Mobile phone text messaging for pharmaceutical care in a hospital in China

J Telemed Telecare 2008;14:410-414
doi:10.1258/jtt.2008.080406
© 2008 Royal Society of Medicine Press

 

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RESEARCH

Original articles


Yudan Mao *,
Yantao Zhang  and
Suodi Zhai * 


* Department of Pharmacy, Peking University Third Hospital, Beijing;
Power System Department, China Electrical Power Research Institute, Beijing, China


Correspondence: Suodi Zhai, Department of Pharmacy, Peking University Third Hospital, Beijing 100083, China (Fax: +86 10 8226 6699 5740; Email: zhaisuodi{at}163.com)




Summary

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Summary
Introduction

Methods

Results

Discussion

References

 

We have developed a mobile pharmacy service system (MPSS) todeliver individualized pharmaceutical care via text messagessent to the mobile phones of patients. The text messages were:(1) reminders about medication – from the day followingdischarge, reminder messages were automatically sent to patientsapproximately 10 minutes before their medication was due tobe taken. The system stopped sending messages when the prescriptionran out and suggested that patients should come to hospitalto renew any prescribed medicines; (2) practical informationabout medicines, such as information about methods of administration;(3) information about adverse drug reactions. In a 3-month trialin a general hospital, 100 patients were provided with pharmaceuticalcare using the MPSS for an average of 3.5 medicines per patient(range 1–9). They received pharmaceutical care for anaverage of 12 days per patient (range 3–19). A surveywas then conducted which indicated that most patients were satisfiedwith the pharmaceutical care provided by MPSS through text messages,and that they had positive attitudes despite some limitations.The use of the MPSS should improve pharmaceutical care, widenthe knowledge of pharmacists, reduce the burden on pharmacystaff, improve pharmacist–patient interaction, and improvethe effect and safety of medication.





Introduction

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Summary

Introduction
Methods

Results

Discussion

References

 

Pharmaceutical care is the integration of pharmacy knowledge, skills and attitudes with the aim of providing the best patient care and therapeutic outcomes in various settings ranging from health-care institutions to the home. Many factors affect therapeutic outcomes, such as medication compliance, especially for patients out of hospital. Some 20–50% of patients do not adhere to therapy, and medication compliance in patients who have left hospital is particularly unsatisfactory.1 In addition, patientsoften have concerns about their medicines, so there is a strongdemand for professional consultation. In a large country likeChina, telemedicine may be useful in facilitating individualizedpharmaceutical care and encouraging good compliance throughbetter pharmacist–patient interaction.

Mobile phones have become easily available and highly popular since the 1990s. The short message service (SMS), in which text messages are sent and received by mobile phones, is increasingly being used for access to information. There are many reports of the use of the SMS in medicine. It has been used for patient reminders, psychological support, chronic disease management, behaviour modification, reporting of critical medical events or laboratory results and even for surveys.29

We have developed a mobile pharmacy service system (MPSS) todeliver individualized pharmaceutical care via the SMS, withthe aim of improving medication compliance and safety.





Methods

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Summary

Introduction

Methods
Results

Discussion

References

 

A pilot study was conducted in three phases.


Phase one

In the first seven months of 2007, a mobile pharmacy service system (MPSS) was developed. MPSS is an SMS-based system which can be run on a computer and facilitates pharmaceutical care by sending mobile phone text messages to patients. It was designed to fulfil four functions:

  1. to allow pharmacists to input, browse, query, inspect, modify and store medication information;
  2. to allow medical staff to browse the evidence-based drug information database and update it rapidly;
  3. to extract medication information and generate various kinds of text message automatically;
  4. to send text messages to patients’ mobile phones automatically at predefined times, and to receive text messages and save them in a database for subsequent browsing.

The MPSS compriseda pharmaceutical care database, a database application systemand the SMS equipment which was linked to a computer. In orderto set up the pharmaceutical care database, we collected theevidence-based drug information for our hospital formulary bysearching drug instruction sheets, the MIMS Reference Systemand the Micromedex Healthcare Series information resource.

In China, the limit of a text message is 70 Chinese charactersor 140 English letters. If the number of characters exceedsthis limit, an SMS message will be automatically divided intopieces before transmission. Because of the length limit, anyevidence-based drug information to be transmitted by SMS mustbe simple, practical and easily understood. Such informationmainly includes administration methods, common adverse effectsand precautions. For example, precautions might include therelationship between medication and food intake, whether thedrug would affect driving, whether food and drink could be takenat the same time, what were appropriate antidotes in the caseof over-dosage and so on.

