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The Implementation and Acceptability of a Combined Mobile Application with a COVID-19 at-Home Test Kit

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Introduction

At the height of the pandemic, access to COVID-19 diagnostics was limited. When testing capacities became more readily available, they were typically offered at hospitals, health care clinics, neighborhood pharmacies, or state-sponsored facilities.1 However, this required patients to leave the safety of their home isolations to get tested, which could lead to unnecessary risk of potential exposure.2,3 Furthermore, testing centers often had long lines, could be challenging to locate, and have long waiting times and appointments difficult to schedule. These barriers are not well suited for vulnerable populations, particularly those with limited ambulatory capability.

Hospital settings were also struggling with a shortage of testing capacity and necessary resources. As a result, staff and patients often could not be tested.4 Hospitals also noted how long it took to receive COVID-19 test results and the fact that they could not run all the tests ordered from the emergency department.4

The United States had been struggling with its response early in the pandemic. Only ∼125 people were tested per million within the first 4 months, versus 2,000+ people per million tested in Italy and 5,000+ people per million tested in South Korea. South Korea’s government even had websites and mobile apps that reported the number of people tested along with their location. In comparison, COVID-19 testing data in the United States from the Centers for Disease Control (CDC) lagged several days and only reported the number of specimens, not the number of people tested. Some states only reported positive results, not negative ones, making it difficult to gauge the number of tested individuals.5

Many states also struggled to stay ahead of new outbreaks due to overwhelmed laboratories experiencing processing delays and shortages of necessary testing supplies. The lack of access to testing was a considerable risk, as it can leave sick individuals undiagnosed and contribute to the virus’s spread.6

Of note, because COVID-19 testing results only reflected the state of an individual at the moment of testing,7 it was critical for the test to be readily available and for its results to be returned promptly.2 This was especially important for those planning to gather for holidays or for travelers scheduled to visit countries with destination policies that included prearrival testing mandates.8,9

In the fall of 2020, demand for COVID-19 tests skyrocketed in Massachusetts, with 160,000 tests performed in the week leading up to the Thanksgiving holiday. As a result, walk-in testing centers had long lines and hours-long wait times, as testing staff tried to keep up with increased demand around the holiday. At the same time, providers felt ill equipped to meet the growing testing demand due to the state’s inadequate testing facilities and staffing.6

To address these challenges, we set forth to design a diagnostic service supported by a mobile application. In addition, we aimed to develop a simple solution to help our employees gain easy access to COVID testing in the safety of their homes during the 2020 holiday season. To achieve this goal, we paired with a COVID-19 testing vendor and a digital health mobile application developer to assess the implementation of a self-administered testing kit managed by a mobile application (App).

Methods

Home-Based COVID-19 Screening

The Massachusetts General Hospital’s (MGH) Center for Innovation in Digital HealthCare (CIDH) selected Discovery Genomics (Newport Beach, CA) as its at-home COVID-19 testing vendor partner. We also collaborated with a mobile App vendor, CarePassport (Newton, MA), to integrate their web-based dashboard and mobile (iOS and Android) App with the at-home testing kit service offered by Discovery Genomics. The publication is the result of a quality improvement activity (not research) and was not formally supervised by the Mass General Brigham IRB, as per institutional policy.

Our goal was to improve access to testing by removing long wait times and providing a more convenient experience. Therefore, we developed a simple process for our employees: they would self-test at home, send the test to our testing partner through mail, and receive their results through the mobile App (Fig. 1).

Fig. 1.

Fig. 1. Workflow required to complete a home-based COVID-19 test and collect the result.

We recruited 92 employees and family members to join the pilot. Our testing vendor sent each participant four test kits, which they could use anytime between November 19, 2020, and January 4, 2021. Each kit included a nasal swab, a collection tube, a biohazard bag, a registration form, a FedEx or UPS shipping label, an envelope, an alcohol pad, a reference card, and two information sheets with QR codes. The first QR code linked to a website URL providing an instructional video demonstrating how to download the App, register, and self-administer the test. The second QR code linked the participants to the App registration process. After completing the self-test, the instructions directed participants to package the sample and leave it at a FedEx or UPS drop location. Questions regarding the App were addressed by the CIDH team or fielded to technical support staff from the App vendor.

