Reduction of Environmental Pollutants and Travel Burden Through an Academic Medical Center-based Electronic Consultation Program.

Background: We evaluated the impact of electronic consultation (eConsult) in reducing the environmental pollutants associated with health care delivery. Methods: A retrospective analysis of the eConsult data between July 2018 and December 2022 was extracted from the electronic health record (Epic). Travel time and mileage from the patient home to the academic medical center (AMC) were calculated along with fuel expenditure and greenhouses gas savings. Projected savings through the end of the decade were forecast using a random walk model. Results: A total of 15,499 eConsults were submitted to AMC specialist providers from community primary care providers. Completed eConsults (n = 11,590) eliminated the need for a face-to-face visit with a specialist provider, eliminating mileage, fuel, time, and pollutants associated with face to face visits. In-state travel distance saved was 310,858 miles, travel time saved was 5,491 h, with an associated fuel reduction of 13,575 gallons and $56,893 savings. This reduced greenhouse gas emissions by 128 metric tons of carbon dioxide, 0.022 tons of nitrogen oxide, 0.005 tons of methane, and 0.001 tons of nitrous oxide. Out of state travel distance saved was 188,346 miles with 2,842 h reduced travel time, and associated fuel reduction of 8,225 gallons and of $34,118. Reduced greenhouse gas emissions were equivalent to 77 metric tons of carbon dioxide, 0.0132 tons of nitrogen oxide, 0.0033 tons of methane, and 0.0007 tons of nitrous oxide. Conclusion: This study indicates that medical care provided through telehealth modalities reduces the environmental impact of pollutants associated with face to face visits.

Communicating Patient Discharge Readiness: An Implementation Evaluation in an Inpatient Hospital Medicine Setting.

BACKGROUND: The progression of patients through a hospital from admission to discharge can be slowed by delays in patient discharge, increasing pressure on health care staff. We designed and piloted the Discharge Today tool, with the goal of improving the efficiency of patient discharge; however, adoption remained low. PURPOSE: To close this implementation gap, we deployed and evaluated a 4-part implementation strategy bundle. METHODS: We measured the success of implementation by evaluating validated implementation outcomes using both quantitative and qualitative methods, grounded in Normalization Process Theory. RESULTS: The implementation strategies used were effective for increasing use of the Discharge Today tool by hospital medicine physicians and advanced practice providers during both the active and passive implementation periods. CONCLUSIONS: While the implementation strategies used were effective, qualitative findings indicate that limitations in the functionality of the tool, alongside inconsistent use of the tool across clinical staff, continued to inhibit adoption.

Mother's Milk Messaging™: trial evaluation of app and texting for breastfeeding support.

BACKGROUND: New mothers experience BF challenges but have limited evidence-based technology-enabled support. OBJECTIVES: 1) Determine if using the Mother's Milk Messaging™ app improved aspects of breastfeeding and breastfeeding rates and 2) Describe engagement as well as themes from the qualitative feedback on the app. METHOD: Randomized Controlled Trial National sample of primiparous, singleton mothers recruited online and then randomized using stratification by language into three arms: 1) BF text messages plus app; 2) BF text messages, app and physician-moderated private Facebook (FB) group; 3) Attention control group who received injury prevention texts. Exclusive breastfeeding rates as primary outcome and knowledge/attitude, confidence, and social support as secondary outcomes. We determined engagement through analysis of app usage metrics. We conducted and content-coded interviews with participants to learn more about app usage and BF experience. Due to the nature of the intervention participants could not be blinded. RESULTS: There were a total of 346 participants in the trial, with 227 in the Intervention (n = 154 group 1 and n = 156 group 2) and 119 in the control group. Because of minimal Facebook activity, the two intervention groups 1 and 2 were combined. There were no differences in breastfeeding exclusivity and duration. (NS). Women in the intervention arm reported significantly higher confidence with breastfeeding and perceived social support to the control group (p < .05). Greater than 80% registered the app and those that engaged with the app had higher scores with time. Mothers appreciated receiving text messages and videos with reliable information. No harm was reported in this study. CONCLUSION: MMM increased confidence with breastfeeding and with gathering social supports. Exclusively BF was high in all participants. Mothers perceived it as useful and dependable especially the texting.

