The conceptualization of the tele-social app began in September 2021 at the Singapore General Hospital (SGH). It stemmed from the Singapore Ministry of Health’s effort to facilitate the COVID-19 Home Recovery Programme [22], an initiative in Singapore where eligible patients with COVID-19 who have mild to no symptoms were to self-isolate and receive remote care from home. The app was designed to complement the health services in the SGH COVID Virtual Ward (CVW) program, where medically complex patients with COVID-19 who would otherwise isolate in an acute hospital receive remote care and recover at home. To implement the app effectively and efficiently, the Rapid Application Development (RAD) process was adopted (Figure 1). The RAD emphasized an incremental and prototyping approach wherein the continual engagement of stakeholders to obtain user feedback contributes to the generation of further discussion for enhancement; this process continues until a satisfactory system is attained [23]. Collectively, the RAD aims to develop cost-effective yet high-quality innovations in a short duration [23].

The project began with the preparatory phase, where stakeholders engaged in discussions to scope the project. The RAD process then took place with a series of requirements gathering sessions with the relevant stakeholders to define and finalize the project requirements, including the project goals and expectations, timeline, and budget. This information was communicated to research engineers from the Agency for Science, Technology, and Research (A*STAR) for the initial prototype development, followed by an iterative process of User Acceptance Tests and improvement works with key stakeholders before the actual development and implementation.

Co-designing principles were applied throughout the RAD process. Key stakeholders were encouraged to participate actively to understand their needs, opinions, and experiences to ensure the app’s usability and relevance [24] and were respected as equal collaborators, sharing their expertise and having an agreement on the eventual product [25,26].

Stakeholder engagement began in September 2021. Interdisciplinary and multiprofessional stakeholders—including decision makers, physicians, nurses, and health care administrators operating the SGH CVW and SGH Hospital-at-Home program (a home-hospital program designed to encourage early inpatient discharge and home care)—were invited to join the project team to leverage their knowledge and expertise in home care for patients. Local research engineers from A*STAR, who had prior skills and knowledge in developing the Doctor Covid chatbot [14], were also engaged to assist with the designing and development of this mHealth app.

The RAD process involved constant iterations of discussions to capture the requirements, needs, and opinions of key stakeholders. These sessions were conducted via a web-based videoconference platform, Zoom (Zoom Video Communications), in a work group meeting format. Table 1 documents the overview of the discussions, key questions, and outcomes held throughout the RAD phases. All key points were recorded on pen and paper and simultaneously analyzed by 2 research engineers from A*STAR at the end of each work group meeting to facilitate the rapid development. Thematic analysis methodology was adopted wherein similar points were identified and grouped to form themes that informed the features to be included in the mHealth app [27]. This was followed by a series of discussions within the team on the feasibility (ie, whether the feature can be built with existing skills, technology, and time), usability (ie, how user-friendly the features are), and viability (ie, if the feature can be scaled and operated on other similar apps) of the ideas [28].

No ethics review was required for the project as no patients were involved in the design and development of the app. Only health care personnel (ie, physicians, nurses, and health care administrators) and software engineers were involved throughout the process. Moreover, the DrCovid+ app was incorporated as part of an established home care program (ie, SGH CVW) to provide complementary remote care to patients with COVID-19 and is not part of a human subject research study. The privacy and confidentiality of patient data were ensured, with these data collected only for routine patient care purposes.

Through a systematic and iterative RAD approach, DrCovid+, an expansion of the Doctor Covid use case [14], was developed. Decision makers, physicians, nurses, health care administrators, and research engineers were involved in the RAD process. Table 2 shows the demographics of the stakeholders involved.

The project scope, key requirements and challenges were gathered in phase 1.

Given the widespread transmission and the need for close medical attention for patients with COVID-19, DrCovid+ had to be developed and implemented efficiently and effectively. To achieve this, collaborative decisions were made to develop DrCovid+ through an expansion of the Doctor Covid use case and to incorporate DrCovid+ into the established work processes of the SGH CVW (Figure 2).

