Health Text Messaging Recommendations to the Secretary
Written by the U.S. Department of Health and Human Services (HHS) Text4Health Task Force
Text4Health Task Force Members
Todd Park (co-chair): HHS, Immediate Office of the Secretary
Wanda Jones, DrPH (co-chair): HHS, Office of the Assistant Secretary for Health
Julia Eisman, MPA (co-chair): HHS, Office of the Assistant Secretary for Public Affairs
Audie Atienza, PhD: HHS, Immediate Office of the Secretary
George Askew, MD: Administration for Children and Families
Erik Augustson, PhD, MPH: National Institutes of Health
Katherine Beckmann, MPH: Administration for Children and Families
Aman Bhandari, PhD: HHS, Immediate Office of the Secretary
Diane Bogusz, C.P.C.M., CPM: HHS, Assistant Secretary for Administration
Valerie Borden, MPA: HHS, Office of the Assistant Secretary for Health
Jennifer Buschick, MPA: HHS, Office of the Assistant Secretary for Health
Mark Carroll, MD: U.S. Indian Health Service
Arnaub Chatterjee, MHA, MPA: HHS Office of the Assistant Secretary for Administration
David Dietz, MD: HHS, Office of the Assistant Secretary for Health
Greg Downing, MD: HHS, Immediate Office of the Secretary
Ira Dreyfuss, PhD: HHS, Office of the Assistant Secretary for Public Affairs
Adam Greene, JD, MPH: HHS, Office for Civil Rights (until June 2011)
Yael Harris, PhD: Health Resources and Services Administration
Elizabeth Kittrie, MMHS: HHS, Office of the Assistant Secretary for Planning and Evaluation
Sanjay Koyani, MPH: U.S. Food and Drug Administration
Cristian Liu: HHS, Office of the Assistant Secretary for Administration (until July 2011)
Sabrina Matoff-Stepp, PhD: Health Resources and Services Administration
Joseph McCannon: Centers for Medicare and Medicaid Services
Bakul Patel, MBA, MSc: U.S. Food and Drug Administration
AJ Pearlman: HHS, Office of External Affairs
Paul Stange, MPH: U.S. Centers for Disease Control and Prevention
Martina Taylor, MT: National Institutes of Health
Robyn Whittaker, MBChB: Health Resources and Services Administration (until July 2011)
Andrew Wilson, MS: Substance Abuse and Mental Health Services Administration
Michael Yea: HHS, Office of the Assistant Secretary for Administration
Wil Yu: HHS, Office of the National Coordinator for Health Information Technology
Health Text Messaging: HHS Text4Health Task Force Recommendations
Rapid Growth of Mobile Technology
Mobile phones and other portable health information technologies offer unprecedented opportunities to improve the health of the U.S. population and reach traditionally underserved subgroups (e.g., rural communities, low-income groups, and ethnic minority populations). Mobile phone use, in particular, has proliferated at an astounding rate. As of December 2010, there were more than 302 million wireless subscribers1 in the U.S. and an estimated 5 billion mobile cellular subscriptions worldwide2. Currently, 85% of U.S. adults own mobile phones, with 17% of them accessing health information using their mobile phones3. Ethnic minority groups are more likely to own a mobile phone4 and use mobile phones to access health information3. In addition, 75% of teenagers own a mobile phone5. The iTunes App Store currently offers more than 8,000 Healthcare and Fitness and Medical iPhone/iPad applications (accessed August 25, 2011); the Google Android Market offers more than 2000 Health & Fitness and Medical applications (accessed August 25, 2011). Although smart phones are expected to increase from approximately 25% to over 50% of the U.S. mobile phone market by the end of 20116, a significant portion of the population will still lack access to this technology. However, text messaging (also referred to as Short Message Service (SMS)) is a mobile phone application that is widespread among large segments of the population, cutting across various mobile phone handset devices, operating systems, and telecommunications networks.
Approximately 2.2 trillion text messages were sent in the U.S. in 20101. Text messaging is particularly prevalent among teenagers, with nearly 90% of teenagers who have cell phones reporting that they use text messaging (with >50% texting daily)5. In addition, among a sample of low-income households on Medicaid, 80% of patients report texting regularly7. A growing body of empirical studies suggests that the use of mobile phone text messaging can be effective in improving health behaviors and health outcomes8-11
The Department of Health and Human Services (HHS) has been actively exploring means to capitalize on the rapid proliferation of mobile phone technology and platforms, such as text messaging, to develop programs and/or partnerships with the overall aim of improving public health. HHS has embarked on several health text messaging initiatives that show great promise, including the ‘text4baby’ program12, a public-private partnership supported by non-Federal funding to a non-governmental organization; HHS’ role has been to ensure evidence-based non-commercial messages and to evaluate the program. The HHS evaluation results of the “text4baby” program are expected to be available in 2012. The potential to provide citizens with an unprecedented level of access to resources using mobile technology can help HHS achieve its goal of a healthier and more secure nation, even as we help individuals and families get critical information that can improve -- and even save -- their lives.
