Simple is a unique project in many ways — it was released under the MIT Open License, which means it can be used and modified by anyone, anywhere. It is designed to have a long term impact, and was built to scale internationally. In order to ensure robust localisation, we have partnered with organisations on the ground in different regions and countries to understand concerns around data privacy and consent in those specific jurisdictions. Simple already exists in eight Indian languages, and has most recently been deployed in Bangladesh, which is the first instance of it being used outside India and will be launched in Ethopia later this year.

Design decisions

In order to build Simple, our engineering and design teams make frequent trips to the field to learn about how it might be used in busy rural clinics, where a nurse has less than 4 minutes per patient, compared to about 15 minutes in the USA. Previously, nurses were using paper records which took 2-5 minutes per patient for tracking hypertensive patients, which made recording longitudinal data time-consuming and tedious. This process needed to be streamlined as such data is essential information for bringing patients back to care.

When we asked healthcare workers what they would like to see in new software, they consistently told us: "Just please don't make my work harder." Many medical record systems are designed by administrators or by public health officials. They're often disconnected from the day-to-day work of busy healthcare workers, so they can often add 'interesting' or 'useful' data entry fields. The Simple team, on the other hand, aimed to only ask for the bare minimum to 1) improve an individual's care and 2) create feedback loops to improve BP control rates across a health system. Every time we consider adding a field, we ask tough questions: is it really necessary? Right now, we only ask clinicians to enter basic patient identification, 4 short medical history questions, today's BP, and the patient's current BP medications. The data generated by the dashboard is sufficient to deliver longitudinal data for clinicians and organisations to understand trends, and allows them to tweak delivery of their programmes on the ground to optimise care for hypertensive patients.

In order to truly understand the workflows of the frontline health workers who would be using Simple in rural environments, we used different approaches to help us think through the challenges they would encounter in the field. We are constantly in conversation with the nurses and doctors who use Simple, and recently worked together with some of our advanced users (who had been using it for about a year) to co-create solutions that work best for them in their own contexts. We learnt from them which ideas worked best for them and why, as well as encouraging them to share their own valuable ideas which spoke precisely to the issues they needed the app to address. We also use regularly scheduled, structured telephonic interviews in order to understand:

• What are the most pressing issues faced by the users?

• Is it making their work easier and better?

• Are there important user needs that we haven't thought of?

Another way by which we sought to understand the needs of our users was by simulating a hypertension clinic in our Bangalore office, and our team played the role of nurses, doctors, and patients. Everyone on the team learned firsthand how hard it is to juggle the different tasks in a busy clinic and we experienced how our software fits into a healthcare worker's job.

Adoption & implementation

Usually, adoption can be a bottleneck for new clinical software. Training staff and changing workflows takes up significant staff time. Easy-to-use software is easier for healthcare workers to learn and easier for managers to adopt. We aim for a nurse or doctor to be able to install Simple from Play Store, watch a 5 minute YouTube tutorial, practice for 30 minutes, and then start recording patient visits. While trainers still conduct short sessions with staff and give out handbooks, Simple is relatively fast to learn and many trainings are done at the point of care.

We took an unusual approach to deployment — we asked healthcare workers to install Simple on their personal Android smartphones, where they're willing to do so. By doing this, we minimised the learning curve, and ensured rapid adoption, and currently Simple is used in 592 public health facilities, from district hospitals to community clinics.

At the outset of the project, the Android engineering lead was emphatic that the software had to be designed offline-first. This means that Simple has to be fully functional with no internet connection for days at a time. While connectivity is actually quite good even in rural India, where we deployed the app — the biggest benefit of going offline-first is that the app is incredibly responsive in all environments, from those places with barely a bar of mobile service or on a WiFi connection. When a clinician is in front of a patient, they need to get their work done, not wait for the app to send messages to-and-from the cloud. Every screen in Simple is snappier because it was built offline-first.

Simple is already having an impact — patient follow-up and hypertension control rates are going up, and doctors and nurses (some of whom are using a smartphone for the first time) consistently report on how easy and enjoyable their experience of using Simple has been.

Through a combination of innovative engineering and empathetic, contextually relevant design, we are glad to have been able to have played a part in creating a life-saving system that makes the work of thousands of dedicated healthcare workers just a little bit more simple.