How to Make At-Home Coronavirus Testing Work

How to Make At-Home Coronavirus Testing Work

by Neeti Sanyal and Shantanu Nundy - March 24, 2020

One of the most critical elements to reducing the spread of the novel coronavirus, Covid-19, and providing health care to those who suffer complications is our ability to rapidly and safely test large numbers of people for the virus. At-home testing, which several organizations hope to soon introduce once guidance from the U.S. Food and Drug Administration (FDA) has been clarified, could play an important role in rapidly expanding the number of people who are tested.

The test that’s currently being performed in hospitals and clinics employs a polymerase chain reaction (PCR) molecular technique and involves a nasal swab usually administered by a trained care professional. It presents a major challenge in times of a pandemic like we are in now. We are hearing dozens of stories of patients, like 29-year old Katherine, who have to first understand if they are qualified to get a test, then go to a facility to get tested where they may inadvertently expose others to infection, including health care workers, and then if there happen to be tests available, get tested and wait days for the result.

To address this challenge, a paper we published last week in the Journal of the American Medical Association (JAMA) describes a straightforward and seemingly effective way to expand safe access to Covid-19 testing: at-home testing. Already there are reports of organizations planning to offer a home-testing option, including the Gates Foundation for individuals in Seattle and direct-to-consumer start-up companies. A recent HBR article includes home-testing as part of a comprehensive national response.

Here is how home testing would work. It starts with a telemedicine call with a clinician to determine whether testing is needed. A test kit would then be mailed to your home, where you would perform the test and then send your sample to a laboratory for analysis. While awaiting the results, you would remain self-quarantined. The entire diagnostic process is done virtually, and for the vast majority of people who are low-risk and can be safely cared for at home, the entire diagnosis, treatment, and recovery process can be done at home.

Such a service can promote social distancing  - which is crucial for reducing the spread of the virus  - and improve health outcomes by freeing up capacity for hospitals and clinics to provide care for people who truly need it.

The novelty of the solution is its simplicity. But if you take a deeper look, you will see that the success of such a service is predicated on a number of assumptions about how users will behave. Looking at self-testing for Covid-19 from a human-centered design perspective, it looks like the kind of behavior that we know how to solve.

To better understand what we mean, we can look at Covid-19 self-testing as requiring three fundamental shifts in behaviors.

The first is to encourage people to not run to a health care facility when they feel non-severe or life-threatening symptoms, but rather call a telemedicine service first. When we or a loved one are feeling sick and even scared, it is only natural to seek expertise where we know we will get it and to default to deeply ingrained habits, in this case, going to the doctor’s office or an emergency room (ER).

The second is to help people do the test correctly. Doing a nasal swab is not as natural or easy as swallowing a pill. Putting a cotton swab in your nose is not a natural act, it can cause physical discomfort and, if you do the test incorrectly, you can be subject to a false negative result. In essence, we are asking people to do something they have never done before, not knowing whether they did it right, in a situation where their health could depend on it.

The third is to ask people to correctly and patiently self-quarantine for 48 to 72 hours until their test results come back. Self-quarantine means staying physically isolated, maintaining at least six feet distance from any other human, including loved ones. Not only is this inconvenient, it can also jeopardize people’s jobs, constrain our ability to fulfill our household and caregiver duties, and be emotionally challenging.

Without all three of these behaviors occurring, the service will not achieve its intended individual and public health impact. The good news is that none of these challenges is insurmountable. In fact, when we account for human behaviors, motivations and concerns in the way we design a product or service, it can result in tremendous success. Just consider the fact that we jump into cars with strangers and rent out our homes without much of a thought.

How might we design a self-testing service for Covid-19 that encourages the right behaviors and keeps humans at the center? Here are some principles to keep in mind.

Appeal to altruistic motives. It is important that we help people understand how their actions are helping their community, especially regarding the importance of talking to a health care provider before visiting a facility and staying in isolation while waiting for results. Solutions include simply thanking people for doing the right thing and developing easy-to-understand messaging like “stopping one infection today (as opposed to seven days from now) averts x times as many infections over the next month.”

Provide support throughout the process to instill confidence. People’s decision to self-test shouldn’t result in an outcome that is inferior to what they would get by going into a clinic. From designing insulin pens and other drug delivery devices that are self-injected, we know importance of feedback loops to let people know they are doing it right. What if you could scan a QR code on the packaging of the kit that pulls up an instructional video on your phone? Or get a live video consult if you need support doing the self-swab? We also know that coronavirus tests can have false negatives, particularly if the test is done too early or incorrectly. So a self-service should include a simple way for people to indicate that their symptoms have not resolved or are getting worse and then guide them to additional telemedicine consultation and repeat testing.

Protect people and their privacy. In addition to protecting people from at-home test kits that have yet to meet the FDA’s high standards for approval - perhaps by designing a label that helps people understand the risks and benefits of testing in plain language - we need to make sure we are treating people’s results according to the same confidentiality standards that they would expect if they went into a health care setting. Establishing trust with people is key to the process. Like the controversy with at-home DNA test kits on how your data is used and shared has shown, it is imperative that the service is clear about how your results and personal data will be used. Obtaining the minimal amount of personal data for the service to work is a great place to start.

Overcommunicate to prevent panic and undesirable behaviors. People will flock to what they know if they have doubt in something new. For example, if the service promises a result in a certain time frame, it needs to stick to it; otherwise people might go into the health care setting anyway to get the answers they need. So if the service gets an unexpectedly large set of samples back and can’t adhere to the 48-to-72-hour time frame, it needs to make sure users know the new estimated time frame and why it changed.

Identify the right target population. Finally, self-testing won’t be for everyone. Some individuals need to be physically examined by a doctor or receive more acute care in an emergency room, and others will be unwilling or physically unable to perform a self-swab. To ensure that self-testing reaches the right people, clinical expertise should be used to create a design that allows the service to identify individuals who are appropriate for self-testing and then makes it easy throughout the process for users to switch to an alternative testing modality if they feel uncomfortable with it.

To help the world contend with Covid-19, multiple innovative solutions are coming our way, from drive-through testing facilities popping up across the country to multiple efforts to produce a vaccine to at-home testing. We need every ounce of science, technology, dedication, compassion, and creativity to respond to this global pandemic. By putting humans in the center, we can make great strides.

Neeti Sanyal is an executive creative director at Artefact, a strategy and design firm based in Seattle. She previously worked at PATH, a global health organization, where she commercialized medical devices for communities in China, Brazil, India, and South Africa.

Shantanu Nundy, MD, is a primary care physician and chief medical officer at Accolade, a population health company that provides personalized health and benefits solutions for employers. He also serves as a professorial lecturer at the George Washington University Milken Institute of Public Health.