A Pilot Study and Ecological Model of Smoking Cues to Inform Mobile Health Strategies for Quitting Among Low-Income Smokers.

One crucial factor that leads to disparities in smoking cessation between groups with higher and lower socioeconomic status is more prevalent socioenvironmental smoking cues in low-income communities. Little is known about how these cues influence socioeconomically disadvantaged smokers in real-world scenarios and how to design interventions, especially mobile phone-based interventions, to counteract the impacts of various types of smoking cues. We interviewed 15 current smokers living in low-income communities and scanned their neighborhoods to explore smoking-related experiences and identify multilevel cues that may trigger them to smoke. Findings suggest four major types of smoking cues influence low-income smokers-internal, habitual, social, and environmental. We propose an ecological model of smoking cues to inform the design of mobile health (mHealth) interventions for smoking cessation. We suggest that user-triggered strategies will be most useful to address internal cues; server-triggered strategies will be most suitable in changing perceived social norms of smoking and routine smoking activities to address social and habitual cues; and context-triggered strategies will be most effective for counteracting environmental cues. The pros and cons of each approach are discussed regarding their cost-effectiveness, the potential to provide personalized assistance, and scale.

Under-immunization of pediatric transplant recipients: a call to action for the pediatric community.

Vaccine-preventable infections (VPIs) are a common and serious complication following transplantation. One in six pediatric solid organ transplant recipients is hospitalized with a VPI in the first 5 years following transplant and these hospitalizations result in significant morbidity, mortality, graft injury, and cost. Immunizations are a minimally invasive, cost-effective approach to reducing the incidence of VPIs. Despite published recommendations for transplant candidates to receive all age-appropriate immunizations, under-immunization remains a significant problem, with the majority of transplant recipients not up-to-date on age-appropriate immunizations at the time of transplant. This is extremely concerning as the rate for non-medical vaccine exemptions in the United States (US) is increasing, decreasing the reliability of herd immunity to protect patients undergoing transplant from VPIs. There is an urgent need to better understand barriers to vaccinating this population of high-risk children and to develop effective interventions to overcome these barriers and improve immunization rates. Strengthened national policies requiring complete age-appropriate immunization for non-emergent transplant candidates, along with improved multi-disciplinary immunization practices and tools to facilitate and ensure complete immunization delivery to this high-risk population, are needed to ensure that we do everything possible to prevent infectious complications in pediatric transplant recipients.

Home Visitations for Delivering an Early Childhood Obesity Intervention in Denver: Parent and Patient Navigator Perspectives.

Objective This qualitative study explored parent and patient navigator perspectives of home visitation as part of a childhood obesity program in a low-income, largely Latino population. Methods Three patient navigators and 25 parents who participated in a home-based, childhood obesity program participated in focus groups or interviews. Emergent themes were identified through content analysis of qualitative data. Results Three overall themes were identified. Patient navigators and parents perceived: (1) enabling characteristics of home-based program delivery which facilitated family participation and/or behavior change (i.e., convenience, increased accountability, inclusion of household members, delivery in a familiar, intimate setting, and individualized pace and content); (2) logistic and cultural challenges to home-based delivery which reduced family participation and program reach (i.e., difficulties scheduling visits, discomfort with visitors in the home, and confusion about the patient navigator's role); and (3) remediable home-based delivery challenges which could be ameliorated by additional study staff (e.g., supervision of children, safety concerns) or through organized group sessions. Both patient navigators and participating parents discussed an interest in group classes with separate, supervised child-targeted programming and opportunities to engage with other families for social support. Conclusions for Practice A home visitation program delivering a pediatric obesity prevention curriculum in Denver was convenient and held families accountable, but posed scheduling difficulties and raised safety concerns. Conducting home visits in pairs, adding obesity prevention curriculum to existing home visiting programs, or pairing the convenience of home visits with group classes may be future strategies to explore.

A conceptual model of the role of complexity in the care of patients with multiple chronic conditions.

