Triage on the Move (ToM)

The Covid-19 pandemic presents a significant risk to migrant workers. They suffer due to limited access to healthcare and Covid-19 information, inability to shelter-in-place, societal discrimination, and co-morbidities such as diabetes and hypertension. Sustainable Innovations’ (SI) Triage on the Move (ToM), a portable, knowledge-driven, online system, travels with migrant workers. Equipped with ToM, trained entrepreneurial migrant women capture symptoms (including Covid-19), perform triage and relay the symptoms to a remote physician / health authority as well as deliver prescriptions, and educate the migrants. 

Mother nature awards those who excel at being adaptive, not the smartest. TOM capitalizes on the migrant’s social capital and their adaptability. It enables migrants to care for migrants. With data analytics TOM will amplify the impact of social capital on basic healthcare and limiting the spread of pandemics.  Globally, when scaled, ToM can improve lives of 300+ million migrants and arm them to fight Covid-19.

Providing contiguous primary healthcare and, more recently Covid-19 tracking, for migrant workers has experienced significant obstacles over the decades. The ToM system and service delivery approach delivers the solution via the provision of these services to the migrant community, by the community.

The Covid-19 pandemic puts the plight of migrant workers on a global pedestal, commanding attention. The International Labor Organization (ILO) estimates there are 164 million foreign migrant workers worldwide. Of these, 14 million comprise of mostly farm workers who have come from Mexico to the US while India has 139 million domestic migrant laborers -- all generally residing in extreme crowded conditions. Exacerbating the living conditions are significant financial, cultural and language barriers in accessing basic healthcare. Leaning on family and friends for support “social capital” is what sustains them. For example, the older men in a Mexican farm workers community are called ‘Tio’ or uncle; it is the same with Indian migrant communities. This population is aspirational, entrepreneurial, and hardworking. 

ToM, is a tablet loaded with medical protocols for common ailments, preventable diseases, and managed health conditions. Diagnostic devices like blood pressure meter and spirometer can be connected for gathering and storing data. Business-wise we train aspirational and entrepreneurial migrants called Roving Healthcare Interveners (RHIs) who operate their own enterprises for primary healthcare delivery and tracking of Covid-19 within their community.

Operationally, the RHIs issues to each immigrant a unique health identifier card and using ToM, collects demographic (familial) data, symptoms, performs triage for common and preventable diseases, as well as Covid-19 symptoms, communicates the data to a remote physician and health authorities and finally relays the physician’s recommendation and prescription to the patient. All for <$1 per visit.

ToM’s Unique Capabilities:

1. Highly portable and easy to use.

2. Builds health enterprises owned and run by the unemployed migrants as self-sustaining enterprises.

3. Provides for the rapid creation of new protocols in days based on its knowledge database and AI.

4. Collects millions of health data elements – 100 million in 3 years. A great value in knowledge dissemination,

5. Forewarns of impending disease breakouts in today’s milieu.

6.  Creates multiple revenue streams for organic growth and systemic sustainability

Migrant farm workers in California or laborers in India, reside in cramped accommodations. They lack the vocabulary to articulate symptoms and are tradition-bound, making telehealth ineffective. They will value TOM’s human interface -- the Roving Healthcare Intervener (RHI) -- delivering trusted care to their doorstep and preventing loss of daily wages.

Dr. Michele Parker, a Public Health faculty member at Santa Clara University has overseen multiple global projects in low resource settings. Dr. BP Agrawal has been working with India’s impoverished for 20+ years and understands migrants social and cultural norms and is transformed these norms from perceived liability into an asset.

Our approach is to understand their culture and empower migrants to provide care and health education to their own communities, while also providing them with job opportunity. Let the youth own and operate ToM. We will support them through seed funding, intellectual capital, and business training. 

