Text or Not to Text? A Narrative Review of Texting as a Case Management Intervention.

PURPOSE: To review current literature on texting as a sustainable intervention of case management in the outpatient setting. FINDINGS: Texting, as a case management intervention, provides the medically complex client with a pathway to achieve care plan goals. Texting increases adherence, communication, and self-management. It can increase client enrollment in disease management programs, while providing support, flexibility, convenience, cost savings, and increased participation. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: In current practice, such as management of the coronavirus (COVID-19), other pandemics, or natural/environmental disasters, texting is a solution-focused intervention that can deliver and retrieve real-time information to a medically complex population. It can link patients to resources and increase outreach, efficiency, quality, and coordination of care. Texting can promote adherence to appointments, increase medication compliance and disease management interventions, and provide motivational change messages. However, there are legal and regulatory concerns that carry potential consequences and implications that should be approached judiciously (Mellette, 2015). Texting is not one size fits all; it can cause HIPAA breeches, hinder communication with certain populations, confuse health messaging, and replace human communication, thereby reducing staffing in practice.

Development and feasibility of a Configurable Assessment Messaging Platform for Interventions (CAMPI).

INTRODUCTION: Short message service (SMS) is a widely accepted telecommunications approach used to support health informatics, including behavioral interventions, data collection, and patient-provider communication. However, SMS delivery platforms are not standardized and platforms are typically commercial "off-the-shelf" or developed "in-house." As a consequence of platform variability, implementing SMS-based interventions may be challenging for both providers and patients. Off-the-shelf SMS delivery platforms may require minimal development or technical resources from providers, but users are often limited in their functionality. Conversely, platforms that are developed in-house are often specified for individual projects, requiring specialized development and technical expertise. Patients are on the receiving end of programming and technical specification challenges; message delays or lagged data affect quality of SMS communications. To date, little work has been done to develop a generalizable SMS platform that can be scaled across health initiatives. OBJECTIVE: We propose the Configurable Assessment Messaging Platform for Interventions (CAMPI) to mitigate challenges associated with SMS intervention implementation (e.g., programming, data collection, message delivery). METHOD: CAMPI aims to optimize health data captured from a multitude of sources and enhance patient-provider communication through a technology that is simple and familiar to patients. Using representative examples from three behavioral intervention case studies implemented among diverse populations (pregnant women, young sexual minority men, and parents with young children), we describe CAMPI capabilities and feasibility. CONCLUSION: As a generalizable SMS platform, CAMPI can be scaled to meet the priorities of various health initiatives, while reducing unnecessary resource utilization and burden on providers and patients. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Guidance for using text, email, and video communication in practices devoted to reproductive medicine.

The prevalence and ease of electronic communication, specifically email through patient portals associated with electronic medical records or via traditional enterprise email clients (e.g., Outlook) and video, have resulted in increased use for rapid communication between practitioners and their patients. Concerns regarding patient privacy and compliance with the regulations of the Health Insurance Portability and Accountability Act (HIPAA) remain a barrier to routine incorporation of electronic communication into practice. Furthermore, capital investment, implementation, and maintenance costs may provide additional barriers. These long-standing concerns have been heightened and tested by the COVID-19 pandemic. Best-practice guidelines for the secure and safe use of electronic communication with reproductive care patients are provided.

Patient Interaction Phenotypes With an Automated Remote Hypertension Monitoring Program and Their Association With Blood Pressure Control: Observational Study.

BACKGROUND: Automated texting platforms have emerged as a tool to facilitate communication between patients and health care providers with variable effects on achieving target blood pressure (BP). Understanding differences in the way patients interact with these communication platforms can inform their use and design for hypertension management. OBJECTIVE: Our primary aim was to explore the unique phenotypes of patient interactions with an automated text messaging platform for BP monitoring. Our secondary aim was to estimate associations between interaction phenotypes and BP control. METHODS: This study was a secondary analysis of data from a randomized controlled trial for adults with poorly controlled hypertension. A total of 201 patients with established primary care were assigned to the automated texting platform; messages exchanged throughout the 4-month program were analyzed. We used the k-means clustering algorithm to characterize two different interaction phenotypes: program conformity and engagement style. First, we identified unique clusters signifying differences in program conformity based on the frequency over time of error alerts, which were generated to patients when they deviated from the requested text message format (eg, ###/## for BP). Second, we explored overall engagement styles, defined by error alerts and responsiveness to text prompts, unprompted messages, and word count averages. Finally, we applied the chi-square test to identify associations between each interaction phenotype and achieving the target BP. RESULTS: We observed 3 categories of program conformity based on their frequency of error alerts: those who immediately and consistently submitted texts without system errors (perfect users, 51/201), those who did so after an initial learning period (adaptive users, 66/201), and those who consistently submitted messages generating errors to the platform (nonadaptive users, 38/201). Next, we observed 3 categories of engagement style: the enthusiast, who tended to submit unprompted messages with high word counts (17/155); the student, who inconsistently engaged (35/155); and the minimalist, who engaged only when prompted (103/155). Of all 6 phenotypes, we observed a statistically significant association between patients demonstrating the minimalist communication style (high adherence, few unprompted messages, limited information sharing) and achieving target BP (P<.001). CONCLUSIONS: We identified unique interaction phenotypes among patients engaging with an automated text message platform for remote BP monitoring. Only the minimalist communication style was associated with achieving target BP. Identifying and understanding interaction phenotypes may be useful for tailoring future automated texting interactions and designing future interventions to achieve better BP control.

