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NHSmail is gr8 4 patient care

by Marina Kyriaku

SMS is a shot in the arm in the fight against flu

Each year millions of people in the UK visit their GP’s surgery for a flu jab. Many respond to the individual letters sent out by surgeries across the country inviting patients to receive the jab. Others are persuaded to visit their local GP thanks to the widespread TV and press campaigns that run each year. Whatever finally prompts people to attend their surgery, the annual flu jab is a part of a well-orchestrated communications campaign that covers the whole country. But it’s expensive in terms of administration, postage and advertising. And even so, some people still miss out.

One surgery is looking to technology to help improve the numbers of people who receive their annual inoculation. Instead of writing to patients, GPs at the Blackheath Medical Centre in the Wirral send emails and texts instead. And it’s all done using NHSmail.

“We make use of NHSmail to email and text patients when our annual stocks of influenza vaccinations arrive,” said Dr Bennett Quinn, one of three GPs at the Blackheath Medical Centre. “We have contact details for about a quarter of our flu jab target patients and it gets the annual vaccination process off to a good quick start when these patients respond to their electronic invitation.”

It’s a simple yet highly effective solution to the problem of contacting patients at the practice. What’s more, sending text messages is free, as part of the NHSmail service.

“NHSmail has undoubtedly saved the practice money,” said Dr Quinn. “Sending texts costs us nothing and means that staff time is more efficiently used on those who need a bit more chasing up.”

The SMS and email alert service has proved so popular Dr Quinn is now examining ways to relay weather warnings to patients who suffer from Chronic Obstructive Pulmonary Diseases (COPD) such as chronic bronchitis and emphysema. It’s this kind of innovative thinking that is taking the NHS’ email service to a new level.

NHSmail is maintained and operated by Cable&Wireless on behalf of Connecting for Health. At its heart, it is an enterprise-wide email service available to everyone in the NHS. As well as offering a range of features - such as enabling staff to send a mix of email, fax and SMS text messages – it also comes complete with a full electronic calendar that can be shared with colleagues across the NHS. And it provides access to an NHSmail directory that contains the professional contact details of all staff in the NHS.

The benefit of this collaborative tool is that clinicians can seek the expertise of others regardless of where they are in the country. This is helping to create “virtual communities” where knowledge, expertise and different working practices can be shared among those in similar areas of medicine and administration.

For Dr Quinn, though, the ability to communicate electronically is paramount, opening up a whole new range of possibilities. “For instance, our anticoagulant management software can send texts, faxes and emails to our warfarin patients using NHSmail.”

“The wording of the message is created by the program, thus practically eliminating the risk of human error in the dosage instructions. We are collecting data to assess the safety of this but anecdotally there have been no adverse incidents so far. About 40% of our warfarin patients receive their dosing instructions this way. One chap in his 70s got his grandchildren to teach him how to view text messages - just so he could use the service.

“We also make good use of the fax and SMS services too. Being able to fax an urgent referral or admission letter straight from the PC is really useful. We can also send standard emails or SMS messages to patients using the practice intranet – especially useful when you want to give good news that a test is normal or improved.”

For Will Moss, the Head of the NHSmail Programme at CfH, hearing how Dr Quinn is using the service to communicate with colleagues and patients underlines the importance of all the technological changes happening throughout the NHS. “Some people dismiss NHSmail as ‘just another email system’, but that couldn’t be further from the truth,” he said. “NHSmail is a fantastic application that provides NHS staff with the communications tools to carry out their jobs more effectively. The feedback from users is that NHSmail is a must-have tool that improves communications between health professionals and, in turn, provides better care for patients.”

He’s right. Just ask Dr Quinn.

Using NHSmail to send SMS messages

The ability to send SMS messages direct from email is integral to the NHSmail service. Messages can be sent from any NHSmail account to any mobile number in the UK and the cost is centrally funded as part of the NHSmail service.

How do you do it? Use email to send your text to the mobile number, adding ‘@sms.nhs.net’ to the end of each number.

Increasingly NHS Trusts and Practices are using this to send appointment reminders to patients. It is possible to set up an automated process to send the reminders, but the exact process for this will depend on the systems and services in place locally.

