Digital Platform for Screening Healthcare Professionals for COVID-19

Deploying a Digital COVID Screening Tool for Healthcare Professionals using AWS CDK and Serverless Architecture

Screen2Work platform — designed by Lauren Marvell
Screen2Work Platform — Artwork by Lauren Marvell
  • A Serverless backend using Amazon Web Services.

Frontend Mobile App

Design and User Experience Workflow

Rather than gathering requirements, we explored how to design an experience — digital and physical — that can help the end-user start their day and be confident to go to work in the midst of the pandemic. In a gist, we extracted the tasks that each individual would have to perform daily and grouped them in the following actions:

  • Each individual will have to demonstrate at the entrance of the healthcare facility that she/he has completed the screening right before coming to work . The clearance has to be timestamped and only valid for a specific duration (i.e. 12 hours for instance).
  • In case of suspected symptoms, the individual should be notified immediately. The notification must be clear and concise with enough information about next steps. The experience has to be supportive of the end-user. It must help navigate the various options rather than acting as an alert system. Because of the rapid rollout and the constant change of guidelines, most users will need as much information as possible at this step without creating confusion. Otherwise, they might miss important steps and/or perform wrong actions.
  • “Jumping” to the digital loop of COVID testing should be seamless. At the time of the design phase, our digital team has released a fully digital and asynchronous e-Visit for COVID testing solution. We decided to integrate with the solution and enable a seamless “hand-over” between the screening platform and the e-Visit service.

Integration in Froedtert & MCW Mobile App

On-Boarding for Screening
  • We own the entire mobile platform. Hence, we can ensure that the experience is tailored to our design heuristics. More importantly, since the mobile app is developed in-house, we had the ability to experiment, deploy, and redesign the digital experience at a much higher velocity than relying on third-party vendors. At the peak of our design of the screening service, we were updating the mobile application several times a day.
  • Full control of the data flow and a clear separation of the data was fundamental. We knew that embedding the service in our app will ensure a full end-to-end privacy by-design and ensure that we have full control of the chain of custody of the data submitted by our personnel. We chose from the beginning to have separate APIs and authentication flow for the screening service inside the app. There was no lateral movement of data and the code was logically segregated and compiled in its own bundle.

Backend Architecture

Design Principles

We had to build a backend architecture that will enable 4 core tenants:

  • Scalability was also a big concern. With thousands of employees potentially using the solution within the same time window around coming to work, we had to make sure that the service was scalable. We previously experimented using Fargate and Kubernetes. But, we worried about the resource overhead to deploy such architecture. Alternatively, we chose to use a purely Serverless architecture using AWS Lambda function and AWS API Gateway.
  • Adaptive Algorithm for Screening was also important. We needed to make sure that we controlled as much as possible of the flow and the screening logic of the frontend. Hence, we chose to create backend APIs to manage the screening logic and several of the frontend interfaces. This makes most of the changes to the logic and the interfaces of the app centrally controlled and deployable anytime without any update to the app itself.
  • Reporting was a key function. We created two types of report. One is a generic traditional reporting. The second was a more reactive, event-based reporting and alerting. This latter approach was for monitoring the infrastructure (using AWS CloudWatch alerts) and for notification of exposure (using SNS Topics and SES for notifications).

Infrastructure as a Code — CDK

The cloud can be thought as a remote data center. However, that view does not take into account that the cloud also creates new challenges for infrastructure engineers and distributed computing scientists which in turn create new solutions and new modalities to deliver infrastructure. Those solutions — as in all things related to scalability — embed by-design Automation and Repeatability. This is where AWS Cloud Development Kit (AWS CDK) really shines!