Mobile Texting and Lay Health Supporters to Improve Schizophrenia Care in a Resource-Poor Community in Rural China (LEAN Trial): Randomized Controlled Trial Extended Implementation.

BACKGROUND: Schizophrenia is a severe and disabling condition that presents a dire health equity challenge. Our initial 6-month trial (previously reported) using mobile texting and lay health supporters, called LEAN, significantly improved medication adherence from 0.48 to 0.61 (adjusted mean 0.11, 95% CI 0.03 to 0.20, P=.007) for adults with schizophrenia living in a resource-poor village in rural China. OBJECTIVE: We explored the effectiveness of our texting program in improving participants' medication adherence, functioning, and symptoms in an extended implementation of the intervention after its initial phase. METHODS: In an approximated stepped-wedge wait-list design randomized controlled trial, 277 community-dwelling villagers with schizophrenia were assigned 1:1 in phase 1 into intervention and wait-list control groups. The intervention group received (1) lay health supporters (medication or care supervisors), (2) e-platform (mobile-texting reminders and education message) access, (3) a token gift for positive behavioral changes, and (4) integration with the existing government community-mental health program (the 686 Program) while the wait-listed control group initially only received the 686 Program. Subsequently (in the extended period), both groups received the LEAN intervention plus the 686 Program. The primary outcome was antipsychotic medication adherence (percentage of dosages taken over the past month assessed by unannounced home-based pill counts). The secondary outcomes were symptoms measured during visits to 686 Program psychiatrists using the Clinical Global Impression scale for schizophrenia and functioning measured by trained student assessors using the World Health Organization Disability Assessment Schedule 2.0. Other outcomes included data routinely collected in the 686 Program system (refill records, rehospitalization due to schizophrenia, death for any reason, suicide, wandering, and violent behaviors). We used intention-to-treat analysis and missing data were imputed. A generalized estimating equation model was used to assess program effects on antipsychotics medication adherence, symptoms, and functioning. RESULTS: Antipsychotics medication adherence improved from 0.48 in the control period to 0.58 in the extended intervention period (adjusted mean difference 0.11, 95% CI 0.04 to 0.19; P=.004). We also noted an improvement in symptoms (adjusted mean difference -0.26, 95% CI -0.50 to -0.02; P=.04; Cohen d effect size 0.20) and a reduction in rehospitalization (0.37, 95% CI 0.18 to 0.76; P=.007; number-needed-to-treat 8.05, 95% CI 4.61 to 21.41). There was no improvement in functioning (adjusted mean difference 0.02, 95% CI -0.01 to 0.06; P=.18; Cohen d effect size 0.04). CONCLUSIONS: In an extended implementation, our intervention featuring mobile texting messages and lay health workers in a resource-poor community setting was more effective than the 686 Program alone in improving medication adherence, improving symptoms, and reducing rehospitalization. TRIAL REGISTRATION: Chinese Clinical Trial Registry; ChiCTR-ICR-15006053 https://tinyurl.com/y5hk8vng.

Telessaúde (teleconsulta) aplicativos de celular e uso de mensagens de texto/SMS na atenção a adultos com sobrepeso e obesidade / Telehealth (teleconsultation) mobile apps and the use of text messages/SMS in the care of overweight and obese adults

