Just Text Me Using SMS Technology forCollaborative Patient .docx

Just Text Me: Using SMS Technology for
Collaborative Patient Mood Charting
By April C. Foreman, Chris Hall, Karen Bone, Je�rey Cheng
and Adam Kaplin |
September 26, 2011
Abstract
Summary: Mood 24/7 is an innovation in traditional mood
charting using text messaging
technology. Mood 24/7 allows the user to collect mood data in a
standardized text message
format, receives optional 160-character annotations from users
in addition to their daily
mood ratings, and securely stores user response data on a
protected server. Adopting this
strategy for monitoring mental health symptoms may be one
way to increase patient
engagement and accuracy in reporting mood symptoms.
Keywords: Mental health, depression, mood tracking, HIT,
SMS, texting, patient
engagement.
Citation: Foreman AC, Hall C, Bone K, Cheng J, Kaplin A. Just
text me: using SMS technology
for collaborative patient mood charting. J Participat Med. 2011
Sept 26; 3:e45.
Published: September 26, 2011.
Competing Interests: Chris Hall leads the product and business
development of Mood 24/7
as Director, Clinical Platforms at HealthCentral. Adam Kaplin
is entitled to a share of royalty
received by the University on sales of products used in the

study described in this article,
Under a licensing agreement between The HealthCentral
Network Inc., and Johns Hopkins
University. The terms of this arrangement are being managed by
Johns Hopkins University
in accordance with its con�ict of interest policies.
Introduction
Depressed mood and “mood swings” are common complaints
from patients in both medical
and behavioral health care settings. A common intervention for
patients expressing these
symptoms is to advise them to monitor their mood, often using a
Likert scale. The usual
clinical practice of mood monitoring uses a simple paper chart
that patients can complete
on a daily basis. Based on a subjective rating scale, patients can
chart (and clinicians can
monitor) the progression of patients’ mood changes over
time.[1]
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High reliability and validity of subjective mood rating has been
demonstrated over the past
forty years.[2] For example, longitudinal charting of a single
scale for subjective mood rating
has been shown to correlate highly with other more elaborate
rating scales such as the
Hamilton, Beck, and Zung rating scales for depression. When
patients can rate their moods
consistently, and remember to bring them to their appointments,
these charts can provide
highly valuable clinical information. This information is useful
for the patient, clinicians, and
other members of a treatment team.
Poor Compliance with Traditional Paper Charting
Patient compliance with paper charting of mood is notoriously
low. First, depressed
patients often have low motivation for task completion.
Decreased cognitive function and
memory de�cits are two other symptoms often experienced by
patients with depression,
leading to di�culties with active involvement and self-
monitoring of symptoms.[3]
Moreover, some patients might “back�ll” the mood charts to
avoid the image of non-
adherence. Current research suggests a compliance rate of 11%
with paper mood charting.
[4]
Low compliance rates may lead some clinicians to avoid
recommending charting symptoms.
Traditional paper charts may also create problems for patients
who already struggle with
memory, cognitive impairment, motivation, impulsivity, and
chaotic behavior. They may feel
that they must choose between “failing” their health care

provider by reporting their “non-
compliance,” or “back�lling” their mood diary. Unfortunately,
a “back�lled” mood chart is
very likely to be inaccurate, in�uenced by the mood and
cognitive distortions of the
moment.
If mood charting is recommended, but leads to non-compliance
(as it does in 89% of cases),
the patient often feels frustrated or disappointed with
themselves, their clinician, or the
recommended treatment.[1] All of these scenarios run the risk
of reducing collaboration
and patient participation in health care.
These problems may be even more likely to occur in patients
with health needs that are
complicated by medical conditions, or comorbid mental health
diagnoses. People with
mood problems may also face poverty or other factors that
negatively in�uence treatment
outcomes. The authors believe that patients with these
complications could signi�cantly
bene�t from careful daily mood monitoring. Unfortunately, the
barriers they face may also
make them less likely to be successful with traditional paper
mood charting.
Case Study
Mood 24/7 was developed as a solution to three problems
associated with mood
monitoring and participatory health: data collection, data
visualization, and data
connection. We recognized that there was a need to create
incentives for certain patients to
provide mood data on a regular basis. We also wanted to

