Opal
Homeless individuals often face a complex web of health issues, including mental illness, addiction, chronic diseases, and injuries, which are exacerbated by their lack of stable housing. This leads to heightened morbidity and a stark disparity in life expectancy, with homeless individuals experiencing a life expectancy of only 41- 47 years, compared to the national average of 79 years. The current fragmented healthcare ecosystem and community resources further compounds health outcomes, as discharged patients lack proper communication and coordination of resources, resulting in disrupted recoveries and a cycle of emergency room visits and hospital readmissions. Moreover, these readmissions are penalizing hospitals and costing millions of dollars in wasted spend. In the US alone, there are 1.5 million people (and growing) experiencing homelessness each year. This represents a cost of $27 billion to US taxpayers per year for homeless ER visits. The disparities and complex health needs of our unhoused community members are a particularly pressing place to begin to address social determinants of health and to reduce wasted spend.
The Opal framework is aimed at creating a bridge between health and social service providers (HSSP) and the unsheltered community, fostering effective communication and support systems to address social determinants of health (SDOH). The platform will provide a safe space for people experiencing homelessness (PEH) to locate, assess, and interact with a network of health and social service providers while offering providers working in separate organizations a user-friendly interface to manage cases together.
The Opal application will be developed using an open protocol called NOSH: Nostr for Health (More information here), where each interaction is encrypted by the cryptographic key of the account holder and stored in public servers called Relays. With the use of cryptographic techniques and decentralized networks of Relays, users can trust the authenticity and reliability of the information they access without compromising privacy. NOSH is based on HL7 FHIR data models, which increases the interoperability of medical information shared through the protocol. The app will serve as a resource hub and can be scaled to other vulnerable populations as well as creates the foundation of a new data model model for a Vulnerable Person Health Record (VPHR).
Our pilot will serve vulnerable individuals experiencing homelessness and will begin with a pilot in Olmsted County, Minnesota with the Zumbro Valley Medical Society Street Medicine Team. The pilot will be designed to address the complex and interconnected needs of PEH, as well as to help community and medical providers with a framework that enhances coordinated care. This population faces significant disparities and is currently underserved in several ways:
Following hospital visits, discharged patients often arrive at shelters without crucial information about their hospitalization, medical conditions, follow-up appointments, or medications, which disrupts their recovery and leads to poor health outcomes.
A population that is often on the move, PEH are constantly planning where they are going to sleep, eat and take care of their basic needs. With such a narrow time horizon, people can face difficulties in making or keeping doctor appointments, pursuing mental health recovery services, applying for a job and even applying for housing. Opal will support this population by coordinating their care between the hospital and community resources.
This population is often faced with stigma and trauma, underscoring the importance of building trust. Opal will assist these individuals to overcome barriers to care by incorporating people’s lived experiences into the development of the framework.
Our solution aims to prioritize the patient needs of this underserved population by providing a comprehensive and integrated application that can be used by service and medical providers in coordination of care. It will facilitate communication and coordination among health and social service providers, ensuring that individuals receive the necessary support, resources, and follow-up care to improve health outcomes and overall well-being. By addressing the specific challenges faced by this population and offering a tailored approach to their needs, the Opal framework can directly and meaningfully impact the lives of homeless individuals by enhancing their access to care and, ultimately, their quality of life.
The partnership between PathCheck Foundation and the Zumbro Valley Medical Society brings together a consortium of nearly 8,000 medical providers, epidemiologists, technologists, data scientists, developers and digital privacy evangelists whose primary goal is to build the next generation of open source, privacy preserving solutions that fill public health gaps.
As a team dedicated to enhancing the lives of individuals across the globe, the PathCheck Foundation was born during the COVID-19 pandemic to launch applications that enabled contact tracing and exposure notifications without exposing personal information of its users. This information was used by health departments around the world to respond to the global pandemic.
The leadership teams at both PathCheck and the Zumbro Valley Medical Society have committed to serving vulnerable populations in unique ways in order to influence positive health outcomes. Both nonprofit organizations have committed themselves to ensure that vulnerable populations in Olmsted County and around the world have resources that support their access to better health outcomes.
As a non-profit executive for the last 17 years, I have made it my mission to prioritize education and health equity and access. I have focused on developing empowering solutions that break down barriers to care for underserved communities, while respecting diversity and fostering inclusion. I believe that innovation in public health must put the needs of vulnerable populations first. To do this, we must collaborate with partners who share this vision, so we can drive systemic change that will create a more just and compassionate healthcare system for all.