BACKGROUND: Effective healthcare for people with multiple chronic conditions (MCC) is a US priority, but the inherent complexity makes both research and delivery of care particularly challenging. As part of AHRQ Multiple Chronic Conditions Research Network (MCCRN) efforts, the Network developed a conceptual model to guide research in this area. OBJECTIVE: To synthesize methodological and topical issues relevant to MCC patient care into a framework that can improve the delivery of care and advance future research about caring for patients with MCC. METHODS: The Network synthesized essential constructs for MCC research identified from roundtable discussion, input from expert advisors, and previously published models. RESULTS: The AHRQ MCCRN conceptual model defines complexity as the gap between patient needs and healthcare services, taking into account both the multiple considerations that affect the needs of MCC patients, as well as the contextual factors that influence service delivery. The model reframes processes and outcomes to include not only clinical care quality and experience, but also patient health, well being, and quality of life. The single-condition paradigm for treating needs one-by-one falls apart and highlights the need for care systems to address dynamic patient needs. CONCLUSIONS: Defining complexity in terms of the misalignment between patient needs and services offers new insights in how to research and develop solutions to patient care needs.

Harnessing technology to improve sleep in frontline healthcare workers: A pilot study of electronic noise-masking earbuds on subjective and objective sleep measures.

Objective: This pilot study assessed the effects of electronic noise-masking earbuds on subjective sleep perception and objective sleep parameters among healthcare workers (HCWs) reporting sleep difficulties during the COVID-19 pandemic. Methods: Using a pre-post design, 77 HCWs underwent 3 nights of baseline assessment followed by a 7-night intervention period. Participants wore an at-home sleep monitoring headband to assess objective sleep measures and completed subjective self-report assessments. The difference in mean sleep measures from baseline to intervention was estimated in linear mixed models. Results: Compared to baseline assessments, HCWs reported significant improvements in sleep quality as measured by the Insomnia Severity Index (ISI) (Cohen's d = 1.74, p < 0.001) and a significant reduction in perceived sleep onset latency (SOL) during the intervention (M = 17.2 minutes, SD = 7.7) compared to baseline (M = 24.7 minutes, SD = 16.1), (Cohen's d = -0.42, p = 0.001). There were no significant changes in objective SOL (p = 0.703). However, there was a significant interaction between baseline objective SOL (<20 minutes vs >20 minutes) and condition (baseline vs intervention) (p = 0.002), such that individuals with objective SOL >20 minutes experienced a significant decrease in objective SOL during the intervention period compared to baseline (p = 0.015). Conclusions: HCWs experienced a significant improvement in perceived SOL and ISI scores after using the electronic noise-masking earbuds. Our data provide preliminary evidence for a nonpharmacological intervention to improve the sleep quality of HCWs which should be confirmed by future controlled studies.

Assessment of a Mobile Health iPhone App for Semiautomated Self-management of Chronic Recurrent Medical Conditions Using an N-of-1 Trial Framework: Feasibility Pilot Study.

BACKGROUND: Management of chronic recurrent medical conditions (CRMCs), such as migraine headaches, chronic pain, and anxiety/depression, remains a major challenge for modern providers. Our team has developed an edge-based, semiautomated mobile health (mHealth) technology called iMTracker that employs the N-of-1 trial approach to allow self-management of CRMCs. OBJECTIVE: This study examines the patterns of adoption, identifies CRMCs that users selected for self-application, and explores barriers to use of the iMTracker app. METHODS: This is a feasibility pilot study with internet-based recruitment that ran from May 15, 2019, to December 23, 2020. We recruited 180 patients to pilot test the iMTracker app for user-selected CRMCs for a 3-month period. Patients were administered surveys before and after the study. RESULTS: We found reasonable usage rates: a total of 73/103 (70.9%) patients who were not lost to follow-up reported the full 3-month use of the app. Most users chose to use the iMTracker app to self-manage chronic pain (other than headaches; 80/212, 37.7%), followed by headaches in 36/212 (17.0%) and mental health (anxiety and depression) in 27/212 (12.8%). The recurrence rate of CRMCs was at least weekly in over 93% (169/180) of patients, with 36.1% (65/180) of CRMCs recurring multiple times in a day, 41.7% (75/180) daily, and 16.1% (29/180) weekly. We found that the main barriers to use were the design and technical function of the app, but that use of the app resulted in an improvement in confidence in the efficiency and safety/privacy of this approach. CONCLUSIONS: The iMTracker app provides a feasible platform for the N-of-1 trial approach to self-management of CRMCs, although internet-based recruitment provided limited follow-up, suggesting that in-person evaluation may be needed. The rate of CRMC recurrence was high enough to allow the N-of-1 trial assessment for most traits.

