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Posted on Sep 16, 2012 in Letters | 0 comments

The use of short message service (SMS) for patient appointment reminders


Susan McClean1, Dr Mahendra Perera MBBS1
1Albert Road Clinic, Melbourne, Australia
Corresponding Author: mcLeans@ramsayhealth.com.au
Journal MTM 1:3:53-55, 2012
DOI:10.7309/jmtm.24


Albert Road Clinic is an acute care private psychiatric hospital with active and committed Psychiatrists who work with us. The Albert Road Clinic Consulting Suites is based within the hospital and this space is tenanted by approximately 40 consultant psychiatrists who work either full time or on a sessional basis in their private practice.  Several psychiatrists approached me to try and resolve the issue of their patients not attending for scheduled appointments; the non- attendance has potential detrimental effects for the patient (who may have forgotten the appointment) leading to possible clinical risk. The other consequences have been an adverse effect on the consultant psychiatrists’ business and the inability to back fill the appointment for which the patient has not attended.

There is evidence in the literature that reminder systems have reduced the non-attendance in various practice settings1-31. Prasad S, Anand R. (2012) 'Use of mobile telephone short message service as a reminder: the effect on patient attendance.' International Dental Journal. 17;62(1):21–6.
2. Taylor NF, Bottrell J, Lawler K, Benjamin D. (2012) 'Mobile Telephone Short Message Service Reminders Can Reduce Nonattendance in Physical Therapy Outpatient Clinics: A Randomized Controlled Trial.' Arch Phys Med Rehabil 1;93(1):21–6.
3. Sims H, Sanghara H, Hayes D, Wandiembe S, Finch M, Jakobsen H, et al.(2012) Text Message Reminders of Appointments: A Pilot Intervention at Four Community Mental Health Clinics in London. Psychiatric Services. Am Psychiatric Assoc; 63(2):161–8.
. Sims et al33. Sims H, Sanghara H, Hayes D, Wandiembe S, Finch M, Jakobsen H, et al.(2012) Text Message Reminders of Appointments: A Pilot Intervention at Four Community Mental Health Clinics in London. Psychiatric Services. Am Psychiatric Assoc; 63(2):161–8.in a controlled study demonstrated a relative risk reduction of 28 and 25 % in terms of non-attendance, in the two year studied when comparing the attendances with the year prior to no reminders being sent. Prasad and Anand 11. Prasad S, Anand R. (2012) 'Use of mobile telephone short message service as a reminder: the effect on patient attendance.' International Dental Journal. 17;62(1):21–6.
using a broader outcome  measure i.e. attending on the day and on time, noted that it occurred overall in 79% of those who received reminders and only 34% who did not receive the reminder.  Stubbs44. Stubbs ND, Geraci SA, Stephenson PL, Jones DB, Sanders S.(2012) 'Methods to Reduce Outpatient Non-attendance.' Am J Med Sci. Apr. 3. doi: 10.1097/MAJ.0b013e31824997c6 in their review noted that all reminder systems improved attendance rates but SMS reminders were the most cost effective.  It was decided that we would try and harness technology to improve patient appointment attendances within the consulting suites and we commenced a trial of sending SMS reminders, on the previous business day to the patients who indicated through the individual practices that they would like to be contacted in this way.

Our system was a corporate telecommunications service and our implementation process was communication to recruit those practices that were interested in participating in the trial of this new process. The consultants were informed that instead of calling patients to remind them of their appointments, an SMS reminder would be sent out to patients who did not object to a reminder of the appointment on the working day before.   Education was provided re the system and process to each of the consulting suites secretarial staff who were to implement the system.

The initial trial was well received by those who agreed to participate.  In view of the success we decided to implement the scheme for all of the suites.  A decision was made at the medical executive with an ‘opt out’ option, for the consultant psychiatrists.  Patients were required to sign a consent form (which is maintained by the individual consultant psychiatrists’ practices) in order to receive the reminder. Most patients understood the nature of the activity but where necessary a detailed explanation was offered by the doctor/secretarial staff.  The SMS reminder system is now a routine in all of the consulting suites none of the psychiatrists opted out.

Some strategies had been previously trialed in some of the private practices.   This has included medical secretaries attempting to telephone patients directly to confirm appointment times with them but had limited success due several issues not least the ‘human factor’ such as work demand of the medical secretaries, patients availability to respond to phone calls and the not insignificant comments that many of patients found these phone calls intrusive; particularly if they occurred within their working hours.  The strategy of calling patients was used in a limited fashion at the Clinic as well but the inherent problems outlined seemed to outweigh the benefits.