Our solution, ToM is an end-to-end self-sustaining system. It increases both health security and provides entrepreneurship opportunities for the migrant worker population. Building a trusted relationship with health providers helps accurately track new Covid cases and provides patients with appropriate care, thus improving overall heath, mitigating pandemic associated risks and saving lives in migrant communities. Creation of new business and sustainable employment of migrant youth links improved health with economic growth potential and community security. Health, economic opportunity, and security go hand-in-hand to raise marginalized communities out of poverty.

ToM innovation was fueled by demographic and perception changes.  Demographically, ILO reported that the population of international migrant workers, excluding domestic ones, grew from 150 – 164 million from 2015 to 2017; women comprise 42%. Domestic migrant workers in India number 139 million! These migrants have limited access to basic healthcare and Covid-19 information.

Migrant workers are perceived as lazy, deficient, and uncultured*. That is a misconception. They are aspirational, entrepreneurial, determined, and resourceful. That has been Sustainable Innovation’s founder, Dr Agrawal’s personal experience. They excel were someone to trust and believe in them.

ToM empowers a new dimension of performance for migrant women by providing them with the means to deliver healthcare at the doorstep within their communities. They set up their own enterprises becoming role models for the community, especially girls.

Migrant workers, especially undocumented ones, are fearful of approaching government funded clinics. ToM’s innovative solution removes this fear of authorities and offers a significant decrease in the cost of receiving basic healthcare at home. (In India, it can cost $4+ to see a doctor)

For comparison, there are several similar apps but none provide the holistic and entrepreneurial approach of ToM. For example, there are single service ones such as storing demographic information, locating housing for quarantine, and connecting migrants with jobs. None offer a system for healthcare delivery integrating patient, healthcare intervener, physician and public health authorities while providing entrepreneurial opportunities to the under-served.

*The Alternative” by McArthur Genius Fellow Mauricio Miller, 2017

ToM combines a new business model/process with new and existing technology. 

Business Model: It creates a cadre of migrant women entrepreneurs who set up their own healthcare enterprises owned and run by them. A cluster of enterprises form a business unit; each business unit (BU) is managed by a physician. The BUs work with Sustainable Innovations, which assures flow of seed capital, intellectual capital (e.g. software and rapid protocol development for new diseases), and managerial capital (e.g. building revenue streams, monetizing data repository, forewarning health authorities of epidemics). 

New Technology: ToM builds a dynamic knowledge database of symptoms for prevalent diseases. It’s inbuilt logic chains the symptoms rapidly into an algorithm for emerging diseases and new strands. Its built-in profiles for practices and physicians allow auto-filling of prescriptions or indicate which government provided medications are available for free. It lets migrant patients communicate with a BU’s physician visually. The visual capability overcomes one of the banes of telehealth, patient's inability to articulate their symptoms. 

Existing Technology: Uses electronic medical records (EMR) technology to build medical records for every migrant -- captures as many as 200 health data elements per patient. The EMR repository for a population of 20,000 will be 4 million! Its internet-based mobile communications technology enables an online communication loop between patient to Roving Healthcare Intervener (RHI) to physician to  RHI to patient. There is provision to integrate EyeNetra, an imaging technology developed by MIT for vision screening and other screening (hearing, Covid-19 tracking) technologies.

Dr Agrawal piloted Triage on the Move (ToM) twice in Rajasthan’s rural communities covering approximately 2500-3000 people. Both pilots lasting 6 to 8 months were unsuccessful. The first time, the physicians at the government operated Primary Health Centers (PHC) perceived ToM as an imminent threat in that it would establish measurable norms for care and personnel performance wherein currently, they are not accountable for their performance. Additionally, the PHC staff were convinced that ToM would deprive them of their after-business hours income. (Patients are asked to see the PHC physicians at their homes for a fee.) 

Sustainable Innovations approached the Rajasthan government a second time for permission to launch a second pilot. This process took more than two years. The second pilot failed because it ran into the schism of the cultural sensitivities. For example, the job designation” health worker” is perceived by the communities as someone doing menial work, as menial job, devoid of any dignity. The lesson we learned was that lexicon, cultural traditions, and societal structure matter.

