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Twilio SMS and Voice Call services for Surveys and Alerts

Table of Contents:

INITIAL CONSIDERATIONS

If you wish to use this service, ensure your IRB has approved the study for SMS communications!

NOTE: It may 4+ weeks before a Twilio number can be released to a project team.

  • BMIC will be unable to configure Twilio service in your project until the sub-account campaign registration is finalized by Twilios third-party vetting service, please plan accordingly!

Twilio Services

This feature allows SMS text messages or one-way voice calls to be delivered to end-users. This is accomplished using a third-party web service named Twilio.

  • Images (MMS) are not supported with this service

  • Individual users cannot make outgoing calls using this service

  • REDCAP Features such as ASI’s (automated survey invitation) and/or simple Alerts & Notifications are compatible with Twilio SMS services.

    • This service is most commonly used with REDCap to send a [survey-link] to participants to capture needed information or send notices/reminders.

    • One-way voice calls, utilizes text-to-speech technology to audibly read the notification or survey to the recipient

  • If a [survey-link] is generated to the end user via SMS, once they click the link they will be directed to the associated REDCap webpage/survey via their phones web browser

Simple Alerts:

Survey Invitation:

Survey invite display via phone web browser:

Simple Alerts:

Survey Invitation:

Survey invite display via phone web browser:

Survey Invitation types available for use in REDCap:

Survey Invite Type

Notes

Survey Invite Type

Notes

1

Survey as a webpage via [survey-link]

(most commonly used)

  • This method MUST be used when PHI or PII is contained within the survey questions or responses

  • Send survey invitation as a survey link via SMS. Participants use said link to open their survey in their phones web browser to take the survey.

  • The Field Embedding feature works when taking a survey in webpage format only

2

Survey as voice call

(limited use cases supported)

  • PHI/PII capture is NOT supported/allowed with this survey method

  • If your project utilizes Field Embedding to reposition fields on the instrument, please keep in mind that this method does not support Field Embedding.

  • There are three ways to send survey as voice call

    • Initiate survey as voice call

    • Send Survey invitation via SMS to take survey as voice call – ie, respondent makes call

    • Send Survey invitation via SMS to take survey as voice call –ie, respondent receives call when replying via SMS

    • When participants take a survey as a voice call

      1. Questions are asked one at a time.

      2. Twilio service uses text-to-speech technology to read the questions to the participant audibly on their phone.

      3. Participants will respond by entering numbers on their phone's keypad.

      4. Note - only numeric responses can be used in the survey. This includes the use of integer/number fields and also multiple choice questions with numeric coding, in which the participant will enter the numeric coded value on their keypad, not the label that is read to them over the phone.

3

Survey as SMS conversation

(limited use cases supported)

  • PHI/PII capture is NOT supported/allowed with this survey method

  • If your project utilizes Field Embedding to reposition fields on the instrument, please keep in mind that this method does not support Field Embedding.

  • When participants take an SMS survey, questions are asked one at a time as an SMS text message conversation/thread.

    1. Participants may respond with any kind of alpha-numeric text for SMS survey.

    2. SMS is not considered a secure form of communication, so you may not want to administer surveys as SMS conversations if the participant will be submitting identifying information (PHI or PII) unless you have been granted special permission from the participant to do so.

    3. Only REDCap administrators are allowed to enable the Twilio option to initiate a survey as an SMS conversation.

SMS technology does not support transport encryption.

  • The actual text messages which are delivered to end-users are NOT encrypted.

    • Per best practices, PHI/PII should only be captured using the REDCap [survey-link]

    • The SMS body itself, should never include any PII or PHI

The interaction with Twilio (to/from) REDCap is encrypted and the BAA currently in place with Twilio requires that the data we share with Twilio be safeguarded. However, SMS technology does not support transport encryption. This means the text messages which are delivered to end-user(s) are NOT encrypted, however the [survey-link] provided within the SMS is encrypted as REDCap is HIPAA compliant.

If you have questions about what information is acceptable to disclose via SMS please reach out to the Privacy Office (privacy@utah.edu​​) to describe your specific use case and guidance can be provided.