Esta revisão rápida foi comissionada e subsidiada pelo Ministério da Saúde, no âmbito do projeto GEREB-010-FIO-20 e faz parte da Coleção "Rapid response for health promotion". Pergunta: Qual é a eficácia/efetividade e a segurança das intervenções oferecidas via telessaúde (teleconsulta), aplicativos de celular e uso de mensagens de texto/SMS na atenção a adultos com sobrepeso e obesidade (IMC ≥ 25)? Métodos: A partir de um protocolo prévio, nove bases eletrônicas da literatura foram consultadas em novembro de 2020, para identificar revisões sistemáticas (RS), publicadas em inglês, português e espanhol, sem restrição quanto ao ano de publicação. A qualidade metodológica das revisões sistemáticas foi avaliada utilizando o instrumento AMSTAR 2. Para executar está revisão rápida em 15 dias, apenas o processo de triagem de títulos e resumos foi realizado em duplicidade e de forma independente. Resultados: A busca nas bases de dados resultou em 1.269 estudos e após seleção foram incluídas 14 revisões sistemáticas. Com relação à qualidade metodológica, uma revisão foi categorizada como de confiança alta, cinco apresentaram confiança baixa e oito criticamente baixa. A análise dos estudos trouxe resultados de intervenções individuais e em grupo, com tecnologias únicas e combinadas. As ferramentas usadas variaram entre interações online, mensagens de texto, e-mail, programas, websites, fóruns, chats, aplicativos, telefone e automonitoramento. A maioria de participantes foi composta por mulheres, que receberam intervenções de 4 semanas a 30 meses, e cujos desfechos se referiam a peso, Índice de Massa Corporal (IMC), circunferência da cintura, hábitos alimentares ou de atividade física e proporção de gordura corporal. De modo geral, o uso de diferentes tecnologias proporcionou maior facilidade de acesso aos cuidados em saúde e práticas para melhorar a qualidade de vida. O desfecho mais estudado e que apresenta maior quantidade de resultados favoráveis é a perda de peso, avaliada com relação a intervenções de telessaúde, seguidos por aplicativos de celular, mensagem de texto, websites/computador e tecnologias combinadas. O Índice de Massa Corporal (IMC) resultou em pelo menos um resultado favorável para intervenções por meio de aplicativos de celular, mensagens de texto e tecnologias combinadas, enquanto para a mudança de circunferência da cintura os resultados foram indiferentes aos comparadores. Os estudos voltados para mudança de hábitos alimentares e atividades físicas foram indiferentes ou mais favoráveis a atividade presencial em detrimento do uso de aplicativos. Apenas uma comparação de intervenções analisou o efeito sobre a produção de gordura corporal e obteve bons resultados para programas online e aconselhamento contínuo por telefone celular. Conclusão: A revisão mostrou que intervenções por meio de aplicativos, ferramentas online, mensagens de texto e telessaúde podem ter efeitos positivos para alcançar a redução de peso, IMC e proporção da gordura corporal. Desta forma, vale a pena considerar o uso de tais ferramentas em programas de saúde. No entanto, também é preciso compreender que os resultados aqui apresentados são quase todos provenientes de estudos primários citados nas revisões sistemáticas, e não de metanálises. Além disso, chamamos a atenção para a qualidade metodológica das RS analisadas

This rapid review was commissioned and subsidized by the Ministry of Health, within the scope of the GEREB-010-FIO-20 project and is part of the "Rapid response for health promotion" Collection. Question: What is the efficacy/effectiveness and safety of interventions offered via telehealth (teleconsultation), mobile apps, and use of text messages/SMS in caring for overweight and obese adults (BMI ≥ 25)? Methods: Based on a previous protocol, nine electronic literature databases were consulted in November 2020 to identify systematic reviews (SR), published in English, Portuguese and Spanish, without restriction as to the year of publication. The methodological quality of the systematic reviews was evaluated using the AMSTAR 2 instrument. To perform this rapid review in 15 days, only the process of screening titles and abstracts was carried out in duplicate and independently. Results: The search in the databases resulted in 1,269 studies and, after selection, 14 systematic reviews were included. With regard to methodological quality, one review was categorized as having high confidence, five had low confidence and eight critically low. The analysis of the studies brought results from individual and group interventions, with single and combined technologies. The tools used ranged from online interactions, text messages, email, programs, websites, forums, chats, apps, phone and self-monitoring. Most participants were women, who received interventions from 4 weeks to 30 months, and whose outcomes referred to weight, Body Mass Index (BMI), waist circumference, eating or physical activity habits and body fat proportion. . In general, the use of different technologies provided easier access to health care and practices to improve quality of life. The most studied outcome with the highest number of favorable results is weight loss, evaluated in relation to telehealth interventions, followed by mobile apps, text messaging, websites/computer and combined technologies. The BMI resulted in at least one favorable result for interventions through mobile apps, text messages and combined technologies, while for the change in waist circumference the results were indifferent to the comparators. Studies aimed at changing eating habits and physical activities were indifferent or more favorable to face-to-face activity over the use of apps. Only one comparison of interventions looked at the effect on body fat production and found good results for online programs and ongoing cell phone counseling. Conclusion: The review showed that interventions through apps, online tools, text messages and telehealth can have positive effects in achieving weight reduction, BMI and body fat ratio. Therefore, it is worth considering the use of such tools in health programs. However, it is also necessary to understand that the results presented here are almost all from primary studies cited in systematic reviews, and not from meta-analyses. In addition, we draw attention to the methodological quality of the analyzed SRs.

Improving Adherence to Weight-Loss Medication (Liraglutide 3.0 mg) Using Mobile Phone Text Messaging and Healthcare Professional Support.