Irrespective of these failures ToM, from a technical perspective, worked well. However, from the perspective of providing entrepreneurial opportunities, the trials were too short to mature this concept. Further trials have been on hold pending availability of funding.

Our “theory of change” is based on system thinking: Thinking of a system from end to end. That is the design should start with community insights, fail early on rapid prototyping, not seek societal change and finish the race with predictable revenues and impactful healthcare delivery.

Triage on the Move (ToM) is a system with several constituent sub-systems that chain the activities from initiation to the final outcome(s). Change flows from one constituent sub-system to its succeeding sub-systems. They have a parent-child relationship. The subsystems are, to name a few, capturing of symptoms, checking them for validity (for example - does the blood pressure reading entered by the RHI fall within normal range?), algorithmic screening to rule out potential diseases (the algorithms use the symptoms and knowledge database), relaying of symptoms and outcomes to a  physician, receiving prescriptions or the treatment plan from the physician (like an in-person visit, follow up visit, emergency, etc.), checking the prescription against “free medicines” supplied by the government or charitable organizations, capturing and relaying additional symptoms and visual images asked for by the physician, collecting service fees, building predictable revenue streams, and designing new medical protocols within a matter of days.

The subsystems are a chain of innovations linked to each other -- together they create an innovative system for the delivery of healthcare.  

Economically, the enterprise is envisioned to be seeded through grants. By year 3, ToM will build predictable revenue streams and by Year 5 ToM it should be able to support its growth organically. 

Our vision is to reach the 139 million migrant workers in India and 14 million farm workers in California. Simultaneously, make ToM available to other NGOs such as African Diaspora Network for them to provide care in their own regions.  

The first year’s goal is to develop robust product and health information services. Realistically, we can reach 20,000 migrant workers in one year. In parallel we will form alliances with other NGOs to reach one million people in 5 years. The second prong of our strategy is to find commercial partners to offer at-home health care services to upscale areas that hunger for western style healthcare services and have disposable income. Just four cities, New Delhi, Mumbai, Hyderabad, and Bangalore would mean several million people

1. Our first-year goals are:

• Providing basic care and Covid-19 tracking to aggregate 20,000 people in California and India. 
• Train 12 RHIs, 4 in the US and 8 in India, to set up their own enterprises.
• Train and engage 4 physician business units, 2 in the US and 2 in India.
• Integrate Covid-19 tracking 

2. The five-year goals are multi-dimensional:

• Provide care to an aggregate 2 million migrants globally, in the US, India, and beyond. Build SI's organizational capacity. 
• Form partnerships with NGOs and socially minded commercial outfits to implement ToM in the regions they operate in.
• Offer preventive care, for example, vision screening (integrate MIT’s EyeNetra), hearing screening, blood pressure screening, asthma screening, and others. Design and launch campaigns
• Design revenue generating health information services for upscale markets. These services will be browser or mobile phone based
• Develop data analytics to create services for health authorities, public policy institutions, and others.
• In year 3, ToM should become self-sustainable, funded by its revenue services. We project to have a rich repository of 200 million health data elements by then. 
• By Year 5 ToM should be able to support its growth organically. 

1. Capacity: Sustainable Innovations lacks organizational capacity to scale its programs and a strong balance sheet to attract large investments or contributions.
2. Legal: Triage on the Move (ToM) may face government regulatory issues and HIPAA compliance issues both in India and the US. Resolving these may take time
3. Financial: Yes, financial resources are a major factor.
4. Cultural Barriers:   From experience we know that, these can inhibit health seeking behavior. These can range from gender biases, shyness about discussing the body to strong belief in prayers and rituals (over medical care) to rid oneself of diseases.

5. Technical: One of the challenges will be to build a library of medical symptoms for Spanish and other regional languages and to integrate various diagnostics devices that work both in India and the US.

6. Inter-operability issues: ToM is designed using SS7 protocol for communication, yet interface issues are likely to arise while  communicating with other health systems.

