Simple is an app that helps busy clinicians to manage hypertensive patients by tracking their blood pressure and medications and ensuring, through regular check-ups, that patients stay on treatment.
As part of the India Hypertension Control Initiative (IHCI), Simple aims to improve hypertension control by 25% by the year 2025, in order to drastically reduce the incidence of heart attacks and strokes.
While hypertension is easily treatable, one in four adults in India suffer from the condition and tend to neglect their treatment as it is asymptomatic. 90% of the 200 million adults diagnosed with hypertension are not on a regular treatment regime.
Nurses and clinicians can play an active role in ensuring patients under their care have regular check-ups, but in a large country like India, a typical nurse sees around a hundred patients a day. How then, can she keep track of patients who have missed their visits?
Our challenge was to create a system that was:
• Easy to learn and use, even for first time smartphone users;
• Capable of fitting into existing workflows;
• Offline first, so it could work with low or no internet connectivity.
While nurses were already using paper cards to track patients, and data entry was quick, retrieving the right patient treatment card from a stack of hundreds, would take at least four to five minutes. This meant that it was also difficult for nurses to establish which patients had missed scheduled visits.
We interviewed around 180 doctors and nurses and worked with them to develop concepts through iterative prototyping and testing. This allowed us to constantly refine and simplify the app from the first proof of concept to launch and beyond. Now clinicians using Simple can find patients and record their data in less than half a minute. This data then allows nurses to easily track patients who have missed their appointments, and remind them over a phone call.
Simple is disruptive due to it being a purpose-built, thin EMR that drives positive outcomes for hypertension control by bringing patients back to care, regularly in a way that traditional EMRs fail to.
Simple is revolutionary because it is engineered to be used on readily available, personal handheld devices. It can continue to function without internet connectivity, and data collected offline will sync automatically to secure cloud storage when the phone is in an area with network availability.
Telephonic interviews and field visits with doctors and nurses have been overwhelmingly positive. Simple has optimised patient management, as nurses now spend only half a minute, rather than four to five minutes to attend to paperwork, allowing them to spend more time in counseling patients. Simple is now being used in nearly six hundred healthcare facilities to manage the health of over 200,000 patients in India and Bangladesh, and will be rolled out to other Indian states and Ethiopia in 2020.
A doctor and nurse using Simple in a typical clinic in rural Punjab, India
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.
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.