- Using data sharing and interoperability of systems.
- Creating user-friendly interfaces to improve communication between experts and patients, including providing better information, results, and reminders.
- Pilot: An organization testing a product, service, or business model with a small number of users
- Financial (e.g. accounting practices, pitching to investors)
- Human Capital (e.g. sourcing talent, board development)
- Legal or Regulatory Matters
- Public Relations (e.g. branding/marketing strategy, social and global media)
Opal will be the first tested solution to offer real-time superior care coordination to enhance the outcomes for those experiencing housing insecurity. The proposed infrastructure will be the first natively-interoperable digital health information system for decentralized health and social service providers to be developed in an open information exchange protocol. This proposal will use interoperable machine-readable standards to cryptographically protect the provenance of health information of users without having to impose an operational cost on the partners using this system. More importantly, since NOSH is an open protocol, any other team around the globe can develop on top of what we will deliver in this proposal.
Our solution addresses the UN Sustainable Development Goal 3 for Good Health and Well-Being by making accessibility to quality essential-healthcare at the core of our work. By creating a cohesive and interoperable healthcare system that looks at patients as complex individuals and addresses the social determinants of health, we are successfully advancing Good Health and Well-Being. By testing our pilot in Olmsted County, we will have proof of concept and will be able to scale the Opal framework and translate it to other vulnerable populations.
The Opal framework architecture will have three components: Capture, analyze, and engage. For capture, we use no-peek computational software. For analysis, we use privacy-preserved machine learning and NLP. For engagement, our platform extends to the vulnerable population.
Data capture will include measuring patient’s use of the ER, readmission rates, lengths of stay, patient outcomes, specific life circumstances, social determinants of health and partnership and collaboration.
Here's how Opal leverages AI to achieve this:
Machine Learning Algorithms: Opal will employ machine learning algorithms to analyze and make predictions based on historical and real-time data. These algorithms will aim to identify patterns and trends in patient data, enabling the system to make predictions about future ER readmissions.
Predictive Models: Opal will use predictive models that take into account a range of factors, including a patient's medical history, demographics, social determinants of health, and more. These models are trained to predict the likelihood of an individual experiencing an ER readmission. By connecting broadly disparate, multimodal datasets we can identify patterns or insights to serve the vulnerable population.
Natural Language Processing (NLP): NLP will be used to extract valuable information from unstructured data sources such as medical notes, patient records, or clinical narratives. This helps in gaining a deeper understanding of the patient's health status and history.
Underlying Data collected upon patient approval:
Patient Health Records: Opal relies on comprehensive patient health records, which include medical history, diagnosis, treatment plans, and past ER visits. These records are essential for training AI models.
Demographic Data: Information about a patient's age, gender, location, and other demographics are significant factors in predicting readmissions.
Social Determinants of Health (SDOH): The Centers for Medicare & Medicaid Services (CMS) have mandated that hospitals reporting to the Inpatient Quality Reporting (IQR) program submit two new measures, SDOH-1 and SDOH-2. Due to this new requirement, Mayo Clinic, our partner for this pilot, is now screening for SDOH for all inpatient treatment. This data can be leveraged to better serve and understand the broader context of a patient’s health.
The Opal platform will be built to facilitate proactive and targeted interventions for street medicine teams and community providers. One way to do this is to build an alert that will notify community partners should an individual be likely to be readmitted to the ER. Community partners can then reach out to the individual with appropriate resources and interventions, which could include medical check-ups, medication adherence support, or assistance with social determinants of health, ultimately aiming to prevent unnecessary ER visits.
Opal is focused on patient agency, strong governance, and proactive engagement with stakeholders to ensure appropriate, secure, and ethical use of health data to improve lives.
Using Nostr as the base of this framework, Opal is an ideal platform for sharing EMRs between healthcare providers and patients when coupled with HL7 FHIR standards and add-ons that Nosh-enabled clients can incorporate. Here are the main benefits of Nostr/Nosh:
Tamper-proof, interoperable data exchange - Less attack surfaces
All EHRs use/post to the same user id/relay - No more data silos / patient identification issues
Patient in control - Direct consent for data sharing
Nosh allows anyone to quickly and easily develop new clients that can leverage these new standards. However, it is important that implementing a decentralized identity management system requires collaboration and coordination between various stakeholders, including patients, healthcare providers, regulators, and technology providers. It also requires careful consideration of data privacy and security concerns, as well as the potential risks and benefits of such a system. Therefore, below are the following steps we are taking to address these concerns:
Opal will obtain informed consent from patients to share their data, explaining clearly how it will be used and by whom. Patients will be able to opt-out at any time.
