Texting works well for healthcare workflows such as scheduling, billing, patient surveys, and day-to-day communication, and applying the technology to much larger challenges such as chronic care management and social determinants of health (SDOH) is promising.
“We spend about $4 trillion a year on healthcare in this country, and the majority of that is related to chronic care,” says Josh Weiner, chief executive officer at SR Health by Solutionreach. “We need to find more effective ways to manage care for these patients.”
Q: We’ve talked in our last two discussions about why healthcare providers need to improve their appointment workflow and the role text messaging can play there. Can these strategies help address bigger issues in healthcare like chronic care management or SDOH?
A: Chronic care management and work on SDOH can definitely benefit from the use of text-based workflows. The technology’s widespread acceptance and the immediacy it brings to patient-provider communication helps improve patient engagement, and provides a platform for messages such as appointment reminders, recall activities, targeted education campaigns, and medication adherence reminders.
A typical chronic care management workflow for stroke patients includes a post-discharge follow-up text and survey one day after the initial care visit, followed by a series of texts over the next few weeks providing links to stroke education materials as well as various reminders to schedule a follow-up appointments with a rehab therapist, primary care physician, and/or neurologist. The key to the workflow’s effectiveness is the way that it is based on the patient’s specific chronic disease or condition and the corresponding provider care strategy to address it.
The approach for SDOH is also based on patient health data and uses text-based workflows, but it takes into account a broader range of attributes such as whether patients have a primary care physician, are high-risk, need help with care coordination, or have other risk factors that require real-time communication. SDOH workflows mirror chronic disease management in many ways, featuring text-based appointment scheduling, reminders, patient education, and healthcare instructions, and all with a focus on eliminating gaps in care.
Q: Can you provide some examples of how you have seen healthcare organizations use text to address these bigger challenges?
A: A good chronic care management example is an initiative that Solutionreach did with Community Medical Center, a 25-bed critical access hospital in Nebraska. The organization was experiencing challenges with high no-show rates (19% overall) and poor patient outcomes for diabetic patients (roughly 50% had an A1C level of 9% or higher) and looked to Solutionreach for some help. Although it had an older system in place for appointment reminders, it wasn’t very effective.
The Solutionreach offering gave patients the option of selecting text, e-mail, or phone reminders, and established a regular cadence of automated communication. The results have been quite positive, with the no-show rate falling from 19% to just over 3%, an 80% decline. Likewise, the numbers for diabetic patients also improved dramatically after Community Medical Center pulled data on patients due for A1C testing and then sent automated appointment reminder texts. The percentage of patients with A1C levels 9% or higher declined from about 50% to 17%–19%.
An example of an SDOH initiative using texting is a project that SR Health did with a Michigan healthcare system that primarily provides care for a very diverse population. During COVID-19, patients weren’t always able to see a provider face-to-face, a problem that was present even during the best of times. With SR Health’s help, the organization created a virtual urgent care program to help patients communicate with a provider about health issues, order a COVID test, or get a prescription for medications. The use of text was so effective they began using it to follow-up with at-risk patients after discharge, including those who had no primary care provider or were particularly isolated to improve care adherence and reduce readmission rates.
Q: Healthcare organizations have been overwhelmed by continuing to treat COVID patients and delivering the vaccine. Why is now the time to be thinking about improving their appointment workflow?
A: COVID-19 exposed challenges that already existed in healthcare, and more work needs to be done to engage patients in their care and move beyond a one-off approach. Many providers were already on their way toward greater use of digital communication to help address these issues, but COVID-19 accelerated the process. There’s no better time than now for providers to build a more dynamic and flexible system of appointment workflows, with text-based solutions at the forefront as they rebuild financially from the pandemic and welcome back the many patients who have postponed care.
Texting is the preferred method of personal communication, and it’s rapidly becoming the top healthcare industry method of patient communication.
“We no longer need to make the case for texting as an industry communication workflow because of how widely its been adopted by providers and patients alike,” says Josh Weiner, chief executive officer at SR Health by Solutionreach. “At this point, we’ve moved on to making the case that it should be at the center of every perfect appointment workflow.”
Q: In Part 1 of our conversation about creating the perfect workflow you explained how things have changed. Patients have different expectations and providers need to rebuild relationships and get patients in for the care they need. Why is text messaging an important part of that process?
A: Texting is ideal for engaging patients in their care because of its widespread acceptance and the immediacy it brings to patient-provider workflows. Industry research indicates that 95% of texts are opened and responded to within three minutes, making it perfectly suited for appointment scheduling workflows where providers must react quickly to changing patient circumstances. For providers, the case for using text-based communication instead of the phone is clear—while 99% of text messages are opened, 90% of patients don’t answer their phone and 20% don’t check their voicemail. As for patients, SR Health research indicates that 80% want to receive texts from their provider, and 75% would like to be able to text their provider.
Texting also offers the benefit of efficiency when used in scheduling workflows. According to Accenture, a typical scheduling phone call takes approximately eight minutes, while sending a text takes just 30 seconds. Texting offers time savings that allow providers to reduce manpower and operating costs, while also improving patient experience around the scheduling process.
Q: Is text really a tool that can be across the patient journey?
A: The range of applications for text-based solutions is quite broad, and we have yet to encounter a healthcare workflow where texting isn’t a good fit. When used for scheduling, providers are able to communicate in real time throughout the entire process. This includes setting the original appointment, sending automated meeting reminders, rescheduling appointments as conflicts arise, communicating patient instructions, and handling the digital registration and check-in process. After the appointment takes place, text can be used for things like follow-up instructions, patient satisfaction surveys, and billing.
