Overview

A multidisciplinary team at the BWH Endoscopy Center used Medumo’s text message reminder system to provide patients with a digital colonoscopy prep guide in advance of their procedure in order to increase adequate preparation rates and decrease colonoscopy no-show rates.

Organization Name

Division of Gastroenterology, Hepatology and Endoscopy; Brigham & Women’s Hospital

Organization Type

• Academic Hospital
• Academic Medical Center

Local/Organizational Context

• Brigham Health is a healthcare organization devoted to maintaining and restoring health for people everywhere. It is composed to Brigham and Women’s Hospital (BWH), Brigham and Women’s Faulkner Hospital, and Brigham and Women’s Physicians Organization. The organization also includes 150 outpatient practices with over 1,200 physicians.
• BWH is a major teaching hospital of Harvard Medical School.
• The Endoscopy Center at Brigham and Women’s Hospital (BWH), led by Medical Director John Saltzman, MD, offers inpatient evaluations, outpatient evaluations and treatments for disorders of the esophagus, stomach, small bowel, colon and the biliary/pancreatic system. It is one of only 17 endoscopy programs in the world to be named as a Center of Excellence by the World Organization of Digestive Endoscopy.
• Colonoscopy preparation can be complex and sometimes confusing for patients, as it requires a series of time-sensitive actions and dietary changes in the days leading up to the procedure.
• When patients are unable to prepare adequately, the procedure may take longer or may not be able to be performed due to physicians’ inability to visualize the bowels (which often is not determined until the patient has been sedated and the procedure has begun).
• Prior to the intervention, 11.5 percent of Endoscopy Center at BWH’s patients were found to have inadequate colonoscopy prep within a three-month period.
• Jennifer Nayor MD identified the need early on for improved colonoscopy prep, approached the Brigham Care Redesign Incubator Startup Program, and served as the clinical champion to lead the Department of Gastroenterology’s efforts on Medumo implementation.
• Karl Laskowski MD leads the Brigham Care Redesign Incubator Startup Program and was initially involved in selection, investment, coaching, strategic positioning, and project management in the first year of the implementation.
• As the intervention evolved from a pilot to a Brigham Health institutional priority, Josie Elias from the Brigham Digital Innovation Hub became an executive sponsor.
• This effort also received funding and leadership support from the Brigham Digital Innovation Hub in addition to the Brigham Care Redesign Incubator Startup Program (BCRISP).

Leadership

• • Jennifer Nayor MD served as the clinical champion on behalf of the Department of Gasteroenterology.
  • Karl Laskowski MD from the Brigham Care Redesign Incubator Startup Program and Josie Elias of the Brigham Digital Innovation Hub were also intimately involved with this implementation.

Funding

• • This intervention was funded by the BCRISP incubator.

Research + Planning

• Surveying Current Practices:
  • • • The leadership team surveyed GI physicians from the two initial pilot sites to obtain the patient education mailers / flyers / handouts these physicians were giving patients detailing colonoscopy preparation.
• Creating Colonoscopy Prep Guide
• • • • The Medumo team then created a composite colonoscopy preparation guide from these materials that was amenable to delivery by text message reminder.
      • At each pilot site during routine physician group meetings, the GI physicians approved the content of the Medumo colonoscopy preparation guide to be sent out to their patients and reconciled differences of opinion and practice.
• Researching EMR Integration:
• • • The leadership team sought to integrate Medumo into the EMR (Epic), but they found this process to be more difficult than anticipated.
      • They utilized Redox Engine to manage API interface between Medumo and Epic.
    • They developed workflows for clinic administrative staff to generate manual reports of patients scheduled for colonoscopies and to upload these reports to the Medumo platform each day so that Medumo could push out the appropriate text message reminders.

Tools or Products Developed

• • Medumo – Brigham & Women’s Hospital Digital Colonoscopy Prep Guide
  • 25 different Medumo applications within Brigham Health

Training

• • Clinic Administrative Staff:
    • ~30 minutes one-time training for 2-3 administrative staff per clinic by clinical champion and Medumo team on generating EMR-based report to upload via secure file transfer to Medumo platform
    • On job training for 2-3 administrative staff per clinic to respond to Medumo-generated requests for scheduling new appointment or rescheduling appointments
    • One week trial period after Medumo go-live with close supervision by clinical champion and clinic operations supervisor to troubleshoot interruptions to workflows
  • Physicians should be made aware of program roll-out.

Tech Involved

• Epic
• SMS
• Telephone

Team Members Involved

• Administrative Assistant

Workflow Steps

• Administrative staff member uploads a report of upcoming colonoscopy appointments to secure Medumo file transfer website daily.
• The administrative staff receives a Medumo report with requests and follow-up items for the day, i.e. “Mrs. Smith wants to be called back at Tuesday at 12pm”
• The patient-facing text message reminder system runs automatically:
  • At predetermined intervals, patients receive automated instructions and reminders via text message explaining what steps they need to complete at that time. These include timely notifications about when to stop eating solid food or when to consume the laxative prep solution, among other check-ins. On the day of their procedure, patients also receive a text with directions to the center using BWH’s new wayfinding tool.

Budget

• $25K to $50K

Budget Details

In the initial two years of the intervention, the variable costs to implement totaled ~$50,000 and are anticipated to decrease.

Where We Are

The intervention is still ongoing and the Endoscopy Center began to use Medumo’s text messaging reminder system for colonoscopy procedure scheduling.

Brigham Health has also used Medumo in other surgical subspecialty departments for applications such as radiology procedure scheduling, outreach around surgical procedures, opioid counseling, physical therapy referrals, and other peri-procedural consultations.

Outcomes

• After the three-month pilot, inadequate colonoscopy preparation rates fell to 3.8 percent.
• In addition, the no-show rate dropped from 6.1 percent to 4.3 percent.

Benefits

• More patients were prepared for the colonoscopy, and fewer patients did not show up for their colonoscopy appointment.
• The implementation surfaced conversations about standardization of procedural preparation clinical pathways.

Unique Challenges

• As patients began offering more responses to Medumo text message reminders, adequate staffing to respond to patient requests has posed more of a challenge.
  • Gastroenterology fellow physicians had been receiving increased calls about inadequate preps
  • In response, text message reminder content was edited to encourage patient feedback within normal business hours.

Sources

BWH Bulletin, “Endoscopy Center Sees Success with Text Message Reminder System”. https://bwhbulletin.org/2018/02/01/endoscopy-center-sees-success-with-text-message-reminder-system/

Brigham Health, “Endoscopy Center”. https://www.brighamandwomens.org/medicine/gastroenterology-hepatology-and-endoscopy/endoscopy-center

Brigham Health, “About Brigham and Women’s Hospital”. https://www.brighamandwomens.org/about-brigham-and-womens-hospital