Project StepOne, started during the early days of the pandemic, shows how affordable tech tools, the power of volunteering, and government support can deliver a well-functioning digital platform for public good, providing basic health care services to citizens during an emergency. Since its launch in May 2020, StepOne has provided COVID-19 medical teleconsultation, mental health support, and grief counselling to 3.6 million people in India. All this with the help of 20,000 volunteers from medical and non-medical backgrounds.
In early March 2020, when few cases of COVID-19 had appeared in India, a group of entrepreneurs, led by Raghavendra Prasad, started brainstorming ideas on what would be the best way to create a digital public good that could serve as an effective health intervention. After several ideas, the group concluded that if there was one thing people would need in the time of an epidemic, it was access to doctors. And since health care services came to a grinding halt due to lockdowns, virtual health care became an urgent necessity. It was in this context that the idea of a volunteer- driven telemedicine system took shape.
Prasad, armed with his experience in the digital health care space, started working on this idea with the view that any state government could easily adopt and deploy the platform in their management of COVID-19. One year after the launch of StepOne, 22 Indian states have adopted this telemedicine system as part of their health offering.
How can you adapt/replicate this promising practice?
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What are the lessons learned from this bright spot?
Raghavendra and others who worked on the StepOne platform say altruism was at the crux of the volunteer-driven platform. Otherwise, it would not have been possible to run this initiative across 22 Indian states for 10 months. “We continue to surprise ourselves with the kindness of people”, Prasad says. Government officials such as Dr Parthasarathy and Dr Duraiswamy also agree that thanks to the enthusiasm and the spirit shown by student volunteers, they were able to better execute on the system. Operationally, the government’s backing in getting volunteers onboard, the sharing of tech, and the trust placed in StepOne made this initiative work. The governments’ sophisticated prebuilt systems were also advantageous to triaging patients.
For example, Karnataka is one of the few Indian states that has an advanced IT system. In most places outside the state, the StepOne team had to manually download the list of positive cases. But in Karnataka, there was no need, as the case list got updated on a real time basis. This reduced the overall turnaround time to reach a positive COVID-19 patient. The geotagging of the ambulance system also helped volunteers locate the exact location of ambulances so they could direct them to needy patients.
Dr Duraiswamy from the Puducherry government says his biggest lesson from using this platform is that too much technical work in small platforms is not feasible. Hence, keeping it simple and narrowing down the focus for use of specific tech is essential. His team had given up using tech solutions for pandemic management, until StepOne. “Our health workers were not able to use the previous tech for follow-up, but this simple tele network made their lives simpler”, he says, adding that it was important to modify tech platforms to get their maximum utility. Abandoning something when it won’t work is also equally important, Duraiswamy explains. For example, the StepOne platform did not help in the allocation of hospital beds for patients, an insight that confirmed not all gaps can be filled with tech.
How was the promising practice implemented?
Building the platform and getting technology partners
To make such a large volunteer-driven telemedicine network feasible and user-friendly, the StepOne team created a system that was bare minimum: for an effective telemedicine system to work technically, all that was needed was a phone number and a voice response over which patients and doctors could connect. StepOne chose a cloud-based voice calling system that could be used with any mobile phone. In India, where over 600 mobile phone users are not smartphone users, this was realistic. “We wanted our solution to be as inclusive as possible”, said Prasad.
Amazon provided their cloud software for free. And the entire system was built on open-source software, which meant anyone who wanted to use it, could.
Creating communication protocols
Once the medium was decided, the team’s next challenge was enlisting doctors and volunteers to answer these calls. Given the large number of COVID-19 cases being reported in 2020, the StepOne team realised that providing telemedicine real time would not be possible. So, volunteers who received patient calls would take down symptom details and ask a doctor to call patients back. This triage made it easier to attend to every caller who had reached out.
Once StepOne was integrated with the government network, the same workflow was applied to positive COVID-19 patients, so they proactively received calls from the StepOne team (instead of patients calling the number and seeking advice). This also helped government health systems keep track of the health of patients in home isolation (constituting over 80% of the total case burden).
Launch of the promising practice
With systems in place in May 2020, when India announced its first lockdown, StepOne went live. The organisation started with the south Indian state of Karnataka. Since it was launched as an independent network, StepOne knew they had to integrate their system with the government’s own tele-helpline. The Karnataka government had a similar telemedicine helpline called ‘104’ for COVID-19 patients. StepOne asked the Karnataka government if they could integrate their system to supplement the government system to increase efficiency.
The government agreed and StepOne hit the ground. Dr Rajani Parthasarathy, who oversaw home isolation of COVID-19 patients, said that considering the large number of patients under home treatment, government officials could not be physically present to check on all such patients. But through constant follow-up calls from StepOne volunteers, the government could keep track of the health of patients and intervene when they thought a patient’s condition was not improving under home isolation.
Getting volunteers on board
After the technology was sorted out the biggest challenge was how to get qualified people to answer these calls. In the initial days of its launch, StepOne only had 15 doctors to manage these calls, and it was not enough. The team sent out SOS messages through WhatsApp, calling on doctors to help. The day the message was sent, over 700 doctors came on board. On its first live day, StepOne received 30,000 calls, and that number kept increasing. By the arrival of COVID-19’s second wave, the call volume was up to 85,000 calls per day. “Our doctor count was not enough to handle this volume of calls, but we had to keep this going. So, we decided to get non-medical volunteers and medical students who could help us with initial triaging. This really helped”, Prasad explains.
