Adolescent Text Messaging Research Paper

Keys to Improve Text Messaging Initiatives with Adolescent Patients:And Why It is Important

By: Matt ByrdMentor: Eric Swirsky

BHIS 593

Submitted as partial fulfillment of the requirementsfor the degree of Master of Science in Health Informatics

in the Graduate College of theUniversity of Illinois at Chicago, 2015

Adolescent Text Messaging, M. Byrd Page 1

Table of Contents

Abstract 3

Introduction 4

Literature Review 6

Current Studies 7

Keys to Success 9

Documented Use in the Healthcare Setting 11

Challenges 13

Solution 16

Conclusion 18

Appendix 20

References 23


Abstract

Mobile technology is offering people more opportunities to communicate because of low

barriers for use. When looking at mobile technology use, adolescents (ages 13-19) are the fastest

growing segment of smart phone owners. Through use of smart phones and other mobile devices,

adolescent patients are proving that text messaging is their chosen form of communication; giving

medical providers an opportunity to communicate with these patients where there is a better chance to

reach them. This is important because adolescent patients are considered a high risk patient group due

to low utilization of the healthcare system at a time when they insist on independence, but need

guidance. Text messaging offers the flexible, real time information these patients need.

Past research examines into how to engage this hard to reach patient group through text

messaging, but, to date, the data is not conclusive. However, there are clues to indicate a focus on

engagement and education can be successful. In addition to research, there is a small group of

physicians nationwide who are using mobile technology to reach this patient group. Although providers

are claiming success there are concerns with their initiatives that must be addressed.

This paper looks at past research and the experience of one medical provider to propose ideas

that will be valuable in helping to make text messaging a viable communication platform to use with the

adolescent patient group.

Keywords: adolescent patient, engagement, informed consent, HIPAA compliance, Natasha Burgert ,

social media, teenage patient, text messaging, pediatrics, patient education, secure messaging, SMS


Introduction

Dr. Jennifer Dyer (2015), a pediatrician in Columbus, OH says that patient engagement is the

blockbuster drug of the century. As technology becomes increasingly more prevalent in healthcare,

alternative ways to communicate with patients and engage them are becoming available. These

technologies act as tools to help increase awareness around topics when there is not enough time to

discuss those topics in the office, ensure topics discussed in the office are not forgotten, and engage

patients when they are not in the office. While the use of technology to communicate is controversial

we must explore its place in the care process. One place healthcare is examining is the adolescent

patient who is considered high risk and hard to reach.

The American Academy of Pediatrics defines adolescent patients as being aged 14-19, and they

are considered a hard to reach patient group because of their low healthcare utilization; meaning they

are not in regular contact with a healthcare provider (Selkie, Benson & Moreno, 2011). This coincides

with a high-risk period in their life where impulsive behaviors can have lasting, long-term effects on their

future (Wong, Merchant & Moreno, 2014). “Many unhealthy behaviors established in adolescence…

become lifelong addictions negatively affecting health” (Preseton, Walhart &O’Sullivan, 2011). To help

confront this issue while adolescent patients are still developing behaviors, providers must find a way to

communicate with them and inform adolescent patients of the risks their choices carry.

Face-to-face communication is becoming outdated because the adolescent patient prefers other

methods of communication (Devine et al., 2014). Without a communication medium that fits the

patients preferences there is a risk the patient will not talk to anyone when they have questions, or

worse yet, they will use easily accessible websites that may or may not be reliable. In Pew Research,

Lenhart (2015) shows 92% of teens are on the Internet daily, and the Internet is where they search for

information (Appendix A). The data also show teen’s use of the Internet is “cell mostly” Internet


meaning adolescent patients are not leaving their cell phones to search the Internet, but, rather using

the Internet available on their mobile device (Appendix B).

In 2013 “more than 75% of US adolescents own[ed] a cell phone (Woolford, Blake and Clark).

Adolescent patients tend to always have their cell phone with them because it is their phone, and

houses their music, calendars, cameras, alarms and any other apps they rely on (Schnall et al., 2013).

Pew Research shows owning a mobile device opens up numerous avenues for adolescents to

communicate such as texting, social media, phone calls, gaming, video chat tools and blogging (Lenhart,

2015)(Appendix C). Although not all of these types of communication are widely used in this age group,

numerous studies report that texting is the preferred method of communication for adolescents. This is

supported by Pew Research which report that “The number of text messages sent or received by cell

phone owning teens ages 13 to 17 (directly through phone or on apps on the phone) on a typical day is

30” (Lenhart, 2015). As adolescents get closer to the top of the age range that defines them the amount

of texts increases above the average; especially for adolescent girls.