COST FACTORS

NOTE: Twilio services will not be closed out by default, you MUST submit a ticket to request account closure when appropriate to ensure recurring charges do not continue!

Cost Breakdown

A  BAA agreement between the University of Utah and Twilio gives researchers, operational support groups and other users of SMS Twilio accounts BAA protection of PHI and auditing services within Twilio using a “HIPAA Accounts” product from Twilio. For more information on Twilio's HIPAA accounts, view https://www.twilio.com/hipaa

To cover the cost of Twilio services and University BAA, the below charges are captured:

  1. Annual usage fee of $350 per per Project Account

    1. The annual usage fee will be charged the same month for each subsequent year of Twilo use

    2. If you have a single project purpose, that will utilize multiple projects, you may register multiple phones numbers under your twilio service, however this requires each number that is being used under you account to meet the submitted campaign-use-case description that was approved by Twilio’s Third Party vetting team.

    3. If you anticipate your project will be utilized over many years and will likely require updates as the study progresses, we do suggest purchasing 2 numbers under your projects account.

      • 1 phone number for your ‘production’ project

      • 1 phone number to be used in a copied version of your production project, allowing you to test updates for accuracy before implementing to your existing production environment.

  2. Variable monthly usage fees will be passed to each user monthly.

TWILIO EXAMPLE COSTS:

Effective January 26, 2023, A2P Campaign registrations are required for all Twilio accounts and are subject to a new vetting process, which includes a one-time $15 campaign vetting fee.

All usage charges from Twilio, carriers and A2P-10DLC registration fees are passed to each account.

[Pricing Update] Carrier Fee Increase on AT&T, Rogers, and Other Networks; Effective October 1, 2023

  • $350 annual HIPAA account enterprise recharge fee per Project Account

    • A2P-10DLC one time campaign vetting fee - $15

    • A2P-10DLC - One time registration fee  - $50 one time for T-mobile

    • A2P-10DLC - Campaign registration fee, $5 per month

    • Twilio Phone number charge per month $1.15

    • Twilio and carrier fees $0.0075 cents per message

    • UNITED STATES Inbound SMS - T-Mobile 0.00790

    • UNITED STATES Outbound SMS - AT&T 0.00790

    • UNITED STATES Outbound SMS - Other 0.00790

    • UNITED STATES Outbound SMS - T-Mobile 0.00790

  • Administrative monthly overhead recharge

    • $8.82 per month

Example average monthly usage passthrough for sending 2500 messages per month: ~$42

Example average annual total cost with HIPAA account and admin fees: ~$893

REQUEST PROCESS

Complete the following steps to request Twilio services:

How to request Twilio SMS service

  1. Submit a CTSI Support Ticket to request Twilio SMS configuration

    1. https://utahctsi.atlassian.net/servicedesk/customer/portal/3/group/16/create/52 ensure to include your projects CTSI number

  2. BMIC REDCap Admins will provide a request form for you to provide required information, such as:

    • Examples of text messages verbiage which will be sent to participants/end-users

    • PI acknowledgement of OPT-OUT requirements and approval sign-off of Twilio service

    • Work Authorization details

  3. BMIC Admin will initiate your Twilio Start-Up-Fees invoice after the above is complete

  4. The BMIC team requests a sub-account registration for your project under the CTSI Master Twilio Account in accordance with the University’s BAA

    1. Once registration activity is completed by Twilio, a REDCap Admin will enable your project to utilize the Twilio service

  5. Project team must then configure Twilio settings based on project needs as described below

PROJECT SETUP & CONFIGURATION:

(1) Project Setup:

  • Create a field to capture participants preferred method of contact (phone vs email).

    • This field is most helpful in the event an end-user ‘OPT-OUT’ of SMS communications during the study. Why? This field allows you to quickly update the end-users preference to ‘email’ which ensures any scheduled survey invites will be sent to the user’s email moving forward.

