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.
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
