- Platform
- Web App
- Duration
- 14 weeks
- Industry
- Healthcare
- Read time
- 9 min
Short answer
RaftLabs built Galen, a nurse-assisted telehealth platform where a clinic nurse operates connected diagnostic peripherals (examination camera, otoscope, digital stethoscope) while a remote doctor conducts the consultation via live video, directs device placement via a shared body diagram, and issues e-signed prescriptions through Zoho Sign. Adopted across 150+ hospitals, the platform cut in-person visits by 60%, raised patient engagement by 30%, and onboarded 50+ clinics in the first 12 weeks - including low-bandwidth rural settings. Built in 14 weeks on React, Twilio Video, HIPAA-eligible AWS Lambda, Hasura, and PostgreSQL.
A US healthcare team came to us with a specific gap: existing telehealth platforms delivered audio and video, but a physician on a call cannot examine a patient. They needed Galen, a platform where a clinic nurse operates the diagnostic hardware on-site while a remote doctor conducts the full consultation, directs device placement, records vital signs, and issues signed clinical documents.
The nurse streams four simultaneous feeds (main camera, handheld examination camera, otoscope, digital stethoscope audio) via Twilio Video. The doctor sees all feeds in a role-specific view, marks a shared body diagram to tell the nurse exactly where to place each device, and at session end signs the prescription and SOAP note through Zoho Sign. Twilio server-composes every session into a single MP4 audit trail for reimbursement.
Fifty-plus clinics onboarded in the first 12 weeks, including rural settings where people previously had to travel for routine checkups. In-person visits dropped 60%. The platform now operates across 150+ hospitals.
before & after
What changed
- Remote consultations meant audio and video only: physicians could talk with patients but could not conduct real examinations without the patient physically present
- Diagnoses depended on delayed reports; physicians had no access to real-time patient data during a virtual session, which extended care gaps and decision time
- Sessions produced no clinical structure: no shared body diagram for directing device placement, no SOAP note framework, and no way to issue a legally-signed prescription at the end of a remote visit
- Sessions were not recorded; there were no audit trails for reimbursement documentation, making insurance reimbursement for remote visits uncertain
- Care coordination broke when patients moved between providers: no shared session records, no continuity of clinical history across the platform
- Patients in rural and underserved areas still had to travel for routine checkups because the existing platform could not close the diagnostic gap: no peripheral hardware, no structured data, no signed document the care team could act on
- A nurse at the clinic operates the examination camera, otoscope, and digital stethoscope while the remote doctor conducts the consultation via Twilio Video; the doctor directs device placement via a shared body diagram, with device state and control signals synced over Twilio DataTrack JSON messages between roles, no separate chat infrastructure required
- Real-time diagnostic feeds stream into the consultation; the doctor sees and hears exactly what the nurse captures, not a description of what was found
- Doctors issue e-signed prescriptions and SOAP notes via Zoho Sign at the end of each session; signed PDFs land in the record, immediately downloadable as the reimbursement document
- The platform records every session: Twilio captures the doctor's full screen as a named track and server-composes it into a single MP4 audit trail, protecting both physician and patient and enabling insurance reimbursement for every remote visit
- Patients join via a browser link, no login and no app to install, so rural and low-tech users can access care without setup friction
- In-person visits dropped 60% for conditions that do not require physical presence; patient engagement increased 30% as routine care moved to fully structured virtual sessions
What we had to solve
- 01
Streaming four simultaneous Twilio tracks from a single nurse device without adding setup friction
A nurse in a clinical visit cannot pause to configure a multi-camera streaming setup. The platform had to detect and activate four simultaneous Twilio Video tracks (main camera, handheld examination camera, otoscope, and digital stethoscope audio) from a single device session, each with its own toggle visible only to the nurse. Twilio simultaneously publishes the doctor's full screen as a named track and server-composes it into a single MP4 audit trail. The design requirement: the nurse spends zero time on stream configuration during a live patient visit.
- 02
Meeting HIPAA requirements across video, data storage, and peripheral device feeds without degrading performance
HIPAA compliance is not a checkbox added after the platform is built: it is a constraint on every architectural decision. Two independent layers enforce PHI access: Hasura row/column-level permissions per role so a patient's query cannot return another patient's records at the database layer, and a second authorization check inside each AWS Lambda that verifies the caller owns the appointment before the function acts. All video runs on HIPAA-eligible Twilio with a signed BAA. Zoho Sign e-signs every prescription. Building this two-layer access model while keeping consultation sessions performing on rural low-bandwidth connections was the architecture problem the design had to solve from day one.
