational information) and the health center (ie, the obstetrics team’s phone number and hospital location).

Offering messages in both English and Spanish also can enhance patient engagement. Adding features such as language-specific texting shortcuts and culturally sensitive language makes patients feel more comfortable.

The frequency at which messages are sent can factor into whether patients buy into the program. In the pilot, sending one to two weekly messages at the start and then two to four messages per week as the pregnancy progressed was found to be effective.

What’s to Come
The Center for Connected Health is using technology in exciting and new ways to deliver quality care to patients, connect providers and patients, and provide educational messages and support. Text messaging offers an opportunity to better engage patients in their care by communicating with them via a preferred method. Texting programs have great potential for providing low-cost, accessible educational messaging to patients.

Based partly on the success of the Boston-area pregnancy pilot, text messaging programs now are being developed for chronic disease management and health and wellness, including campaigns to promote activity, better nutrition, and healthier living.

— Joseph C. Kvedar, MD, is founding director of the Center for Connected Health and Partners HealthCare.