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This project aims to evaluate different approaches to increase COVID-19 vaccine uptake among at-risk patients at Penn Medicine in an equitable and systematic manner through a centralized outreach program. The investigators will evaluate different text-based scheduling and messaging approaches informed by behavioral science to increase uptake among eligible patients, including the use of clinician endorsement, opt-out framing, and scarcity.
This project will evaluate a centralized approach to increasing COVID through direct outreach to eligible patients via text messaging. This pragmatic randomized controlled trial has the following aims:
Aim 1: To conduct systematic large scale text message outreach for vaccine delivery among a defined group of Penn Medicine in a way that advances equity.
Aim 2: To offer different scheduling workflows through text messaging that might increase uptake and reduce disparities.
Aim 3: To compare the equity and efficiency of different messages informed by behavioral science, including PCP endorsement, opt-out framing, and scarcity.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| 1: Usual Care | Active Comparator | Patients will receive a phone call to schedule their appointment from an Access Center representative. Access Center representatives will make up to 3 attempts to schedule an appointment with the patient. Patients randomized to this arm will not receive any text messaging. |
|
| 2A: Call Back + Standard Msg | Experimental | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. |
|
| 2B: Call Back + Clinician Endorsement | Experimental | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. |
|
| 2C: Call Back + Scarcity | Experimental | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Opt-In (Call-Back) | Behavioral | Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. |
| Measure | Description | Time Frame |
|---|---|---|
| Dose 1 Completion | Percentage of patients who complete the first dose of the COVID vaccine within 1 month of initial outreach | 1 month |
| Measure | Description | Time Frame |
|---|---|---|
| Dose 1 Completion | Percentage of patients who complete the first dose of the COVID vaccine within 2 months of initial outreach | 2 months |
| Vaccine Completion | Percentage of patients who complete the vaccination process within 2 months of initial outreach |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Shivan Mehta, MD | University of Pennsylvania | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Hospital of the University of Pennsylvania | Philadelphia | Pennsylvania | 19104 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 35696165 | Derived | Mehta SJ, Mallozzi C, Shaw PA, Reitz C, McDonald C, Vandertuyn M, Balachandran M, Kopinsky M, Sevinc C, Johnson A, Ward R, Park SH, Snider CK, Rosin R, Asch DA. Effect of Text Messaging and Behavioral Interventions on COVID-19 Vaccination Uptake: A Randomized Clinical Trial. JAMA Netw Open. 2022 Jun 1;5(6):e2216649. doi: 10.1001/jamanetworkopen.2022.16649. |
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Waiver of informed consent obtained. 19,554 patients randomized.
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| ID | Title | Description |
|---|---|---|
| FG000 | 1: Usual Care | Patients will receive a phone call to schedule their appointment from an Access Center representative. Access Center representatives will make up to 3 attempts to schedule an appointment with the patient. Patients randomized to this arm will not receive any text messaging. Phone Call: The access center will call these patients to schedule their vaccine appointment. These patients will not receive text messaging. |
| FG001 | 2A: Call Back + Standard Msg | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Standard Message: The message describes that the patient is eligible for the COVID vaccine. |
| FG002 | 2B: Call Back + Clinician Endorsement | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Clinician Endorsement: The message will describe an endorsement from the provider to get the vaccination. |
| FG003 | 2C: Call Back + Scarcity | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Scarcity: The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. |
| FG004 | 2D: Call Back + Opt-Out Framing | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-outWill include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Opt-Out Framing: This will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. |
| FG005 | 3A: In-Bound Call + Standard Msg | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Standard Message: The message describes that the patient is eligible for the COVID vaccine. |
| FG006 | 3B: In-Bound Call + Clinician Endorsement | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Clinician Endorsement: The message will describe an endorsement from the provider to get the vaccination. |
| FG007 | 3C: In-Bound Call + Scarcity | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Scarcity: The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. |
| FG008 | 3D: In-Bound Call + Opt-Out Framing | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-Out Framing: This will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. |
| Title | Milestones | Reasons Not Completed | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
|
All randomized patients who were not excluded from analyses for receiving one or more vaccine doses prior to outreach.
