Participatory Medicine Discussion

Just Text Me: Using SMS Technology for Collaborative Patient Mood Charting By  April C. Foreman, Chris Hall, Karen Bone, Je�rey Cheng and Adam Kaplin | September 26, 2011  

Abstract Summary: Mood 24/7 is an innovation in traditional mood charting using text messaging technology. Mood 24/7 allows the user to collect mood data in a standardized text message format, receives optional 160-character annotations from users in addition to their daily mood ratings, and securely stores user response data on a protected server. Adopting this strategy for monitoring mental health symptoms may be one way to increase patient engagement and accuracy in reporting mood symptoms. Keywords: Mental health, depression, mood tracking, HIT, SMS, texting, patient engagement. Citation: Foreman AC, Hall C, Bone K, Cheng J, Kaplin A. Just text me: using SMS technology for collaborative patient mood charting. J Participat Med. 2011 Sept 26; 3:e45. Published: September 26, 2011. Competing Interests: Chris Hall leads the product and business development of Mood 24/7 as Director, Clinical Platforms at HealthCentral. Adam Kaplin is entitled to a share of royalty received by the University on sales of products used in the study described in this article, Under a licensing agreement between The HealthCentral Network Inc., and Johns Hopkins University. The terms of this arrangement are being managed by Johns Hopkins University in accordance with its con�ict of interest policies.

Introduction Depressed mood and “mood swings” are common complaints from patients in both medical and behavioral health care settings. A common intervention for patients expressing these symptoms is to advise them to monitor their mood, often using a Likert scale. The usual clinical practice of mood monitoring uses a simple paper chart that patients can complete on a daily basis. Based on a subjective rating scale, patients can chart (and clinicians can monitor) the progression of patients’ mood changes over time.[1]

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High reliability and validity of subjective mood rating has been demonstrated over the past forty years.[2] For example, longitudinal charting of a single scale for subjective mood rating has been shown to correlate highly with other more elaborate rating scales such as the Hamilton, Beck, and Zung rating scales for depression. When patients can rate their moods consistently, and remember to bring them to their appointments, these charts can provide highly valuable clinical information. This information is useful for the patient, clinicians, and other members of a treatment team.

Poor Compliance with Traditional Paper Charting Patient compliance with paper charting of mood is notoriously low. First, depressed patients often have low motivation for task completion. Decreased cognitive function and memory de�cits are two other symptoms often experienced by patients with depression, leading to di�culties with active involvement and self-monitoring of symptoms.[3] Moreover, some patients might “back�ll” the mood charts to avoid the image of non- adherence. Current research suggests a compliance rate of 11% with paper mood charting. [4]

Low compliance rates may lead some clinicians to avoid recommending charting symptoms. Traditional paper charts may also create problems for patients who already struggle with memory, cognitive impairment, motivation, impulsivity, and chaotic behavior. They may feel that they must choose between “failing” their health care provider by reporting their “non- compliance,” or “back�lling” their mood diary. Unfortunately, a “back�lled” mood chart is very likely to be inaccurate, in�uenced by the mood and cognitive distortions of the moment.

If mood charting is recommended, but leads to non-compliance (as it does in 89% of cases), the patient often feels frustrated or disappointed with themselves, their clinician, or the recommended treatment.[1] All of these scenarios run the risk of reducing collaboration and patient participation in health care.

These problems may be even more likely to occur in patients with health needs that are complicated by medical conditions, or comorbid mental health diagnoses. People with mood problems may also face poverty or other factors that negatively in�uence treatment outcomes. The authors believe that patients with these complications could signi�cantly bene�t from careful daily mood monitoring. Unfortunately, the barriers they face may also make them less likely to be successful with traditional paper mood charting.

Case Study Mood 24/7 was developed as a solution to three problems associated with mood monitoring and participatory health: data collection, data visualization, and data connection. We recognized that there was a need to create incentives for certain patients to provide mood data on a regular basis. We also wanted to facilitate data presentation that would be useful to clinicians and patients. Ideally, this tool could become widely available,

with few barriers to patient access. With these criteria in mind we explored the use of cell phone text messaging technology to enhance the bene�ts of traditional paper mood charting.