This paper will look at samples of current data and the experience of a doctor in this field to

show that text messaging with adolescent patients is a viable option. In addition, text messaging can be

used by more providers to engage and educate their adolescent patients who are in need of a flexible,

real time communication option. This type of tool is important to adolescent patients to help them deal

with stressful choices at a transitional time in their life. Current research is focused on hard endpoints

such as changing outcomes and behaviors like lowering glycemic control. However, softer endpoints

such as engaging and educating patients may give a better look at how text messaging actually affects

adolescent patients. By taking evidence from past research on what is working, we can create initiatives

that protect patients’ privacy while also engaging them. The hope is that this research will serve as a

starting point in establishing best practices for texting initiatives with adolescent patients.


Literature Review

Studies researching text messaging with adolescent patients have not shown conclusive data to

date. When Woolford, Blake and Clark (2013) looked at a study of diabetic patients it showed mixed

results, and was unable to show significant improvement in hard endpoints such as glycemic Control. In

addition, Preston, Walhart and O’Sullivan (2011) did an analysis of four different studies, and three were

unable to show significant improvements in changing health behaviors or outcomes. All studies

discussed were looking at changing behaviors and outcomes.

Aside from results that are not conclusive in studies, there are concerns with the inability to

protect personal health information (PHI) when using text messaging. At every point in a text messaging

transmission, there is a risk to the PHI of the patient (Woolford, Blake & Clark, 2013). This has been

noted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) who issued a ban

physician text messaging calling it a “not acceptable” form of medical communication (Montgomery,

2011). Comstock (2013) notes similar concerns with privacy when referring to the Health Insurance

Portability and Accountability Act (HIPAA).

A focus on softer endpoints, such as engagement and education, as opposed to changing

outcomes, are showing significant results in the adolescent patient population. Devine et al. (2013)

focused on teen pregnancy education and received positive feedback from participants in the education

they received. Another study that focused on sexual health education was able to show significant

improvement in patient’s knowledge around specific topics after having participated in the program

(Gold et al., 2010). Gold et al. (2010) also showed other factors play a role in text messaging success

such as ease of understanding the message, message length and a positive tone.

Outside of research studies, there has been limited clinical experience that has been

documented. Hoffman (2012) wrote an article documenting the clinical experiences of Dr. Natasha

Burgert, a pediatrician in Kansas City, MO, who is a pioneer in using text messaging as a tool. After


multiple years of using short message service (SMS) text messaging, her patients and their families have

been happy with the results (Burgert, 2012). Dr. Burgert’s experience gives us the opportunity to look at

a real life application of text messaging to see what is working and what is not.

Current Studies

As mentioned above, current literature is not conclusive on the use of text messages with

adolescent patients. In addition, data beyond a six month time frame suggests there is no significant

improvement in changing health related behaviors or outcomes. Many of these studies, however, are

focused on chronic conditions. This may be because younger individuals with chronic diseases are more

prone to non-adherence in their treatment, which leads to a need to study anything that may help them

(Preston, Walhart & O’Sullivan, 2011). While studies focused on chronic diseases show mixed results,

other studies on behaviors of adolescents without an underlying chronic disease show better results

with different end points suggesting that text messaging could be useful with this hard to reach patient.

An article by Preston, Walhart and O’Sullivan (2011) looked at four different studies involving

adolescent patients, with three of them focusing on chronic conditions. Of the three, two did not show

significant improvement. The two studies that did not show significance looked at changing behaviors

around blood glucose monitoring and exercise in diabetic patients. One of the issues investigators saw

was patients who receive more text messages generally did not read them carefully. Too many

messages being sent may cause communication fatigue, leading to messages not being read as carefully.

The difference between three messages per week versus one message per week could be enough to

reduce the effectiveness of text messaging as a tool (Preston, Walhart & O’Sullivan, 2011). While alert

fatigue is not a new concept, it is important to understand what all patient groups’ preferences are.