- 03
Real-time clinical collaboration between doctor and nurse without a separate messaging backend
The doctor needs to tell the nurse exactly where to place each device: a body diagram with a precise location marker, not a verbal instruction like "a little lower." Building a dedicated real-time messaging service for this would have added infrastructure, latency, and a new failure point. Instead, body-diagram pointing state, device activation toggles, and control signals all ride Twilio DataTrack JSON messages between the doctor, nurse, and patient. The trade-off: more client-side state reconciliation. The result: one infrastructure layer handling both the video streams and the clinical collaboration signals, with no separate service to maintain or expand.
outcomes
What we achieved
Patients with chronic conditions had no way to access routine care remotely. Each checkup required travel, which reduced how often patients followed through on scheduled visits.
Clinics had no production-ready telehealth infrastructure for remote care with real diagnostic capability. Adoption required a platform that could operate reliably in low-bandwidth rural settings.
Without diagnostic peripheral integration and a structured clinical workflow, patients with conditions requiring examination had no option but to make in-person visits even for routine follow-ups.
What clients say
Trusted by teams like yours.
Three-year average engagement. Founders and operators describing the work in their own words. No marketing varnish.
The telehealth app is a lifesaver! Now I can have my doctor's checkups from home through virtual visits.
Your patients need remote care but your platform cannot support real examinations?
the build
What we built
The platform is built around one clinical commitment: a remote consultation should deliver the same diagnostic capability as an in-person visit for conditions where physical presence is not required.
Sessions are recorded automatically, audit trail ready for reimbursement
Twilio publishes the doctor's full screen as a named Video track and server-composes it into a single MP4 at session end: a complete, timestamped record of what the team saw, heard, and decided. The session interface captures SOAP notes during the consultation. At close, the doctor e-signs the prescription and SOAP note through Zoho Sign; Zoho Sign stores signed PDFs, immediately downloadable as the reimbursement record. No separate document workflow. No manually assembled audit trail.
Nurse operates the peripherals; doctor sees and hears everything, directs placement in real time
The nurse streams four simultaneous Twilio Video tracks: main camera, handheld examination camera, otoscope, and digital stethoscope audio. Each track has its own toggle in a nurse-only device-status panel; the doctor's view shows all feeds without device controls. When the doctor marks a location on the shared body diagram, a Twilio DataTrack JSON message delivers the placement instruction to the nurse's screen instantly. No verbal reinterpretation, no delay. The doctor directs the examination as precisely as they would in person.
Every session produces a complete compliance record, BAAs signed from day one
Two independent layers enforce PHI access. First, Hasura row/column-level permissions per role: a patient's database query cannot return another patient's records before any application code runs. Second, each AWS Lambda function re-verifies that the caller owns the appointment or holds the required role before acting. Video runs on HIPAA-eligible Twilio with a signed BAA. Zoho Sign e-signs every prescription. No compliance control lives only in application logic; the enforcement is structural.
Patients in rural areas stay connected: poor bandwidth doesn't break the session
The patients who most need remote care often live in areas with the worst connectivity and the least comfort with technology. They join via a browser link with no login required; there is no app to install, removing the single biggest barrier for rural and low-tech users. We tuned the video and data layers for low-bandwidth connections: adaptive bitrate for video, compressed peripheral data streams, and graceful degradation that maintains session continuity when bandwidth drops. Over 50 clinics in rural and remote settings onboarded in the first 12 weeks without performance issues.
Engagement
How we worked together
- 01Weeks 1–2
Discovery and scoping
We map the problem before writing code. Two weeks of technical audit, stakeholder interviews, and prototype, so both teams align on scope and risk before sprint one. - 02Ongoing
Two-week Agile sprints
Each sprint ends with working software, not a status update. You review a real build, request changes, and approve before we move forward. No surprises at handover. - 03Ongoing
Daily async updates
Slack for daily progress, Asana for task visibility, weekly video calls for decisions. You have full visibility without needing to attend every meeting. - 04Final
Handover and warranty
Full code handover with deployment runbooks and documentation. Thirty-day warranty period for production issues at no extra cost.
stack
Why we chose this stack
- 01ReactGalen has six role-specific interfaces (Galen admin, facility admin, head nurse, nurse, doctor, and patient), each with a different view into the same Twilio real-time data layer. React's component model kept these role views isolated without state conflicts between concurrent streams. Fluent UI provided accessible, WCAG-compliant primitives so clinical UX met healthcare accessibility standards without custom component builds.
- 02TwilioThe consultation room requires four simultaneous video tracks, real-time body-diagram state sync between roles, SMS notifications, and a session recording server-composed into a single MP4 audit trail. Twilio Video's multi-track API handled all four streams from the nurse's device; Twilio DataTrack carried device toggles, body-diagram placement instructions, and control signals between doctor, nurse, and patient as JSON messages, replacing a dedicated messaging backend and eliminating a second service to maintain.
