This article presents a technological and innovative approach developed to help the Uruguayan government in their fight against COVID-19. The first version of the system (with only the most urgent services at that time) was released only seven days after the first case of COVID-19 was reported in Uruguay! At press time, some months after its first release, the fourth version is operative. Part of the system is a cellphone app available freely to the public, and it was downloaded by half a million people in a country with a population of 3.5 millions.
The project is innovative because it is the only worldwide solution, that we are aware of, that integrates in a unified way for patients, all health services of a country, the Ministry of Health, self-monitoring, remote patient monitoring, and telemedicine. Furthermore, the system makes full tracking possible from end to end to follow citizens' and patients' situation. Because of this, Uruguay was one of the first three countries and the first in Latin America to incorporate exposure notifications for COVID-19.
Uruguay is one of the first countries to incorporate contact tracing for COVID-19.
As we write this article (July 2020), the world is immersed in a context of total uncertainty regarding health issues caused by the coronavirus. In Uruguay, the first case of COVID-19 was confirmed on March 13, 2020. The same day, a CoronaVirus UY Plan was launched by the Uruguayan government, where technology (as in South Korea and other countries) had to play a key and strategic role.
Some of the main objectives to be achieved were:
To achieve these objectives, a team of private and public companies collaborated as well as interested individuals, organizing themselves to carry out a software engineering project never seen before, at least in Uruguay.
The Uruguayan government (through the Presidency Board) asked the group to work quickly to achieve a first delivery in less than seven days. This first version had to include at least registration, classification based on epidemiology surveys that would make it possible to understand which citizens were more likely to have the virus, and it had to communicate about them to different health providers (using multiple channels) by telephone or a video call protecting in this way the health personnel.
This was, as the reader has probably already noticed, a mission-critical project to be executed in a few days.
In order to avoid the collapse of the communication channels in the health care systems, a multi-channel solution (for receiving automated evaluation from the citizens or a request for information about COVID-19) was developed. During these seven days, the team built native mobile apps for Androida and iOS,b a Progressive Web application,c a form to be used by call centers, chatbots integrated in several conversational channels: Whatsapp,d Facebook Messenger, and WebChat embedded in the government pages. The team also developed epidemiological risk calculation modules, a survey module, a registration module, and the implementation of workflow processes for the correct handling of data by health providers.
Figure 1 shows one of the several workflows of the system. The user sends her data and the system processes it in different levels, also providing the possibility of a drive through coronavirus test to be scheduled.
It is important to emphasize that not only has Uruguay's health system not been saturated, but also 100% of COVID-19 suspected cases have been handled by coronavirus.uy.
On the first day, the team could not know whether this was going to result in a successful project or not. The majority of the people involved had never worked together before, no development process was established, there were no channels of communications between people or companies and, primarily, there were no written functional specifications. But it did, it worked! Figure 2 shows members of the development team in virtual meetings.
Preserving privacy and information security was a design decision from the beginning. The national e-government agency (AGESIC)f demanded not only these conditions but also specialized equipment in the project to ensure they were enforced.
Apple and Google have acknowledged that exposure notification was integrated in the last version of the coronavirus. uy app.g The first exposure notifications were sent at the beginning of July 2020 and the people whom received them used the system to be in contact with the health care provider, who finally took the coronavirus tests.
One remarkable fact is that while in countries like Germany, where their exposure notification solution costs $22.5 million,h the entire coronavirus.uy system (not only exposure notification!) has no cost at all. In Uruguay, the developers worked for free and the whole system (not only the phone app) belongs to the government.
This was a very difficult project with an extremely tight deadline. This achievement was possible thanks to the particular (and unique) Uruguayan ecosystem in software development. A solid education in software engineering, a highly digitized government, an integrated and digitally strong healthcare system, the use of a low-code platform (GeneXus) for a rapid development of the system, and other important advantages that the country offers, are at the basis of this "Uruguayan miracle."
Two months after the first case of COVID-19 was reported in Uruguay, the government and the population have an integrated (and evolving) system to handle this pandemic. Furthermore, the system is very flexible and can be set up to cover similar crises in the future.
From a total population of 3.5 million people (2.5 million active), the system has been accessed more than 2.6 million times (through the different communication channels offered). In other circumstances, the phone system of the country would have collapsed! The novel approach (in contrast with all other technological solutions in the world) is the fact that the citizen does not call the health provider if symptoms of COVID-19 are suspected. To the contrary, it uses the technological solution that automatically contacts the appropriate health provider. Then, based on their priorities (for example, risk factors or health symptoms recorded in the online form), the provider calls the citizen. It is important to emphasize that not only has Uruguay's health system not been saturated, but also 100% of COVID-19 suspected cases have been handled by coronavirus.uy.
The design and success of coronavirus.uy was a key element for Google and Apple to contact Uruguay to incorporate their contact tracing software for Exposure Notification in it. Its fourth version includes a contact-tracing system in order to help, even more, the population and the Government in this pandemic crisis. Moreover, coronavirus.uy has been requested by other countries like Brazil, Paraguay, Peru, and Surinam.
Regarding privacy, the Agency for Electronic Government in Uruguay (AGESIC) published all the code of this solutioni to allow the code to be reviewed and inspected. Also, the team has been in contact with several universities to give early access to the code to allow for auditing and to ensure privacy preservation.
A key contribution of coronavirus.uy to the public health system in Uruguay (that serves one third of the population) is the installation of an inbox-driven data tracking tray to at-tend the suspected cases automatically. Moreover, these tools will be available in the future to be used in their general needs beyond the virus. In addition, the telemedicine integrated in the system, is protecting doctors and nurses by avoiding contact with infected people without life-threatening complications. This technological innovation improved the quality of attention paid to the country's public health system.
Uruguay has managed to have an essential software system in virus management in record time. Thirty companies worked together, with no written functional requirements, with no clear software engineering process in place, and also, without having in place other aspects that we normally consider essential in any software develop-ment project. In spite of these constraints, the system is working, it incorporates innovative worldwide features compared to other similar technological solutions, and it is evolving. Coronavirus.uy is now an asset of the Uruguayan people and of the state. Furthermore, it can handle any kind of epidemic with a small configuration change in the system.
For future work we plan to analyze what has happened behind the curtains. We want to investigate which non-written processes were followed, how, and when the team communicated, how they handled the non-written requirements situation and how they managed and controlled this project. We expect to find a highly agile process with an extreme commitment of the developers in order to achieve their goals.
The world is clearly changing; maybe the way academia, industry, and government interact, and how we develop software will change too.
a. coronavirus.uy cell app at Google Play; https://play.google.com/store/apps/details?id=uy.gub.salud.plancovid19uy
b. coronavirus.uy cell app at Apple Store; https://apps.apple.com/us/app/coronavirus-uy/id1503026854)
Gastón Milano participated actively as chief architect in the development of coronavirus.uy. Diego Vallespir and Alfredo Viola did not participate in the development of the coronavirus.uy system.
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