Monitoring Hypertension made Simple.
Simple helps busy clinicians manage hypertensive patients by tracking their blood pressure, prescribing medications and scheduling regular follow-ups.
It is a joint initiative of India Hypertension Control Initiative (IHCI) and Resolve to Save Lives (RTSL) — a venture of Vital Strategies that works to strengthen public health systems all over the world. With a mission to save 100 million lives over the next decade, RTSL works to combat one of the most common causes of deaths in the world: hypertension.
Healthcare workers operate in busy environments and struggle to record high volumes of patient data.
Simple was therefore created for mobile as an offline-first, thin-sliced Electronic Health Record (EHR) to empower the nurses and clinicians. As the project progresses, the team has been continuously discovering the right set of problems and opportunities to improve the app and help patients control their hypertension.
- Immersing in user environments and conducting simulation exercises to build an easy to use offline-first app
- Identifying constraints for better nurse workflows and simplifying search for a faster patient registration experience
- Prioritising and adapting research findings to build an operative patient-centric system for all conditions
Consistently immersing in user environments to build an offline-first app
Right from the get-go, the team understood that Simple would have to operate in a very challenging environment. To discover the context in which the app would have to thrive, the team has been continuously conducting first-hand research via regular field trips. This has helped the team understand the gravity of on-ground problems, and take preemptive decisions to improve the user experience on the app.
Early on, the team observed that the network connectivity in most rural hospitals was weak and patchy. Phones were often offline and consumed extra battery power looking for a network. This meant that any patient data recorded by a healthcare worker might not be sent to hospital servers on time. To combat this, the team decided to make all solutions offline-first.
Historically, nurses followed up with patients via regular phone calls and manually recorded information. With Simple, they could now make phone calls directly through the app, but it was still difficult to mask their numbers there for safety.
With the active support of healthcare officials and the government, DTMF was chosen to route calls through a proxy and mask nurses’ numbers even offline. The app dialled a toll-free number when a nurse tried to call a patient and played the patient’s number as DTMF tones. The server received the patient’s number through Twilio, decoded the tones, and connected the nurse with the right patient. This maintained confidentiality while replacing traditional registers and phone calls.
Simulating a Public Health Centre to test ease of use in the real world
Along with regular trips to the field, the team has also been conducting regular simulation exercises such as Bodystorming and phone interviews to gather insights and make well-informed decisions. A hypertension clinic was simulated to understand how an app fits into a healthcare worker's daily schedule.
During one session, it was discovered that patient data moves between the nurse and the doctor through a combination of patient ID cards, registers and the app. This meant that the nurse had the demanding task of duplicating information on multiple mediums while treating patients.
To make it easier for the nurses to access the most recently seen patients at one go, multiple solutions were explored. A “Recent” section was then designed, which sorted the list of patients by daily visits. The nurse could now scroll through the entire list of patients who visited the facility on that day and easily update their personal registers at one go. This moved their documentation efforts to the end of the day and allowed them to focus more on counselling their patients.
Identifying and removing constraints to ease the nurses’ workflow and protect patient data
To make the healthcare workers’ system as simple as possible and ensure the app fits their needs, the Simple team makes sustained efforts to identify areas of improvement.
Frequent visits to public health facilities brought a few important aspects to the fore:
Healthcare workers in public health facilities within countries such as India carried out multiple functions and attended to hundreds of patients every single day
Many patients shared the same names, did not have phone numbers, did not remember their numbers or frequently changed them, and were not restricted to residing in only one geographical area
People in the 60+ age bracket did not know their date of birth or age
With these constraints, any glitch in the app, or repetitive interactions, could increase the time a healthcare worker spent on the app and reduce their ability to care for a patient attentively. Additionally, the team had also decided with the government to protect patients’ personal data and not require government-issued IDs when registering a patient in the system.
Given that time and protection of personal data were critical components in quality healthcare, a BP Passport—a physical patient ID card with a QR code printed that encodes a full UUID—was introduced.
This BP Passport holds a physical record. It helps the nurses—who might not have access to patient data all the time—record the patients, identify return patients quickly, provide care according to recent history, and merge the data later. It also reduces the nurses’ interactions with the app to a minimum, while still getting things done. For patients, the BP Passport is an identifier that can be used at any centre to continue receiving care at their convenience.
As the project moves forward and the app expands to other nations, the team has been working towards generating BP Passports at scale to protect hypertensive patient data.
Simplifying search for a faster patient registration experience on the app
In the preliminary version of Simple, the nurses had to type in the full name of the patients, tap on ‘next’ to see the search results, scroll through a lengthy list and then find the patient's details. This operated under the assumption that nurses wouldn’t know whether a patient was already registered on the app. Adding an extra step to show a list of registered patients seemed like a safe bet to avoid double registrations.
However, after initial use, it was observed that in most cases, the nurses already knew the status of a patient’s registration. The team wanted to test if employing simultaneous instant search instead would make the registration experience more efficient. The traditional prototypes used back then were not built for this, and the team needed another version that would resemble the final implementation to gain reliable insights.
The engineering team then worked closely with the design team to create a special version of the production app. This one worked similar to the actual app and had a front-end implementation of the instant search feature. With this special prototype, the teams studied interactions of multiple nurses to quantitatively understand whether the feature worked.
Once the new hypothesis was validated, the extra step of tapping on ‘next’ was removed, and the app showed search results in real-time as nurses typed in the patient's name or number. It significantly reduced the time otherwise taken to find a previously registered patient. Since it helped nurses find out faster if the patient was already registered, it also eased their effort on adding a new patient to the database.
Establishing a research funnel to prioritise a patient-centric system and improve access
As long-term partners with Simple, the team has built a research funnel to consistently log and prioritise research findings. This funnel acts as a guide for the team to run experiments and arrive at validated solutions that can then be deployed widely.
Because of first-hand immersion in the field, the team knew that people living in remote villages in a country such as India faced challenges in accessing healthcare services. For some, it was the long distance between home and district hospitals; for others, it was the poor networks and the inability to return for follow-ups in time. Such patients were flagged as “overdue” and eventually fell off the healthcare systems. The nurses were also sceptical of registering new patients, resigned to the possibility that they wouldn’t return for follow-ups.
Adapting past learnings to make timely changes for the COVID-19 lockdown
When the COVID-19 pandemic hit and the country went into a blanket lockdown, the majority of public hospitals were tasked with pandemic care, and patients were unable to visit these hospitals for continued treatment.
To tackle this, the team designed a telemedicine service for Simple that used smartphones to deliver healthcare services remotely. A pilot version was first developed to test for feasibility and several remote research studies were conducted. The healthcare workers were trained, the service’s effectiveness was checked through feedback, and the feature was incorporated into the Simple app once it worked.
Through telemedicine, healthcare workers were able to mediate tele-consults between patients and doctors, delivering care to hundreds of patients a day. For those who could not be treated using tele-consults, the app was also designed to support refilling of medications. Iterative improvements were then made by the team to include offline-first support via SMS requests, provide e-prescriptions, and maintain tele-consult logs.
Collectively, these efforts have been helping programme managers prioritise, monitor and ensure that patients continue receiving care from the comfort of their homes, even during a pandemic. Simple also recently won the "Best in Show" at the IxDA awards 2020 conference held in Milan.