The database applications involved the main MPSS program, whichcould execute operations such as data input, editing, modificationand query, collect relevant medication information, generatetext messages with a certain format and drive the SMS equipmentto send out text messages at the predefined time.


Phase two

After the MPSS had been developed, it was trialled in a generalhospital. The trial was approved by the appropriate ethics committeeand subjects were fully informed about the trial. Hospitalizedpatients were recruited during a 3-month period starting inAugust 2007. After a period of treatment in hospital, patientswere discharged and required to take their medicines. Our pharmacistsintroduced the MPSS to patients prior to discharge, and recruitedthem into the trial with their agreement.

The participants’ medications were recorded in the MPSS in accordance with their physicians’ advice. Each day following discharge, the system checked information about the patients’ prescriptions, generated corresponding text messages and sent them to the patients automatically. The text messages were:

  1. reminders about medication. From the day following discharge, reminder messages were automatically sent to patients approximately 10 minutes before their medication was due to be taken. The system stopped sending messages when the prescription ran out (in China, patients generally take home no more than 14 days’ dosage). The last of the messages also suggested that patients should come to hospital to renew any prescribed medicines;
  2. practical information about medicines. The MPSS sent messages about methods of administration and some precautions, with easily understood words;
  3. information about adverse drug reactions. Text messages containing the most common adverse drug reactions were automatically sent to patients. Patients were also reminded to contact a pharmacist if an adverse drug reaction occurred.

The MPSS could also receive text messages from patients. Patients used this function to report their medication status, raise questions about medications and consult a pharmacist. When the pharmacists read these text messages, they would reply to the patients by sending text messages. The information flow in the MPSS is shown in Figure 1.



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Figure 1 MPSS flowchart


Phase three

After using the MPSS, patients were surveyed. The survey was conducted using a standardized questionnaire, administered either by text message or mobile phone call. The questionnaire contained four questions:

  1. When did you take your medicines after receiving the reminder messages? The choices were: immediately; within 10 minutes; within 0.5 h; 0.5 h or later;
  2. Which type of messages do you want to receive most? The choices were: messages for timely reminders about medications; messages about administrative matters; messages about precautions; messages about adverse drug reactions;
  3. If it became an official paid service of the hospital, how much could you afford for pharmaceutical care by text message every day? The choices were: ¥0.5; ¥1; ¥1.5 (¥10.09US$0.15);
  4. Please give a mark (maximum mark 100) to the pharmaceutical care you received via text messages.

Patients were encouraged to answer these questions by textmessage. The pharmacists telephoned any patients who did notcomplete the questionnaire via SMS.





Results

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Summary

Introduction

Methods

Results
Discussion

References

 

A total of 100 patients were enrolled in the trial. Most ofthem came from the departments of haematology, orthopaedicsand dermatology. All patients completed the trial, i.e. nonewere lost to follow-up.

Among the 100 subjects, there were 57 men and 43 women. Their average age was 46 years (range 12–92) (Figure 2). Each patient was provided with pharmaceutical care for an average of 3.5 medicines per patient (range 1–9) (Figure 3). They received pharmaceutical care for an average of 12 days per patient (range 3–19) (Figure 4).



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Figure 2 Patients’ ages (n = 100)



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Figure 3 Numbers of medicines per patient (n = 100)



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Figure 4 Pharmaceutical care time for each patient (n = 100)

 

Sixty-four subjects provided feedback and interaction by text messages, and some of the messages are shown in Table 1.The pharmacists answered each question that the subjects raiseduntil they were satisfied.



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Table 1 Patients’ feedback and interaction with the pharmacists


Survey

Those 64 subjects who sent feedback to us completed the questionnaire by text messages. The other 36 patients finished the questionnaire by telephone, i.e. overall there was a 100% response rate to the survey. The results are shown in Table 2. The averagemark given by patients was 92 (range 60–100). Accordingto the answers to question 4, most participants were satisfiedwith pharmaceutical care by text messaging and felt that theMPSS could become a routine service.