In November 2010, HHS established the Department-wide Text4Health Task Force as part of our commitment to promoting innovation at HHS. The Task Force was charged with identifying ongoing initiatives and proposals for feasible new projects which would deliver health information and resources to users' fingertips via their mobile phones. In addition, the Task Force provided general recommendations for HHS’ role in encouraging and/or developing health text messaging and mobile health programs in the future.
Health text messaging and mobile health technologies offer significant potential for addressing HHS key priority areas. Because health text messaging is relatively new, however, application of this technology has been limited to just a few health issues. Based on the initial health text messaging programs conducted thus far [e.g., Centers for Disease Control and Prevention’s H1N1 Flu Text Messaging Pilot13, the text4baby program12, and research supported by the National Institutes of Health (NIH; e.g., mDiet research program14)], the Task Force makes the following recommendations:
Recommendation 1: Facilitating Health Text Messaging Development.The Task Force recommends that HHS develop and host evidenced-informed health text message libraries to leverage HHS’ rich and scientifically-based information. This information should be open access and free to the public. Areas prime for development include smoking cessation, emergency response/preparedness, early childhood health, maternal/child health, heart disease, diabetes, mental health, oral health and obesity.
Recommendation 2: Research and Evaluation. The Task Force recommends that HHS develop further evidence on the effectiveness of health text messaging programs. HHS is currently conducting a formal evaluation of the text4baby program, a public-private partnership that is the first free-to-end-user health text messaging program available nationwide. Future health text messaging programs by HHS, or in which HHS is a partner, should also include a scientific evaluation component. To keep pace with the dynamic nature of mobile technology, robust and periodic (e.g., quarterly or annually) assessments of funding opportunities and the development of new/emerging technologies are also recommended.
Recommendation 3: Partnerships among Federal Government Agencies and with Non-Federal Organizations.The Task Force recommends HHS explore and develop partnerships to create, implement and disseminate health text messaging and mobile health (mHealth) programs. It is further recommended that in FY2012 specific HHS staff persons (e.g., HHS mHealth lead) serve as main points of contacts to represent HHS in discussions of collaborations or partnerships with other stakeholders in the mHealth ecosystem. Because health text messaging and mHealth utilize consumer-facing technologies and are relevant to many stakeholders, partnerships among HHS, other governmental agencies, and non-federal organizations often are needed to develop successful projects. Identifying specific HHS representatives would facilitate the development and coordination of partnerships and should work closely with the HHS Chief Technology Officer.
Recommendation 4: Coordination across HHS. The Task Force recommends that HHS form a mobile health (mHealth) community of practice, initially led by HHS staff in the Office of the Secretary, that meets regularly (e.g., monthly or quarterly) to discuss and coordinate mHealth activities, including health text messaging, across the Department. An HHS-specific group does not yet exist to systematically explore and discuss which topic areas or health problems might best be addressed by HHS via health text messaging and mobile technologies. The community of practice can serve to encourage synergy and collaboration among related projects across the Department when appropriate.
Recommendation 5: Integration of Health Text Messaging/mHealth with Other HHS Health Information Technology Priorities (e.g., Electronic Health Records, Cloud Computing, Health Games, etc.). The Task Force recommends that HHS align health text messaging/mHealth activities with other HHS Health IT priorities. Although mobile technology programs can enhance other Health IT systems if thoughtfully integrated and coordinated, complications or unanticipated consequences may result if not considered in concert. The HHS mHealth community of practice can also facilitate information sharing related to the integration of mHealth with HHS health information technology initiatives more broadly.
Recommendation 6: Delineating Privacy/Security Issues. The Task Force recommends that HHS conduct further research into the privacy and security risks associated with text messaging of health information and establish guidelines for managing such privacy/security issues. Furthermore, mHealth issues should be discussed within the HHS Inter-Division Health IT Policy and Security Task Force. The exchange of health information via text messages raises privacy and security issues specific to this medium. Text messaging programs may be subject to numerous privacy and security laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules.
Recommendation 7: Regulatory Issues.The Task Force recommends that relevant HHS agencies (FDA, NIH, AHRQ, ONC, etc.) conduct research on future trends of text messaging technologies and establish regulatory guidelines for these interactive systems that can be used in treating, curing, mitigating or preventing diseases or conditions. Future developments in health text messaging and mHealth technology will likely create and extend beyond its current capabilities to create interactive systems that will enable active treatment and prevention of diseases or conditions in humans. Applying medical device and clinical research principles to evaluate interactive text messaging programs must take into account the safety and effectiveness of SMS technology while also facilitating innovation.