- 03AWSAll consultation logic, scheduling, vital signs, prescriptions, notifications, and payments run serverless on HIPAA-eligible AWS Lambda, scaling to any concurrent session count without provisioned capacity. Hasura event triggers fan out to Lambda handlers for tri-channel notifications (in-app, Postmark email, Twilio SMS) and payment-link expiry, so no polling loop runs in the application layer.
- 04HasuraSix roles with strictly different PHI access requirements needed enforcement at the query layer, not in application code. Hasura's row/column-level GraphQL permissions enforce what each role can read and write before a query reaches the database. Hasura's event triggers also drive the notification layer: appointment reminders, payment-link expiry, and status changes fire Lambda handlers automatically without a separate scheduler.
- 05PostgreSQLSession recordings, vital signs, SOAP notes, prescription logs, and audit entries require ACID-compliant storage with guaranteed write integrity. No entry in a HIPAA audit trail can be lost or partially written. PostgreSQL's transactional guarantees made every clinical record complete and defensible for reimbursement documentation and compliance audit.
- 06StripeDoctor subscriptions gate platform access; per-booking payments fund clinic operations. Stripe's webhook model integrates with Hasura scheduled events so subscription status changes and payment-link expiry update automatically. No manual reconciliation, no polling.
Common questions about this telehealth platform
A standard telehealth call gives the physician what the patient can describe. A nurse-assisted visit adds a trained clinical presence on-site: the nurse operates examination peripherals (camera, otoscope, and digital stethoscope) while the physician conducts the session remotely. The physician directs device placement via a shared body diagram, sees and hears the same diagnostic data they would in person, and at session end issues a legally-signed prescription through Zoho Sign. The result is a complete clinical encounter (structured, recorded, and reimbursable), not a call where the physician advises based on a description alone.
HIPAA compliance is not a feature layer added after the platform ships: it is a constraint on every architectural decision from day one. Two independent layers enforce PHI access on Galen. Hasura row/column-level permissions per role mean a patient's database query cannot return another patient's records before any application code runs. A second authorization check inside each AWS Lambda function verifies the caller owns the appointment before the function acts. Video runs on HIPAA-eligible Twilio with a signed Business Associate Agreement. Zoho Sign e-signs every prescription. AWS encrypts secrets at rest; data sits on managed infrastructure with encryption throughout. Retrofitting this two-layer access model after the platform is built is significantly more expensive and disruptive than designing for it upfront.
The nurse opens a device-status panel (a nurse-only UI element, hidden from the doctor and patient views) and activates each peripheral. The platform establishes four simultaneous Twilio Video tracks: main camera, handheld examination camera, otoscope feed, and digital stethoscope audio. When the doctor marks a location on the shared body diagram, a Twilio DataTrack JSON message delivers the placement instruction to the nurse's screen instantly. The doctor sees all four feeds in their role-specific view, hears stethoscope audio through their headset, and can follow the nurse's device-status toggles. The nurse manages physical device positioning; the doctor manages clinical interpretation. Device detection is automatic; no manual configuration during the visit.
We designed the onboarding flow for clinical administrators, not technical staff. The admin portal provisions clinic accounts. Physician and patient interfaces require no installation; they run in the browser. Device integration uses standard USB and Bluetooth connections with the platform handling driver communication. Patients join via a public link with no login required, removing the single biggest barrier for rural and low-tech users. The 12-week figure reflects clinics that were fully operational (creating appointments, running sessions, and processing reimbursement documentation), not just accounts created.
Yes, and that was an explicit design requirement. The patient population this platform serves clusters in areas where connectivity is inconsistent. The video layer uses adaptive bitrate: it adjusts quality in real time based on available bandwidth rather than dropping the call. The platform compresses peripheral data streams. Session state persists through brief connectivity drops so the consultation resumes without either party needing to reconnect. We load-tested the platform against rural bandwidth conditions before launch, not just urban broadband. Over 50 clinics in rural and remote settings onboarded in the first 12 weeks without performance issues.
We delivered Galen in 14 weeks: HIPAA-compliant infrastructure, multi-track Twilio Video streaming for four peripheral types, real-time body-diagram collaboration via DataTrack, Zoho-signed prescriptions and SOAP notes, tri-channel notifications, role-specific interfaces for six user types, appointment scheduling with timezone overrides, and low-bandwidth optimization. Three factors drive the timeline: the number of peripheral device types requiring integration, the complexity of the role and permission model, and the compliance audit work required before launch. Contact us to scope based on your device integration requirements, user role structure, and target markets.