Why Text Messaging?

It is estimated that in 2009 there were 286 million cell phone subscribers in the United States, representing 91% of the population.[5] Because cell phones are almost ubiquitous and are familiar, they represent an ideal technology for patients to chart a mood rating.

One of the authors (A.K.) initiated e�orts to develop an SMS-based system that would work on any mobile phone to track patients’ moods. Through a partnership between Johns Hopkins University and HealthCentral, a mood charting system using this technology was developed. SMS texting was chosen because the vast majority of cell phones have this technology available. This technology has the additional advantage of being widely available and widely used in rural regions that are characterized by poverty, where there are also many barriers to computer and internet use. By contrast, tools using smart phone applications are available to fewer than 20% of potential users.[6] These applications are likely to become more useful as smart phones are more broadly adopted.

How the Innovation Works

Mood 24/7 (the SMS mood-tracking tool developed by HealthCentral based on a technology licensed from Johns Hopkins) uses text messages and a secure website to help people log and track their moods. Mood 24/7 is accessible to the 91% of Americans who send �ve billion text messages per day from their cell phones.[5] Information generated by patient registration with Mood24/7 is “owned” by the patient who opts to allow participating clinicians to view it on the Mood24/7 website.

Figure 1. Screen shot showing the Mood 24/7 web site home page.

Individuals may sign up securely and select a time to receive daily text messages which ask for mood ratings on a scale from one to 10. Mood 24/7 uses hypertext transport protocol secure (https, or “secure” http) to encrypt all data that a patient sends to the website. All personally identi�able information (such as email addresses or phone numbers) is stored in encrypted form. No one has access to view a patient’s mood other than the registered user, or those to whom he or she explicitly grants permission. More information about data security and privacy can be viewed here: https://www.mood247.com/faq

Figure 2. Mood 24/7 message using SMS texting methodology.

Participants may also add a text message comment related to their rating. Text message responses and notes are then added to a personal mood chart that participants can share with providers using the “Trusted Circle” feature. This data can be viewed over any “user speci�ed” time interval, such as week, month, or year intervals. This chart allows patients, clinicians, and other treatment team members to view mood variability, longitudinal mood course, and the e�ects of various treatment interventions in real time.

Figure 3. Screen shot illustrating the “Trusted Circle” option.

The design of Mood 24/7 di�ers from smartphone mood charting applications (eg, the T2 Mood Tracker) due to its use of a secure website. This allows the patient, clinician, and other members of the “Trusted Circle” to view mood chart data online, instead of viewing it only on the smartphone. Additionally, online viewing allows clinicians to print out mood charts and add the information to the medical record. This feature is not only clinically useful but also important for medico-legal considerations.

Figure 4. Illustration of “mood index” charting using Mood 24/7.

System Development

This tool was developed through a partnership between Johns Hopkins and HealthCentral. Our goal was to introduce a novel technology into the practice of mental health, which has traditionally been low-tech in its approach to treatment intervention.

Hurdles that needed to be addressed and are common to any new technological healthcare innovation include developing an optimal user interface; ensuring availability of the service across phone carriers; providing security for the information collected; and establishing a model for generating sustainable revenue without passing on prohibitive costs to patients in need of this service.

The initial barriers to introduction of this tool were largely procedural. In a rural community mental health care setting, we educated administration, sta�, and patients about con�dentiality; data storage and security; how and when the information would become a part of a patient’s medical record; and patient safety. Mood 24/7 terms of service were reviewed with patients, and they were instructed to continue using existing crisis plans and services because clinicians would not be expected to continuously monitor mood in real time. Patients were informed that clinicians would print out mood diaries, and these printouts would be added to their existing medical records. Patients and clinicians agreed that they would discuss patient mood diaries at the beginning of each session to monitor user interface concerns. Clinicians agreed to make the developers aware of any adjustments or updates that might be useful. Clinicians agreed to review patient-generated mood charts with other members of the treatment team prior to clinical contacts, and to discuss this data with patients at least brie�y during appointments.

Many of the barriers that patients experience in keeping a mood diary are largely behavioral, and may be directly related to their clinical problems. Thus, one of the most important barriers overcome by this intervention was to allow patients with motivational, cognitive, and behavioral impairments to conveniently, successfully, and consistently collect and transmit daily information about their mood to their treatment team.