Using Nostr, Opal access controls are only opened to authorized providers by patients themselves. These providers will then be able to view patient data relevant to their care, enforced through relays.
Establish an ethics review board to oversee policies and address emerging concerns related to equitable access to care.
Partner with patient advocacy groups and community organizations to incorporate diverse perspectives into the system design and data sharing protocols.
Provide comprehensive training to healthcare partners on secure data handling, minimizing biases, and delivering equitable treatment.
Conduct ongoing reviews to identify any potential disparities in health outcomes that could stem from data misuse.
The pilot will be built over 12-months and includes the following impact goals:
Coordinate targeted solutions for better care through Opal: Targeted solutions will include care that is specific to each individual based on the lived experience they are facing. Opal will provide medical and community partners with information that allow them to deliver personalized care that increases the overall wellbeing of those affected by homelessness.
Securely transfer health information for those experiencing homelessness to medical and community providers: Maintaining integrated systems of care at multiple points of service is an every day challenge for community and health providers. With multiple providers serving the same client, Opal will allow the secure sending of health information that informs practitioners and helps them to measure the number of clients they serve, the services they provide, and health outcomes.
Increase provider and community partnership and communication to improve care outcomes: Real-time data will allow community and medical providers to retrieve data that has been entered by different locations. This will allow them to track an individual's medical history, medications, service access and health outcomes. It will increase communication and allow medical and community providers to intervene at appropriate points of care to ensure the best possible outcome for each individual.
Identify gaps in the homeless service system and avoid readmissions to ERs: Opal will provide a multi-pronged approach to care and will allow users to seek services that are important to their case. Many individuals experiencing homelessness find out about services through word of mouth and may not have access to them. Opal will allow individuals to learn about services and will give them a communication tool to access them.
To achieve these goals, we will be working directly with the Zumbro Valley Medical Society and five community partners in Olmsted County: Dorothy Day Hospitality House, The Landing MN, Olmsted County Housing Stability Team, Community Paramedicine, and Rochester Community Warming Center.
We will work with individuals with lived experience of homelessness to design and implement the framework. These experts-by-experience will help us to co-design the project and guide the development of Opal to ensure it meets the direct needs of those who are using the application. We will include individuals in this process by building an advisory board, hosting workshops and asking specific questions during medical and community provider visits. These efforts will help us to improve discharge planning and provide a resource that is truly beneficial to the unhoused community.
Following the 12-month proof of concept, we hope to scale Opal to the Street Medicine programs in 140 cities in 27 countries over six continents. In addition, we hope to develop a Vulnerable Person Health Record (VPHR) and robust digital tools that health and community providers can use globally to deliver positive health outcomes. Building Opal in an open source ecosystem holds promise to scale this solution to other vulnerable populations seeking care and will help build a playbook of best practices other parties can utilize in response to specific individual needs.
- Nonprofit
3 full-time team members
1 part-time team member
3 months
Community has been a fundamental component to PathCheck Foundation as an established open source organization. Our consortium of epidemiologists, data scientists, medical providers, data privacy enthusiasts, developers, engineers and researchers from all over the globe first came together to create solutions that delivered vaccine verification and exposure notifications to several states, countries and territories during the pandemic. Our open source community welcomes individuals from all backgrounds and locations and is built on the principle that bringing people together to contribute to projects are essential to growth, reach and innovation.
Our community of practice encourages individuals to join activities and discussions, as well as lend their expertise to projects they may be interested in. It is a safe environment where we learn from one another through safe dialogue, community forums, and working on challenging problems. We also work to create a welcoming learning environment by providing peer-to-peer mentoring, hackathons, and open slack channels for increased collaboration. The PathCheck Foundation will continue to operate as a community of practice, welcoming all to come together to solve public health problems by innovating new solutions and products.
To improve health, enhance health care delivery, and promote greater health equity, PathCheck Foundation will pilot Opal with the Zumbro Valley Medical Society (ZVMS) Street Medicine Initiative in Olmsted County, Minnesota.