BACKGROUND: Adherence to weight-loss medication is suboptimal, leading to poor health outcomes. Short message service (SMS) can potentially improve adherence. METHODS: A total of 3,994 participants with overweight or obesity in Australia receiving Saxenda® (liraglutide 3.0 mg) were enrolled from September 1, 2017, to February 28, 2018, through doctors, pharmacists, or websites and were randomly assigned to receive none, three, or five SMS per week. Participants were additionally offered a face-to-face consultation with a diabetes educator or a call from a dietitian. Medication adherence was measured as whether the total scripts claimed were at least as many as the total claims expected by March 31, 2018, and was modeled adjusting for age, sex, baseline BMI, residential region, enrolment channel, the total number of SMS, and additional patient support. RESULTS: Participants receiving five SMS (OR, 6.25; 95% CI: 4.28-9.12) had greater adherence than those receiving three SMS (OR, 3.67; 95% CI: 2.67-5.03) or zero SMS per week. The effectiveness of SMS on adherence decreased as participants received more SMS over time. Moreover, the odds of adhering to liraglutide were higher for participants enrolled with pharmacists compared with those enrolled with doctors (OR, 2.28; 95% CI: 1.82-2.86) and for participants who received a face-to-face consultation (OR, 3.10; 95% CI: 1.82-5.29) or a call (OR, 1.31; 95% CI: 1.02-1.68) compared with those who received no extra support. CONCLUSIONS: Integration of SMS into routine clinical practice should consider not only the frequency and content of reminders but also additional patient support to achieve higher and more sustained adherence to medication and health behavior changes.

Behavior Change Text Messages for Home Exercise Adherence in Knee Osteoarthritis: Randomized Trial.

BACKGROUND: Exercise is a core recommended treatment for knee osteoarthritis (OA), yet adherence declines, particularly following cessation of clinician supervision. OBJECTIVE: This study aims to evaluate whether a 24-week SMS intervention improves adherence to unsupervised home exercise in people with knee OA and obesity compared with no SMS. METHODS: A two-group superiority randomized controlled trial was performed in a community setting. Participants were people aged 50 years with knee OA and BMI ≥30 kg/m2 who had undertaken a 12-week physiotherapist-supervised exercise program as part of a preceding clinical trial. Both groups were asked to continue their home exercise program unsupervised three times per week for 24 weeks and were randomly allocated to a behavior change theory-informed, automated, semi-interactive SMS intervention addressing exercise barriers and facilitators or to control (no SMS). Primary outcomes were self-reported home exercise adherence at 24 weeks measured by the Exercise Adherence Rating Scale (EARS) Section B (0-24, higher number indicating greater adherence) and the number of days exercised in the past week (0-3). Secondary outcomes included self-rated adherence (numeric rating scale), knee pain, physical function, quality of life, global change, physical activity, self-efficacy, pain catastrophizing, and kinesiophobia. RESULTS: A total of 110 participants (56 SMS group and 54 no SMS) were enrolled and 99 (90.0%) completed both primary outcomes (48/56, 86% SMS group and 51/54, 94% no SMS). At 24 weeks, the SMS group reported higher EARS scores (mean 16.5, SD 6.5 vs mean 13.3, SD 7.0; mean difference 3.1, 95% CI 0.8-5.5; P=.01) and more days exercised in the past week (mean 1.8, SD 1.2 vs mean 1.3, SD 1.2; mean difference 0.6, 95% CI 0.2-1.0; P=.01) than the control group. There was no evidence of between-group differences in secondary outcomes. CONCLUSIONS: An SMS program increased self-reported adherence to unsupervised home exercise in people with knee OA and obesity, although this did not translate into improved clinical outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry 12617001243303; https://tinyurl.com/y2ud7on5. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12891-019-2801-z.

Electronic Health Record Portal Messages and Interactive Voice Response Calls to Improve Rates of Early Season Influenza Vaccination: Randomized Controlled Trial.