Once the samples arrived at the testing laboratory, the vendor processed them immediately and entered the results into a web-based dashboard, which automatically sent a notification through the App to the participant (Fig. 2). The testing results were confidential and only accessible by the user or proxy. The test results were automatically time-stamped and labeled “Positive,” “Negative,” or “Inconclusive.” Once the results were available, the testing vendor would notify participants immediately through a phone call and a notification through the App. When test results were inconclusive, the staff would request participants to send a new sample.

Fig. 2.

Fig. 2. The user receives a notification from the App when a test result is available. This screen displays (a) the homepage with the most recent test result; (b) the health badge, which includes a QR code that links to an independent verification site from the CLIA-compliant laboratory; and (c) a history of all tests performed. CLIA, Clinical Laboratory Improvement Amendments.

At the conclusion of the pilot, we adapted a survey based on the mHealth App Usability Questionnaire10,11 to include additional questions specific to our use case. This anonymous survey was sent through e-mail by Survey Monkey, Inc., (San Mateo, CA) to participants. We then collected and consolidated feedback provided to our team through e-mail. Next, we collected de-identified data from the testing vendor, including test results, dates, and times when participants swabbed their noses, when the testing vendor received samples, and when participants were notified of their results.

Results

To evaluate the home test kit and the App user experience, we recruited a total of 92 participants (13 employees from CIDH and 79 relatives or friends of those employees). Of the participants, 56 subjects (61%) started the survey, while 52 (56%) completed it (Table 1).

Table 1. Volunteer Characteristics (n = 56)
Characteristic
 Age (years), n (%)
  Under 18 2 (3.6)
  18–24 4 (7.1)
  25–34 12 (21.4)
  35–44 10 (17.9)
  45–54 11 (19.6)
  55–64 7 (12.5)
  65+ 10 (17.9)
 Female, n (%) 32 (57.1)
 Race, n (%)
  American Indian/Alaskan Native 0
  Asian 21 (37.5)
  Black/African American 1 (1.8)
  White 32 (57.1)
  Pacific Islander/Native Hawaiian 0
  Two or more races 1 (1.8)
  Decline to specify 1 (1.8)
 Ethnicity, n (%)
  Hispanic 1 (1.8)
  Non-Hispanic 55 (98.2)
 Primary language: English, n (%) 54 (96.4)
 Education  
  Did not complete high school 2 (3.6)
  High school or G.E.D. 2 (3.6)
  Some college 3 (5.4)
  College graduate 29 (51.8)
  Postgraduate degree 20 (35.7)
 MGH employee 9 (16.1)

The median time between sample collection by the participant and the time the testing vendor received the sample was 47.1 h (IQR 26.9–69.6). The median time between the testing vendor receiving the sample and the time the results were shared with the participants was 4.9 h (IQR 3.6–5.8). Thus, the total median time from sample collection to results was 2.1 days (IQR 1.3–3.2).

Of the 92 participants, 52 completed the entire acceptability and usability survey, while 4 partially completed the survey. Overall, acceptability and usability were favorable among the participant sample (Table 2). Participants also reported that the test kit usability, shipping instructions, and reporting of the results through phone were favorable. We conducted our statistics using the R statistical package.12

Table 2. Acceptability and Usability Results
TESTING KIT QUESTIONS (1 = VERY EASY, 5 = VERY DIFFICULT) (n = 55) MEAN
 How did you find the understandability for instructions for the use of the test kit? 1.9
 How did you find the identification of the different components of the test kits? 1.7
 How did you find the sample collection? 1.7
 How did you find shipping the sample? 1.4
 How did you find your ability to surmount difficulties encountered? 1.9
APP QUESTIONS (1 = STRONGLY AGREE, 5 = STRONGLY DISAGREE) (n = 54) MEAN
 The App was easy to use. 1.8
 It was easy for me to learn to use the App. 1.6
 The interface of the App allowed me to use all the functions offered by the App. 2.0
 Whenever I made a mistake using the App, I could recover easily and quickly. 2.1
 I like the “look and feel” of the App. 1.7
 The information in the App was well organized. 1.6
 I feel comfortable using this App in social settings. 1.4
 The amount of time involved in using this App has been fitting for me. 1.5
 I would use this App again. 1.6
 Overall, I am satisfied with this App. 1.7
 The App would be useful for my health and well-being. 1.8
 The App improved my access to health care services. 2.1
 The App helped me manage my health effectively. 2.1
 This App has all the functions and capabilities I expected it to have. 2.1
 I could use the App even when the internet connection was poor or not available. 2.7
OVERALL EXPERIENCE (1 = STRONGLY AGREE, 5 = STRONGLY DISAGREE) (n = 52) MEAN
 This solution provided an acceptable way to receive health care services. 1.7
 The pilot gave me peace of mind to gather and feel safe for the Thanksgiving holiday. 1.6