Three priorities were highlighted in phase 1. First, DrCovid+ would have to be translated into a functional and acceptable prototype, suitable for older adults who were expected to form the majority of the patients in SGH CVW. Second, DrCovid+ should serve as a remote monitoring app where patients would perform self-reporting of daily vital signs through a web link. Adherence to self-reporting was hence essential and had to be achieved without increasing the existing workload of health care providers. Third, health care providers should be informed at a glance of patients’ latest health status and be able to provide timely follow-up actions where necessary. This resulted in a prototype featuring a multilingual secure communication platform for the remote monitoring and timely dissemination of clinical and social interventions for patients with COVID-19.

DrCovid+ has been developed and incorporated into the SGH CVW workflow to complement the remote care services (Figure 2) since October 2021 and has enrolled 400 patients with COVID-19 to date. These are patients who would otherwise be isolated as inpatients and receive care from the hospital premises in the absence of DrCovid+. Table 3 illustrates the demographics of the patients. The DrCovid+ app caters to older adults who are deemed medically stable to receive remote care for their existing medical conditions beyond COVID-19. To date, 94.5% (378/400) of patients enrolled onto the DrCovid+ app has been discharged, with only 5.5% (22/400) of cases being escalated due to unforeseen medical conditions such as abnormal vital signs readings or the patient having died due to other medical conditions. With DrCovid+ providing complementary care to the SGH CVW workflow, this has resulted in a shorter total length of stay (LOS), despite an average LOS of 0.64 days more as compared to patients enrolled in the SGH CVW only. The LOS for patients in the DrCovid+ has contributed to an equivalence of 2822 hospital bed–days saved. Additionally, the remote care capability also reduced the need for routine home visits, contributing to productivity and person-days saved.

Ongoing enhancements and feedback sessions were conducted routinely to ensure the system’s reliability and usability. Although minor technical issues including downtime and crashes were recorded, these issues were escalated and rectified immediately by the research engineering support team.

To further cope with the growing care demands of patients with COVID-19, DrCovid+ was implemented at Changi General Hospital (CGH), another acute hospital in Singapore since March 2022. CGH was selected as the second site for implementation as it is an academic medical institution located in Eastern Singapore that serves a community of more than 1 million citizens in Singapore. Moreover, the process and requirements for early inpatient discharge and home care for patients with COVID-19 were similar at both CGH and SGH. The implementation process including development, vulnerability assessment test, and security assessment at CGH took only 2 weeks, highlighting the adaptability and flexibility of the app and its capacity for rapid deployment and implementation in a similar setting.

As part of the response plan to the COVID-19 crisis in Singapore, this paper documents the RAD process of a tele-social app, DrCovid+. Equipped with essential functions such as secure tele-social communication and back-end patient monitoring, the app was codeveloped with key stakeholders to allow for timely remote monitoring and continuity of care for existing patients with COVID-19.

The implementation of DrCovid+ served to address many of the unprecedented challenges posed by the COVID-19 pandemic. Knowing that COVID-19 spreads predominantly through droplets, there was a need to support early hospital discharge and home recovery as the default care management model for suitable patients to minimize the spread [31] without compromising the quality of care delivery. DrCovid+ was developed to ensure that patients are adequately cared for remotely, with a corresponding platform to track, monitor, and communicate with patients. Moreover, given the need to divert resources to meet the needs of existing patients and curb the spread of the virus, innovative solutions to manage and care for patients had to be developed efficiently [16]. DrCovid+ leveraged existing program workflows and processes and the use case of Doctor Covid and its engineering team’s expertise to assist with its development and implementation. This expedited the development process, resulting in the completion of DrCovid+ within a short duration. DrCovid+ also serves to reduce the personnel required to care for patients. Compared to an inpatient setting where approximately 1 consultant, 5 junior doctors, and 5 nurses are required to care for 20-30 patients, the same number of health care professionals can now care for over 100 patients with such remote monitoring system [32]. In addition, this can also contribute to substantial cost savings in the form of bed-days saved, hence improving issues relating to bed crunch. Notwithstanding, with any patient data storage platform, security issues must be addressed to safeguard confidential patient data. Given the need for rapid development and implementation, an elaborate and sophisticated security system may be challenging and inefficient to achieve. Nevertheless, DrCovid+ has various security measures such as collecting only enrolled patients’ last names and the last 4 characters of their National Registration Identity Card number during registration, restricted access to the back-end dashboard, and manual verification for onboarded patients to minimize any possible security breaches and leakage of patient data. With a large majority of patients enrolled for SGH CVW being older adults, DrCovid+ is also equipped with multilingual communication functions to prevent communication breakdown and enhance the usability of the app.