Serverless Architecture

Using CDK, we designed a fully serverless architecture. In a nutshell, the platform is composed of the following components:

  • API Gateway with WAF and Cognito Authorizer: API Gateway is a fully managed API platform offered by AWS. It integrates seamlessly with AWS Cognito, Lambda functions, and has several built-in functionalities such as throttling, api key management, tracing, data model schema validation, and WAF integration. It is reliable and scalable to support thousands of transactions per second.
  • Lambda Functions: We used lambda functions throughout the architecture. From custom User Pool Workflows with Lambda Triggers, to running our screening algorithm, to triggering alerts and notifications using DynamoDB Streams and AWS Lambda Triggers, Lambda function is perhaps the most versatile service we had the chance to use. This is a huge shift from our traditional development which often relied on an end-to-end framework such as Django, or Hapi.js. We found for our use case that distinct and small self-contained lambda functions were the best approach to operate a scalable and loosely-coupled architecture; although, the limited number of functionalities of the screening service helped with the limitation of using Lambda functions without tight integration. We are currently exploring using NestJS serverless integration and AWS Serverless Application Framework (SAM) for larger projects that require more structure. For the screening project though, using bare Lambda functions was sufficient.
  • CloudWatch and X-Ray: We enabled by default X-Ray tracking in AWS Lambda and API Gateway. We used an amazing Python package AWS-Lambda-powertools to enable tracing, monitoring, and added custom metrics for all our lambda functions.
  • Simple Notification Service (SNS) Topics for notifications and alerts: SNS is a very simple, yet very powerful Pub/Sub service. We implemented SNS to enable notifications and alerts that can be sent by email, stored in S3 bucket if needed, or published to any HTTPS endpoint.
  • AWS Amplify is an open source Mobile SDK that basically offers most of the boilerplate to integrate our mobile application with AWS Cognito, AWS API Gateway, and other AWS Services. The SDK is battle tested and hence helped us speed the development of the mobile integration extremely well. It is not yet well documented and the documentation takes a very opinionated approach to configure the SDK.

Results

Rollout

We started the project in July 2020 and we had the first prototype ready within 10 days. The screening service was officially launched by mid-August. We updated the app more than a dozen times and upgraded the API multiple times.

Operational Metrics

Since we launched the service, we had more than 18,000 employees signing up for the service; with more than 12,000 screenings performed daily. In total, more than half a million screening were performed using the application since its launch. On average, our API response time was 180 ms with a peak of few hundreds requests per second. We had less than 0.002% 5xx errors through the API Gateway. The only major glitch was when AWS us-east-1 went down.

Customer Support

In addition to the technical team, we established a small support center to help users. With thousands of users trying to use the app, we had a few hundreds (or perhaps less) frustrated users. In most cases, it was out of the scope of the application itself. It was either a network issue, an email activation code in the spam, or an incompatible device. However, all those cases required attention.

Lessons learned

We learned a few lessons along the way:

  • Responsiveness and Observability of the entire experience, not only of the components we have control over. This means that we had to test and check the Wifi connectivity in the parking lots (which was very limited), make sure that the mobile application was performing well on all mobile platforms (which was not true, specifically for Android), and that we had good monitoring of the user experience (work-in-progress…). Observability is hard.
  • Innovation and Product Management are two faces of the same coin. We had to develop the experience, roll the product, build the documentation, update the help center, deliver support to end users, and maintain the algorithm in accordance with CDC guidelines. This is a snapshot of the miscellaneous tasks and operations that had to be in place and maintained in order to support digital transformation. This was required to maintain a stable and seamless experience. Without such full-responsibility model, the results would have been unfavorable.
  • Socio-technical model is always at play. Building a digital solution requires careful consideration of the balance between potential benefits and its side-effects on users, and vice-versa. While technology could be an enabler, it could also create a wider digital divide. This is more pronounced when we build digital care services. The socio-technical interaction has to be considered throughout the design, development, and release.

In Summary

The pandemic has been a shockwave of the entire healthcare ecosystem. Most providers are today aware of the importance of resiliency and ability to be Agile in delivering healthcare services and being digital rather than merely doing digital. As I mentioned in a previous post, we will learn rapidly whether what we are witnessing is a patchwork under unusual circumstances or the beginning of a new era of healthcare transformation.

Acknowledgment

I would like to thank all the people who contributed to this work including — non-exhaustively — Brad Crotty, Michael Anderes, David Hotchkiss, Lauren Marvell, Inception Health team, Froedtert & Medical College legal, communication and HR teams, AWS NPO Team, and our entire healthcare staff and personnel.

Assistant Professor of Biomedical and Clinical Informatics and Global Health. President and founder of Tunisian Centre for Public Health

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