Appl Clin Inform 2019; 10(02): 326-330
DOI: 10.1055/s-0039-1688554
Case Report
Georg Thieme Verlag KG Stuttgart · New York

A Bottom-Up Approach to Encouraging Sustained User Adoption of a Secure Text Messaging Application

Surafel Tsega
1   The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, United States
Angeli Kalra
2   New York, United States
Cesar T. Sevilla
3   Population Health and Payer Systems, Mount Sinai Health System, New York, New York, United States
Hyung J. Cho
4   Department of Quality, New York City Health and Hospitals, New York, New York, United States
› Author Affiliations
Further Information

Publication History

18 January 2019

05 March 2019

Publication Date:
15 May 2019 (online)


Background Inpatient providers are increasingly utilizing alternative communication modalities outside what has traditionally been used, including short messaging service text messaging and application-based chat tools. Text messaging that meets the recommendations of the Joint Commission (“secure text messaging”) allows for the communication of sensitive patient information through an encrypted platform.

Objective In this quality initiative utilizing the Plan-Do-Study-Act (PDSA) model, we attempted two rollout designs to maximize user adoption of a secure text messaging application.

Methods Our institution launched a secure text messaging application (Cureatr) using a top-down approach during the first PDSA cycle, defined as communication and outreach through department chairs and administrative leaders throughout the hospital. After inadequate user adoption, we transitioned to a bottom-up approach in the second PDSA cycle, defined as direct communication and engagement with end users. This campaign targeted the hospital medicine and inpatient social work department, and used discharge planning as a use case to encourage adoption.

Results Over a 6-month period, we observed an increase in active users in the hospital medicine department (7.5 unique users per month to 29 users during the first and second PDSA cycles, p < 0.01). Additionally, we saw an increase in messages sent and received by the medicine (687 messages on average per month and 7,367 messages per month in each respective PDSA cycle, p < 0.01) and social work departments (350 messages on average per month and 6,083 messages during the first and second PDSA cycle, p < 0.01). We did not observe a significant change in active users or messages sent in the surgery department, which did not participate in the second PDSA cycle.

Conclusion We believe that a bottom-up approach is important to introducing mobile applications to the inpatient setting and can contribute to sustained user adoption.

Protection of Human and Animal Subjects

Our project was deemed a quality project by the Quality Improvement Committee in the Department of Medicine at Mount Sinai Hospital, and thus an Institutional Review Board submission was not required.

  • References

  • 1 Drolet BC. Text messaging and protected health information: what is permitted?. JAMA 2017; 317 (23) 2369-2370
  • 2 Frizzell JD, Ahmed B. Text messaging versus paging: new technology for the next generation. J Am Coll Cardiol 2014; 64 (24) 2703-2705
  • 3 Shah DR, Galante JM, Bold RJ, Canter RJ, Martinez SR. Text messaging among residents and faculty in a university general surgery residency program: prevalence, purpose, and patient care. J Surg Educ 2013; 70 (06) 826-834
  • 4 Prochaska MT, Bird AN, Chadaga A, Arora VM. Resident use of text messaging for patient care: ease of use or breach of privacy?. JMIR Med Inform 2015; 3 (04) e37
  • 5 “Standards FAQ Details: Texting - Use of Secure Text Messaging for Patient Information.” Available at: . Accessed February 11, 2019
  • 6 O'Leary KJ, Liebovitz DM, Wu RC. , et al. Hospital-based clinicians' use of technology for patient care-related communication: a national survey. J Hosp Med 2017; 12 (07) 530-535
  • 7 Franko OI, Tirrell TF. Smartphone app use among medical providers in ACGME training programs. J Med Syst 2012; 36 (05) 3135-3139
  • 8 Astarcioglu MA, Sen T, Kilit C. , et al. Time-to-reperfusion in STEMI undergoing interhospital transfer using smartphone and WhatsApp messenger. Am J Emerg Med 2015; 33 (10) 1382-1384
  • 9 Johnston MJ, King D, Arora S. , et al. Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. Am J Surg 2015; 209 (01) 45-51
  • 10 Drake TM, Claireaux HA, Khatri C, Chapman SJ. WhatsApp with patient data transmitted via instant messaging?. Am J Surg 2016; 211 (01) 300-301
  • 11 Przybylo JA, Wang A, Loftus P, Evans KH, Chu I, Shieh L. Smarter hospital communication: secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow. J Hosp Med 2014; 9 (09) 573-578
  • 12 Hansen JE, Lazow M, Hagedorn PA. Reducing interdisciplinary communication failures through secure text messaging: a quality improvement project. Pediatr Qual Saf 2018; 3 (01) e053
  • 13 Patel N, Siegler JE, Stromberg N, Ravitz N, Hanson CW. Perfect storm of inpatient communication needs and an innovative solution utilizing smartphones and secured messaging. Appl Clin Inform 2016; 7 (03) 777-789
  • 14 Moriates C, Wong BM. High-value care programmes from the bottom-up… and the top-down. BMJ Qual Saf 2016; 25 (11) 821-823
  • 15 Ogunlayi F, Britton P. Achieving a ‘top-down’ change agenda by driving and supporting a collaborative ‘bottom-up’ process: case study of a large-scale enhanced recovery programme. BMJ Open Qual 2017; 6 (02) e000008
  • 16 Haun JN, Hathaway W, Chavez M. , et al. Clinical practice informs secure messaging benefits and best practices. Appl Clin Inform 2017; 8 (04) 1003-1011