Closing the consultation: The role of Short Message Service (SMS) in sexual health result provision Dr Anatole S Menon

-Johansson
a.menon-johansson@nhs.net Clinical Lead for Sexual Health Guy’s & St Thomas’ Hospitals, London, UK mHealth Conference & Expo Dubai, 15th September, 2010

• Sexual Health services are open access in the UK • Over one million sexual health screening and diagnostic visits are performed annually • The majority of results from tests are negative • Result provision takes up time and resources • Providing timely results (positive / negative) are important to effectively close the consultation
– Reduce the time to treatment – Manage anxiety – Increase capacity to see new patients

the UK: The communication challenge

Patient acceptability and confidentiality guidelines
• Questionnaire (November 2003)

-98% owned a mobile phones -68% had access to a personal email address -Result format preference: -Phone > Text message > In person -No patient identifiable information in text -Non-attributable text message header -Text message does not contain details of tests performed

• Caldecott guidelines

Mont Numbe Number of text h, r of messages 2004 sexual health screen “All your “Please “Please s results ring the come are clinic” back to negative” the clinic” March 875 17 4 1

The first six months of the text message result service
Number of results and staff time required (number of results hours taken) Text

Proporti Cost of on of result total service results (£) Phone In Total by text (%) person

22 (0.3) 123 (3.1) 176 (4.0) 199 (4.8) 147 (3.5) 285 (6.5)

410 (27.3) 293 (19.5) 263 (17.5) 290 (19.3) 410 (27.3) 365 (24.3) 2031

441 873 (88.2) (115.8 ) 302 (60.4) 718 (83)

4

1505

April May June July Augus t

774 746 947 987 889

100 149 172 125 218

14 22 15 13 54

9 5 11 10 13

17 26 26 19 34 20

1079 930 1000 1011 897 6445

250 689 (50.0) (71.5) 264 753 (52.8) (76.9) 235 792 (47.0) (77.8) 191 (38.2) 1683 841 (69)

Total 5218 781 122 49 952 trachomatis infection. Sex Transm Infect. 2006;82(1):49-51

Menon-Johansson AS, McNaught F, Mandalia S et al. Texting decreases the time to treatment for genital Chlamydia

4666

Impact of text message result service
Text group (n=28) Number (%) 27 (96.4) Standard group p Value (n=21) Number (%) 20 (95.2) 0.835 Gender female Race White British White other Black British Black other Other Not known Mean age, years (SD) 11 (39.3) 5 (17.9) 4 (14.3) 4 (14.3) 3 (10.7) 1 (3.6) 24.8 [3.9) 6 (28.6) 5 (23.8) 4 (19.0) 1 (4.8) 5 (23.8) 0 (0.0) 27.2 [8.6) 12.5 (4.5) (6–20) 1 (IQR 0 to 2) (0–15) 15 (9 to 18) (7–35) 0.227* <0.001* 0.756† 0.005†

Mean time to diagnosis, days (SD) (range) 7.9 (3.6) (4–23) Median time from contact to treatment, days (range) 1 (IQR 0–3) (0–20)

Median time from test to treatment, days 9 (IQR 7–14) (4– (range) 27)

Menon-Johansson AS, McNaught F, Mandalia S et al. Texting decreases the time to treatment for genital Chlamydia trachomatis infection. Sex Transm Infect. 2006;82(1):49-51

• The UK has some of the worst sexual & reproductive health indices in Europe

Public Health need / Policy driver

• Increasing access to sexual health services was made a key objective for the Department of Health (DH) in England and Wales in 2005 • In 2006 the DH published ten high impact changes designed to enhance 48-hour access to genitourinary medicine (sexual health) services
– Department of Health. 10 High Impact Changes for Genitourinary Medicine 48-hour Access. 277527/10 DH Publications. (accessed 17th March, 2010)

Project management, timeline & papers partnership Clinician leadership & private company
• (Mikkom www.mikkom.com) • Local start-up investment & payment for ongoing use of the technology by the hospital • Key milestones March 2004 & October 2006 • Pilot > evaluation (E) > publication (P) > E > P ….

Papers published to date: – Menon-Johansson AS, McNaught F, Mandalia S et al. Texting decreases the time to treatment for genital Chlamydia trachomatis infection. Sex Transm Infect. 2006;82(1):49-51 – Menon-Johansson, A.S., McNaught, F, Sullivan, A.K. Closing the clinical consultation: saving time and money in result provision. Sex Transm Infect 2006; 82(Suppl II): A18 – Jones R, Menon-Johansson A, Waters AM et al. eTriage - a novel, web-based triage and booking service: enabling timely access to sexual health clinics. Int J STD AIDS. 2010;1:30-33

• Clinical acceptance won by:

Critical steps during implementation

– Clinical champions, small pilots, no harm & benefit demonstrated, transparent evaluations & publications, support from the profession & DH

• In house start-up funding essential for technology and extra staff, able to cover ongoing costs until returns were realized • Challenges: Building error free process (cards & 2/52 safety window), working with stand alone databases and hospital IT Department

Menon-Johansson AS, Cohen CE, Jones R et al. Interventions to increase access to STI services: A study of England’s ‘High Impact Changes’ across three central London clinics.

Results, impact
• Four evaluations completed & published • Main outcomes
– Faster treatment times for Chlamydia – Fall in follow-up to new patient ratio (0.67 > 0.21) – 80% results by text – 15% appointments via website

• IT changes > 2x rise in patient access (44% vs 20%) • Limitations to analyzing the impact of IT • Observation: The power of libertarian paternalism
(Nudge by Thaler & Sunstein, Penguin books http://nudges.org/)

Critical success factors
• Strengths: Clinical champions, responsive IT partner, independent funding, focus on evaluation • Weaknesses: Separate IT databases, slow to implement opt-out, limited social marketing • Success factors: Support at front line, evaluation, results communication, economic logic (PbR) • Lessons learned: Many [IT, sociology, anthropology] • Reactions / Attitudes: Patients reactions are positive, staff & profession have been convinced, DH supportive

Future challenges
• Changing IT landscape
– NHS mail now provides free email / text / fax – New SMS providers in marketplace

• Areas to address
– New providers of sexual & reproductive health care – Non-standard electronic patient record software – Silos [data, provision & expertise] – Sexual networks – Economies of scale

• New priorities
– Cost pressures / Cloud computing / mobile technology

• Telephonetics VIP: Patient can call to hear results & text message automatically sent to patient using NHS mail (www.telephoneticsvip.co.uk) • Text to book: patient texts clinic requesting an appointment. Pre-allocated slots in clinic made available to SMS engine (www.mikkom.com) • Partner notification by text: partner texted by patient or provider informing them of potential exposure to a sexually transmitted infection

Automation and expanding the role of SMS in sexual health care service

Acknowledgements
• Dr Ann K Sullivan at Chelsea & Westminster NHS Foundation Trust • Mike Unger at Mikkom (Windsor, UK) • Guy’s & St Thomas’ NHS Foundation Trust

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