The authors hope this tool will increase the likelihood of compliance with mood monitoring, which may lead to improved clinical decision making and treatment outcomes. This strategy for collecting and charting mood data also saves time and e�ort for the treatment team. In addition, a tool like Mood24/7 gives patients incentives for mood charting, engaging them through a convenient, visual medium.

Preliminary Findings This tool has been used at Johns Hopkins as a means of collaborating with users across the country. At Johns Hopkins, in a non-clinical population, daily compliance with mood charting was 86.67% over a 40-day period, according to unpublished data. This compliance far exceeds previously reported compliance with paper and pencil mood tracking.

Mood 24/7 also facilitates the ability of care providers and patients to review the mood chart together to track clinical progress. Patients at Johns Hopkins who use this tool almost

universally describe that they become more aware of their own mood variations and response to treatment. They also report that health care providers seem more engaged, because patients’ daily comments and mood changes are reviewed at the time of their visits, and can be easily accessed when patients call their care providers.

According to user data collected from Mood 24/7 servers 242,057 mood ratings were submitted by users between December 2010 and July 2011. While the number of active, registered users varies from day to day, within the last six months the active user base stabilized at roughly 4,000 users per month. It appears in that case that a relatively small number of active users generated a large number of mood ratings, suggesting their strong engagement with this tool. Also, 86,010 of these mood ratings contained an annotated message attached to the numeric mood rating. This means that in 35.5% of cases, people rating their mood opted to include additional (possibly richer) information about their mood.

Mood 24/7 has currently been adopted by four therapists and a nurse practitioner in a rural community mental health care setting with patients who have complex mental health care needs. Similar to the experience at Johns Hopkins, compliance rates for the one therapist who was tracking her clinical use of this tool (A.F.) were 91.4% for 35 of her patients. Compliance in this context was de�ned as texting a mood rating on most days in order to provide mood chart data for at least one follow-up appointment. This increase in compliance, in comparison with 11% of paper chart users,[1] would be a considerable improvement in any population. The majority of patients provided almost daily ratings, and continued charting their moods for longer than one month. In a rural community mental health center, with a caseload of patients predominantly diagnosed with borderline personality disorder, located in one of the poorest rural counties in Kansas, this degree of compliance is especially remarkable.[7]

Speci�c Example of Use

One of the authors (A.F.), a psychologist, used this service as a part of an intervention strategy for a dialectic therapy group for clients with Borderline Personality Disorder, and related Axis II concerns. Patients in this group enrolled in Mood24/7, and assistance was provided to register each patient. Another author, a nurse practitioner (K.B.), provided medication services to many patients in this setting. Other therapists on the patients’ treatment teams were also included, so that all treatment team members had convenient, consistent, timely, and asynchronous access to patient mood charts. In one case, this led to a revision of the treatment team’s diagnosis due to the improved quality of information about the patient’s symptoms. The mood diary service’s successful implementation in this challenging setting suggests that this is a highly generalizable mental health tool.

Conclusions

Experience with Mood 24/7 suggests that using text messages to conveniently provide daily, reliable mood charts can improve compliance and accuracy of patient mood charting. This

can provide both patients and clinicians with better data for making and evaluating treatment decisions.

In situations where followup visits are not readily available, health care providers can reliably track patients’ daily progress. This is especially advantageous in poor and rural health care settings where there may be barriers such as geographic distance, or provider availability. And if a patient misses a regularly scheduled appointment, clinicians can use this tool to assess whether a patient is doing well or su�ering from an acute problem, such as a mood downturn. It may also serve as a cue for the treatment team to reach out to patients with crisis services, or to change medical or behavioral treatment strategies. For patients and their health care teams, a service like Mood24/7 may provide novel ways to diagnose and predict the course of mental illnesses.

Tools like Mood 24/7 appear to improve patient engagement and mood monitoring compliance at low or no cost to patients. Currently, the wide availability of SMS technology makes this innovation highly accessible and convenient. Unique features such as the “Trusted Circle” allow online data collection and sharing without requiring a patient to remember to collect the data or bring it to an o�ce appointment. The printable mood chart is easily read by all members of the “Trusted Circle” and is convenient to print out and add to patient records, even when a patient is not at the o�ce.