Capacity: SI solicits MIT's help to assist in developing partnership introductions and direct support of Sustainable Innovation team’s capability to deliver services.  

Legal: Dr. Agrawal has worked with the Rajasthan government in the past to secure approvals for ToM’s predecessor, Arogya. He is familiar with government processes and confident about getting approvals, though these may take time. Regarding the US, ToM will be positioned to deliver health information and not healthcare or Covid-19 care. Migrant women will facilitate health information flow between the patient and physician, thus meeting HIPAA requirements. Additionally, the patient’s consent will be secured beforehand.

Financial: For the development of ToM, SI has secured $550,000+ from various donors. We will approach our donors for matching funds, though there is no assurance of this. We are working with Santa Clara University based in Silicon Valley to jointly approach high net worth individuals located there.    

Cultural Barriers:  Having worked in rural communities for a decade, we have a deep understanding of cultural and social norms. Similarly, Dr. Michele Parker has good rapport with Mexican farm workers.  

Technical: The software has built-in hooks for multi-language operation. However, finding commonly understood words and descriptions for medical lexicon will be challenging. We plan to consult the social science faculty at BITS Pilani and Santa Clara University. 

Inter-operability issues: It is a known and well understood problem. We will select one or two health systems that are more popular and start operations with them. Over time we will interface with other systems 

N/A

• Three employees full-time
• Other workers:
• • Two Board Advisors
  • India based systems development company estimated at two to three developers assigned to the solution.
• One India representative to manage India deployment
• Others will be hired based on funding

Dr BP Agrawal, SI’s founder, received 10+ patents for innovations while spearheading R&D at Fortune 100 companies. His own start-up in health informatics transformed health IT from cost to revenue center. He secured $3 million in grants, awards and in-kind donations for SI. Significant among his many awards is the 2010 Lemelson-MIT Award Winner for Sustainability.

The ToM system created by Dr Agrawal is backed by local knowledge, in-place expertise and a knowledgeable team of dedicated professionals driven by success

• Aditi Banerjee, Program Director, has worked in India for most of her career and understands the Indian market.
• Vinay K Bansal, an IT professional, heads SI’s Philanthropic Outreach in the Silicon Valley
• The Managing Trustee of SI sister organizations, SITI’s, Jugad Bawa, is a lifelong Sales professional with significant business contacts.

India relationships include government bodies and universities including Dr Agrawal’s alma mater the premier technology institute BITS Pilani which is involved in ToM’s design.

SI’s partnership with University of Santa Clara, CA on ToM is overseen by Dr Michele Parker, a public health expert who has overseen multiple projects in low resource settings. Both faculty and students will be engaged in technology development, productizing ToM and service delivery.

SI’s medical fraternity is composed of Dr. Aarthi Vemana, (US) and Dr. Sanjay Choudhary, (India) who led the development of disease protocols for ToM’s launch. Dr Nivedita Bansal, a Board certified Internal Medicine physician, recently joined to assist with enhancing ToM to support the coronavirus detection and abatement efforts.

1. Frugal Innovation Lab, University of Santa Clare, California for the development of medical protocols pertaining to migrants in California and piloting the program
2. Birla Institute of Technology and Sciences, Pilani, India for program design
3. Sustainable Innovations Trust India for piloting the program in India
4. Others
   • Contract with Ready2Solution, an India-based organisation focused on software development and IT solutions 

Triage on the Move (ToM) provides under-served clients affordable healthcare using incentivized local staff, who in turn are supported by incentivized professional healthcare workers called the business unit (BU) physicians.

The Roving Healthcare Interveners (RHI) are the secondary clients who are trained to become entrepreneurs after one year of financial support from the enterprise.

Physicians form the third clientele whose BUs receive a monthly fee from the enterprise for diagnosing the patients and are allowed use of ToM to sell/upsell more customized offerings to their clients.

Healthcare organizations, authorities, and other enterprises are the fourth clientele. They can take advantage of the vast data gathered by ToM for timely healthcare analysis that could be used to further their goals.