BACKGROUND: Patient reminders for influenza vaccination, delivered via an electronic health record patient portal and interactive voice response calls, offer an innovative approach to engaging patients and improving patient care. OBJECTIVE: The goal of this study was to test the effectiveness of portal and interactive voice response outreach in improving rates of influenza vaccination by targeting patients in early September, shortly after vaccinations became available. METHODS: Using electronic health record portal messages and interactive voice response calls promoting influenza vaccination, outreach was conducted in September 2015. Participants included adult patients within a large multispecialty group practice in central Massachusetts. Our main outcome was electronic health record-documented early influenza vaccination during the 2015-2016 influenza season, measured in November 2015. We randomly assigned all active portal users to 1 of 2 groups: (1) receiving a portal message promoting influenza vaccinations, listing upcoming clinics, and offering online scheduling of vaccination appointments (n=19,506) or (2) receiving usual care (n=19,505). We randomly assigned all portal nonusers to 1 of 2 groups: (1) receiving interactive voice response call (n=15,000) or (2) receiving usual care (n=43,596). The intervention also solicited patient self-reports on influenza vaccinations completed outside the clinic. Self-reported influenza vaccination data were uploaded into the electronic health records to increase the accuracy of existing provider-directed electronic health record clinical decision support (vaccination alerts) but were excluded from main analyses. RESULTS: Among portal users, 28.4% (5549/19,506) of those randomized to receive messages and 27.1% (5294/19,505) of the usual care group had influenza vaccinations documented by November 2015 (P=.004). In multivariate analysis of portal users, message recipients were slightly more likely to have documented vaccinations when compared to the usual care group (OR 1.07, 95% CI 1.02-1.12). Among portal nonusers, 8.4% (1262/15,000) of those randomized to receive calls and 8.2% (3586/43,596) of usual care had documented vaccinations (P=.47), and multivariate analysis showed nonsignificant differences. Over half of portal messages sent were opened (10,112/19,479; 51.9%), and over half of interactive voice response calls placed (7599/14,984; 50.7%) reached their intended target, thus we attained similar levels of exposure to the messaging for both interventions. Among portal message recipients, 25.4% of message openers (2570/10,112) responded to a subsequent question on receipt of influenza vaccination; among interactive voice response recipients, 72.5% of those reached (5513/7599) responded to a similar question. CONCLUSIONS: Portal message outreach to a general primary care population achieved a small but statistically significant improvement in rates of influenza vaccination (OR 1.07, 95% CI 1.02-1.12). Interactive voice response calls did not significantly improve vaccination rates among portal nonusers (OR 1.03, 95% CI 0.96-1.10). Rates of patient engagement with both modalities were favorable. TRIAL REGISTRATION: ClinicalTrials.gov NCT02266277; https://clinicaltrials.gov/ct2/show/NCT02266277.

The Effects of Mobile Texting and Walking Speed on Gait Characteristics of Normal Weight and Obese Adults.

The aim of this study was to examine how usage of mobile devices while simultaneously walking affects walking characteristics and texting performance of normal weight (NW) and obese (OB) individuals. Thirty-two OB (body mass index [BMI] = 34.4) and NW (BMI = 22.7) adults performed two 60-s walking trials at three-step frequencies along a rectangular walkway in two conditions (No Texting and Texting). Dual-task cost as well as unadjusted spatial and temporal gait characteristics were measured. Dual-task costs for the gait parameters as well as texting performance were not different between the groups, except for the lateral step variability showing a larger variability at the preferred frequency in OB individuals. For the unadjusted variables, OB exhibited longer double support, longer stance time, and lower turn velocity compared with NW. Overall, the results highlight a similar dual-task cost for the OB individuals compared with the NW individuals, in spite of underlying differences in gait mechanics.

Text Messaging Adherence Intervention for Adolescents and Young Adults with Chronic Kidney Disease: Pilot Randomized Controlled Trial and Stakeholder Interviews.

BACKGROUND: Up to one-third of adolescents and young adults (11-21 years old) with chronic kidney disease exhibit suboptimal rates of adherence to renal-protective antihypertensive medications. Mobile health interventions may promote higher adherence to these medicines in these individuals, but empirical research is needed to inform best practices for applying these modalities. OBJECTIVE: In this multiphase investigation, we developed and tested a theoretically informed text messaging intervention based on the COM-B model, a well-established health intervention framework stating that capability, opportunity, and motivation interactively modify health behaviors, to improve participants' antihypertensive medication adherence in a pilot randomized controlled trial. Qualitative data on user experiences were obtained. METHODS: In phase 1, intervention messages (Reminder+COM-B Message) were developed via stakeholder engagement of participants and pediatric nephrologists. In phase 2, the Reminder+COM-B Message intervention was tested against a Reminder-only Message active control condition in an 8-week pilot randomized controlled trial. The primary outcome was daily electronically monitored antihypertensive medication adherence and secondary outcomes included pre-post participant surveys of adherence self-efficacy, adherence barriers, outcome expectancies for taking medicine, and motivation for and importance of taking medicine. In phase 3, qualitative interviews related to user experiences were conducted with participants in the Reminder+COM-B Message intervention group. RESULTS: Following phase 1, 34 participants (mean age 16.59 years, 41% female, 38% African American/Black, 35% hypertension diagnosis) completed the phase 2 pilot randomized controlled trial (n=18 in the Reminder+COM-B Message intervention group, n=16 in the Reminder-only Message active control group). All participants in the Reminder+COM-B Message intervention group completed a phase 3 qualitative interview. Overall, study procedures were feasible and the Reminder+COM-B Message intervention was acceptable to the participants (eg, 15/18 participants reported reading the majority of messages sent to them, 0/18 reported that the messages reduced their desire to take medicine). Prerandomization, there were no significant group differences in the rate of change in daily adherence over time. However, postrandomization, there was a significant group by time interaction (B=.01, P=.04) in which daily adherence decreased significantly over time in the Reminder-only Message active control group but remained stable in the Reminder+COM-B Message intervention group. There were no significant differences between groups in pre-post changes in survey responses. Qualitative interviews revealed participants' perceptions of how the Reminder+COM-B Message intervention changed adherence behavior and highlighted several areas for improving the intervention (eg, adapt messaging timing, intensity, and content to match daily adherence, send praise when medicine is taken). CONCLUSIONS: The Reminder+COM-B Message intervention was feasible and acceptable to adolescents/young adults and demonstrated potential to promote participants' daily medication adherence beyond simple reminders. Further research is needed to determine the Reminder+COM-B Message intervention's mechanisms of adherence behavior change and to incorporate qualitative participant feedback into a modified version of this intervention to enhance its acceptability. TRIAL REGISTRATION: ClinicalTrials.gov NCT03651596; https://clinicaltrials.gov/ct2/show/NCT03651596.