Teaming up with local governments also helped. In Karnataka, for example, the state government reached out to one of the biggest medical colleges for help and managed to mobilize 10,000 medical students to be part of this network. In the city of Puducherry, also in South India, state officials asked schoolteachers to volunteer for the network. In this way, day by day, StepOne managed to enlist thousands of volunteers. “All of them worked day and night attending calls tirelessly without expecting any return”, said Dr Rajani Parthasarathy, of Karnataka government, who oversaw the home isolation of COVID-19 patients.
The founding team of StepOne divided its workflow into two groups of volunteers: Functional and Platform volunteers.
The Platform volunteers were doctors, medical students, and non-medical volunteers who would answer calls and pass on details to government health departments for further follow-up. Some of these volunteers’ job was to speak to the dean of medical colleges to recruit their students. This team also ensured they reached out to corporations who offered their own staff for volunteering.
The Functional volunteers were the backend and backbone of the platform. They were responsible for building, operating and marketing the platform. The government gave this team data on positive cases and in turn, they had to ensure those data were followed up. Their challenge was to figure out the operational and tech issues that needed to be fixed, so end delivery happened. “Our task was to firefight, to make sure we closed the loops on cases and automate the process as much as we could. We are becoming more efficient as time goes by”, Prasad says.
Volunteer training
As volunteers came on board, it was time to ensure they were trained to triage calls accurately and follow up with patients, escalating issues when they encountered a patient whose condition was not improving under home isolation. Since not all volunteers had a medical background, these trainings became essential to the smooth functioning of the network. Dr Parthasarathy says the Karnataka government trained 5000 medical students in five weeks. State government health officials took daily review meetings with all volunteers about the teleconsultation calls, the number of escalations done, the number of text messages sent to patients asking them for an update, etc. Volunteers were trained on the standard medical protocols they had to communicate while talking to positive COVID-19 patients. This included asking the patients about their symptoms, their age, and comorbidities. The government also roped in specialist doctors to handle more complex calls.
Besides this training, the government also performed quality checks on calls made to patients. Dr Parthasarathy says the key considerations for a good call were whether the callers asked all patients details, such as comorbidities, age, etc. Every time there was a change in the medical guideline, there would be additional training. “We would do an end-to-end check with our volunteers and there were follow-up meetings every day in morning and evening”, Dr Parthasaratyhy said.
Dr Duraiswamy, a physician from the Puducherry government, said that through StepOne, state officials were able to follow up on 100% of cases. The Puducherry government also created its own work chart for volunteers. For example, as soon as state officials got data about positive COVID-19 patients, it was immediately uploaded in the Step One platform. Then the tele-callers would guide patients through the treatment process. “At the rural level, people had no clue about the disease, but this tele-triaging helped us to motivate people to get tested, seek treatment”, Duraiswamy said. There was a separate team that extracted reports on whether patients actually got called. So, at times patients would get calls multiple times from the government. “So, even though they were fed up with calls, we thought it was a good thing as it helped us monitor them better”, Duraiswamy adds.
SOPs for call drill
The Puducherry government assigned the task of screening patients to StepOne volunteers. Their job was to log into the StepOne System every day and call COVID-19 positive patients using a “click to call” link. The screeners would assess patients based on a wide range of criteria, and forward reports to public health centers for further action. Patients would be called up to three times (if they had not picked up the first call). Screeners followed this protocol:
- Call patients assigned to them
- Verify name and telephone number
- Verify address, house number, street, area
- Verify town
- Ask them to identify their nearest Primary Health Center
- Ask constituency
- Ask occupation
- Ask occupation address
- Note contact history
- Collect symptoms
- Collect comorbidities
- Find out if they have a separate room with toilet
- Ask if they can isolate themselves for 14 Days
- Send update to local PHC
- Advise patient about HI protocols and procedures and tell them about the automated daily IVR callout
Based on recommendations on the severity of patients (mild, moderate, or severe) health authorities would take further action. For example, once the screeners directed a patient detail to the ‘hospital team’ of the state government managing patient flow, they would call patient and ask them to be ready to move. This team would book a bed for the patient and send an ambulance to their residence. They would track the patient until they were discharged or deceased. If the screener referred a patient to the home isolation team, this team would do an in-person check on the patient’s condition to re-verify if the patient is fit to isolate at home. All these procedures would be reflected in the StepOne platform, with government officials and platform volunteers having a real time picture on the status of each patient who had been called. To note, when patients were unreachable, it was often because patients had installed spam-blocking apps.
To ensure patient privacy, the tele-consult was built via a secure bridge that keeps phone numbers of volunteers and patient hidden from each other. The data was made available only to those who needed to see it, i.e., volunteers who work with a patient could view that person’s information but not others, and only those involved in emergency response could view addresses, etc. In addition, the database itself was hosted on secure cloud servers and access remained available to only a few people. To ensure the system remained hacker-proof, StepOne designers engaged a few ethical hackers who tested the system and helped them fix loopholes.
Way forward
The conversations with government officials show that this volunteer-driven platform is here to stay, though challenges remain in retaining volunteers over a long period of time. But for now, all state governments that have used StepOne plan to keep it active in anticipation of a third wave of COVID-19. They are also planning to scale up the platform for other non-communicable diseases where poor referral systems lead to delay in treatment. A starting point for scale up is to use the StepOne platform for routine maternal and child health check-ups and as a complement to the *** cancer helpline. “These are initial days, but we are sure we want this system going”, concludes Dr Parthasarathy.
Supplementary material
Project StepOne - a Volunteer-Driven Public Telemedicine System in India.pdf