Other endpoints focused less on changing outcomes and behaviors, and more on engagement

and patient-centered education. This could be more valuable in studying the effectiveness of text


messaging with adolescent patients. A study looking at education around teen pregnancy had a goal of

engaging patients rather than simply looking at reducing teen pregnancy (Devine et al., 2013). While the

choices of adolescent patients may not be a problem that can be directly solved through text messaging,

educating this patients gives them the tools necessary to make informed choices. Ensuring a large reach

and engaging patients may be just as important as reducing outcomes and behaviors. It leads to the

question with adolescent patients of why is educating a hard to reach group not enough? When

discussing education, Schnall et al. (2013) says, “This is particularly important because behaviors and

decision-making processes learned and habituated at a young age are more likely to be more

sustainable over time, and thus may have greater impact than attempting to change the behavior of

adults” proving education may be just as important as changing behaviors and outcomes in the

adolescent age group.

Similar to Devine et al. (2014), Gold et al. (2010) also showed a positive impact from delivering

messages to young adults. The shortfall of their study is that it included patients outside of the

adolescent age range by allowing study participants to be as old as 24. Despite this, the results show the

benefit of using text messaging. In addition to the benefits of engaging and educating adolescents, the

trial showed another benefit in the ability to reach more people than the intended target. “Participants

reported they were most likely to show other people the message if there were others around when

they received the message” (Gold et al., 2010). Receiving messages while with a group led to another

benefit such as reinforcing the message through reading and discussing with friends, versus simply

reading it alone.

Unpublished research by Dr. Jennifer Dyer demonstrated text messaging benefits to diabetic

patients; however, that effectiveness wore off after six months. It was her belief that patients needed

more support than a once a week text after a certain amount of time (Dyer, 2015). Dr. Dyer suggests

there are three components of technology that are needed to facilitate change in patients: ease of use,


motivation, and the ability to remind (Dyer, 2015). Text messaging is both easy to use and can act as a

reminder for patients, but it lacks the ability to actively motivate patients. The lack of motivation is what

appears to be keeping patients from successfully changing health outcomes.

Keys to Success

Aside from a focus on education and engagement, other clues have been found in studies that

should be considered when attempting to make text messaging a viable option. From past research,

other matters to consider when creating text message initiatives to use with adolescent patients are

language, length of messages, tone of messages, and the overall tone of the provider. While looking at

different endpoints may show how text messaging can be successful, these other considerations will

ensure the technology is working with the preferences of the adolescent patient.

Language used in text messages could be a key driver in ensuring adolescent patients will use

this communication medium. Adolescents want plain language they can understand which helps

accomplish two things (Selkie, Benson & Moreno, 2011). First, it keeps the conversation informal as

opposed to feeling like they are reading from a text book for school. If they can read information that

does not feel like statistics being forced on them, then they are less likely to tune out this information.

Second, by using language that is too scientific or above their reading level patients run the risk of not

understanding it. One participant in the study by Selkie, Benson & Moreno (2011) said “we’re not

illiterate either, we can read, but…I’m not going to understand [a long scientific] word.” While health

literacy is not specific to adolescent patients, this is what research tells us they want.

Not only are the words chosen to write the message important, but the length of the message is

also important. Gold et al. (2010) found that when messages were too long it lessened the impact of the

message on the recipient. Patients want texts to be short, to the point, and easy to remember. With

cell phones being prominent with this age group, adolescents have the ability to get information from


numerous sources. They prefer the information quick and easy, but when it is not they do not have a

problem going to the Internet to look that information up. The problem with the Internet, however, is

while it may be easy for them to access they may not be prepared to distinguish good sources from bad.

If providers can get patients to focus on text messages for information, then it could help ensure the

patient is limiting his/her access to bad information online; instead focusing on his/her trusted provider.

Along the lines of using language that is easy to understand the tone of the message is

important to adolescent patients as well. Gold et al. (2010) mention, “the positive angle of messages”

was liked by numerous participants.” Many healthcare advertisements and public service

announcements (PSAs) focus on the negative side of health issues affecting adolescents. One

participant in Gold et al. (2010) felt advertisements and PSAs throw statistics out and just try to scare

intended targets, leading to a situation where adolescents do not want to be bothered with the

information. However, by sharing information in a positive way it draws the adolescent in, as opposed

to, scaring them away from reading more.

This positive tone should be extended beyond the message. A key to making text messaging a

success goes beyond having someone available for adolescents to communicate with. This patient

group, similar to other patients groups, does not want to feel judged by asking for information or help.

Selkie, Benson and Moreno (2010) found that “participants further described that they often feel they

cannot ask adults about sexual health because they are afraid of being met with disapproval.” During

adolescents kids are still learning who they are and where they fit in. Some questions may be alarming,

but it is important to remember a question does not indicate a decision to take part in a behavior; it

represents a curiosity that is normal for this age group.