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| ID | Title | Description |
|---|---|---|
| BG000 | 1: Usual Care | Patients will receive a phone call to schedule their appointment from an Access Center representative. Access Center representatives will make up to 3 attempts to schedule an appointment with the patient. Patients randomized to this arm will not receive any text messaging. Phone Call: The access center will call these patients to schedule their vaccine appointment. These patients will not receive text messaging. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Dose 1 Completion | Percentage of patients who complete the first dose of the COVID vaccine within 1 month of initial outreach | All randomized patients who were not excluded from analyses for receiving one or more vaccine doses prior to outreach.Comparisons were made between all patients assigned to a texting + outbound call arm (arms 2A+2B+2C+2D) and the outbound phone call only arm (arm 1), and between texting + inbound call arm (arms 3A+3B+3C+3D) and the outbound phone call only arm (arm 1). This was the original analysis as outlined in the protocol, which is why results are reported in this fashion. | Posted | Count of Participants | Participants | 1 month |
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Adverse events were not monitored/assessed.
Adverse events were not monitored/assessed. The research solely tested methods of outreach for getting patients to complete the COVID vaccine, separately approved for use by the FDA with an EUA. No drug, medical device or medical procedure was under investigation.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | 1: Usual Care | Patients will receive a phone call to schedule their appointment from an Access Center representative. Access Center representatives will make up to 3 attempts to schedule an appointment with the patient. Patients randomized to this arm will not receive any text messaging. Phone Call: The access center will call these patients to schedule their vaccine appointment. These patients will not receive text messaging. |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Shivan Mehta | University of Pennsylvania | 215-898-6027 | shivan.mehta@pennmedicine.upenn.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Nov 19, 2021 | Feb 14, 2022 | Prot_SAP_000.pdf |
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| ID | Term |
|---|---|
| D000086382 | COVID-19 |
| ID | Term |
|---|---|
| D011024 | Pneumonia, Viral |
| D011014 | Pneumonia |
| D012141 | Respiratory Tract Infections |
| D007239 | Infections |
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| ID | Term |
|---|---|
| D000085222 | Water Insecurity |
| ID | Term |
|---|---|
| D060766 | Drinking Water |
| D001628 | Beverages |
| D000066888 | Diet, Food, and Nutrition |
| D010829 | Physiological Phenomena |
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| 2D: Call Back + Opt-Out Framing | Experimental | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-outWill include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. |
|
| 3A: In-Bound Call + Standard Msg | Experimental | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. |
|
| 3B: In-Bound Call + Clinician Endorsement | Experimental | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. |
|
| 3C: In-Bound Call + Scarcity | Experimental | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. |
|
| 3D: In-Bound Call + Opt-Out Framing | Experimental | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. |
|
| Opt-in (In-Bound) | Behavioral | Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. |
|
| Standard Message | Behavioral | The message describes that the patient is eligible for the COVID vaccine. |
|
| Clinician Endorsement | Behavioral | The message will describe an endorsement from the provider to get the vaccination. |
|
| Scarcity | Behavioral | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. |
|
| Opt-Out Framing | Behavioral | This will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. |
|
| Phone Call | Behavioral | The access center will call these patients to schedule their vaccine appointment. These patients will not receive text messaging. |
|
| 2 months |
| BG001 | 2A: Call Back + Standard Msg | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Standard Message: The message describes that the patient is eligible for the COVID vaccine. |
| BG002 | 2B: Call Back + Clinician Endorsement | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Clinician Endorsement: The message will describe an endorsement from the provider to get the vaccination. |
| BG003 | 2C: Call Back + Scarcity | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Scarcity: The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. |
| BG004 | 2D: Call Back + Opt-Out Framing | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-outWill include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Opt-Out Framing: This will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. |
| BG005 | 3A: In-Bound Call + Standard Msg | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Standard Message: The message describes that the patient is eligible for the COVID vaccine. |
| BG006 | 3B: In-Bound Call + Clinician Endorsement | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Clinician Endorsement: The message will describe an endorsement from the provider to get the vaccination. |
