title: Qualitative analysis of programmatic initiatives to text patients with mobile devices in resource-limited health systems.
abstract: BACKGROUND
  Text messaging is an affordable, ubiquitous, and expanding mobile communication technology. However, safety net health systems in the United States that provide more care to uninsured and low-income patients may face additional financial and infrastructural challenges in utilizing this technology. Formative evaluations of texting implementation experiences are limited. We interviewed safety net health systems piloting texting initiatives to study facilitators and barriers to real-world implementation.
  
  
  METHODS
  We conducted telephone interviews with various stakeholders who volunteered from each of the eight California-based safety net systems that received external funding to pilot a texting-based program of their choosing to serve a primary care need. We developed a semi-structured interview guide based partly on the Consolidated Framework for Implementation Research (CFIR), which encompasses several domains: the intervention, individuals involved, contextual factors, and implementation process. We inductively and deductively (using CFIR) coded transcripts, and categorized themes into facilitators and barriers.
  
  
  RESULTS
  We performed eight interviews (one interview per pilot site). Five sites had no prior texting experience. Sites applied texting for programs related to medication adherence and monitoring, appointment reminders, care coordination, and health education and promotion. No site texted patient-identifying health information, and most sites manually obtained informed consent from each participating patient. Facilitators of implementation included perceived enthusiasm from patients, staff and management belief that texting is patient-centered, and the early identification of potential barriers through peer collaboration among grantees. Navigating government regulations that protect patient privacy and guide the handling of protected health information emerged as a crucial barrier. A related technical challenge in five sites was the labor-intensive tracking and documenting of texting communications due to an inability to integrate texting platforms with electronic health records.
  
  
  CONCLUSIONS
  Despite enthusiasm for the texting programs from the involved individuals and organizations, inadequate data management capabilities and unclear privacy and security regulations for mobile health technology slowed the initial implementation and limited the clinical use of texting in the safety net and scope of pilots. Future implementation work and research should investigate how different texting platform and intervention designs affect efficacy, as well as explore issues that may affect sustainability and the scalability.
authors: Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA. sachin.garg@ucsf.edu.
authors: Sachin K
authors: SK
authors: Garg
authors: Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA.
authors: Courtney R
authors: CR
authors: Lyles
authors: Department of Social and Behavior Sciences, UCSF, San Francisco, USA.
authors: Sara
authors: S
authors: Ackerman
authors: Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA.|Department of Epidemiology and Biostatistics, UCSF, San Francisco, USA.
authors: Margaret A
authors: MA
authors: Handley
authors: Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA.
authors: Dean
authors: D
authors: Schillinger
authors: Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA.
authors: Gato
authors: G
authors: Gourley
authors: Center for Care Innovations, Oakland, USA.
authors: Veenu
authors: V
authors: Aulakh
authors: Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA.
authors: Urmimala
authors: U
authors: Sarkar
mesh_terms: D002140:California; D006801:Humans; D011320:Primary Health Care / Q000706:statistics & numerical data*; D036301:Qualitative Research; D064876:Safety-net Providers / Q000706:statistics & numerical data*; D017216:Telemedicine / Q000706:statistics & numerical data*; D060145:Text Messaging / Q000706:statistics & numerical data*