If text messaging is used in-line with adolescent preferences the technology offers many

benefits that adolescent patients will not get through their normal face-to-face visits. Participants in a

study commented they learned new information from messages shared with them, in addition, to


helping with apprehension around specific topics (Gold et al., 2010). The ability to offer a

communication type that is flexible, and can educate them at any time, offers an opportunity to engage

a hard to reach patient. These adolescent patients possibly would have learned this information

eventually. The fear, however, is did they learn too much wrong information on the way to the right

information, and was the right information available when it was needed.

Documented use in the Healthcare Setting

Dr. Natasha Burgert, a pediatrician in Kansas City, MO has been a pioneer in using texting

messaging with her adolescent patients for years because she feels it is important to reach patients

where they are. For adolescent patients, text messaging is a realistic tool for communication. Her use

of text messaging is “very goal focused” and is used as a way to engage patients to “work on specific

issues” (Burgert, 2015). For example, Dr. Burgert would use text messaging when a patient is struggling

with depression or psychological disorders, eating disorders, weight gain/loss or high risk social

behaviors. When Dr. Burgert uses text messaging it is not meant to replace office visits, but enhance it.

Although Dr. Burgert has had success, there are aspects of her initiative that are concerning and need to

be discussed.

The way Dr. Burgert uses this tool is fairly informal, but ensures that her patients are not left to

deal with their issues alone. What she is doing ensures, that in addition to their parents, adolescent

patients know there is another adult who cares about them and the decisions they are making. Because

of the issues involved, adolescent patients may not feel comfortable talking with their parents about

what they are going through, and Dr. Burgert’s texting initiative helps to give them another trusted

source to communicate with.

The way her texting initiative works is fairly simple. The first rule is texting between provider

and patient does not happen without the parents’ permission. There is nothing in writing; everything is


a verbal agreement. They discuss how they will work on this issue together, in the office, with the

parents present. The three parties (patient, provider and patient’s parents) discuss texting as a tool, its

lack of security and compliance, and an understanding that this is a luxury she is offering that can be

revoked if improperly used (Burgert, 2015). Dr. Burgert also councils patients that their parents should

be allowed access to their text messages to ensure at any time they can see and understand what their

child is discussing with another adult.

Next, they discuss how texts will be initiated. When Dr. Burgert wants to talk with the patient

she will first text to see if they are available to talk. When they respond yes, she will then ask for a safe

word that she and the patient agreed to during their initial discussion in the office to ensure she is

actually speaking to the patient. Once she has received the safe word, Dr. Burgert and the patient move

forward with the discussion she contacted the patient about. Communication like this will continue until

the issue is resolved at which time text messaging between the two will end.

Dr. Burgert herself will take precautions to protect the patient, knowing SMS text messaging is

not a secure form of communication. One of those precautions is to not enter the patients name into

the mobile device she is using. Instead she uses a sequence of letters that allow her to authenticate the

patient. In addition, Dr. Burgert does not share PHI in a message living by the HIPAA guideline for email

to "only send what you feel comfortable to place on a billboard” (Burgert, 2015) (Appendix D). There

are times when the conversation could turn to a place where the information is no longer safe to be

online, and, at the time, she would end the conversation and take it offline. If at any time Dr. Burgert

feels the patient is a danger to themselves she contacts the parents immediately.

What Dr. Burgert does is controversial. She understands this is not scalable for large

organizations, and many private providers may not feel comfortable taking part. However, she adds

that “using technology to communicate with families is happening now because we are trying

desperately to connect and engage with our patients in a responsible way” (Burgert, 2015). To that


point, an article by West (2012) mentions “If we can trust doctors with sharp instruments and narcotics,

we can trust them with [social media].” We need organizations like JCAHO and HIPAA to ensure

patients’ rights are protected, however, we also need to trust that providers will live by the Hippocratic

Oath they have taken to do no harm as they use all means necessary to treat their patients.

When looking at Dr. Burgert’ s initiative, using text messaging gives the ability to deal with issues

now, and supports the data Gold et al. (2010) and Devine et al. (2014) shared showing text messaging

can be a good tool when focused on education. In addition, Divine et al. (2014) also viewed text

messaging as a successful tool when the goal of simply engaging patients was used, which is something

Dr. Burgert sees as well. By creating a new avenue for communication with adolescent patients, there is

an increased ability to engage and educate a patient who was previously hard to reach.

