At Zuckerberg San Francisco General, text message system keeps nurses off the phones
Zuckerberg San Francisco General Hospital and Trauma Center serves a diverse, urban population. Approximately 40% of the population identifies as Hispanic/LatinX, 20% Asian, 18% white and 16% Black.
These backgrounds encompass a variety of socioeconomic statuses, languages spoken and education levels. The provider organization’s patients are insured by Medicaid and Medicare.
This diversity can make it difficult to ensure patients receive equitable and appropriate information prior to procedures, according to Dr. Shreya Patel, assistant professor of clinical medicine in the gastroenterology division of Zuckerberg SF General Hospital & Trauma Center.
“Currently, colorectal cancer screening is recommended by the U.S. Multi-Society Task Force for all average-risk individuals above the age of 50 and all Black individuals above the age of 45,” she explained. “Therefore, ensuring that all patients – regardless of their background – are adequately educated, prepared and willing to attend their procedure is crucial.”
However, Zuckerberg’s endoscopy unit struggled with no-shows and patients arriving unprepared for procedures despite significant, labor-intensive phone calls by nursing.
“We realized that medicine could learn a lot from the digital world that exists in our daily lives,” Patel observed. “We receive text messaging to remind us of restaurant reservations or other appointments, why not for important medical procedures?
"Additionally, we wanted an opportunity to provide patients some education and instructions. Finally, we wanted to be able to use the data gained from patient responses to help guide our scheduling.”
Given that Zuckerberg is a safety net hospital, a technology solution had to be low-cost and easy to operate, she added.
“CipherHealth technology presented us with the ability to reach out to our patients in an automated way, sending them text messages or voice calls in a scheduled fashion leading up to their appointment,” she said. “The messaging was particularly appropriate for our population, given that it could occur in multiple languages to any phone number, without the need to download a separate app.”
There are a variety of patient relationship management tools on the health IT market today, including CipherHealth, Luma Health, RevenueWell, Salesforce, Solutionreach, Weave, WebPT and WELL.
MEETING THE CHALLENGE
Zuckerberg General initially ran a pilot program on a select, high-risk group of patients and found such promising results that it now has expanded use of the technology to all patients scheduled for endoscopic procedures.
“Through our Epic electronic health record, we run a report to list all patients scheduled for procedures in the next two weeks,” Patel explained. “The report then is sent to CipherHealth multiple times a week by our research assistant. CipherHealth then uploads the data and schedules patients for the outreach.”
"It allows our nurses to have better control over scheduling, optimizing open slots and improving efficiency, which ultimately increases access for patients."
Dr. Shreya Patel, Zuckerberg SF General Hospital & Trauma Center
Currently, all patients receive a message seven days before their procedure asking them to confirm or reschedule their appointment. The message also offers other instructions to help prepare for the visit.
“This message is repeated a few times over the next 24 hours to the various phone numbers listed for anyone who does not respond,” Patel said. “The message also goes out in the patient’s preferred language, if it is English, Spanish or Chinese. The remainder default to English or ask patient preference if none is listed.”
Nurses then collect the responses from the CipherHealth platform online to understand who is planning to attend their appointment. On the day prior to the appointment, patients receive instructions on how to prepare for their procedure, either with diet or diet and laxative instructions, depending on what procedure they will undergo.
The initial program ran from December 2019 to March 2020, when COVID-19 stopped elective procedures and the program was temporarily suspended. Overall, 58% of patients responded to outreach, with 86% confirming their appointment and 14% requesting rescheduling.
Since the outreach occurs seven days prior to the appointment, Zuckerberg was able to follow up with any patient requesting rescheduling and use their slot for another patient. Text messaging in general is a fairly inexpensive intervention, especially when compared to nursing outreach, Patel noted.
“We found that patients who confirmed their appointment by text had a 75% show rate compared to 49% for patients who did not confirm,” she reported. “The data we received from our initial outreach helped us refine the program further.”
The second iteration that started in August 2020 helps engage more patients immediately, sends outreach directly in the patient’s preferred language to capture non-English speakers, and allows for more voice calling to help reach older patients who may not be comfortable with text messaging.
“Since relaunching, we already are seeing higher patient engagement with the program, with 66% of patients responding, 83% confirming their appointment, 14% indicating rescheduling, and only 1% opting out,” she said.
“Directly improving show rates helps our endoscopy unit run at full capacity, which thereby improves access to care and notably cancer screening for this vulnerable population,” she continued. “We have been able to decrease our procedure wait times and can better accommodate urgent procedures, leading to greater patient satisfaction.”
Another notable impact has been on Zuckerberg’s nursing staff. Nurses previously would spend at least 2-3 hours a day making reminder phone calls, trying to reach patients who often are difficult to contact.
“Nurses did not make any reminder phone calls during our initial program run and our show rates improved or stayed the same when compared to prior months,” she reported. “The CipherHealth system allows patients to read and respond to messages on their own time or contact us at a convenient hour.”
ADVICE FOR OTHERS
Automated text messaging and phone calls are very attractive technology in healthcare, Patel opined.
“First, it is overall a low-cost technology that can be easily scaled up and altered to fit the needs of specific departments or systems,” she advised. “It allows our nurses to have better control over scheduling, optimizing open slots and improving efficiency, which ultimately increases access for patients. Text messaging in general is a fairly inexpensive intervention, especially when you compare it to nursing outreach.”
Second, it can provide appointment confirmation as well as instructional or educational materials to the patient, she said.
“This allows providers to build the program and language to suit their particular needs,” she concluded. “Third, it helps decrease barriers to care for patients who are non-English speakers or have limited medical literacy. Finally, it decreases workload on staff and providers who can then focus their time on patients who might have questions or need extra guidance through the medical system.”