Simplicity is precious. Its absence is irksome. We spent the past week (unsuccessfully) troubleshooting one Microsoft networking glitch. Microsoft engineers are trained to camouflage their messes as simplicity.

Google engineers have a different approach. They deliver simplicity. Google can send its web-based Google Calendar alerts to mobile phones with no configuration.

Exco InTouch appears to have drawn more of its inspiration from Google than Microsoft. Based in Britain, with U.S. offices, Exco InTouch has a solution to use short message services, or “SMS,” in a health care context.

We recently had a chat with the company’s co-founder, Tim Davis. He previously served at electronic patient-reported outcome firm CRF and at Procter & Gamble, where he worked on electronic data capture (EDC). He understands the requirements of a regulated industry. The Exco text-messaging technology conforms to strict European privacy laws, and to HIPAA and wireless regulations in the U.S.

3 Billion Txtrs

As Exco appraised the gold standard of usability in the handheld computer sector—Palm—the company believed it could do better. “We looked around to find a lower common denominator of technology, something people were already familiar with,” Davis explains. “Half of the world’s population has a cell phone. We’re capitalizing on that. It’s getting to the device they already have.”

In the U.S., he reminds us, more than 70 percent of the population has a cell phone, and the vast majority of those devices can send and receive text messages. Ordinary citizens just want to make calls on their mobiles. They don’t want to use their cell phone to film a documentary, edit a spreadsheet, or make popcorn.

Exco: Using Patients’ Cells

We were surprised to learn that just a few percent of the population in the U.S. owns a Palm-Treo or Blackberry-based smartphone. When they are given as gifts, smartphones are frequently returned. Indeed, Davis says, more than half of the functionality on smart phones is never used at all. It will be interesting to watch whether Apple’s iPhone can change that.

Exco InTouch’s vision, meanwhile, is to use SMS on ordinary cell phones to reach patients. Simple messages can serve as reminders about clinic appointments or confirmations of whether medication has been taken. And that can happen programatically, without human intervention. Other clinical systems have used SMS and email alerts. But the Exco system is being positioned as one that can ensure messages are delivered around the world.

The firm has done eight trials in 26 countries. To do so, Exco negotiated agreements with all of the major SMS “gateways.” It has also assisted in another 10-15 projects that were just focused on patient retention or compliance. The telecommunications access is not always easy to arrange. “Establishing these connections has taken a lot of time, but we now offer connectivity to 200 countries across 550 cellular operators,” says Davis.

Integration With IVR, EDC

Sites, crucially, are relieved of massive robo-calling duties and can make more important calls. Exco InTouch is selling the technology into both the clinical trial and the marketing sectors of the industry, with help from Patrick Hughes, a former ClinPhone executive.

Davis notes the Exco system can be connected to EDC systems or interactive voice response (IVR) systems if needed. At any predetermined time interval or milestone, the system can identify, then send the appropriate message. Messages can be customized by patient name and other variables.

Infrastructure Workaround

The company is making lemonade from the fact that wired infrastructure in the developing world can be limited. “We’re going into India, China,” he says. “Landline infrastructure as we all know it doesn’t exist.”

The price of the company’s solution varies according to the scope and duration of a project. In a two-year global study with 600 patients, Davis says, the budget might be $10 per patient per month. In a five-year project with 6,000 patients, the monthly fee might be closer to $1 per patient per month. Those figures include all costs. Patients, needless to say, should need no training to use their own phones. Sites access the system via the internet.

Raising Compliance

The sponsor community, Davis says, is interested that Exco can prove that a particular patient got a particular text message, and that response rates from patients are dramatically higher when the SMS protocol is used to contact them than when the telephone or email are used. There seems to be something about the urgency of an SMS message that makes people less likely to ignore it. “People can discreetly pull out their mobile phone and respond to it,” Davis says.

In some instances, ethics boards or institutional review boards (IRBs) may have to decide whether cellular phones will be supplied to patients who do not already own them. So far, Exco has shipped a few dozen phones around the globe. “It depends on how valuable it is to retain that patient,” Davis says. In some trials, the costs of finding new patients to replace those who have dropped out might far exceed the cost of Exco’s system.

The system can also be used to prod investigators to address data clarification forms (DCF) or “queries.” The system “can be used to send specific DCF reminders direct to the Investigators’ mobile phone so as to direct them to the most urgent outstanding queries,” the company website notes.

Saving The Site

But most of the company’s pitch is saving sites from having to make hundreds or thousands of calls. “We’re making something appealing, very warm and friendly and not so much of a burden for the sites,” he says. A sample text message is admittedly short and pithy. It might just read, Hi Susan, it’s Dr. Smith, I’m looking forward to your next assessment.

In Russia, Exco discovered something interesting about the provenance of cellular phones there. Exco had programmed its system to use the Cyrillic alphabet. But one project in the country immediately encountered problems as clinical research associates reported unexpected ”#” symbols. It turns out that ... ahem, an informal, nontraditional distribution channel funnels phones from elsewhere on the planet to the former Soviet Union. “The common man in the street in Russia sends text messages in Roman characters,” says Davis.

Whatever the source of a phone, the use of text messages in large clinical trials is just getting started, and seems like an ideal match of an extremely scalable, user-friendly technology with a low total cost of ownership.