Challenges

As healthcare explores text messaging as an option, we have to be careful that we do not use

ends to justify means. Based on what has been written about Dr. Burgert, can she or others use SMS

text messaging without written informed consent? Dr. Burgert (2015) said she feels blessed with the

patients she has because she has been able to obtain verbal consent when discussing her text messaging

plan, as opposed to, needing forms and legal documents which may not encompass all situations. This

raises questions concerning legal compliance and ethical obligations such as was the patient actually

informed, were all the risks shared, and are all patients being given the same information regarding text

messaging risks?

In 2011, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a

ban “on physician texting saying it’s ‘not acceptable’ for medical professionals to communicate patient

information via SMS” (Montgomery, 2011). While this ban is in regards to healthcare provider’s

communications with each other, not providers communicating with patients; JCAHO has taken a clear


stance on SMS and the ability of the technology to protect information. Comstock (2013) notes similar

concerns when reviewing the Health Insurance Portability and Accountability Act (HIPAA) privacy and

security rules saying, “text messaging is not a secure form of electronic communication,” and even if the

provider could guarantee protection on their side, messages travel through mobile operators where

providers have no control. There is also the risk of who receives the message on the other side. This is

especially concerning with adolescent patients who have a tendency to have lapses in access to their

phone where PHI could be viewed by others. Teens reported lapses in access due to loaning their phone

to a friend or losing their phone (Devine et al., 2014). Both JCAHO and HIPAA brought the risks of text

messaging to light, but it remains to be seen if patients are being informed of these risks.

The Department of Health and Human Services (2000) says consent is needed for more than

physical intrusion of a person’s body and also is applicable “to intrusions on information about the

person”. Because text messaging is an unsecure communication platform, there is a risk of intrusion of

personal information about the patient. However, according to the Center for Connected Health Policy

(2014), the rules regarding informed consent vary by state leaving verbal versus written informed

consent open to debate.

The idea of informed consent is centered on the concept of autonomy which allows patients to

make choices independently after receiving information about the risks and benefits of an intervention

from their provider (Beauchamp & Childress, 2013). Without written consent, is a verbal agreement

enough to ensure patients truly understand the risks with which JACHO and HIPAA are concerned? The

answer has to be no. Because mobile devices and text messaging are technologies people use every day

that does not mean they understand the risks involved; especially when it comes to the protection of

their PHI. Dr. Burgert discussed encoding patients’ names, however, their phone number alone is

enough to identify them; not to mention the information they discuss in the message. When discussing

consent and the legalities of newer technologies Woolford, Blake and Clark (2013) say, “this area of law


is nuanced, and although there is guidance on how these laws apply to technology such as e-mail, it is

often unclear how best to safeguard newer technologies such as text messaging.” While governing

bodies do not appear to like text messaging as a communication channel, they also have not formally

ruled it out as a communication option.

It is important that patients are protected and that providers use evidence-based interventions

to meet the standard of care. While informed consent is a process as opposed to a form; a verbal

agreement is not enough to meet the rules of informed consent (Health and Human Services, 1993). As

we consider this technology, and all of the good it can potentially offer, we cannot ignore the risks it

poses. If text messaging is going to be a tool that is used moving forward then written informed consent

must be obtained to ensure patients maintain their autonomy as they make choices that could affect

them well into the future. Written informed consent also ensures protection for the provider in an area

of the law that is still nuanced and looking to find a definitive set of guidelines.

Another ethical barrier is the inability to easily incorporate text messaging communications into

a patient’s health records. With email communication through a patient portal, the interaction will be

captured and added automatically to a patient’s history. In addition, patient visits are well documented

in the patients’ medical history. The challenge with text messaging is twofold. First, there is no easy

way to document the electronic communication to the patient history. It will take time when providers

currently have trouble keeping pace with simply recording information from patient appointments. In

addition, the sheer volume of patients who providers could be texting makes the documentation

problem exponentially harder.

Dr. Burgert (2015) does not include all text communications in a patients chart, saying she only

includes information that would change future prescribing. While providers cannot predict the future

regarding what will be relevant to a patients care, the idea of not incorporating every aspect of a

patient-provider conversation in the patient chart is no different from current medical practices during


an appointment in the office. Doctors throughout the country use their medical education to decipher

what goes into the patients chart. Although this is a controversial topic with text messaging initiatives; it

is no different from what is currently done in regular medical practice.