facilitate data presentation that
would be useful to clinicians and patients. Ideally, this tool
could become widely available,
with few barriers to patient access. With these criteria in mind
we explored the use of cell
phone text messaging technology to enhance the bene�ts of
traditional paper mood
charting.
Why Text Messaging?
It is estimated that in 2009 there were 286 million cell phone
subscribers in the United
States, representing 91% of the population.[5] Because cell
phones are almost ubiquitous
and are familiar, they represent an ideal technology for patients
to chart a mood rating.
One of the authors (A.K.) initiated e�orts to develop an SMS-
based system that would work
on any mobile phone to track patients’ moods. Through a
partnership between Johns
Hopkins University and HealthCentral, a mood charting system
using this technology was
developed. SMS texting was chosen because the vast majority of
cell phones have this
technology available. This technology has the additional
advantage of being widely available
and widely used in rural regions that are characterized by
poverty, where there are also
many barriers to computer and internet use. By contrast, tools
using smart phone
applications are available to fewer than 20% of potential

users.[6] These applications are
likely to become more useful as smart phones are more broadly
adopted.
How the Innovation Works
Mood 24/7 (the SMS mood-tracking tool developed by
HealthCentral based on a technology
licensed from Johns Hopkins) uses text messages and a secure
website to help people log
and track their moods. Mood 24/7 is accessible to the 91% of
Americans who send �ve
billion text messages per day from their cell phones.[5]
Information generated by patient
registration with Mood24/7 is “owned” by the patient who opts
to allow participating
clinicians to view it on the Mood24/7 website.
Figure 1. Screen shot showing the Mood 24/7 web site home
page.
Individuals may sign up securely and select a time to receive
daily text messages which ask
for mood ratings on a scale from one to 10. Mood 24/7 uses
hypertext transport protocol
secure (https, or “secure” http) to encrypt all data that a patient
sends to the website. All
personally identi�able information (such as email addresses or
phone numbers) is stored in
encrypted form. No one has access to view a patient’s mood
other than the registered user,
or those to whom he or she explicitly grants permission. More
information about data
security and privacy can be viewed here:

https://www.mood247.com/faq
Figure 2. Mood 24/7 message using SMS texting methodology.
https://participatorymedicine.org/journal/columns/innovations/2
011/09/26/just-text-me-using-sms-technology-for-collaborative-
patient-mood-charting/attachment/mood-24-7-screenshot/
Participants may also add a text message comment related to
their rating. Text message
responses and notes are then added to a personal mood chart
that participants can share
with providers using the “Trusted Circle” feature. This data can
be viewed over any “user
speci�ed” time interval, such as week, month, or year intervals.
This chart allows patients,
clinicians, and other treatment team members to view mood
variability, longitudinal mood
course, and the e�ects of various treatment interventions in real
time.
Figure 3. Screen shot illustrating the “Trusted Circle” option.
patient-mood-charting/attachment/mood-24-7-message/
The design of Mood 24/7 di�ers from smartphone mood
charting applications (eg, the T2
Mood Tracker) due to its use of a secure website. This allows
the patient, clinician, and other
members of the “Trusted Circle” to view mood chart data
online, instead of viewing it only
on the smartphone. Additionally, online viewing allows

clinicians to print out mood charts
and add the information to the medical record. This feature is
not only clinically useful but
also important for medico-legal considerations.
Figure 4. Illustration of “mood index” charting using Mood
24/7.
System Development
patient-mood-charting/attachment/mood-24-7-screenshot-2-2/
patient-mood-charting/attachment/mood-24-7-mood-index/
This tool was developed through a partnership between Johns
Hopkins and HealthCentral.
Our goal was to introduce a novel technology into the practice
of mental health, which has
traditionally been low-tech in its approach to treatment
intervention.
Hurdles that needed to be addressed and are common to any new
technological healthcare
innovation include developing an optimal user interface;
ensuring availability of the service
across phone carriers; providing security for the information
collected; and establishing a
model for generating sustainable revenue without passing on
prohibitive costs to patients
in need of this service.
The initial barriers to introduction of this tool were largely