The impact of tailored diabetes registry report cards on measures of disease control: a nested randomized trial.

BACKGROUND: Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback. METHODS: 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews. RESULTS: Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources. CONCLUSIONS: Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00827710.

Building MedVenture - A mobile health application to improve adolescent medication adherence - Using a multidisciplinary approach and academic-industry collaboration.

OBJECTIVE: Mobile health (mHealth) tools are increasingly used to support medication adherence yet few have been designed specifically for the pediatric population. This paper describes the development of a medication adherence application (MedVenture) using the integration of patient and healthcare provider input, health behavior theory, and user engagement strategies for adolescents with chronic gastrointestinal disease. METHODS: MedVenture was created by a multidisciplinary research team consisting of a gastroenterologist, a social health psychologist, software developers, and digital health researchers. Healthcare providers and adolescent patients were interviewed to identify barriers to medication adherence, explore ways that technologies could best support medication adherence for both patients and providers, and determine user requirements and core design features for a digital health tool. Intervention mapping was used to match themes from qualitative content analysis to known efficacious adherence strategies, according to a conceptual framework based on self-determination theory. Iterative design with review by the research team and two rounds of user testing informed the final prototype. RESULTS: Three themes were identified from content analysis: 1) lack of routine contributes to nonadherence, 2) adolescents sometimes purposefully forgo medications, and 3) healthcare providers would prefer a tool that promotes patient self-management rather than one that involves patient-provider interaction. These findings, combined with evidence-based adherence and user engagement strategies, resulted in the development of MedVenture - a game-based application to improve planning and habit formation. CONCLUSIONS: Academic-industry collaboration incorporating stakeholders can facilitate the development of mobile health tools designed specifically for adolescents with chronic disease.

"It depends:" a qualitative study on digital health academic-industry collaboration.

BACKGROUND: Academic-industry collaborations (AICs) are endorsed to alleviate challenges in digital health, but partnership experiences remain understudied. The qualitative study's objective investigated collaboration experiences between academic institutions and digital health companies. METHODS: A phenomenology methodology captured experiences of AICs, eliciting perspectives from academic researchers and industry affiliates (e.g., leadership, company investigators). Semi-structured interviews probed eligible collaborators about their experiences in digital health. Analysts coded and organized data into significant statements reaching thematic saturation. RESULTS: Participants (N=20) were interviewed from 6 academic institutions and 14 unique industry partners. Seven themes emerged: (I) Collaboration evolves with time, relationships, funding, and evidence; (II) Collaboration demands strong relationships and interpersonal dynamics; (III) Operational processes vary across collaborations; (IV) Collaboration climate and context matters; (V) Shared expectations lead to a better understanding of success; (VI) Overcoming challenges with recommendations; (VII) Collaboration may help navigate the global pandemic. CONCLUSIONS: Digital health academic industry collaboration demands strong relationships, requiring flexible mechanisms of collaboration and cultural fit. Diverse models of collaboration exist and remain dependent on contextual factors. While no collaboration conquers all challenges in digital health, AICs may serve as a facilitator for improved digital health products, thus advancing science, promoting public health, and benefiting the economy.

Benefits, Facilitators, and Recommendations for Digital Health Academic-Industry Collaboration: A Mini Review.

Digital health remains a growing and challenging niche in public health practice. Academic-industry collaboration (AIC) offers a mechanism to bring disparate sectors together to alleviate digital health challenges of engagement, reach, sustainability, dissemination, evaluation, and equity. Despite the ongoing endorsements for AIC in digital health, limited understanding exists of successful AIC exists. Most published research highlights the barriers of collaboration rather than efficacy, leaving collaborators asking: What are the benefits and facilitators of AIC and do they apply in digital health? As an initial effort to fill the gap in the literature, the purpose of this mini review outlines the benefits and facilitators from previous AIC and offers recommendations specific to digital health.

Development and Implementation of a Multidisciplinary Electronic Discharge Readiness Tool: User-Centered Design Approach.

