Closing the consultation: The

role of Short Message

Service (SMS) in sexual health
result provision
Dr Anatole S Menon-Johansson
a.menon-johansson@nhs.net
Clinical Lead for Sexual Health
Guy’s & St Thomas’ Hospitals, London, UK
mHealth Conference & Expo
Dubai, 15th September, 2010
 Sexual Health Services in the UK:
The communication challenge
• Sexual Health services are open access in the UK
• Over one million sexual health screening and
diagnostic visits are performed annually
• The majority of results from tests are negative
• Result provision takes up time and resources

• Providing timely results (positive / negative) are

important to effectively close the consultation
– Reduce the time to treatment
– Manage anxiety
– Increase capacity to see new patients
 Patient acceptability and
confidentiality guidelines
• Questionnaire (November 2003)
-98% owned a mobile phones
-68% had access to a personal email address
-Result format preference:
-Phone > Text message > In person

• Caldecott guidelines
-No patient identifiable information in text
-Non-attributable text message header
-Text message does not contain details of tests performed
 The first six months of the
text message result service
Number of results and
staff time required
Number of text messages (number of results hours taken)
“Please
Number come Proportio Cost of
of sexual “All your “Please back to n of total result
Month, health results are ring the the results by service
2004 screens negative” clinic” clinic” Text Phone In person Total text (%) (£)
March 875 17 4 1 22 410 441 873 4 1505
(0.3) (27.3) (88.2) (115.8)
April 774 100 14 9 123 293 302 718 17 1079
(3.1) (19.5) (60.4) (83)
May 746 149 22 5 176 263 250 689 26 930
(4.0) (17.5) (50.0) (71.5)
June 947 172 15 11 199 290 264 753 26 1000
(4.8) (19.3) (52.8) (76.9)
July 987 125 13 10 147 410 235 792 19 1011
(3.5) (27.3) (47.0) (77.8)
August 889 218 54 13 285 365 191 841 34 897
(6.5) (24.3) (38.2) (69)
Total 5218 781 122 49 952 2031 1683 4666 20 6445
(23.8) (135.4) (336.6) (495.8)
Menon-Johansson AS, McNaught F, Mandalia S et al. Texting decreases the time to treatment for genital Chlamydia
trachomatis infection. Sex Transm Infect. 2006;82(1):49-51
Impact of text message result service
Text group Standard group p Value
(n=28) (n=21)
Number (%) Number (%)

Gender female 27 (96.4) 20 (95.2) 0.835

Race

White British 11 (39.3) 6 (28.6)

White other 5 (17.9) 5 (23.8)

Black British 4 (14.3) 4 (19.0)

Black other 4 (14.3) 1 (4.8)

Other 3 (10.7) 5 (23.8)

Not known 1 (3.6) 0 (0.0)

Mean age, years (SD) 24.8 [3.9) 27.2 [8.6) 0.227*

Mean time to diagnosis, days (SD) (range) 7.9 (3.6) 12.5 (4.5) <0.001*
(4–23) (6–20)
Median time from contact to treatment, days 1 (IQR 0–3) 1 (IQR 0 to 2) 0.756†
(range) (0–20) (0–15)
Median time from test to treatment, days (range) 9 (IQR 7–14) (4–27) 15 (9 to 18) 0.005†
(7–35)
Menon-Johansson AS, McNaught F, Mandalia S et al. Texting decreases the time to treatment for genital Chlamydia
trachomatis infection. Sex Transm Infect. 2006;82(1):49-51
 Public Health need / Policy driver
• The UK has some of the worst sexual & reproductive
health indices in Europe

• Increasing access to sexual health services was made

a key objective for the Department of Health (DH) in
England and Wales in 2005

• In 2006 the DH published ten high impact changes

designed to enhance 48-hour access to genitourinary
medicine (sexual health) services
– Department of Health. 10 High Impact Changes for Genitourinary Medicine 48-hour
Access. 277527/10 DH Publications. (accessed 17th March, 2010)
Project management, timeline & papers
• Clinician leadership & private company
partnership (Mikkom www.mikkom.com)
• Local start-up investment & payment for ongoing
use of the technology by the hospital
• Key milestones March 2004 & October 2006
• Pilot > evaluation (E) > publication (P) > E > P ….
Papers published to date:
– Menon-Johansson AS, McNaught F, Mandalia S et al. Texting decreases the time to treatment
for genital Chlamydia trachomatis infection. Sex Transm Infect. 2006;82(1):49-51
– Menon-Johansson, A.S., McNaught, F, Sullivan, A.K. Closing the clinical consultation: saving
time and money in result provision. Sex Transm Infect 2006; 82(Suppl II): A18
– Jones R, Menon-Johansson A, Waters AM et al. eTriage - a novel, web-based triage and booking
service: enabling timely access to sexual health clinics. Int J STD AIDS. 2010;1:30-33
 Critical steps during implementation
• Clinical acceptance won by:
– Clinical champions, small pilots, no harm & benefit
demonstrated, transparent evaluations &
publications, support from the profession & DH
• In house start-up funding essential for
technology and extra staff, able to cover
ongoing costs until returns were realized
• Challenges: Building error free process (cards
& 2/52 safety window), working with stand
alone databases and hospital IT Department
Menon-Johansson AS, Cohen CE, Jones R et al. Interventions to increase access to STI services: A study of
England’s ‘High Impact Changes’ across three central London clinics. Sex Transm Infect. 2010; In press.
 Results, impact
• Four evaluations completed & published
• Main outcomes
– Faster treatment times for Chlamydia
– Fall in follow-up to new patient ratio (0.67 > 0.21)
– 80% results by text
– 15% appointments via website
• IT changes > 2x rise in patient access (44% vs 20%)
• Limitations to analyzing the impact of IT
• Observation: The power of libertarian paternalism
(Nudge by Thaler & Sunstein, Penguin books http://nudges.org/)
 Critical success factors
• Strengths: Clinical champions, responsive IT
partner, independent funding, focus on evaluation
• Weaknesses: Separate IT databases, slow to
implement opt-out, limited social marketing
• Success factors: Support at front line, evaluation,
results communication, economic logic (PbR)
• Lessons learned: Many [IT, sociology, anthropology]
• Reactions / Attitudes: Patients reactions are
positive, staff & profession have been convinced,
DH supportive
 Future challenges
• Changing IT landscape
– NHS mail now provides free email / text / fax
– New SMS providers in marketplace
• Areas to address
– New providers of sexual & reproductive health care
– Non-standard electronic patient record software
– Silos [data, provision & expertise]
– Sexual networks
– Economies of scale
• New priorities
– Cost pressures / Cloud computing / mobile technology
 Automation and expanding the role of
SMS in sexual health care service
• Telephonetics VIP: Patient can call to hear results &
text message automatically sent to patient using
NHS mail (www.telephoneticsvip.co.uk)
• Text to book: patient texts clinic requesting an
appointment. Pre-allocated slots in clinic made
available to SMS engine (www.mikkom.com)
• Partner notification by text: partner texted by
patient or provider informing them of potential
exposure to a sexually transmitted infection
 Acknowledgements
• Dr Ann K Sullivan at Chelsea & Westminster NHS
Foundation Trust

• Mike Unger at Mikkom (Windsor, UK)

• Guy’s & St Thomas’ NHS Foundation Trust