PathCheck will contribute technical expertise; ZVMS Street Medicine Initiative will provide local knowledge and relationships. Together, we will create a proof of concept that is responsive to the needs and circumstances of our unhoused community members and ensures that confidentiality and security are maintained.
For the proposed project, we will also work with five community partners in the same area: Dorothy Day Hospitality House, The Landing MN, Olmsted County Housing Stability Team, Community Paramedicine, and Rochester Community Warming Center. We have worked with these partners in the Street Medicine selective that we created for first-year medical students at Mayo Clinic Alix School of Medicine, our discharge improvement project, street rounds, community clinics, and efforts to develop recuperative care in Olmsted County.
12-Month Roadmap:
Phase 1: Research and Design Objectives (Months 1-2)
Conduct in-depth research on existing homelessness applications, main user requirements, and potential challenges
Run brainstorming and workshop sessions with key stakeholders to determine the most needed call to actions in the application
Design and iterate the user interface and experience for both health and social providers and people experiencing homelessness.
Phase 2: Development Objectives (Months 3-8)
Develop the application for mobile users from the learnings of Phase 1
Implement geolocation services, secure messaging, and database integration as needed
Conduct extensive pre-testing and gather feedback from target users for improvements
Register accounts for the target pilot community and partner networks.
Phase 3: Deployment and Pilots Objectives (Months 9-12)
Launch the application in the target region/community
Organize training sessions for health and social service providers to use the platform effectively
Implement an educational and awareness campaign to encourage adoption and participation in the application
Monitor and evaluate the application's performance, gathering insights for future enhancements.
Our fee-based model will charge healthcare providers an annual fee to access and utilize the Opal care coordination platform. This recurring revenue model is highly scalable as we expand to new cities and healthcare partners, driving predictable long-term revenue.
The monthly fees will be priced significantly below the costs that hospitals currently face from preventable readmissions and penalties under value-based care programs. By conservatively reducing readmissions in our partner cities by 66% in the first 3 years, Opal's fees will align with and capture a portion of the cost savings from improved care coordination.
Under our 5-year plan, we expect to deploy Opal in 28 major cities with street medicine initiatives by year 4. At an average contract value of $50,000-$100,000 per city, this would result in $1.4 million to $2.8 million in annual recurring revenue just from our city partnerships. Additional revenue streams from health system partners and value-based care contracts will further fuel our growth.
This capital-efficient model will allow us to scale rapidly and cost-effectively, while aligning our incentives with healthcare providers to drive improved coordination, reduced costs, and better health outcomes.
We anticipate our operating costs for the next year to be as follows:
Project Management: $40,000
Administrative Support: $20,000
Research and Design: (includes community participation honoraria) $70,000
Development and Testing of Opal: $230,000
Data Integration Development: $80,000
Server Infrastructure: $15,000
Educational Materials, Training, Support and Promotion: $15,000
Research: $2,500
Contingency and Miscellaneous: $5,000
Total Operating: $477, 500
We are kindly requesting $90,000 to conduct the following work while we are in the residency:
45k for research and design of the Opal app
35k for development and testing - We need to fine-tune and optimize the AI model for accuracy and performance, ensuring that we are meeting ethical and legal requirements
10k for human capital - Funding for our CTO and independent developers
We selected this amount by looking at our current operating expenses while being mindful of the other projects that are requesting funding. We recognize that the value of the Cure Residency is being a part of the community and ecosystem, and we would like to have as many projects funded; therefore, we would be honored to receive any amount and form part of the next wave of leaders in the health x AI space. We are committed to using the funding responsibly and ensuring we have a positive impact in the communities we aim to serve.
Cure asks - How do we cure what ails us? We want to cure the systems that ail us. By taking a Social Determinants of Health perspective in our work, we are designing systems that provide a holistic perspective to health.
PathCheck is focused on building public health solutions that support vulnerable populations. Our leadership team would benefit immensely from being part of the Cure community that is trying to answer the hard questions. Having access to a network like Cure will provide us with the guidance and mentorship we need to help us become the next wave of digital health leaders. Ultimately, we are most excited about giving back to the Cure community and creating a mutualistic relationship by welcoming the community to engage with PathCheck’s open source ecosystem, sharing our expertise, and lastly, committing our energy to solving the world’s most complex health challenges.