    • Ensure you phone and email field have the correct ‘validation' type applied

Project Setup steps

  1. In the appropriate project instrument, create a radio field to capture your participant's preferred contact method within your instrument form/survey

    1. You MUST use the coded options below (shown in bolded black) for your answer choices coded value, however you may edit the text in orange, if necessary. See recommendations shown below

      1. EMAIL, Email

      2. SMS_INVITE_WEB, SMS Text Message

  2.  Ensure the fields which are collecting the participants preferred contact selection, is validated correctly!

    1. Email Field validation: Email

    2. SMS Text Field validation: Phone (North America)

       

(2) Project Configuration:

Project Configuration steps

The BMIC team will first enable your project with your twilio number, once that’s done, it is the study team's responsibility to setup the additional configuration settings to meeting projects needs. See below.

  • The only settings which need updated are shown to you below.

  • If the setting isn’t mentioned, best to leave it off or as is.

  • If you have questions on voice calling or setting up configuration, please contact BMIC REDCap Administrator

  1. From your ‘project setup’ page, scroll halfway down the page and click ‘Configure Twilio settings’

    1. Select modules: ALL: Surveys and survey invitations + Alerts & Notifications (best practice)

    2. Select phone number field (REQUIRED)

    3. Select preferred contact field (best practice)

    5. click ‘Save’ to save your configuration settings

  2. Proceed to setup your Alerts/ASI’s for SMS delivery as needed for your project

(3) How to setup Alerts or ASI’s for SMS delivery

OPT-OUT Requirments

  1. The initial message that you send to an individual needs to include the following language:

    • "You have consented to this study and requested to receive text messages. If you wish to opt-out of study communications via SMS please contact your study coordinator at (xxx-xxx-xxxx) “

    • You have the option to create custom opt-out keyworks upon registration, however this is not recommended, as to not slow Twilio’s third-party campaign review process. If you are interested in using custom opt-out keywords submit a help ticket to: redcap@ccts.utah.edu

  2. If a participant chooses to opt-out an error will be displayed within projects Survey Invitation Log, as shown below:

    1. If you experience the below error, it’s important to understand if the participant wishes to proceed with study communications via email versus SMS so that you can update the associated records ‘preferred method of contact’ selection, then manually resend survey as applicable.

Frequently Asked Questions

  • If a user mistakenly opts-out, how can they opt back in to SMS?

    • Instruct the user to send a SMS text message to your Twilio phone number using one of the below opt-in keywords:

      • START, YES or UNSTOP

        Default reply upon successfully opt-in will be:

        • You have successfully been re-subscribed to messages from this number. Reply HELP for help. Reply STOP to unsubscribe. Msg&Data Rates May Apply.

           

  • I have multiple REDCap projects and multiple phone numbers using Twilio. How is the annual fee assessed?

    • The annual $350 fee is assessed per project phone # in Twilio

  • Why isn’t the University paying for the Twilio BAA?

    • The CTSI is subsidizing half of the annual cost of the Twilio BAA. The remaining amount of the Twilio annual fee has been spread across users. This amounts to $350 per phone number.   A small monthly administrative fee and the monthly usage fees are borne by the user in addition to the assessed annual fee

  • My project has ended, how do I close my Twilio account?

  • I only need to send out surveys via SMS for a month via Twilio. Do I still need to pay the annual fee of $350?

    • Yes.  The $350 is an annual fee to begin use of Twilio for up to 1 year.


  • How do I let you know my grant is ending on a specific date?

    • The ProTrackS registration process captures your grant end date. If you would like to check or update the ProTrackS grant information /data, please submit a CTSI Service Desk ticket

TWILIO IS A THIRD-PARTY SERVICE

It is important to understand that this feature utilizes the third-party service , which means that all voice calls and SMS messages will be routed through Twilio's servers.  REDCap attempts to ensure that voice call records and SMS transcriptions do not stay in Twilio's logs but are removed shortly after being completed. This is done for security and privacy concerns (e.g., HIPAA), in which your survey participants' phone numbers and their survey responses do not get permanently logged on Twilio's servers but instead remain securely in REDCap.