BACKGROUND: Typical solutions for improving discharge planning often rely on one-way communication mechanisms, static data entry into the electronic health record (EHR), or in-person meetings. Lack of timely and effective communication can adversely affect patients and their care teams. OBJECTIVE: Applying robust user-centered design strategies, we aimed to design an innovative EHR-based discharge readiness communication tool (the Discharge Today tool) to enable care teams to communicate any barriers to discharge, the status of patient discharge readiness, and patient discharge needs in real time across hospital settings. METHODS: We employed multiple user-centered design strategies, including exploration of the current state for documenting discharge readiness and directing discharge planning, iterative low-fidelity prototypes, multidisciplinary stakeholder meetings, a brainwriting premortem exercise, and preproduction user testing. We iteratively collected feedback from users via meetings and surveys. RESULTS: We conducted 28 meetings with 20 different stakeholder groups. From these stakeholder meetings, we developed 14 low-fidelity prototypes prior to deploying the Discharge Today tool for our pilot study. During the pilot study, stakeholders requested 46 modifications, of which 25 (54%) were successfully executed. We found that most providers who responded to the survey reported that the tool either saved time or did not change the amount of time required to complete their discharge workflow (21/24, 88%). Responses to open-ended questions offered both positive feedback and opportunities for improvement in the domains of efficiency, integration into workflow, avoidance of redundancies, expedited communication, and patient-centeredness. CONCLUSIONS: Survey data suggest that this electronic discharge readiness tool has been successfully adopted by providers and clinical staff. Frequent stakeholder engagement and iterative user-centered design were critical to the successful implementation of this tool.

Using Telehealth for Hospice Reauthorization Visits: Results of a Quality Improvement Analysis.

BACKGROUND: Increasing hospice need, a growing shortage of hospice providers, and concerns about in-person services because of coronavirus disease 2019 (COVID-19) require hospices to innovate care delivery. MEASURES: This project compared outcomes between hospice reauthorization visits conducted via telehealth and in person. After each visit, providers, patients, and caregivers completed telehealth acceptance surveys, and providers recorded reauthorization recommendations. INTERVENTION: Providers conducted 88 concurrent in-person and telehealth visits between June and November 2019. OUTCOMES: No statistically significant differences in reauthorization recommendations were found between telehealth and in-person visits. Satisfaction with telehealth was high; 88% of patients/caregivers and 78% of providers found telehealth services as effective as in-person visits. CONCLUSIONS/LESSONS LEARNED: Results indicate that telehealth can successfully support clinical decision making for hospice reauthorization. These findings show telehealth to be reliable and acceptable for certain types of hospice care even before COVID-19, which emphasizes its importance both during and after the current public health emergency.

What Do Patients Want? A Qualitative Analysis of Patient, Provider, and Administrative Perceptions and Expectations About Patients' Hospital Stays.

Patient experience is increasingly recognized as a measure of health care quality and patient-centered care and is currently measured through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The HCAHPS survey may miss key factors important to patients, and in particular, to underserved patient populations. We performed a qualitative study utilizing semi-structured interviews with 45 hospitalized English- and Spanish-speaking patients and 6 focus groups with physicians, nurses, and administrators at a large, urban safety-net hospital. Four main themes were important to patients: (1) the hospital environment including cleanliness and how hospital policies and procedures impact patients' perceived autonomy, (2) whole-person care, (3) communication with and between care teams and utilizing words that patients can understand, and (4) responsiveness and attentiveness to needs. We found that several key themes that were important to patients are not fully addressed in the HCAHPS survey and there is a disconnect between what patients and care teams believe patients want and what hospital policies drive in the care environment.

Elements of Social Convoy Theory in Mobile Health for Palliative Care: Scoping Review.

BACKGROUND: Mobile health (mHealth) provides a unique modality for improving access to and awareness of palliative care among patients, families, and caregivers from diverse backgrounds. Some mHealth palliative care apps exist, both commercially available and established by academic researchers. However, the elements of family support and family caregiving tools offered by these early apps is unknown. OBJECTIVE: The objective of this scoping review was to use social convoy theory to describe the inclusion and functionality of family, social relationships, and caregivers in palliative care mobile apps. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review guidelines, a systematic search of palliative care mHealth included (1) research-based mobile apps identified from academic searches published between January 1, 2010, and March 31, 2019 and (2) commercially available apps for app stores in April 2019. Two reviewers independently assessed abstracts, app titles, and descriptions against the inclusion and exclusion criteria. Abstracted data covered app name, research team or developer, palliative care element, target audience, and features for family support and caregiving functionality as defined by social convoy theory. RESULTS: Overall, 10 articles describing 9 individual research-based apps and 22 commercially available apps were identified. Commercially available apps were most commonly designed for both patients and social convoys, whereas the majority of research apps were designed for patient use only. CONCLUSIONS: Results suggest there is an emerging presence of apps for patients and social convoys receiving palliative care; however, there are many needs for developers and researchers to address in the future. Although palliative care mHealth is a growing field, additional research is needed for apps that embrace a team approach to information sharing, target family- and caregiver-specific issues, promote access to palliative care, and are comprehensive of palliative needs.