Routine Health Information System (RHIS) improvements for strengthened health system management.

BACKGROUND: A well-functioning routine health information system (RHIS) can provide the information needed for health system management, for governance, accountability, planning, policy making, surveillance and quality improvement, but poor information support has been identified as a major obstacle for improving health system management. OBJECTIVES: To assess the effects of interventions to improve routine health information systems in terms of RHIS performance, and also, in terms of improved health system management performance, and improved patient and population health outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE Ovid and Embase Ovid in May 2019. We searched Global Health, Ovid and PsycInfo in April 2016. In January 2020 we searched for grey literature in the Grey Literature Report and in OpenGrey, and for ongoing trials using the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. In October 2019 we also did a cited reference search using Web of Science, and a 'similar articles' search in PubMed. SELECTION CRITERIA: Randomised and non-randomised trials, controlled before-after studies and time-series studies comparing routine health information system interventions, with controls, in primary, hospital or community health care settings. Participants included clinical staff and management, district management and community health workers using routine information systems. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed records to identify studies for inclusion, extracted data from the included studies and assessed the risk of bias. Interventions and outcomes were too varied across studies to allow for pooled risk analysis. We present a 'Summary of findings' table for each intervention comparisons broadly categorised into Technical and Organisational (or a combination), and report outcomes on data quality and service quality. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included six studies: four cluster randomised trials and two controlled before-after studies, from Africa and South America. Three studies evaluated technical interventions, one study evaluated an organisational intervention, and two studies evaluated a combination of technical and organisational interventions. Four studies reported on data quality and six studies reported on service quality. In terms of data quality, a web-based electronic TB laboratory information system probably reduces the length of time to reporting of TB test results, and probably reduces the overall rate of recording errors of TB test results, compared to a paper-based system (moderate certainty evidence). We are uncertain about the effect of the electronic laboratory information system on the recording rate of serious (misidentification) errors for TB test results compared to a paper-based system (very low certainty evidence). Misidentification errors are inaccuracies in transferring test results between an electronic register and patients' clinical charts. We are also uncertain about the effect of the intervention on service quality (timeliness of starting or changing a patient's TB treatment) (very low certainty evidence). A hand-held electronic device probably improves the length of time to report TB test results, and probably reduces the total frequency of recording errors in TB test results between the laboratory notebook and the electronic information record system, compared to a paper-based system (moderate-certainty evidence). We are, however, uncertain about the effect of the intervention on the frequency of serious (misidentification) errors in recording between the laboratory notebook and the electronic information record, compared to a paper-based system (very low certainty evidence). We are uncertain about the effect of a hospital electronic health information system on service quality (length of time outpatients spend at hospital, length of hospital stay, and hospital revenue collection), compared to a paper-based system (very low certainty evidence). High-intensity brief text messaging (SMS) may make little or no difference to data quality (in terms of completeness of documentation of pregnancy outcomes), compared to low-intensity brief text messaging (low-certainty evidence). We are uncertain about the effect of electronic drug stock notification (with either data management support or product transfer support) on service quality (in terms of transporting stock and stock levels), compared to paper-based stock notification (very low certainty evidence). We are uncertain about the effect of health information strengthening (where it is part of comprehensive service quality improvement intervention) on service quality (health worker motivation, receipt of training by health workers, health information index scores, quality of clinical observation of children and adults) (very low certainty evidence). AUTHORS' CONCLUSIONS: The review indicates mixed effects of mainly technical interventions to improve data quality, with gaps in evidence on interventions aimed at enhancing data-informed health system management. There is a gap in interventions studying information support beyond clinical management, such as for human resources, finances, drug supply and governance. We need to have a better understanding of the causal mechanisms by which information support may affect change in management decision-making, to inform robust intervention design and evaluation methods.

Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial.