What you need:

• A data source with the appointment information
• An NHSmail account to send from (ideally a ‘non-person’ account)
• An application to extract the appointment information and provide it to the email service. For example, this can be done via MS Access and MS Outlook

An example of how it is being done:

Ashford and St Peters NHS Hospital Trust are using the service to send their appointment reminders. They use iSoft Clinicom as their PAS, but appointment data is extracted from this and stored in a data warehouse (a SQL server). They have written a script that uses MS Access to search the data warehouse for all appointments in three days time that have a mobile number associated with the appointment (searching for a text string beginning 07). The script then sends this information to MS Outlook with instructions for Outlook to use the NHSmail account to send the appointment reminder text to each mobile number, automatically adding ‘@sms.nhs.net’ to the end of each number.

It took about a day of a programmer’s time to write and test the script which now runs automatically every day with no further intervention, and because the NHSmail account is free to users it costs nothing at all to run. The PCT currently sends appointment reminders for three of their outpatient clinics and plans to extend this to all clinics that have an appointment system.

Whilst the exact system in use at Ashford and St Peters cannot be copied across other trusts, the process can be replicated anywhere, assuming a degree of IT expertise and the appropriate technology. This provides, for a minimum outlay, a patient appointment reminder service that is entirely free of charge with no purchase costs and no call costs.

SMS TEXTING SERVICE

Background

Nhs.net mail accounts have the facility whereby a message can be sent to any mobile phone, simply by sending an email to an appropriate address. The body of the email becomes the body of the text message. For example, to send a text to phone number 07742 123456, use email address 07742123456@sms.nhs.net . The recipient of the message appears as ‘NHS’. There is no limit on the number of texts that can be sent in this way, and it is free.

In order to set up a service whereby messages are sent to patients reminding of forthcoming appointments, the following are recommended –

• A PC in a secure location, with any currently supported version of Windows as its OS
• MS Outlook, with an nhs.net account as its default account
• MS Access
• A data source that can be accessed via ODBC.

Database

The source for the text messages needs to be a data source that is updated regularly, and is supported by ODBC. It can be a live PAS system or a data repository that is fed by the live PAS at regular intervals. Necessary data items are appointment date, appointment location, patient id and of course a field that can contain the patient’s mobile number.

Microsoft Access

MS Access is a good tool for this service because :

• It can connect to most data sources
• MS Access skills are relatively straightforward to learn
• It has many useful built-in functions, e.g. the SendObject command
• It is programmable

• MS Access macros make automating tasks easy

Linked to this document is a sample MS Access database (N.B. only accessible from within NHSnet) that contains an example of the source data that might form the basis of the text messages, a query that formats and filters the source data as required, a macro to run the necessary steps in order, and a module that contains an example VBA function to read the source query one record at a time and sends an individual message for each record.

Note that this approach is by no means the only way possible, and there are numerous ways in which the sample database could be modified or improved.

Windows Scheduler

The process can be set to run automatically at regular intervals with Windows Scheduled Tasks.

To run a particular macro in an Access database, three items are needed in the ‘Run’ Line of the scheduled tasks – the full path of the MS Access executable, the full path of the Access database, and the name of the main macro preceded by /x (no space).

The command might look as follows –

"C:\Documents and Settings\All Users\Start Menu\Programs\Microsoft Office\Microsoft Office Access 2003.lnk" "p:\infocom\runtime\apptmail.mdb" /xSendReminders

(quotation marks important)

Microsoft Outlook

Outlook needs to be configured to use an nhs.net account by default, as the texting will only work if the mail messages are sent by an nhs.net account.

Macro Security

Many Microsoft applications are, by default, set so that warnings are displayed if an application tries to do something unexpected. This reduces the risk of virus infection, but the downside is that it prevents the computer from doing certain useful things. Security settings will need to be set to low if you want the service to be automated. It goes without saying that the PC used for this service will be in a secure location, and only operated by competent staff.

NB Disabling MSOutlook warnings can be non-trivial. It will very much depend on the mail setup at your organisation, but there is a wealth of knowledge on the internet about such matters. Here is one example:

http://support.microsoft.com/default.aspx?scid=kb;EN-US;263297

Housekeeping

The nhs.net account that sends the emails should be monitored periodically, firstly to check for password expiry, and secondly to deal with the notification emails that are received as the result of each message sent and which inform of the success or failure of the text message. You may wish to adopt a procedure for dealing with notifications of delivery failure.