In addition to the ethical challenges, another challenge with the use of text messaging services is

provider reimbursement. Currently, no reimbursement model exists for text messaging, however,

“there is a movement to align incentives for patient engagement and value-based outcomes” (Wong,

Merchant & Moreno, 2014). As healthcare progresses towards a comprehensive care model more

focused on outcomes, no technology should be overlooked as an option for helping to reach those goals.

The Center for Connected Health Policy reports that 46 states now reimburse for live video

communication (telemedicine); when just a few years ago, similar to text messaging, reimbursement

was a question for telemedicine. While reimbursement is important, Dr. Burgert (2015) points out that

every profession offers services that are not reimbursable. The healthcare trend with technology

focuses on live communication for reimbursement. Text messaging is not considered live

communication, and, therefore, could end up being a service not reimbursable in healthcare.

Solution

A possible solution to the challenges surrounding text messaging in healthcare is the use of a

HIPAA compliant messaging service. This could include mobile apps or software. Pew Research data

regarding adolescent text messaging and the number of text messages sent per day did not distinguish

between SMS texts and texts sent through a mobile app (Lenhart, 2015)(Appendix E). For providers who

are trying to reach adolescent patients this could mean there is no difference in the patients mind as to

whether they are using an app to text or SMS. The only issue for the adolescent patient is can they

receive messages on the mobile device they carry with them.


The technology for secure messaging currently exists and is how patients receive appointment

reminders and notifications when lab results are available. Dr. Burgert (2015) points out that “these

systems are costly and cumbersome and not practical for individual provider use.” In addition to the

issues Dr. Burgert shares, there is limited ability to personalize messages to patients, which could limit

their impact. It also is important to keep in mind that secure messaging services claim they are HIPAA

compliant; however, none have been vetted by an official government agency (Martinez, 2015). There

are, however, companies that offer secure messaging services that will sign a business associate

agreement (BAA) to show their commitment to the final HIPAA Omnibus rule, as well as, their focus on

being a HIPAA compliant communication tool.

One company willing to sign a BAA is called Everbridge and they offer a secure text messaging

app called HipaaBridge. What is unique about Everbridge is not only do they offer the opportunity for

providers to text message each other, but they also offer the ability for the patient and provider to

directly communicate through secure text messaging. In regards to security, Everbridge (2015) claims

the HipaaBridge app uses “RSA 2048 public/private key encryption while leveraging an encryption key

exchange mechanism…the phone’s database is AES256 encrypted to thwart hacking attempts and

jailbreaks” and “[their] architecture ensures that messages are never decrypted outside of the client.”

In addition, to the security of the message they claim their servers are certified for HIPAA, as well as,

holding other security certifications. Aside from security measure on the Everbridge servers,

HipaaBridge also allows for security on the mobile device with the ability to log in and out of the app

with a username and password created by the user (Appendix F). For the adolescent patient who is

prone to losing or sharing their phone, this ability ensures their conversations and PHI stay private, even

when their phone is not with them.

Currently the HipaaBridge app is available for iOS and PC platforms only, which limits the

patients who can use this product for now. After downloading the app, the user is asked to choose a


user name and password to create their account, receiving a verification email upon completion. Once

in the app, the user (patient or provider) is then taken to a messaging page where they can

communicate with anyone who owns this app (Appendix G). By using an app where users create their

account, HipaaBridge is able to work around the issue of only being able to communicate with a

directory. This is what allows for communication between providers and their patients.

Two challenges mentioned above for text messaging were cost of secure platforms and the

ability to put information in the patient chart. Cost could still be an issue. The service is free to the

patient, so cost is not a barrier that will keep them from using this service. However, providers will have

to pay. According to Danielle Dimond (2015) on the Everbridge sales team, “We offer buckets of patient

licenses at a lower cost than a typically user license, making it feasible for providers to cover those they

are looking to communicate with.” As for the ability to include communicated information in the

patient chart, that will continue to be a challenge.

Conclusion

Dr. Dyer (2015) mentioned that patient engagement is the blockbuster drug of the century. By

reaching patients where they prefer to communicate, there is an opportunity to engage them.

Adolescent patients prefer text messaging for their communication needs creating an opportunity

through text messaging for healthcare providers to better engage them. This is important because the

adolescent patient is a low utilizer of healthcare and needs to be engaged at a time where they are

considered a high risk patient.