procedural. In a rural community
mental health care setting, we educated administration, sta�,
and patients about
con�dentiality; data storage and security; how and when the
information would become a
part of a patient’s medical record; and patient safety. Mood 24/7
terms of service were
reviewed with patients, and they were instructed to continue
using existing crisis plans and
services because clinicians would not be expected to
continuously monitor mood in real
time. Patients were informed that clinicians would print out
mood diaries, and these
printouts would be added to their existing medical records.
Patients and clinicians agreed
that they would discuss patient mood diaries at the beginning of
each session to monitor
user interface concerns. Clinicians agreed to make the
developers aware of any
adjustments or updates that might be useful. Clinicians agreed
to review patient-generated
mood charts with other members of the treatment team prior to
clinical contacts, and to
discuss this data with patients at least brie�y during
appointments.
Many of the barriers that patients experience in keeping a mood
diary are largely
behavioral, and may be directly related to their clinical
problems. Thus, one of the most
important barriers overcome by this intervention was to allow
patients with motivational,
cognitive, and behavioral impairments to conveniently,
successfully, and consistently collect
and transmit daily information about their mood to their
treatment team.

The authors hope this tool will increase the likelihood of
compliance with mood monitoring,
which may lead to improved clinical decision making and
treatment outcomes. This strategy
for collecting and charting mood data also saves time and e�ort
for the treatment team. In
addition, a tool like Mood24/7 gives patients incentives for
mood charting, engaging them
through a convenient, visual medium.
Preliminary Findings
This tool has been used at Johns Hopkins as a means of
collaborating with users across the
country. At Johns Hopkins, in a non-clinical population, daily
compliance with mood charting
was 86.67% over a 40-day period, according to unpublished
data. This compliance far
exceeds previously reported compliance with paper and pencil
mood tracking.
Mood 24/7 also facilitates the ability of care providers and
patients to review the mood
chart together to track clinical progress. Patients at Johns
Hopkins who use this tool almost
universally describe that they become more aware of their own
mood variations and
response to treatment. They also report that health care
providers seem more engaged,
because patients’ daily comments and mood changes are
reviewed at the time of their
visits, and can be easily accessed when patients call their care
providers.

According to user data collected from Mood 24/7 servers
242,057 mood ratings were
submitted by users between December 2010 and July 2011.
While the number of active,
registered users varies from day to day, within the last six
months the active user base
stabilized at roughly 4,000 users per month. It appears in that
case that a relatively small
number of active users generated a large number of mood
ratings, suggesting their strong
engagement with this tool. Also, 86,010 of these mood ratings
contained an annotated
message attached to the numeric mood rating. This means that
in 35.5% of cases, people
rating their mood opted to include additional (possibly richer)
information about their
mood.
Mood 24/7 has currently been adopted by four therapists and a
nurse practitioner in a rural
community mental health care setting with patients who have
complex mental health care
needs. Similar to the experience at Johns Hopkins, compliance
rates for the one therapist
who was tracking her clinical use of this tool (A.F.) were 91.4%
for 35 of her patients.
Compliance in this context was de�ned as texting a mood rating
on most days in order to
provide mood chart data for at least one follow-up appointment.
This increase in
compliance, in comparison with 11% of paper chart users,[1]
would be a considerable
improvement in any population. The majority of patients
provided almost daily ratings, and
continued charting their moods for longer than one month. In a

rural community mental
health center, with a caseload of patients predominantly
diagnosed with borderline
personality disorder, located in one of the poorest rural counties
in Kansas, this degree of
compliance is especially remarkable.[7]
Speci�c Example of Use
One of the authors (A.F.), a psychologist, used this service as a
part of an intervention
strategy for a dialectic therapy group for clients with Borderline
Personality Disorder, and
related Axis II concerns. Patients in this group enrolled in
Mood24/7, and assistance was
provided to register each patient. Another author, a nurse
practitioner (K.B.), provided
medication services to many patients in this setting. Other
therapists on the patients’
treatment teams were also included, so that all treatment team
members had convenient,
consistent, timely, and asynchronous access to patient mood
charts. In one case, this led to
a revision of the treatment team’s diagnosis due to the improved
quality of information
about the patient’s symptoms. The mood diary service’s
successful implementation in this
challenging setting suggests that this is a highly generalizable
mental health tool.
Conclusions
Experience with Mood 24/7 suggests that using text messages to
conveniently provide daily,
reliable mood charts can improve compliance and accuracy of
patient mood charting. This

