How the University of Arizona pioneers life-saving COVID-19 tracing with Twilio SMS

The global scale of the novel coronavirus has seen the health system stretched beyond its capacity. Worldwide shortages of ventilators, test kits, and personal protective equipment means every community must decide how to best allocate limited resources in the fight against COVID-19.

With no clear end in sight, digital tracing efforts quickly emerged at the onset of the pandemic––but only on a wide scale for the first time ever. Unfortunately, government-sponsored and private COVID-19 apps face challenges, with low adoption rates undermining their efficacy.

Thankfully, app-free alternatives are popping up, like AZCOVIDTXT.

Developed by a team of researchers from University of Arizona’s (UofA) Data Science Institute (D7), this two-way SMS system, powered by Twilio Programmable Messaging, is helping reduce the spread of COVID-19.

Heeding the call to combat COVID-19

Prior to COVID-19, the DSI had already been using Twilio Programmable Messaging for a decade to send so-called “wise interventions,” or social science-based psychological notifications, to address a wide range of health issues, including tobacco cessation, obesity, and cancer prevention.

Wanting to expand its portfolio of research projects, DSI Director Nirav Merchant integrated Twilio with a HIPAA-compliant, web-based application for building and managing online surveys and databases, called REDCap (Research Electronic Data Capture), two years ago. His decision proved prescient.

For Merchant and his team, information is the best weapon against COVID-19. In the wake of the virus, it wasn’t long before he started hearing from a colleague at University of Arizona’s College of Medicine: “He said, ‘You guys have the tool in your toolbox—why not use it for this?’”

For more than 20 years, Merchant has overseen the DSI’s high-performance computing for life sciences, genetics, and genomics imaging. He is the current co-principal investigator of the National Science Foundation (NSF) CyVerse, a national-scale cyberinfrastructure for life sciences, and NSF Jetstream, the first user-friendly, scalable cloud environment for the NSF Extreme Science and Engineering Discovery Environment (XSEDE), a single virtual system for scientists to share computing resources.

All of which is to say, Merchant knew just who to call in order to heed the call.

“I called my colleague in public health, who we had done disease surveillance work for on [the Zika virus]. Then, we talked to my other colleague, who we’ve done a lot of text message-based interventions with, and we said, “Look, people are going to need this––will you and your students be willing to help handle that part?” She was like, “Sign me up.”

That colleague is Tracy Crane, Assistant Professor of Nursing and Public Health at the UofA’s College of Nursing.

“We were not testing at a high enough level in Arizona. So we thought, ‘What can we do to help get more information to our counties and to our state level leaders?” Crane said.

The only thing left for Merchant’s new team of old colleagues to do was figure out how they would gather data. Their years of clinical health research experience had prepared them well.

“We’ve gone down the path of apps and knew that people are extremely nervous about their privacy and not willing to use them,” Merchant recalled.

Another factor he and his team had to consider was the population itself. The University of Arizona is located in Pima County, where nearly a quarter of residents earn less than 125 percent of the federal poverty level.

Merchant and the team refused to let poor network connectivity and the rarity of a smartphone deter them. “We decided to take the most low-tech approach we could, one we could launch in less than a week,” Merchant said.

By integrating REDCap with Twilio Programmable SMS, the team would not only bridge the digital divide, but also allow its staff developers to build quickly under the short timeline. “My personal philosophy,” Merchant says, “is to use the tools that do what they do well.”

Text. Map. Combat.

The idea behind the AZCOVIDTXT System is simple but powerful: if you have access to a phone, then you can help slow the spread of COVID-19.

Residents of Pima County, which includes Tucson, can simply text “JOIN” to the system’s phone number. After they reply to a confirmation text with their zip code, they receive the survey in either Spanish or English.

Participants report on the health status of their households weekly. “We go on to ask them a few more questions about if they’re having problems finding food or hygiene products, are they having difficulties being in isolation, any mental health concerns, and if they want to receive additional messages related to these specific concerns.,” said Crane.

Participants also can receive optional SMS updates on the virus’ spread in their zip code. “I like to use the term narrowcast, rather than broadcast, where we are trying to narrowcast our information to the groups and make it specific to their area and needs,” Merchant described.

Information about cases by zip code is continuously updated on a map of the county and publicly available on the AZCOVIDTXT website, along with an online community forum for asking questions and receiving further help.

The more people that join, the more insights decision-makers, public health workers, and health care providers have into how the virus is spreading and where to deliver the right resources to the right people at the right time. The D7 team has a large focus on Pima County, but have expanded to recruit from all across the state of Arizona. To date, 3500 households are participating from 220 zip codes with more than 102,000 messages sent. With Twilio, the team is able to easily scale its SMS survey and make updates ongoing as new information becomes available.

Exploring options beyond text messaging

UofA is also expanding COVID-19 tracing beyond its text line. Pima County enlisted the D7 team to build a wellness app to monitor Tucson’s approximately 300 long-term healthcare facilities, where outbreaks are more likely to occur. “We have to think big because eventually the Arizona State Health Department will soon want to use it. Our target was 100,000 long-term care facility residents, their target was a million,” Merchant said.

This wellness app uses Twilio SMS to ask healthcare workers if there is a change to a patient’s health, and reminds facilities to upload information at their facility via Qualtrics. If there’s no change in a patient’s status, the staff member can simply answer, “No.”

A third version, currently in development, is a voicemail system for frontline healthcare workers to provide information about their experiences. Developer Hagan Franks used Twilio Studio, a stateful visual workflow builder. “I was able to put together a fairly complicated phone tree in about an hour that nearly fulfilled the researchers requirements. We’ll need to integrate with Twilio functions but Studio made quick work of their specified IVR, something that might have taken me a week with traditional Twilio REST API’s,” he describes.

“Kudos to Twilio, because they checked in with our developer to see if he had any particular questions I might need to follow up on and he really appreciated how well Twilio documents all its different features,” said Maliaca Oxnam, DSI Deputy Director.

Due to the growing number of use-cases for the AZCOVIDTXT System, the time horizon of the project has stretched from 3-6 months to an entire year. It’s an encouraging signal that COVID-19 tracing partnerships between municipal government, researchers, and healthcare providers successfully work, and with the right technology partner can ensure solutions are flexible to grow as needed.

Disease tracking through self-reporting has the potential to dramatically limit the spread of COVID-19—not just in Pima County—but in communities across the world who are doing their best to flatten the curve.