Changes in insurance status and access to care in an integrated safety net healthcare system.

This paper focuses on a cohort of uninsured patients that have accessed outpatient healthcare services in an urban safety net, evaluating the degree to which they switch insurance status and the impact this switching has on access to care. The results indicate that in an integrated safety net system, there is a high frequency of insurance status switching by the uninsured. Uninsured patients who switch to insured status were found to be more likely to visit specialty points of care and less likely to visit urgent points of care than the continuously uninsured. It is well documented that insurance coverage and continuity of care influence health status. Continuity of insurance coverage also has an impact on access to care for those receiving services within a safety net healthcare system.

Advancing evidence-based digital health through an innovative research environment: an academic-industry collaboration case report.

The proliferation of technology enthuses clinicians, researchers, and entrepreneurs to revolutionize health care and care delivery. Intersecting in the field of digital health, academic-industry collaboration (AIC) play a critical role in advancing evidence-based innovations into real world application. AIC models vary, but historically have not included the strong emphasis on rapid research and discovery that the digital health field demands. Due to the voluminous availability of real time patient and client data, academic health centers offer a rich interdisciplinary environment to develop, pilot and evaluate innovations in pragmatic settings. Despite the opportunity between academic health centers and industry to advance digital health innovation through rapid research, limited evidence exists of such collaboration. The purpose of this case report is to examine an AIC facilitating research of new health technologies within an academic health center. This paper presents a case report involving collaboration between diverse technology industry partners and an academic health center that encompasses a university health system (UCHealth), a university technology transfer office (CU Innovations), an innovation center (CARE Innovation Center), and research collaborators (mHealth Impact Laboratory). Case assertions discuss the lessons learned and recommendations when implementing such collaboration in practice. The principal finding is that academic health centers offer an innovative environment for AIC in digital health. Collaborations between academia and industry provide much promise in ensuring health innovations are scientifically sound while meeting the needs of a rapidly evolving technical climate.

Appointment reminders by text message in a safety net health care system: a pragmatic investigation.

INTRODUCTION: Short Message Service (SMS) appointment reminders may provide a wide-reaching, low cost approach to reducing operational inefficiencies and improving access to care. Previous studies indicate this modality may improve attendance rates, yet there is a need for large-scale, pragmatic studies that include unintended consequences and operational costs. METHODS: This pragmatic investigation was a before-after analysis that compared visit attendance outcomes among patients who opted into SMS appointment reminders with outcomes among those who declined over an 18-month evaluation period from March 25, 2013, to September 30, 2014. Eligibility in our integrated safety net health care system included age greater than 17, English or Spanish as a primary language, and a cell phone number in our scheduling system. RESULTS: 47,390 patients were invited by SMS to participate, of which 20,724 (43.7 percent) responded with 18,138 opting in (81.5 percent of respondents). Participants received SMS reminders for 77,783 scheduled visits; comparison group patients (N=72,757) were scheduled for 573,079 visits during the evaluation period. Intervention and comparison groups had, respectively, attendance rates of 72.8 percent versus 66.1 percent (p<0.001), cancellation rates of 13.2 percent versus 18.6 percent (p<0.001), and no show rates of 14.0 percent versus 15.3 percent. Patient satisfaction with text messaging ranged from 77 percent to 96 percent. Implementation challenges included a low rate of inaccurate reminders due to non-standard use of the scheduling system across clinical departments. DISCUSSION: SMS appointment reminders improve patient satisfaction and provide a low operating cost approach to reducing operational inefficiencies through improved attendance rates in an integrated safety net health care system.