can provide both patients and clinicians with better data for
making and evaluating
treatment decisions.
In situations where followup visits are not readily available,
health care providers can
reliably track patients’ daily progress. This is especially
advantageous in poor and rural
health care settings where there may be barriers such as
geographic distance, or provider
availability. And if a patient misses a regularly scheduled
appointment, clinicians can use
this tool to assess whether a patient is doing well or su�ering
from an acute problem, such
as a mood downturn. It may also serve as a cue for the treatment
team to reach out to
patients with crisis services, or to change medical or behavioral
treatment strategies. For
patients and their health care teams, a service like Mood24/7
may provide novel ways to
diagnose and predict the course of mental illnesses.
Tools like Mood 24/7 appear to improve patient engagement and
mood monitoring
compliance at low or no cost to patients. Currently, the wide
availability of SMS technology
makes this innovation highly accessible and convenient. Unique
features such as the
“Trusted Circle” allow online data collection and sharing
without requiring a patient to
remember to collect the data or bring it to an o�ce appointment.
The printable mood chart
is easily read by all members of the “Trusted Circle” and is

convenient to print out and add
to patient records, even when a patient is not at the o�ce.
Based on initial clinical success using text messaging and a
secure website to chart mood,
more rigorous research on this and similar tools seems
warranted. Additionally,
experiences with this innovation suggest features that might be
included in future tools. As
smart phones become more commonplace and less costly, mood
tracking applications on
these devices may have wider utility. In future iterations of
technology-based mood
tracking, it may be helpful to develop secure ways to capture
mood data so that it can be
viewed remotely by all treatment team members, and easily
printed or imported into an
electronic medical record.
References
1. Baldassano CF. Assessment tools for screening and
monitoring bipolar disorder. Bipolar
Disord. 2005;7 Suppl 1:8-15. ↩
2. Ahearn EP. The use of visual analog scales in mood
disorders: a critical review. J Psychiatr
Res. 1997 Sep-Oct;31(5):569-79. ↩
3. Burt DB, Zembar MJ, Niederehe G. Depression and memory
impairment: a meta-analysis
of the association, its pattern, and speci�city. Psychol Bull.
1995 Mar;117(2):285-305. ↩

4. Stone AA, Shi�man S, Schwartz JE, Broderick JE, Hu�ord
MR. Patient compliance with
paper and electronic diaries. Control Clin Trials. 2003
Apr;24(2):182-99. ↩
5. Industry Info Page. CTIA-The Wireless Association.
Available at:
http://www.ctia.org/media/industry_info/index.cfm/AID/10323.
Accessed February 14, 2011.
↩
6. Kellogg D. Among mobile phone users Hispanics, Asians are
most-likely smart phone
users. Nielsenwire. 2011, Feb. Available at:
http://blog.nielsen.com/nielsenwire/?p=25901.
Accessed February 14, 2011. ↩
7. State and County Quickfacts. US Census Bureau. Available
at:
http://quickfacts.census.gov/qfd/states/20/20125.html.
Accessed, August 31, 2011. ↩
Copyright: © 2011 April C. Foreman, Chris Hall, Karen Bone,
Je�rey Cheng, and Adam
Kaplin. Published here under license by The Journal of
Participatory Medicine. Copyright for
this article is retained by the authors, with �rst publication
rights granted to the Journal of

