Qualitative Analysis of Programmatic Initiatives to Text Patients with Mobile Devices in Resource-Limited Health Systems

Background

Text 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.

Methods

We 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.

Results

We 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.

Conclusions

Despite 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.

Full article at:   http://goo.gl/SAsnqs

By:  Sachin K. Garg, Courtney R. Lyles, Sara Ackerman, Margaret A. Handley, Dean Schillinger, Gato Gourley, Veenu Aulakh, and Urmimala Sarkar

Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA

Department of Social and Behavior Sciences, UCSF, San Francisco, USA

Center for Care Innovations, Oakland, USA

Department of Epidemiology and Biostatistics, UCSF, San Francisco, USA

Sachin K. Garg, Phone: (415) 353-7900, Email: ude.fscu@grag.nihcas.

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Unintended Adverse Consequences of Electronic Health Record Introduction to a Mature Universal HIV Screening Program

Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. 

A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. 

Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline, leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

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By:  Laura N. Medford-Davis^a*, Katharine Yang^b, Siavash Pasalar^c, M. Tyson Pillow^bc, Nancy P. Miertschin^c, William F. Peacock^bc,Thomas P. Giordano^cde & Shkelzen Hoxhaj^bc

^a Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA

^b Department of Medicine, Section of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA

^c Harris Health System, Houston, TX, USA

^d Department of Medicine, Sections of Infectious Diseases and Health Services Research, Baylor College of Medicine, Houston, TX, USA

^e Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA

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