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e-Health QUERI Evaluates Automated Text-Messaging System for Patient Self-Management

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e-Health QUERI Evaluates Automated Text-Messaging System for Patient Self-Management

The VA’s Office of Connected Care has developed an automated patient text-messaging system named “Annie,” after Nurse Annie Fox, a World War II hero. Developed in consultation with England’s National Health Service, it is modeled after their Simple Telehealth automated text messaging system, nicknamed “Florence,” after Florence Nightingale. With VA’s Annie system, patients can enroll to receive automated one-way and two-way text messages to help facilitate behavior change and improved health. Current Annie protocols include:

  • Reminding patients of appointments and taking medications,
  • Educating patients about topics like weight management and low blood sugar, and
  • Prompting patients to text back information such as blood pressure readings taken at home.

Annie is first and foremost a patient self-management tool, with typically little monitoring or input needed from the clinical team. However, patient use of Annie and the data they submit are viewable on a clinical dashboard.

QUERI’s eHealth Partnered Evaluation Initiative, led by Timothy Hogan, PhD, is currently completing a two-phase evaluation to examine the early experiences of Veterans and VA clinical team members who use Annie. [The principal investigator of this project is D. Keith McInnes, ScD.] In Phase 1, investigators completed a formative evaluation at five VA facilities using an early version of Annie. They gathered qualitative and quantitative data from 43 respondents (23 patients, 20 providers) to identify clinician adoption and workflow challenges, patient ease of use, usefulness, and barriers to use. Analysis of Phase 1 data revealed that 67% of Veterans agreed that Annie was easy to use, 11% felt they needed to learn a lot to use Annie, 46% felt Annie helped them take better care of their health and become more connected with their clinical team, and 91% would recommend Annie to another Veteran. Among providers, 67% agreed leadership and management would support Annie implementation and 60% would recommend Annie to another provider. The Phase 1 qualitative interviews revealed five lessons to support implementation:

  1. Importance of identifying a resource person who is able to bridge technology and clinical issues;
  2. Reminding clinicians of the evidence, innovation, and patient empowerment associated with Annie may lead to swifter adoption;
  3. Clinical sites just starting Annie may want to initially focus enrollment on patients comfortable with technology and who do not need intensive clinical follow-up;
  4. Adaptability of Annie texting protocols to many health conditions will help create broad appeal; and
  5. Patients and clinicians valued Annie as a health coaching tool.

From these insights, QUERI investigators developed a toolkit for other VA facilities wishing to implement Annie. In Phase 2, they are conducting a randomized evaluation of the toolkit to determine its impact on Annie’s adoption. Hepatitis C clinics at seven VA facilities are participating in Phase 2. Four sites received the toolkit coupled with implementation facilitation that included tailoring the hepatitis C protocol, and problem solving on recruitment and technology issues. Three sites received Annie without facilitation. A mixed-methods evaluation is underway, including pre- and post- patient and provider surveys and qualitative interviews, medical chart abstraction, and facilitation tracking (types and quantity), to understand Annie’s potential impacts (i.e., medication and appointment adherence and patient self-efficacy).

The Annie automated text-messaging system offers support through self-management, coaching, and education outside of clinical encounters. If successfully implemented, it may be able to increase patient-centered care, improve self-management, and achieve health gains in an efficient and scalable manner. Findings will inform the iterative development of Annie and its national rollout.

For more information, please contact Tim Hogan, PhD, at

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