Our system now has now been in operation for eighteen months.  Anecdotally patients have expressed that the system works well. This view is in keeping with the conclusion following an extensive review of the literarture55. Guy R, Hocking J, Wand H, Stott S, Ali H, Kaldor J. (2011) 'How Effective Are Short Message Service Reminders at Increasing Clinic Attendance? A Meta-Analysis and Systematic Review.' Health Serv Res. 8;47(2):614–32..  In order to ascertain acceptability, the author spoke informally with consultant psychiatrists.  The responses have been variable. Although there were positive views there were negative comments as well.    The negatives focused upon some difficulties with reliability regarding the provider; which resulted in further investigation and the subsequent move to adopting a SMS messaging system within a patient management system which is used within our consulting suites. The system we currently utilize has the advantage of being fully integrated with the appointment calendar and accounting package for each consultant psychiatrists’ private practice.

There is a minority of patients who do not use mobile phones and the occasional patient who has opted for email reminders, and staff now have adequate time to attend to them on an individual basis.  A significant draw back has been that since patients have now become reliant on the service they have missed appointments when the system has occasionally ‘crashed’. These events have fortunately been rare but do have serious consequences for the individual practices and have caused understandable dissatisfaction to the consultants.  We are now moving towards manual reminders when such eventualities occur.  It has been essential to ensure that we have built processes to quickly respond to system failures; not least to ensure that there are contingencies in place to ensure that more than one staff member checks that the SMS reminders have been successfully sent.

Figure 1

Figure 1 – Appears on the screen of sender

Our experience would lead me to recommend the adoption of similar systems in any practice. Where this is to be introduced the key is to adequately ‘educate’ all parties, i.e. secretarial staff, the clinician or others involved in its operation. A de identified print out of the message received by the patient and confirmation of sending which is available to the secretary can be seen in Figure 1. The system needs to be robust so that if a patient responds to the SMS (Figure 2) it must come directly back to the sender rather than it getting lost in the system. An improvement that is required for the current system we operate. Give the recipient a choice to accept or reject the reminder system and obtain written consent with the phone number on which to receive the message with the onus  on that individual to inform if the number had changed or not functional any longer. The treating psychiatrist needs to keep a record of this.  A disclaimer is that patients should not rely solely on the reminder would minimize the potential of claims against the organisation in case of a bona fide systems failure is handed to the patient. A back up system of sending out reminders is required if there are problems.

Figure 2

Figure 2 – SMS received by patient

Overall, the introduction of a SMS messaging system for outpatient appointments at Albert Road Clinic has been positive. Adopting such a system not only provides a useful service but also the reminder systems have been shown to be a significant saving of costs as well33. Sims H, Sanghara H, Hayes D, Wandiembe S, Finch M, Jakobsen H, et al.(2012) Text Message Reminders of Appointments: A Pilot Intervention at Four Community Mental Health Clinics in London. Psychiatric Services. Am Psychiatric Assoc; 63(2):161–8..  The system provides a cheap, automated alternative of sending out reminders.  In addition it is a saving of the secretarial staff time.  It is recommended that the adoption of such systems will enhance the attendance not only in medical settings (as noted in the literature) but also in psychiatric out patients clinics.  The focus for future research should be directed at patient satisfaction and probable medico-legal implications of failures of the system, even with the disclaimer.  In addition the cost savings to the institution and the time savings to secretarial staff need investigation.

References

1.  Prasad S, Anand R. (2012) ‘Use of mobile telephone short message service as a reminder: the effect on patient attendance.’ International Dental Journal.  17;62(1):21–6.

2.  Taylor NF, Bottrell J, Lawler K, Benjamin D. (2012) ‘Mobile Telephone Short Message Service Reminders Can Reduce Nonattendance in Physical Therapy Outpatient Clinics: A Randomized Controlled Trial.’ Arch Phys Med Rehabil  1;93(1):21–6.

3.  Sims H, Sanghara H, Hayes D, Wandiembe S, Finch M, Jakobsen H, et al.(2012) Text Message Reminders of Appointments: A Pilot Intervention at Four Community Mental Health Clinics in London. Psychiatric Services. Am Psychiatric Assoc; 63(2):161–8. 

4.  Stubbs ND, Geraci SA, Stephenson PL, Jones DB, Sanders S.(2012) ‘Methods to Reduce Outpatient Non-attendance.’ Am J Med Sci. Apr. 3. doi: 10.1097/MAJ.0b013e31824997c6 

5.  Guy R, Hocking J, Wand H, Stott S, Ali H, Kaldor J. (2011) ‘How Effective Are Short Message Service Reminders at Increasing Clinic Attendance? A Meta-Analysis and Systematic Review.’ Health Serv Res. 8;47(2):614–32.