| BG007 | 3C: In-Bound Call + Scarcity | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Scarcity: The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. |
| BG008 | 3D: In-Bound Call + Opt-Out Framing | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-Out Framing: This will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. |
| BG009 | Total | Total of all reporting groups |
| years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Race/Ethnicity, Customized | Count of Participants | Participants |
|
| Race/Ethnicity, Customized | Count of Participants | Participants |
|
| OG001 |
| Arm 2: Text + Outbound Call |
Patients in this arm received a text message asking if they would like to receive a call from the patient vaccine access center. Includes Arms 2A+2B+2C+2D |
| OG002 | Arm 3: Text + Inbound Call | Patients in this arm received a text asking if they would like to receive the phone number to call the patient access center to schedule their vaccine appointment. This arm includes 3A+3B+3C+3D. |
|
|
| Secondary | Dose 1 Completion | Percentage of patients who complete the first dose of the COVID vaccine within 2 months of initial outreach | All randomized patients who were not excluded from analyses for receiving one or more vaccine doses prior to outreach. Comparisons were made between all patients assigned to a texting + outbound call arm (arms 2A+2B+2C+2D) and the outbound phone call only arm (arm 1), and between texting + inbound call arm (arms 3A+3B+3C+3D) and the outbound phone call only arm (arm 1). This was the original analysis as outlined in the protocol, which is why results are reported in this fashion. | Posted | Count of Participants | Participants | 2 months |
|
|
|
| Secondary | Vaccine Completion | Percentage of patients who complete the vaccination process within 2 months of initial outreach | All randomized patients who were not excluded from analyses for receiving one or more vaccine doses prior to outreach. Comparisons were made between all patients assigned to a texting + outbound call arm (arms 2A+2B+2C+2D) and the outbound phone call only arm (arm 1), and between texting + inbound call arm (arms 3A+3B+3C+3D) and the outbound phone call only arm (arm 1). This was the original analysis as outlined in the protocol, which is why results are reported in this fashion. | Posted | Count of Participants | Participants | 2 months |
|
|
|
| 0 |
| 0 |
| 0 |
| 0 |
| 0 |
| 0 |
| EG001 | 2A: Call Back + Standard Msg | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Standard Message: The message describes that the patient is eligible for the COVID vaccine. | 0 | 0 | 0 | 0 | 0 | 0 |
| EG002 | 2B: Call Back + Clinician Endorsement | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Clinician Endorsement: The message will describe an endorsement from the provider to get the vaccination. | 0 | 0 | 0 | 0 | 0 | 0 |
| EG003 | 2C: Call Back + Scarcity | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Scarcity: The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. | 0 | 0 | 0 | 0 | 0 | 0 |
| EG004 | 2D: Call Back + Opt-Out Framing | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-outWill include a prompt to agree to scheduling. The access center will call these patients back to schedule, calling up to 3 times. Opt-In (Call-Back): Messaging will include a prompt to agree to scheduling. If patient agrees, the access center will call these patients back to schedule, calling up to 3 times. Opt-Out Framing: This will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. | 0 | 0 | 0 | 0 | 0 | 0 |
| EG005 | 3A: In-Bound Call + Standard Msg | The message describes that the patient is eligible for the COVID vaccine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Standard Message: The message describes that the patient is eligible for the COVID vaccine. | 0 | 0 | 0 | 0 | 0 | 0 |
| EG006 | 3B: In-Bound Call + Clinician Endorsement | The message will describe an endorsement from the provider to get the vaccination. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Clinician Endorsement: The message will describe an endorsement from the provider to get the vaccination. | 0 | 0 | 0 | 0 | 0 | 0 |
| EG007 | 3C: In-Bound Call + Scarcity | The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Scarcity: The message will highlight the limited availability and the elevated priority for the patient to receive the vaccine at Penn Medicine. | 0 | 0 | 0 | 0 | 0 | 0 |
| EG008 | 3D: In-Bound Call + Opt-Out Framing | The message will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. Will include a prompt to agree to scheduling, which will be followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-in (In-Bound): Messaging will include a prompt to agree to scheduling followed by a prompt to call the Penn Medicine Vaccine Scheduling Hotline to schedule their vaccine appointment. Opt-Out Framing: This will highlight that a vaccine is reserved for the patient, implying that they need to opt-out. | 0 | 0 | 0 | 0 | 0 | 0 |
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| D014777 |
| Virus Diseases |
| D018352 | Coronavirus Infections |
| D003333 | Coronaviridae Infections |
| D030341 | Nidovirales Infections |
| D012327 | RNA Virus Infections |
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
| D019602 |
| Food and Beverages |