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Table 2 Survey results (% shown in parentheses). More than one response was possible per person





Discussion

Top

Summary

Introduction

Methods

Results

Discussion
References

 

In the present study, mobile phones were used for pharmaceuticalcare, and pharmacists were able to provide patients with medicationguidance by text message. This allowed pharmacists to extendtheir reach to patients who had been discharged; patients feltthat through the improved access to pharmaceutical care theybecame more closely linked to the pharmacists. Compared withface-to-face guidance about medications, patients found thatthe mobile phone-based system allowed them to review and rememberthe guidance more clearly.

In our hospital, the pharmacists have a heavy workload: nearly9000 prescriptions need to be dispensed each day. If SMS-basedmedication guidance could be substituted for face-to-face medicationguidance in the future, there would be time savings for thepharmacy staff. In addition, because of the virtue of its immediacyand the high ownership of mobile phones, pharmaceutical careusing text messages may be more effective than Internet-basedpharmaceutical care.

During the development of the MPSS, our pharmacists set up anevidence-based drug information database, which covered morethan 1200 medicines. The pharmacists were able to expand theirknowledge through searching the database. The MPSS also hasthe potential to integrate with the hospital information system(HIS) and thus provide more effective and individualized pharmaceuticalcare.

Many elderly people could not be recruited into the trial despitetheir high demand for pharmaceutical care, because they werenot able to read text messages by themselves. With the availabilityof voice messaging, people who are visually impaired or notable to read text messages can still receive pharmaceuticalcare by mobile phone. We look forward to widening the applicationof the MPSS for pharmaceutical care.

The survey indicated that most patients were satisfied with the pharmaceutical care provided by text messages and that they had positive attitudes to it. However, there were some unresolved problems:

  1. for about one-third of the patients, there was an interval of more than 30 minutes between the arrival of a reminder message and the medication being due. This allowed the possibility for patients to forget about their medication during this period. This aspect could be improved in future;
  2. the survey results showed that 43% of patients wanted to receive messages about precautions. This confirmed that patients valued the information about precautions. Further work should be done to complete the evidence-based drug information database, and messages about precautions should be sent earlier than other messages;
  3. the answers to the third question in the questionnaire showed that most patients preferred low-cost pharmaceutical care by text messages, and some of them hoped for free access to it. We believe that a low cost would enable more patients to accept the service.

Telemedicine systems have been proposed for nearly two decadesas a means of supporting hospitals to achieve improvement. Thepresent study employed text messaging for pharmaceutical careand it was effective and popular with the patients. The textmessages provided patients with rapid, effective medicationguidance and pharmaceutical care after discharge. The use ofthe MPSS should improve pharmaceutical care, widen the knowledgeof pharmacists, reduce the burden on pharmacy staff, improvepharmacist–patient interaction, and improve the effectand safety of medication.

 

 

 

 

 

 

Accepted May 26, 2008




References

Top

Summary

Introduction

Methods

Results

Discussion

References


  1. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med 2007;167:540–50[Abstract/Free Full Text]
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  3. Joo NS, Kim BT. Mobile phone short message service messaging for behaviour modification in a community-based weight control programme in Korea. J Telemed Telecare 2007;13:416–20[Abstract/Free Full Text]
  4. Dunbar PJ, Madigan D, Grohskopf LA, et al. A two-way messaging system to enhance antiretroviral adherence. J Am Med Inform Assoc 2003;10:11–15[Abstract/Free Full Text]
  5. Farmer A, Gibson O, Hayton P, et al. A real-time, mobile phone-based telemedicine system to support young adults with type 1 diabetes. Inform Prim Care 2005;13:171–7[Medline]
  6. Lauruska V, Kubilinskas E. A system for teleconsulting, communication and distance learning for people with disabilities. J Telemed Telecare 2002;8 (Suppl. 2):49–50
  7. Scherr D, Zweiker R, Kollmann A, Kastner P, Schreier G, Fruhwald FM. Mobile phone-based surveillance of cardiac patients at home. J Telemed Telecare 2006;12:255–61[Abstract/Free Full Text]
  8. Iordache SD, Orso D, Zelingher J. A comprehensive computerized critical laboratory results alerting system for ambulatory and hospitalized patients. Medinfo 2001;10:469–73
  9. Ryan D, Cobern W, Wheeler J, Price D, Tarassenko L. Mobile phone technology in the management of asthma. J Telemed Telecare 2005;11 (Suppl. 1):43–6[Abstract/Free Full Text]

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