BACKGROUND: Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain. OBJECTIVE: This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries. METHODS: Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups. RESULTS: A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone-based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04). CONCLUSIONS: In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference. TRIAL REGISTRATION: ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546.

Randomized Trial of Text Messaging to Reduce Early Discontinuation of Adjuvant Aromatase Inhibitor Therapy in Women With Early-Stage Breast Cancer: SWOG S1105.

PURPOSE: Nonadherence to aromatase inhibitors (AIs) for breast cancer is common and increases the risk of recurrence. Text messaging increases adherence to medications for chronic conditions. METHODS: We conducted a randomized clinical trial of text messaging (TM) versus no text messaging (No-TM) at 40 sites in the United States. Eligible patients were postmenopausal women with early-stage breast cancer taking an AI for > 30 days with a planned duration of ≥ 36 months. Test messages were sent twice a week over 36 months. Content themes focused on overcoming barriers to medication adherence and included cues to action, statements related to medication efficacy, and reinforcements of the recommendation to take AIs. Both groups were assessed every 3 months. The primary outcome was time to adherence failure (AF), where AF was defined as urine AI metabolite assay results satisfying one of the following: < 10 ng/mL, undetectable, or no submitted specimen. A stratified log-rank test was conducted. Multiple sensitivity analyses were performed. RESULTS: In total, 724 patients were registered between May 2012 and September 2013, among whom,702 patients (348 in the text-messaging arm and 354 in the no-text-messaging arm) were eligible at baseline. Observed adherence at 36 months was 55.5% for TM and 55.4% for No-TM. The primary analysis showed no difference in time to AF by arm (3-year AF: 81.9% TM v 85.6% No-TM; HR, 0.89 [95% CI, 0.76 to 1.05]; P = .18). Multiple time to AF sensitivity analyses showed similar nonsignificant results. Three-year self-reported time to AF (10.4% v 10.3%; HR, 1.16 [95% CI, 0.69 to 1.98]; P = .57) and site-reported time to AF (21.9% v 18.9%; HR, 1.31 [95% CI, 0.86 to 2.01]; P = .21) also did not differ by arm. CONCLUSION: To our knowledge, this was the first large, long-term, randomized trial of an intervention directed at improving AI adherence. We found high rates of AI AF. Twice-weekly text reminders did not improve adherence to AIs. Improving long-term adherence will likely require personalized and sustained behavioral interventions.

A Prototype Willingness Approach to the Relation Between Geo-social Dating Apps and Willingness to Sext with Dating App Matches.

Despite voiced concerns about sexual online risk behaviors related to mobile dating, little is known about the relation between mobile dating and sexting. The current cross-sectional study (N = 286) examined the relations between the use of geo-social dating apps and emerging adults' willingness to sext with a dating app match. By drawing on the prototype willingness model, both a reasoned path and a social reaction path are proposed to explain this link. As for the reasoned path, a structural equation model showed that more frequent dating app usage is positively related to norm beliefs about peers' sexting behaviors with unknown dating app matches (i.e., descriptive norms), norm beliefs about peers' approval of sexting with matches (i.e., subjective norms), and negatively related to perceptions of danger to sext with matches (i.e., risk attitude). In turn, descriptive norms were positively and risk attitudes were negatively associated with individuals' own willingness to sext with someone they had met through a dating app. As for the social reaction path, it was found that more frequent dating app usage was positively related to emerging adults' favorable evaluations of a prototype person who sexts with unknown dating app matches (i.e., prototype perceptions). The analyses further revealed that such prototype perceptions positively linked with emerging adults' own willingness to sext with a match. These results were similar among women and men and help explain why individuals may be willing to engage in sexting behavior with unknown others.

Secure Instant Messaging Application in Prenatal Care.

The use of mobile phone for medical purposes is rapidly expanding as the number of medical applications rise. Studies show improvement of patient management and communication between medical team members using instant messaging applications. There are currently several smartphone applications routinely used by doctors and nurses. WhatsApp is by far the most common, however, it has several limitations when it comes to medical confidentiality. The aim of this paper is to introduce "Siilo" as an alternative secure messaging application and its advantages in the medical field, specifically in obstetrics. The typical course of consultation for an abnormal fetal finding is very long, cumbersome, frustrating and depends a lot on the patient, whereas, via Siilo the process is fast, efficient, depends more on the medical caregivers and helps ensuring minimum lost to follow-up. This paper demonstrates for the first time the utility of the use of Siilo application in medical management.

"I'm here to listen and want you to know I am a mandated reporter": Understanding how text message-based crisis counselors facilitate child maltreatment disclosures.