While data regarding text messaging has not shown conclusive results, studies focused more on

engaging and educating patients to improve knowledge have seen success. This focus on engagement

versus changing behaviors is the first key to making text messaging a successful communication tool. In

addition, past research has given other keys to success such ease in understanding the message,


message length, message frequency, positive tone, and who is around when the message is received.

While these additional keys are not necessarily unique to the adolescent patient, research indicates this

is what they are looking for from text messaging initiatives.

Although text messaging is the preferred form of communication for adolescent patients there

are concerns around the privacy of PHI. SMS texting is known to not be able to protect information;

leaving the patient vulnerable and the provider who uses SMS text messaging at risk. Pew Research

data indicates that while teens prefer text messaging they do not distinguish between SMS and text

messaging apps (Lenhart, 2015).

Mobile apps, such as HipaaBridge, are options that need to be used by providers. Complaints

about these apps in the past have included that they are cumbersome and lack the ability to personalize

messages, however, HipaaBridge is attempting to change that. Patients can easily download the app

and providers can speak to users outside of their organizations directory; making this an option to

communicate in a personal way with patients.

With secure messaging services that protect the patients’ information providers still cannot

forget their ethical obligation to informed consent. Because patients use mobile devices everyday it

does not mean that they understand the risks to their PHI when using these devices. In using a secure

messaging service and documenting informed consent; it ensures patients are protected the way they

need to be. By protecting adolescent patients PHI, as well as, informing them of the risks of the

technology it helps give text messaging a place in the patient-provider care process. If engagement is

the blockbuster drug of this century and the way to engage adolescent patients is through text

messaging; secure text messaging is the way to ensure this technology is a viable option moving

forward.


Appendix A

(Lenhart, 2015)


http://www.pewinternet.org/2015/04/09/teens-social-media-technology-overview-2015/pi_2015-04-09_teensandtech_10/

Appendix B

(Lenhart, 2015)



Appendix C

(Lenhart, 2015)


http://www.pewinternet.org/2015/08/06/teens-technology-and-friendships/2015-08-06_teens-and-friendships_2-04/

Appendix D

Sample Messages Dr. Burgert uses:

“Better morning with this medication?”

“Go ahead with the plan we discussed. Please reply so I know you received.”

“Prepared. Focused. Calm, Your body is health and well. Good luck today.”

(Hoffman, 2012).


Appendix E

(Lenhart, 2015)



Appendix F

(Screenshot from personal phone)


Appendix G

(Screenshot from Apple App store)


References

Beauchamp, T.L. & Childress, J.F. Principles of Biomedical Ethics. New York: Oxford University Press, 2013. Print.

Burgert, Natasha. Personal Interview. 30 October 2015.

Center for Connected Health Policy. (2014). State Telehealth Policies and Reimbursement Schedules: A Comprehensive Plan of the 50 States and District of Columbia. [September]. Retrieved from http://cchpca.org/sites/default/files/uploader/50%20STATE%20MEDICAID%20REPORT%20SEPT%202014.pdf.

Comstock, J. (2013). How HIPAA hampers text messages for health. mobil health news. Retrieved from http://mobihealthnews.com/20440/how-hipaa-hampers-text-messages-for-health/.

Devine, S., Bull, S., Dreisbach, S. & Shlay, J. (2014). Enhancing a Teen Pregnancy Prevention Program with Text Messaging: Engaging Minority Youth to Develop TOPO Plus Text. Journal of Adolescent Health, 54, S78-S83.

Dimond, D. Personal Interview. 3 December 2015.

Dyer, Jennifer. Personal Interview. 10 October 2015.

Everbridge. (n.d.). HIPAA compliance is more than encryption. Everbridge, Inc. 3 December 2015. Retrieved from http://www.hipaachat.com/security/.

Gold, J., Lim, M.S.C, Hellard, M.E., Hocking, J.S. & Keogh, L. (2010). What’s in a message? Delivering sexual health promotion to young people in Australia via text messaging. BMC Public Health, 10: 792.

Hoffman, J. (2012, October 8). Texting the Teenage Patient. The New York Times. Retrieved from http://well.blogs.nytimes.com/2012/10/08/texting-the-teenage-patient/?_r=1.

Lenhart, A. (2015). Chapter 2: How Teens Hang Out and Stay in Touch With Their Closest Friends. Pew Research Center. Retrieved from http://www.pewinternet.org/2015/08/06/chapter-2-how-teens-hang-out-and-stay-in-touch-with-their-closest-friends/.