Participatory Medicine. All journal content, except where
otherwise noted, is licensed under
a Creative Commons Attribution 3.0 License. By virtue of their
appearance in this open-
access journal, articles are free to use, with proper attribution,
in educational and other
non-commercial settings.
3 Comments
31
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Alex on September 26, 2011 at 9:12 pm
This is amazing! the closest to realtime data capture.
Reply
e-Patient Dave on September 27, 2011 at 10:09 am
https://participatorymedicine.org/journal/media-
watch/conferences/2010/08/16/health-2-0-goes-to-washington/
https://participatorymedicine.org/journal/evidence/research/201
6/06/06/engaging-patients-in-managing-chronic-disease-an-
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http://bushofdoctors.blogspot.com/
patient-mood-charting/?replytocom=16733#respond
I love the cleverness and simplicity of this.
Not to sound like a broken record, but I want to ask that we all
start shifting
away from the guilt-laden blame-implying “compliance” (a
TOTALLY non-
empowering, non-participatory word) and shift to works like
achievement,
completion, ful�llment, performance, which connote the truth:
the patient is
a partner, not an “obeyer,” in ful�lling the plan.

From: “Experience with Mood 24/7 suggests that using text
messages to
conveniently provide daily, reliable mood charts can improve
compliance
and accuracy of patient mood charting”
To: “…can improve completion and accuracy of patient mood
charting”
From: “Patient compliance with paper charting of mood is
notoriously low.
First, depressed patients often have low motivation for task
completion.” to:
“Patient achievement with paper charting of mood is notoriously
low –
depressed patients often have…”
From: “Current research suggests a compliance rate of 11% with
paper
mood charting” to: “Current research suggests a success rate of
11% with
paper mood charting.’
I humbly suggest, too, that the proposed wording appropriately
shifts the
focus away from blaming the patient and onto the reality that
the �ipping
paper forms simple don’t work well – don’t get the job done! –
and the SMS
app does.
And that’s shown in this �nal example: “Low compliance rates
may lead
some clinicians to avoid recommending charting symptoms” to
“Low success

rates may lead some clinicians to avoid recommending
charting.” Indeed –
darn good thinking, to avoid recommending something that
doesnt work!
I’d say, let’s not call it patient compliance – let’s talk about
e�cacy of the new
approach.
LOL, maybe we could even talk about the incompetence of the
paper chart.
�
Anyway I love the app! It appears to do what patients need!
Reply
Charles W. Smith on October 3, 2011 at 4:27 pm
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Thanks for your input about this important issue. Although
there may be
some circumstances when “compliance” is the preferred use, I
agree that, in
this circumstance, the use of “nonadherance” is a more
participatory word
than compliance.
Reply
http://www.docforeman.com/?p=343
http://occupyhealthcare.net/archives/303
http://www.hallicious.com/2011/10/20/mobile-health-kantine/
http://pulseandsignal.com/events/sxsw-health-accelerator-2012/

http://tammymagid.wordpress.com/2011/11/03/just-text-me-
using-sms-technology-for-collaborative-patient-mood-charting-
journal-of-participatory-medicine/
http://www.mindthesciencegap.org/2012/03/14/mood-rings-
using-text-messages-to-treat-depression/
http://davidbriess.wordpress.com/2013/02/20/just-text-me-
using-sms-technology-for-collaborative-patient-mood-charting/
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IFSM 305 7980 Information Systems in Health Care …
Patients are taking a much more active and involved role in
their health care and, in doing so,
they can help ensure the accuracy of their health information
and its use. The Journal of
Participatory Medicine, on its website http://www.jopm.org/
provides the following:
"Participatory Medicine is a model of cooperative health care
that seeks to achieve active
involvement by patients, professionals, caregivers, and others
across the continuum of care on all
issues related to an individual's health. Participatory medicine
is an ethical approach to care that
also holds promise to improve outcomes, reduce medical errors,
increase patient satisfaction and
improve the cost of care."
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your own words how the approach described can help improve
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Laura Darley posted Nov 18, 2019 1:40 PM

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The use of inpatient-hospitalized patients having bedside access
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records is a hot topic in healthcare. In my own career being a
bedside nurse working on a
h it l fl th t i f tl b ht d ith t ith “h k thi i t
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Just Text Me: Using SMS Technology for Collaborative Patient
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Alexander Krasnokutsky posted Nov 18, 2019 10:40 AM
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Many people experience depression and mood swings, a high
occurrence of depression is
found in patients in both medical and behavioral health settings.
Many clinicians suggest daily
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Just Text Me Using SMS Technology forCollaborative Patient .docx

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