BACKGROUND: Emerging research suggests technology-facilitated crisis services are a promising method to support young people during child maltreatment disclosure. Little is known about how employees/volunteers respond to child maltreatment disclosure in these platforms and how they may support young victims through the disclosure process. OBJECTIVES: We sought to determine how crisis counselors respond to child maltreatment disclosures using a content analysis of all conversations within a text-based crisis organization that resulted in a mandatory report. METHODS: We conducted an iterative team-based content analysis of 244 conversations (24,730 text messages) between a young person and a crisis counselor from an anonymous text-based crisis service. All conversations included in the sample resulted in a mandatory report to child protective services. RESULTS: There were two crucial points in maltreatment disclosure conversations. The first occurred immediately after the disclosure. At this point, crisis counselors most often provided sympathy and affirmation. The second crucial point after disclosure was the discussion of mandatory reporting. In many cases, crisis counselors confirmed both parties understood mandatory reporting and encouraged young people to consider the repercussions of their decision to share identifiable information that would permit a mandatory report. CONCLUSION: Understanding how crisis counselors responded to young people in one text-based crisis service, particularly characteristics of well-received conversations, may inform the policies and processes for other organizations. Continued exploration of crisis text-based services may improve the disclosure process for young victims.

Pilot Test of Connecting Pregnant Women who Smoke to Short Message Service (SMS) Support Texts for Cessation.

INTRODUCTION: Most pregnant women know that smoking poses serious risks to baby and mother, yet many still smoke. We conducted a large randomized controlled trial and found that an SMS text-delivered program helped about 10% of these women quit smoking. In this paper, we describe the feasibility of disseminating a text-based intervention to pregnant women who smoke. METHODS: We tested dissemination in two ways from prenatal clinics and compared recruitment rates to those found in our large randomized controlled trial. The first method involved "direct texting" where study staff identified women who smoked and sent them a text asking them to text back if they wanted to receive texts to help them quit. The second involved "nurse screening" where clinic staff from county health departments screened women for smoking and asked them to send a text to the system if they wanted to learn more about the program. Our primary outcome was feasibility assessed by the number of women who texted back their baby's due date, which served as "enrolling" in the texting program, which we compared to the recruitment rate we found in our large trial. RESULTS: Over 4 months, we texted 91 women from the academic health system. Of those, 17 texted back and were counted as "enrolled." In the health departments, across the 4 months, 12 women texted the system initially. Of those, 10 were enrolled. This rate was similar to the rate enrolled in the randomized controlled trial. DISCUSSION: Two different methods connected pregnant women who smoke to a texting program. One of these methods can be automated further and have the potential of helping many women quit smoking with minimal effort. Clinical Trial # NCT01995097.

Home Telemonitoring Improved Pain Registration in Patients With Cancer.

INTRODUCTION: For adequate pain treatment in patients with cancer, it is important to monitor and evaluate pain regularly. Although the numeric rating scale (NRS) is implemented in hospitals in the Netherlands, pain is still not systematically registered during outpatient consultations. The aim of this study was to assess whether home telemonitoring increases pain registration in medical records of outpatients with cancer. METHODS: Patients with cancer were included in the intervention group (IG) when they visited the outpatient clinic. They received a short message service and an interactive voice response on their mobile phones 3 times a week, asking them to provide their pain score (NRS). When the reported NRS pain score was ≥5, a specialized oncology nurse adapted the pain treatment when necessary. Outcomes were compared to a control group (CG) without home telemonitoring. In both groups, medical records were analyzed and data on pain and analgesics were collected. RESULTS: In each group, the medical records of 54 patients were analyzed on 3 consecutive outpatient visits. In the CG, pain registration or its absence was described in 60 visits (37.0%). In the IG, pain registration or its absence was reported in 83 visits (51.2%). Patients in the IG received a prescription for analgesics significantly more often (36/54 patients [66.6%]) than did patients in the CG (18/54 patients [33.3%]), P < 0.01). CONCLUSION: Home telemonitoring for patients with cancer significantly increases registration of pain and prescriptions of analgesics in outpatient medical records. Home telemonitoring helps to increase the awareness of pain and its management.

Communication of Critical Laboratory Values: Optimization of the Process through Secure Messaging.

BACKGROUND: Timely communication of critical laboratory results is important yet cumbersome. OBJECTIVE: To assess the impact of a new technology on the process of reporting critical laboratory results at our 480-bed, adult/children, tertiary-care, medical school-affiliated health center in the southeastern region of the United States. METHODS: We changed the process of reporting critical values by telephone only to reporting via telephone and a secure messaging app. Physician order entry, an online on-call roster for availability, and support from the C-suite (executive branch of the organization) were instrumental in implementation. RESULTS: Consistently, before our process changes, more than 95% of the critical laboratory results were reported in less than 30 minutes. Use of the app reduced the time taken for reporting results. The need to involve pathology residents and attending physicians in reporting has been eliminated by this process. DISCUSSION: Secure messaging has facilitated the reporting of critical laboratory values, making it more efficient and providing a reliable record of the process. This process meets or exceeds the standards of the accrediting agencies. The method is suitable for activating rapid-response teams in case of hypercritical values.