Discussion

As providers are triaging more patients regularly through telehealth, the ability for patients to get a COVID test in the safety of their home and receive results remotely is critical for their overall health. The approach presented in this article enabled people to receive health care when needed, while practicing social distancing from community and health care workers. In addition, the App allowed individuals to receive results sooner, save on travel time and transportation costs, and reduce unnecessary visits to the clinic. Thus, this solution may enhance the regular telehealth experience because the user does not have to wait for a clinician to order the test, and thereby remains in control.

This quality improvement pilot was implemented during the COVID-19 pandemic, preceding the 2020 holiday season, when it was difficult for individuals to get reliable and convenient COVID testing. Our goal was to provide an easy-to-use standardized workflow for individuals to access COVID testing, emphasizing convenience and safety, thereby reducing exposure risk compared to an in-person visit. We recruited a group of volunteers to utilize the platform and to provide user experience feedback. Overall, the participants found that the testing kit and the App were easy to use and navigate. In addition, participants found the sample collection process to be convenient and appreciated the vendor notifying them of their results by telephone and App.

Finally, most participants agreed that the App improved their access to health care services and that this at-home testing process gave them peace of mind to gather with family and friends and feel safe for the holiday.

Following the pilot’s completion, we identified three essential lessons learned related to modifying the workflow. First, we must ensure that the participant is notified through a telephone call before their results appear in the App for positive and inconclusive test results. This step is essential because we need to advise them of the following steps (e.g., self-isolation, monitor symptoms, and resend sample) to prevent unnecessary anxiety. Second, two separate support lines, one for the App and one for the testing kit, confused participants. Access to support should have been consolidated to a single telephone number, and inquiries triaged to the right destination. Finally, we would have reduced multiple sets of directions for starting the pilot, using the test kits, and using the App into one consolidated set of instructions.

Although the testing vendor consistently processed the samples rapidly (4.9 h), the time elapsed between sample collection by the participant and the time the testing vendor received the sample was highly variable (IQR 26.9–69.6 h). Upon further inquiry with our participants and vendor, we identified two potential causes of this variability. First, not all participants brought their testing samples to the overnight delivery services immediately after their collection. Second, the speed of the service depended on when the participant mailed the sample. For example, we noticed delays when mailings happened over the weekend or during peak holiday times.

Limitations of this study included the small sample size not being representative of the general population and a lack of a control cohort. Furthermore, we implemented the workflow within a single institution with participants composed of hospital employees and their family members. However, the positive outcome presented in this pilot may add value to other organizations seeking to establish their at-home COVID-19 testing.

Conclusions

Seamless integration between a patient-facing mobile application and the COVID-19 testing vendor is essential. By operating synergistically, they improve user experience and thereby enhance the adoption of COVID-19 testing. Moreover, utilizing patient-facing mobile applications can strengthen equity as it places control in the user’s hands rather than controlled by the health care system. This last point is particularly relevant during times when resources are scarce, and access to services is limited.

Acknowledgments

We thank Mansee Patel from CIDH for helping with recruitment and for her valuable insights. We are also grateful to Dr. Sanjay Patil, Oliver Guerrero, Deedee Le, Alessandra Ramer, and Mark Lowe from Discovery Genomics for donating the test kits and for supporting the COVID-testing component of the pilot. Finally, we appreciate Dr. Mohamed Shoura and Omar Mhanna from Care Passport and the Discovery Genomics team for working together to integrate the COVID-testing results into the mobile application. This project would not have been possible without their assistance. Finally, we would like to thank Gina Cella for reviewing the article for clarity.

Disclosure Statement

No competing financial interests exist.

Funding Information

Operational funds from MGH CIDH supported this project. Discovery Genomics donated the home test kits and provided free sample shipment, processing, and user support for this initiative. CarePassport contributed the technical work necessary to display the testing results in the App and provided free technical support for the App.

REFERENCES





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