Lenhart, A. (2015). Mobile Access Shifts Social Media Use and Other Online Activities. Pew Research Center. Retrieved from http://www.pewinternet.org/2015/04/09/mobile-access-shifts-social-media-use-and-other-online-activities/.


http://www.pewinternet.org/2015/04/09/mobile-access-shifts-social-media-use-and-other-online-activities/

http://www.pewinternet.org/2015/04/09/mobile-access-shifts-social-media-use-and-other-online-activities/

http://www.pewinternet.org/2015/08/06/chapter-2-how-teens-hang-out-and-stay-in-touch-with-their-closest-friends/

http://www.pewinternet.org/2015/08/06/chapter-2-how-teens-hang-out-and-stay-in-touch-with-their-closest-friends/

http://well.blogs.nytimes.com/2012/10/08/texting-the-teenage-patient/?_r=1

http://www.hipaachat.com/security/

http://mobihealthnews.com/20440/how-hipaa-hampers-text-messages-for-health/

http://cchpca.org/sites/default/files/uploader/50%20STATE%20MEDICAID%20REPORT%20SEPT%202014.pdf

http://cchpca.org/sites/default/files/uploader/50%20STATE%20MEDICAID%20REPORT%20SEPT%202014.pdf

Martinez, X.E. (2015). What Does HIPAA Think About You Texting Patients? Power Your Practice. Retrieved from http://www.poweryourpractice.com/medical-technology-trends/hipaas-stance-on-doctors-texting-patients/.

Montgomery, J. (2011). JCAHO Issues Ban on Physician Texting, Signifies Importance of Secure Mobile Communication Outside SMS. mHealthWatch. Retrieved from http://mhealthwatch.com/jcaho-issues-ban-on-physician-texting-signifies-importance-of-secure-mobile-communication-outside-sms-18266/.

Preston, K.E., Walhart, T.A. & O’Sullivan, A.L. (2011). Prompting Healthy Behavior via Text Messaging in Adolescents and Young Adults. Patient Education, 247-252. DOI: 10.1177/1559827610392325.

“Tips on Informed Consent.” U.S. Department of Health and Human Services. 16 March 1993. Web. 25 November 2015. Retrieved from http://www.hhs.gov/ohrp/policy/ictips.html.

Schnall, R., Okoniewski, A., Tiase, V., Low, A., Rodriguez, M., & Kaplan, S. (2013). Using Text Messaging to Assess Adolescents’ Health Information Needs: An Ecological Momentary Assessment. Journal of Medical Internet Research, 15(3), e54. DOI: 10.2196/jmir.2395.

Selkie, E.M., Benson, M. & Moreno, M. (2011). Adolescents’ Views Regarding Uses of Social Networking Websites and Text Messaging for Adolescent Sexual Health Education. American Journal of Health Education, 42(4), 205-212.

“Standards for Privacy of Individually Identifiable Health Information.” U.S. Department of Health and Human Services. 28 December 2000. Web. 25 November 2015. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2000-12-28/pdf/00-32678.pdf.

West Jr., D. (2014). Doctors Use Social Media to Connect with Patient. Social Media Today. Retrieved from http://www.socialmediatoday.com/content/doctors-use-social-media-connect-patients.

Wong, C.A., Merchant, R.M. & Moreno, M.A. (2014). Using social media to engage adolescents and young adults with their health. Elsevier, 2(4), 220-224. Retrieved from http://www.sciencedirect.com/science/article/pii/S2213076414000992.

Woolford, S.J., Blake, N. & Clark, S.J. (2013). Texting, Tweeting, and Talking: E-Communicating with Adolescents in Primary Care. Contemporary Pediatrics, 12-18.


http://www.sciencedirect.com/science/article/pii/S2213076414000992

http://www.socialmediatoday.com/content/doctors-use-social-media-connect-patients

http://www.socialmediatoday.com/content/doctors-use-social-media-connect-patients

http://www.gpo.gov/fdsys/pkg/FR-2000-12-28/pdf/00-32678.pdf

http://www.hhs.gov/ohrp/policy/ictips.html

http://mhealthwatch.com/jcaho-issues-ban-on-physician-texting-signifies-importance-of-secure-mobile-communication-outside-sms-18266/




http://www.poweryourpractice.com/medical-technology-trends/hipaas-stance-on-doctors-texting-patients/

http://www.poweryourpractice.com/medical-technology-trends/hipaas-stance-on-doctors-texting-patients/

Documents

Adolescent Text Messaging Research Paper