Revenue earned by the enterprise (high level only):

• The under-served: Pay nominal episodic fee for healthcare services - small ticket, large volume.
• The RHIs: Collect the nominal fee and pay it to the enterprise who pays the RHIs a percentage of the collection
• The Physician:
  • Is paid a stipend by SI
  • Using ToM, the physician can upsell his/her services by adding customized revenue generating services applicable in their areas: the enterprise receives a license fee.
• Healthcare organizations, government, pharma companies, other enterprises:
  • Big data sale for analytical purposes
  • Providing analyzed data products
• Other income sources: Delivery of medicines, test results, distribution of products related to health, hygiene and nutrition; logistical support for health awareness drives/campaigns, etc -- to be firmed up on Proof-of-Concept (POC) completion and evidence analysis . 

Like a start-up enterprise, ToM will progress through three stages.

First Stage: The seed stage where we will service 20,000 migrant workers in US and India; be funded by grants/charitable contributions. SI is collaborating with Santa Clara University, California to reach out to Silicon Valley-based philanthropic ventures and high-net worth SCU Alumni and Indian diaspora. We don't expect to generate any revenue other than a nominal collection from episodic fees charged to migrants for health services.

• Expected timeframe: 18 months;
• Estimated budget: $891,250
• Estimated data repository: 4 million health data elements.

Second Stage: Sustainable Innovations will form strategic alliances to expand its services to 1,000,000 migrant workers and build revenue generating services to supplement grants and donations. These include:

• Nominal fee collection (small ticket, high volume) from migrants for healthcare services;
• Value-added services: Preventive and managed care;
• Health information services for upscale communities;
• Sale of data for data analytics to public policy organizations; health authorities; commercial companies.

Target: Be cash flow positive. We have not firmed up the cash flow model and are looking for expert help. This phase will last for 24-30 months

Third Phase:  This is the stage for a fully operational and sustainable enterprise. SI’s preference is to finalize revenues, expenses, and enterprise model in consultation with would-be funding sources, social investors, and venture capitalists. In SI's experience, the best business plans are those written in consultation with funding sources. We look forward to working with MIT Solve to prepare a robust enterprise model.  

Sustainable Innovations needs help to overcome capacity barriers. We need to build our capacity to support projected growth of the health enterprises. The capacity should be strong enough to serve migrant communities and  build predictable revenue streams. Specifically, we are seeking help to build a strong Board which is actively engaged with SI. The Board will open doors to collaboration with or even merger with well-aligned organizations.

We are seeking strategic relationships with organisations that seek to integrate philanthropic activities into their strategies and operations and their goals are aligned with ours.

SI seeks assist in developing, through partnership introductions, the SI Team’s capability to deliver services that not only satisfy present expectations, but anticipate future marketplace opportunities. Included are skills, instincts, abilities, processes, success measurements and resources needed to deliver, sustain and adapt the Triage on the Move solution

Our partnership goal is to create pathways for scaling our programs. We seek  partnering organizations that have organizational capacity and access to funding sources. Sustainable Innovations has the technology, sustainability expertise and understands how to transform cultural traditions into an asset.

We are looking for partners whose mission is aligned with that of Sustainable Innovations and who have capacity to scale the programs. They bring organizational capacity to the table and Sustainable Innovations brings its expertise in holistic sustainability, social innovations, and the already demonstrated systems for healthcare delivery and safe drinking water. These organizations could be, for example, Oxfam, Care International, and PSI.  

Our solution advances the cause of improved health including Covid-19 tracking among neglected migrant communities in India and the US. It delivers accessible, quality healthcare to all migrants and other low income communities through a technology enabled,easily operated healthcare platform operated by the migrants themselves. It offers income opportunities for aspirational, entrepreneurial migrant women from the community. 

The prize money will be used to increase the pool of such entrepreneurial women by funding more training programs. The more the pool, the more people we can deliver healthcare to.