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Automated texting to improve colonoscopy show rates

Project status



Nadim Mahmud, MD, MS, MPH, MSCE 

Sahil Doshi, MD 

Mary Coniglio, MBA 

Michelle Clermont, MD 

Donna Bernard, MSN 

Vandana Khungar, MD, MSc 

Afi Peele

Innovation leads


National Center for Advancing Translational Science 

Institute for Translational Medicine and Therapeutics 


Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the United States. It is recommended that individuals begin regular screenings for CRC at the age of 45. Screening can prevent cancer by discovering precancerous polyps that can be removed before they turn into cancer. It can also find CRC early when treatment often leads to a cure. However, various barriers lead to substantial no-shows and cancellations for screenings done through colonoscopy.   

Current approaches to increase screening rates are challenging and costly (as in the case of phone calls and patient navigators) or have low patient engagement (as with instructional videos or mobile apps). Poor bowel preparation before colonoscopies is also common. 


We leveraged Way to Health to pilot Coloprep, a bi-directional texting program to connect with colonoscopy patients and help them prepare for upcoming CRC colonoscopy screenings. Patients in the program received automated reminders and instructions via text message one week before their colonoscopy. The texts were written in conversational language to engage patients and foster commitment. Patients could also send questions to the service and receive answers from staff within one day. 

We then conducted a clinical trial to test the texting program in a larger population. In this trial, the texting program was modified to be unidirectional (patients could not text back) to make it feasible at scale. In addition, some participants were enrolled through phone calls and others through opt-out text messaging so that we could test different recruitment strategies.   


The initial pilot suggested the intervention could increase colonoscopy show rates. The subsequent clinical trial found that attendance rates did not differ significantly between participants receiving usual care, comprising written instructions and a nurse phone call, and those receiving the automated texts as well as usual care. Nor was bowel preparation quality substantially different between the groups.  

With the automated program, show rates or bowel preparation quality were not compromised, and Coloprep also provided a major benefit: It saved the clinical team considerable time by unburdening nurses from placing and fielding multiple calls. Based on this, Coloprep was implemented as the standard of care at Penn Medicine Radnor and subsequently scaled to Presbyterian Hospital, Penn Digestive and Liver Health Center University City, and Pennsylvania Hospital. Adoption at the Perelman Center for Advanced Medicine is also planned for 2023.

Way to Health Specs

Learn more about the platform
Activity monitoring
Arms and randomization
Criteria-based rules
Dashboard view
Device integration
EHR integration
Multiple languages
Patient portal messaging
Patient-reported outcomes capture
Photo messaging
Remote patient monitoring
Schedule-based rules
Survey administration
Two-way texting
Vitals monitoring

Innovation Methods

Fake back end

It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service. A fake back end is a temporary, usually unsustainable, structure that presents...

Fake back end

For the first phase of the automated texting pilot in colonoscopy preparation, we asked open-ended questions that were answered by a GI fellow. This enabled us to learn more about the needs of patients quickly and at a low cost. It also helped us identify portions of the support process that could be automated.

Fake back end

It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.

A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.

Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"

As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.