Note that a typical billing workflow involves sending a text to the patient with a link to a portal where the actual payment transaction takes place. This is similar to the way that scheduling interactions can be achieved, with a link taking the patient to an online calendar. Texting can also be used for more transactional communications such as informing a patient when they need to call a care provider or nurse to discuss a health issue or lab test.
Q: Are there concerns about HIPAA privacy and security with texting?
A: The simple answer is that in most circumstances HIPAA is not a concern when texting. This is because most patients really like the convenience of texting with their provider and have no problem granting consent. Plus, the majority of automated text messages are exempt from HIPAA regulations and providers don’t need patient consent to use them. Examples of exempt automated text messages include appointment reminders, care instructions, and educational messages.
For text messages where protected health information (PHI) is used by providers, patients must first give consent for its use. Conversely, patients have no limitations if they want to initiate a text-based discussion with their provider using PHI, although it is up to providers to ask for patient consent to continue the discussion using an unsecure method of communication. If a patient doesn’t wish to give consent, the discussion can be moved either to a secure texting app—SR Health offers a secure browser environment in these circumstances based on simply clicking a link—or to the phone or provider’s office.
Q: What about older patients? Will they really use text messaging?
A: We have been pleasantly surprised by the level of text adoption by older patients, and our approach remains a text-first strategy. Older patients adapted to e-mail years ago and have transitioned to texting fairly quickly, with smartphone companies making things easier through accessibility features such as larger screens and font sizes as well as the use of speech-to-text technology. According to a Pew Research Center study, 90% of Americans aged 65 and older own a cellphone, meaning that texting is widely available to older patients. In fact, research indicates that 86% of Americans over age 50 communicate via texting.
The need for new healthcare workflows to meet safety requirements and evolving patient communication preferences increased significantly during the COVID-19 pandemic, accelerating a long-standing trend toward the use of digital communication.
“We believe that patient preferences changed during the pandemic because of safety concerns, and we have increasingly moved toward asynchronous digital communication to meet those needs,” says Josh Weiner, chief executive officer at SR Health by Solutionreach. He discusses the ways that text-based solutions help providers respond to these changing conditions and the benefits of using the technology.
Q: What has happened in the last year or so that has changed the way providers interact with patients?
A: COVID-19 had a direct impact on healthcare providers’ ability to safely deliver care and interact face-to-face with patients, resulting in significant declines of in-person appointments as patients stayed away from provider offices. According to a recent survey by the Medical Group Management Association (MGMA), 87% of health leaders say that safety was the top reason that patients deferred care during the pandemic. This change in behavior has had a negative effect on the financial performance of many providers—a survey by the American Medical Association (AMA) indicates that physicians have averaged a revenue decline of 32% since February 2020, with one-fifth of respondents citing a decline of 50% or more—and also impacted patient outcomes because of delayed care.
In response to the pandemic as well as changes in patient communication preferences, providers have increasingly looked to digital solutions such as texting, e-mail, and telehealth to communicate with patients and also help provide care. Creating new workflows is critical given the high level of dissatisfaction that many patients have when communicating with providers, and the corresponding provider frustration with the complexity of performing basic appointment-related tasks. In fact, 83% of patients in a SR Health survey described poor communication as the worst part of their healthcare experience in 2020, which is saying something. However, a bigger concern is that one-third of respondents also say that they would consider switching providers due to logistical issues like communication.
Q: Why is it not enough to just schedule a visit and see a patient?
A: The traditional appointment scheduling workflow is a manual process that typically can’t be set on autopilot, and there are no guarantees that an appointment will actually happen as planned, or worse yet, happen at all because of cancellations and no-shows. Patients forget their appointments, have last-minute conflicts, and must contend with a variety of minor and major emergencies. According to another recent MGMA survey, 53% of patients who missed an appointment did so because they forgot to attend or cancel it. We live in a real-time world where circumstances are constantly changing, and no-show rates for the industry run between 10%–30%, with some specialties going as high as 50%.
Some of the issues with appointment scheduling are a byproduct of the episodic nature of the fee-for-service model of care. Appointments are treated as one-off events rather than as part of a more holistic approach based on providing longitudinal care. This is a missed opportunity for providers to improve patient engagement and outcomes by proactively using two-way texting and e-mail to communicate on an ongoing basis.
Q: What can providers do to start creating a better experience around the appointment?
A: The key to improving patient experience around the appointment workflow is implementing a more flexible communication system that uses texting, e-mail, and telehealth, with patients able to specify their preferences for methods and aspects such as reminder intervals. Note that SR Health research indicates that texting is the most popular form of patient communication, with 75% of patients saying that they prefer two-way texting that allows them to interact directly with the provider.
Providers can reduce the number of no-shows through implementing an automated system of reminders that contacts patients at specified intervals. According to SR Health research, the reminder system which generates the best results is one that uses a 3-3-3 approach—texting or e-mailing the first reminder three weeks from the appointment, sending a second reminder three days in advance, and sending the last reminder three hours ahead of the appointment. Providers that send out automated appointment reminders can typically expect to reduce no-shows to 5% or less, improving their financials considerably by addressing the problem of lost provider revenue from patient cancellations. Using an automated system also allows providers to save money on operating costs by reducing staff resources and labor spent on the manual process of issuing reminders and performing other recall activities.