Case Study: Texting for Health at Monterey County Clinics

Communications Snafu

California’s Monterey County features a rugged coastline teeming with wildlife. Its fertile farmland produces lettuce, broccoli, cauliflower, and other crops, earning it the nickname, “The Salad Bowl of America.”  But many of the county’s residents are poor and some experience hunger despite this abundance — including the farmworkers who harvest the region’s crops. A 2016 survey found, for example, that 34 percent of county residents can’t afford enough food. Meanwhile, housing prices continue to rise — a recent report found that rental costs in the town of Salinas are twice the national average — adding to the financial stress on low-income families.

For 25 years, Monterey County Health Clinics have provided quality health services for the region’s vulnerable populations, including the uninsured, the elderly, immigrants, and the disabled. The nine clinics are busy and bustling — they receive 600-plus visits a day — and provide primary, pediatric, internal medicine, and specialty care. Patients speak a variety of languages, including Spanish, Vietnamese, Russian, Korean, and Tagalog.

The health clinics had a persistent technical problem that was slowing clinic operations. Since 2015, the clinics have used CareMessage, a digital text messaging system, to send their patients appointment reminders. (CareMessage sends messages in English and Spanish, and is exploring adding other languages as well).

The system works well, patients like it, and it helps minimize appointment no-shows. According to Adriana Velez, Monterey County Health Clinics’ Outpatient Services Manager II, as many as 80 percent of check-up and specialty appointment confirmations are now handled by CareMessage. But the CareMessage platform wasn’t compatible with Epic, the clinics’ electronic health record (EHR) system.

This technical incompatibility meant that clinic staff had to spend time manually changing appointment times in Epic when patients cancelled or rescheduled. “Staff were spending at least two hours a day transferring information from CareMessage to Epic,” says Velez. “It was tedious work.” The situation had an impact on patients too, since it took longer to get phone calls answered and messages returned. It was a frustrating situation for staff and patients alike.

With the support of Technology Hub, Monterey County Health Clinic staff decided to try to resolve this system snarl.

Creating Compatible Systems

The Monterey County Health Clinics’ Epic platform is hosted by Oregon Community Health Information Network (OCHIN), a nonprofit organization that provides technical solutions for safety net health centers.

Monterey County Health Clinics asked OCHIN about integrating Epic and CareMessage. OCHIN had a different text messaging system that was already embedded in Epic, and they suggested that Monterey County Clinics use that instead. But the embedded system could only sent confirmation messages, and Monterey County clinic staff wanted a message system that had more capacity, so they could start sending messages with educational health tips for specific conditions and preventive care.

Monterey County Clinic staff reached out to other health centers around California, and learned that a number were using CareMessage and faced similar system-compatibility issues. They approached OCHIN as a group so they could make a stronger argument for integration.

At that point, according to Velez, OCHIN “jumped on board,” and agreed to try to integrate Epic and CareMessage. “We’ve always found OCHIN flexible that way,” Velez says. “If we put an idea on the table they’ll really listen, they’ll research it and they’ll try to make it happen, unless there is some technical reason it won’t work.”

Next, clinic staff identified team members to spearhead the project and scheduled weekly meetings. At the meetings, the team provided updates on testing, findings, and concerns. They also reviewed text message scripts that OCHIN/Epic provided. Team members customized the scripts so they would be HIPPA compliant, and would include the names of specific clinic location. The scripts were reviewed and tested until all team members were satisfied with the results.

OCHIN/Epic and CareMessage handled the technical side of the transition, while coordinating closely with the clinic team to make sure the text message scripts aligned with clinic needs.

As things came together, a “go live” date was set.

CareMessage and Epic Integration

Monterey County Health Clinics kicked off the project in May 2018; in August the switch was flipped — and the systems were integrated! OCHIN/Epic and CareMessage could now communicate, so, for example when a patient cancelled or changed an appointment in CareMessage, that information showed up in the electronic records system.

There were a few glitches at first, which the team tackled by reaching out to OCHIN/Epic and CareMessage. In response, the organizations would solve the problem or propose a workaround. Early on, for example, multiple duplicate text messages were sent to patients. The problem was corrected in a couple of days.

The biggest glitch, according to Velez, was that the integration didn’t capture appointments made before the go-live date. If a patient had been scheduled a few months earlier for a yearly check-up, for example, their appointment wouldn’t appear in the system so they wouldn’t receive a reminder message. This was an issue that OCHIN/Epic and CareMessage had not anticipated, and weren’t able to resolve, so all of the historical appointments had to be manually added by clinic staff.

Velez says that Technology Hub helped throughout the integration project. “I am always telling everyone, ‘CCI is your best friend,'” she said “For example, they helped us get in touch with other clinics that were using CareMessage, and that made our case stronger when we approached OCHIN. Throughout the process, CCI kept us on target.”

Results

Once the glitches were resolved, the integration worked just as clinic staff had hoped. According to Velez,

“Most people are really happy with the integration. At first a few people were a little resistant. We had to get buy in, and we did; now people are very pleased. Now that we’ve worked out most of the kinks, it’s reduced all that manual work and it’s working on its own!”

Velez took her team out for lunch when the integration was complete, and there was an all-staff meeting to get feedback and celebrate the project’s success.

Measuring Success

While it is difficult to measure the results of the project in metric terms, integration has eased time-consuming manual work by clinic staff — an estimated two hours a day. Staff at the nine clinics are responding positively to the transition. It will result in an estimated cost savings of $12,000 in staff hours annually.  

Lessons Learned

• Monterey County Clinics staff found that the integration process took longer than they anticipated because of staffing issues, technical glitches, and time required to obtain approvals connected to HIPPA and privacy issues.
• The staff also learned that the solutions were often different than they expected (sometimes problems could be resolved with a simple workaround, for example) so they needed to be flexible and to listen.
• Adriana Velez emphasizes the importance of having the right staff leading the project, including people with different backgrounds and types of expertise.
• Finally, staff learned to test and test again — and to “prepare for the unexpected.”

Next Steps

• Clinic staff are currently working to expand CareMessage text outreach to patients to promote health education and self-management. Right now, they are testing the educational message system in-house: employees are signing up to receive CareMessage texts with information tailored for patients with diabetes and hypertension, and staff are working to refine the messages to make sure they are clear and helpful.
• Next, they plan to offer self-management texts to patients, starting with messages for patients with hypertension and diabetes.
• Clinic staff are exploring how to send patients preventive care text reminders.
• They hope to use texting to survey patients on a variety of access and service satisfaction measures.
• Finally, they plan to use this model to integrate other mHealth (mobile health) programs, as adopted, into OCHIN/EPIC.