II. Guiding Principles in Health Text Messaging at HHS
This section outlines guiding principles in the overall creation, implementation and evaluation of health text messaging programs; they are meant to serve as a framework or "playbook" for future programs. These principles do not focus on best practices for creating compelling text messages; guidance is available at: http://www.cdc.gov/socialmedia/tools/guidelines/pdf/textmessages.pdf.
Guiding Principle #1: Determine the role of HHS in the health text message project.
- Identify the particular need or health issue to be addressed by health text messaging, and whether the mission of HHS (or respective HHS agency) can be advanced and achieved by developing the health text messaging program. Reviewing the existing literature on the potential effectiveness of text messaging for the given situation/issue is advised.
- Determine whether similar health text messaging programs are being developed by others at HHS, other Federal agencies, or outside the government. An environmental scan of HHS activities can help avoid unnecessary overlap, reduce costs, identify potential partners, and create synergy among various projects.
- Determine which aspects of the project are uniquely or ideally governmental and therefore should be the responsibility of HHS to develop.
- Determine whether the health text messaging program is or could be part of a larger health initiative. While stand-alone health text messaging programs can be developed, integrating the health text messaging program within a larger initiative may be more effective and have a greater public health impact.
- Projects should abide by federal legislative and legal policies and regulations (Section 508, federal procurement policy, etc.). Consultation with the HHS Office of the General Counsel is strongly advised.
Guiding Principle #2: Establish plans for program implementation and evaluation.
- Conduct formative usability and user-centered research with the target audience at the beginning of the project and when major program changes occur. Content should be tailored to target populations and match relevant needs of the groups of interest (e.g., text messages should be culturally and linguistically appropriate).
- Develop plans for process, program and outcome evaluations from the beginning of the project. Ideally, outcome evaluations should be hypothesis-driven and conducted by an independent, objective entity.
- Address privacy and security issues associated with text messaging and mobile health directly.
- Assess lessons learned from evaluations of similar or related projects to aid in shaping the development of new projects
Guiding Principle #3: Delineate partnerships, governance structure and business models.
- If partnerships or collaborations exist, develop a governance structure to outline clearly the roles and responsibilities of the various partners. Partners should determine collaboratively and clarify in writing through MOUs or similar documents how each partner will contribute to the collaboration, the program decision making process, and program/content ownership.
- Identify one HHS representative to serve as the lead point of contact for the respective health text messaging project. For very large initiatives, an alternate(s) should be identified. Key contacts at collaborating organizations also should be identified.
- Outline potential business models for the development and possible sustainability of the health text messaging programs.
- CTIA, 2010. U.S. wireless quick facts. http://www.ctia.org/advocacy/research/index.cfm/aid/10323
- International Communications Union, 2010. Key Global Telecom Indicators for the World Telecommunication Service Sector.
- Fox, Susanna. Mobile health 2010. Pew Internet and American Life Project, 19 October 2010. http://www.pewinternet.org/~/media//Files/Reports/2010/PIP_Mobile_Health_2010.pdf
- Smith, Aaron. Mobile access 2010. Pew Internet and American Life Project, 7 July 2010. http://www.pewinternet.org/~/media//Files/Reports/2010/PIP_Mobile_Access_2010.pdf
- Lenhart, Amanda et al. Teens and mobile phones. Pew Internet and American Life Project, 20 April 2010. http://www.pewinternet.org/~/media//Files/Reports/2010/PIP-Teens-and-Mobile-2010-with-topline.pdf
- Entner, Roger. Smartphones to overtake features phones in U.S. by 2011. 26 March 2010.
- Pricewaterhousecoopers, Healthcare unwired: New business models delivering care anywhere. 2011.
- Fjeldsoe et al., 2010, MobileMums: a randomized controlled trial of an SMS-based physical activity intervention. Annals of Behavioral Medicine; 39(2):101-11.
- Krishna et al., 2009, Healthcare via cell phones: a systematic review.Telemedicine and e-Health; 15(3):231-40.
- Whittaker et al., 2009, Mobile phone-based interventions for smoking cessation.Cochrane Database of Systematic Reviews; 4.
- Cole-Lewis and Kershaw, 2010, Text messaging as a tool for behavior change in disease prevention and management Epidemiologic Reviews; 32(1):56-69.
- The Department of Health and Human Services, Office of Women’s Health, 2010. Text4baby. http://www.womenshealth.gov/about-us/government-in-action/text4baby.cfm. Also see Centers for Disease Control and Prevention, 2011. Text4baby for Pregnant Women and New Moms. http://www.cdc.gov/Features/Text4Baby/.
- Centers for Disease Control and Prevention, 2011. Social Media at CDC. http://www.cdc.gov/SocialMedia/Tools/Mobile.html
- National Institute of Health. “mDiet: A Text Message Intervention for Weight Loss”. 27 July 2010. http://clinicaltrials.gov/ct2/show/NCT01171586