Experts say SMS-based engagement tools can help pharmacists improve medication adherence and reduce hospital readmissions by addressing common patient barriers such as forgetfulness and cost.
In this Pharmacy Times Explainer, Ben Long, MD, director of hospital medicine at Magnolia Regional Health Center; and Weston Blakeslee, PhD, vice president of clinical data strategies at DrFirst, discuss how personalized short message service (SMS) reminders can improve medication adherence and reduce 30-day hospital readmission rates among patients with heart failure. They authored a study, recently published in PLOS Digital Health, showing that SMS text reminders increased prescription filling by 19% among patients with heart failure.
Long and Blakeslee explain that forgetfulness, cost concerns, and lack of understanding are major barriers to medication adherence, and that timely text nudges, educational content, pickup reminders, and savings options can help overcome these challenges. The experts emphasize the importance of not overwhelming patients with messages and stress that digital interventions should be automated, clinically effective, and seamlessly integrated into pharmacy workflows. They also highlight the unique role pharmacists play in monitoring adherence, identifying adverse effects, and collaborating across care teams to eliminate silos and improve long-term patient outcomes.
• Personalized text message reminders significantly increased prescription fill rates and helped reduce 30-day readmissions.
• Digital engagement tools work best when messages are timely, useful, and focused on education, cost support, and pickup reminders.
• Pharmacists have a unique vantage point to identify adherence issues and collaborate with care teams to improve long-term patient outcomes.
Pharmacy Times: The study showed that patients who interacted with personalized SMS reminders had about a 19% higher likelihood of filling their heart failure prescriptions after discharge. How should pharmacists interpret these results when considering strategies to improve adherence in this high-risk population?
Ben Long, MD: It’s a great question. First, I think it's important to have a common understanding about adherence vs compliance. Adherence implies understanding, alignment, and ultimately active engagement with care on the part of the patient.
In our study, we specifically mentioned patient outcomes. We were interested in 30-day hospital readmissions or even return emergency department visits. So the question is, what role does improved adherence have in driving outcomes? As I mentioned, engagement and adherence are closely related, and patient engagement is a big topic of interest when it comes to delivering high-quality health care and patient safety.
The point has been made by other authors, such as Kristin Carman, PhD, MA, that while some highly motivated individuals may become engaged in their care on their own, the vast majority of people will not. In our study, we looked at a simple strategy aimed at overcoming some of the many health disparities or individual factors that might limit a patient's access to care or their capacity to engage with it. Obviously, having the ability to engage with text messages and smartphone utilization is far from universal, but the prevalence of personal devices today and this whole notion of your care coming to you clearly has a place in advancing this idea that promoting better access to care leads to better outcomes and experiences.
Pharmacy Times: What aspects of the engagement platform used in the study do you believe were most effective in driving adherence, and how can pharmacists reinforce that engagement?
Weston Blakeslee, PhD: Another great question. The first thing we always want to address with our SMS digital interventions is forgetfulness. It's one of the most common reasons patients don't fill their medications. They simply forget to go to the pharmacy and fill them. So the first gap we address is that as soon as the prescriber hits send for the prescription to go to the pharmacy, the patient gets a text message about 5 minutes after that happens. Oftentimes, prescriptions can get queued up in the prescriber’s workflow and don't immediately get sent right after the patient has their visit. By addressing this, you know for a fact that your prescriber has actually sent the prescription to the pharmacy, and then you get that mental cue to say, “OK, great, I can go to my pharmacy.”
Additionally, we always want to focus on other gaps that can provide barriers to making sure patients actually fill their medications. Our end-user experience, after you click into that text message, provides educational material about why patients should be taking their medications. As Dr Long mentioned, compliance is also very important when talking about engaging these patients, in addition to adherence. They can also schedule pickup reminders for their medications, and they're also presented with additional savings options because we know cost is a big barrier to ensuring patients are filling their medications regularly. We want to make sure we're addressing all of these barriers in a way that is effective to engage the patient.
Pharmacy Times: From your hospital medicine experience, what are the biggest barriers to medication adherence you see, and how did the text nudges help overcome them?
Long: In my experience, the barriers are numerous, complex, and individualized. Common themes I see start with simple understanding: What am I supposed to be taking and why? What's this going to cost me? Is it going to change the way I feel? Is my regular doctor going to approve of the change? When am I expected to fill and start this treatment?
I would also add that polypharmacy is a prevalent issue for which we lack a unified effort to address. Society has become accustomed to this notion of a single pill for every ill. But when it comes to more complex treatment strategies, like managing heart failure, for instance, that becomes more challenging for people to understand, and sometimes they just don't want to do it. I think the text nudges help care feel less episodic, and I think they promote better communication and equity.
Pharmacy Times: With such high patient engagement and a low opt-out rate, what lessons does your study offer pharmacists on using mobile communication tools to support patients without overwhelming them?
Blakeslee: You certainly don't want to inundate the patient. Our team is always optimizing when the right time is to message a patient and how often to message them. The reason we have such low opt-out rates is because we consistently study this and improve upon it. From the pharmacy perspective, when that medication actually gets to the pharmacy, there are a lot of strategies that could be useful. The way you maintain a low opt-out rate is to make sure that all the messages you send are useful to the patient. For example, is this prescription in or out of stock? Is that medication ready to be picked up? Are there additional savings options?
To Dr Long's point, polypharmacy is a large issue and has been for decades. Any clinical program information that helps connect patients to better manage all of their medications together for their individualized condition set would be useful and help keep engagement high.
Pharmacy Times: Given the reduction observed in 30-day readmissions, how can pharmacists collaborate with care teams to use similar digital engagement strategies to reduce readmissions in their practices?
Long: There are ample opportunities for better teaming across our health care system. It starts with a common understanding that even though many of us have different roles and even different employers, we are, in a macro sense, a single system with a common goal. Wes and I often talk about our shared vision of eliminating care silos. One example of that might look like better integration of feedback loops. What's the point of reducing 30-day readmissions if those interventions don't reduce admissions and readmissions over a lifetime or improve mortality? Pharmacists have a really unique line of sight to medication adherence, adverse effects, and high-risk interactions over time. Utilizing that knowledge to improve care is a huge opportunity that warrants more research.
Pharmacy Times: Looking ahead, do you see opportunities to integrate SMS adherence tools more widely into pharmacy workflows? What would be the key challenges and considerations for successful implementation?
Blakeslee: The short answer is absolutely. Pharmacists are one of the most underappreciated assets in our health care ecosystem, but their workflow is incredibly strained. Employing digital interventions that are safe, effective, and automated with minimal oversight by pharmacists and technicians is critical. Any digital intervention needs to be accurate, clinically effective, and not add to the burden pharmacy staff already has when filling, consulting, and caring for patients. Those are the big challenges any intervention should take into consideration.
Pharmacy Times: Is there anything else that either of you would like to add, or anything that I missed?
Blakeslee: I think focusing digital interventions on vulnerable populations first is the best place to start. Getting to these vulnerable patients avoids a snowball effect that can result in avoidable outcomes for all stakeholders, especially the patient.
Once you refine digital interventions with vulnerable populations, all patients will benefit down the road. An effective strategy is starting with those patients most vulnerable because they have the most severe symptoms and place the most strain on the system, and then applying what you learn to the broader population. Also, efforts should focus on ensuring patients are not only filling their medications but taking them as prescribed. As Dr Long mentioned, compliance is one of the big challenges that is still not fully addressable with many digital interventions, so that compliance gap is really the next big step to focus on.