Above is an Access database containing sample data structure, macro and code.

Questions put to Ashford & St Peter’s Trust

Have you experienced issues with reliability?

There are certain situations that are beyond our control e.g. mobile provider outage or delay, but if you follow general housekeeping rules e.g. making sure the mailbox password doesn’t expire, and clearing out the mailbox regularly, then it’s a very reliable system.

Ashford & St Peter’s use iSoft Clinicom PAS – how will your system work with other clinical systems?

The access database doesn’t link to the PAS itself but to a separate data warehouse which is fed by the PAS. As long as you can build a database that can link to the data warehouse the system will work.

What’s the content of the text message that is sent?

You can put any text that you wish in the message. Ours is on the lines of, ‘You have an appointment at orthopaedics at x hospital on x date. Please call xxxx if you have a query’. It is possible to have a different message for every type of recall if you wish.

Do you have to ask for the patients consent to contact them?

In Ashford & St Peter’s view, once the patient gives you their number they are consenting you to contacting them on that number. We do however notify patients that we intend to contact them in this way so they could opt out if they choose although no one has.

Is the text message kept on the patient’s clinical record?

A record is kept of every text that is sent but the body text in the message isn’t kept. However it is possible to retrieve this if necessary. Clearly a text message does not actually constitute a clinical record.

Where do I go from here if I want to set this up?

Someone with technical knowledge will need to create an access database and write the appropriate codes for you.

I’d prefer not to use Outlook, is this possible?

Anything that can link to an IMAP connection and support 128bit SSL encryption will be fine.

When is the reminder sent to the patient?

You can set the system to send the message whenever you want.

Are the text messages sent hard coded or configurable?

The messages are entirely configurable. Ashford & St Peter’s use an Access database and VBA to send the message and can set the message to say whatever you want it to.

Can you text patient results with this system?

Yes. Anything you can put in an Access database can be sent.

Can you add an appointment time as well as the date?

Yes.

Can patients respond to the text?

No, but the ability to receive incoming texts on NHSmail will be developed in the future. The message sent from Ashford & St Peter’s contains a contact telephone number that patients can ring if they want to respond to the message.

What’s your success rate?

No detailed analysis has been carried out yet but approximately 75% of messages are delivered successfully. Clearly the original patient letter is the definitive way to communicate appointment information to patients and the text reminder is additional to this but the system as a whole demonstrates that Ashford & St Peter’s are improving their communication with patients.

Have DNA rates been reduced?

There has been a noticeable drop in paediatrics outpatient DNAs and Ashford & St Peter’s expect a drop in other DNA rates in the future.

Would each practice or Trust have to set this system up?

Yes but detailed instructions are available on this site (again, only accessible via an NHSnet connection) along with the visual basic code you need.

How many messages a day are being sent out by Ashford & St Peter’s?

A year ago the Trust was sending out reminders for just four specialties, sending 100-200 messages per day.

How often do you clear out the mailbox?

Once a fortnight.

Can you put an exclusion in the database if a patient doesn’t want to be contacted?

Yes. You’d need to record an exclusion code on the PAS system which would be carried forward to the data warehouse. The texting system would recognise that piece of code as an exclusion and refrain from sending to that number

Have you had any complaints from any patients?

No. One person complained that they’d received a text at 10pm so we changed the macro to ensure that messages were sent at an earlier time.

What version of Access are you using at Ashford & St Peter’s?

2003

Does this version prompt you to confirm you actually want to send the message? i.e. to make sure that you’re not spam or a virus

Yes that was an issue we had to get around. For further information on this issue see this link (again, only across an NHSnet connection).

Who is the sender shown as on the recipients phone?

NHS

Do you have to set up a separate mail account to send the texts from?

No you don’t have to, but the best practice would be to set up a generic account.

Are there any preferred conventions for naming the generic accounts?

No

Has the text messaging facility replaced patient reminder letters?

No, as Ashford & St Peter’s don’t send out letters as a rule.

For further information, contact the NHSmail team at feedback@nhs.net