Based on initial clinical success using text messaging and a secure website to chart mood, more rigorous research on this and similar tools seems warranted. Additionally, experiences with this innovation suggest features that might be included in future tools. As smart phones become more commonplace and less costly, mood tracking applications on these devices may have wider utility. In future iterations of technology-based mood tracking, it may be helpful to develop secure ways to capture mood data so that it can be viewed remotely by all treatment team members, and easily printed or imported into an electronic medical record.

References 1. Baldassano CF. Assessment tools for screening and monitoring bipolar disorder. Bipolar

Disord. 2005;7 Suppl 1:8-15. ↩

2. Ahearn EP. The use of visual analog scales in mood disorders: a critical review. J Psychiatr

Res. 1997 Sep-Oct;31(5):569-79. ↩

3. Burt DB, Zembar MJ, Niederehe G. Depression and memory impairment: a meta-analysis

of the association, its pattern, and speci�city. Psychol Bull. 1995 Mar;117(2):285-305. ↩

4. Stone AA, Shi�man S, Schwartz JE, Broderick JE, Hu�ord MR. Patient compliance with

paper and electronic diaries. Control Clin Trials. 2003 Apr;24(2):182-99. ↩

5. Industry Info Page. CTIA-The Wireless Association. Available at:

http://www.ctia.org/media/industry_info/index.cfm/AID/10323. Accessed February 14, 2011.

↩

6. Kellogg D. Among mobile phone users Hispanics, Asians are most-likely smart phone

users. Nielsenwire. 2011, Feb. Available at: http://blog.nielsen.com/nielsenwire/?p=25901.

Accessed February 14, 2011. ↩

7. State and County Quickfacts. US Census Bureau. Available at:

http://quickfacts.census.gov/qfd/states/20/20125.html. Accessed, August 31, 2011. ↩

Copyright: © 2011 April C. Foreman, Chris Hall, Karen Bone, Je�rey Cheng, and Adam Kaplin. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with �rst publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open- access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.

   

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Alex on September 26, 2011 at 9:12 pm

This is amazing! the closest to realtime data capture.

Reply

e-Patient Dave on September 27, 2011 at 10:09 am

I love the cleverness and simplicity of this.

Not to sound like a broken record, but I want to ask that we all start shifting away from the guilt-laden blame-implying “compliance” (a TOTALLY non- empowering, non-participatory word) and shift to works like achievement, completion, ful�llment, performance, which connote the truth: the patient is a partner, not an “obeyer,” in ful�lling the plan.

From: “Experience with Mood 24/7 suggests that using text messages to conveniently provide daily, reliable mood charts can improve compliance and accuracy of patient mood charting”

To: “…can improve completion and accuracy of patient mood charting”

From: “Patient compliance with paper charting of mood is notoriously low. First, depressed patients often have low motivation for task completion.” to: “Patient achievement with paper charting of mood is notoriously low – depressed patients often have…”

From: “Current research suggests a compliance rate of 11% with paper mood charting” to: “Current research suggests a success rate of 11% with paper mood charting.’

I humbly suggest, too, that the proposed wording appropriately shifts the focus away from blaming the patient and onto the reality that the �ipping paper forms simple don’t work well – don’t get the job done! – and the SMS app does.

And that’s shown in this �nal example: “Low compliance rates may lead some clinicians to avoid recommending charting symptoms” to “Low success rates may lead some clinicians to avoid recommending charting.” Indeed – darn good thinking, to avoid recommending something that doesnt work!

I’d say, let’s not call it patient compliance – let’s talk about e�cacy of the new approach.

LOL, maybe we could even talk about the incompetence of the paper chart. 🙂

Anyway I love the app! It appears to do what patients need!

Reply

Charles W. Smith on October 3, 2011 at 4:27 pm

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Thanks for your input about this important issue. Although there may be some circumstances when “compliance” is the preferred use, I agree that, in this circumstance, the use of “nonadherance” is a more participatory word than compliance.

Reply

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