mHealth solutions are gaining traction among health care professionals, especially for remote monitoring during the pandemic to manage the increasing caseloads, and this is evident from the existing literature. For instance, e-CoVig, a system featuring a mobile app, web/cloud platform, and a device for acquiring patient’s vital signs, was developed, and it allows for real-time monitoring of patients with COVID-19 without the need for direct phone calls and has demonstrated high flexibility, modularity, and accuracy and positive feedbacks from users [33]. Another program, GetWellLoop, a remote patient monitoring solution consisting of patient engagement and educational materials, has also been implemented to monitor the symptoms of patients with COVID-19, send daily check-in questions and reminders, and serve as a platform for queries [34]. Similar to the DrCovid+ app, these programs were designed to be developed rapidly and cost-effectively, serving the needs of the population and the urgent demand for remote care amid the pandemic. However, DrCovid+ is unique in that it tapped and expanded on existing resources to develop an innovation that serves existing needs. Moreover, despite the limited time frame for development and implementation, a systematic RAD process was in place to ensure that the final prototype adheres to the needs and requirements of its end users.

The ubiquitous nature of mobile technology coupled with the increasing acceptance of mHealth has provided new windows of opportunity to augment its use in population health. Shifting from the COVID-19 pandemic to other pressing global public health issues such as the aging population, where increasing chronic and complex health care needs are pertinent and care needs extend beyond the hospital walls [35], a concerted effort has to be invested to empower patients and increase access to resources within the community to ensure a sustainable health care system [36]. Tele-social apps such as DrCovid+ can be a promising innovation to advance patient care and empowerment [37]. Designed to ensure modularity and flexibility, the app can be tailored to suit various use cases, such as sending text reminders for vaccination or medication intake, providing health education materials, and teleconsultations [38-40]. This also addresses the concern on sustained engagement given that DrCovid+ engages the patient on multiple fronts with different use cases. The adaptation of the use case for DrCovid+ can potentially minimize unnecessary waiting time and travel expenses for clinic visits and contribute to the reduction in hospital-acquired infection [41,42], making it a promising way forward.

The development and implementation of DrCovid+ had to be rapid to cope with the increasing COVID-19 caseloads. Despite this constraint, the process of developing the app used systematic RAD processes and co-designing principles such as continual engagement and taking the stance of equal collaboration to ensure the relevance and adoption of the eventual product. Regular meetings were also conducted to gather feedback and suggestions on the grounds for further modifications of the app. The current project, however, requires an evaluation of the cost-effectiveness and overall efficacy as more patients are enrolled. It will also be appropriate to assess time savings for health care providers and the difference in the characteristics of patients who onboarded the DrCovid+ app compared to controls.

The impetus to provide remote care and support to the increasing home recovery of COVID-19 cases and the urgency of the COVID-19 situation prompted the need to leverage mHealth technologies and rapid deployment. However, this was met with various challenges including cost-, labor-, and time-intensive requirements in developing an app; data security issues; and poor adoption rates due to communication-related barriers. The DrCovid+ app was developed to address the pressing demands for remote patient management and support the existing cost and technological bottlenecks. The rapid, cost-effective, yet strategical development of a tele-social app efficiently reaches out to a large number of patients while ensuring timely care provision, and this use case can also be scaled and expanded to meet other population health needs to tackle rising health care challenges.