Treating Tuberculosis Using Video Directly Observed Therapy

Benefits of vDOT

vDOT can support treatment adherence and increase patient satisfaction.

Through vDOT, TB programs observe a patient ingesting TB medication through either live (synchronous) or recorded (asynchronous) videos. This can provide patients greater flexibility and autonomy as they undergo TB treatment, which may improve patient satisfaction.

Recorded vDOT enables TB programs to observe a patient ingesting TB medication outside of normal clinic hours, such as during nights, weekends, and holidays. Depending on the software, patients can record themselves ingesting the TB medication. Patients can forward the videos to the TB program when they have internet access.

Live vDOT provides flexibility because TB programs can observe a patient ingesting TB medication when the patient travels.

vDOT can decrease expenses and save time for TB programs and patients.

Cost savings may include:

• Decreased time health care workers spend traveling for community-based DOT and
• Decreased vehicle maintenance and fuel costs.

CDC developed a vDOT Costing Tool to help TB programs estimate or compare vDOT and traditional in-person DOT costs.

Patients who would otherwise go to a clinic for DOT may experience cost savings with vDOT related to:

• Decreasing travel, clinic wait times, and the need for dependent care, and
• Taking less time off from work.

vDOT can help TB programs conduct quality assurance activities.

Supervisory staff can participate in monitoring during live video sessions as part of quality assurance activities. Also, staff can rewatch recorded video sessions as needed to verify a patient ingested the TB medication.

Using vDOT for TB case management

TB programs can implement vDOT as a component of case management for patients in most settings that use traditional in-person DOT. This includes:

• Patients with HIV
• Pediatric and adolescent patients, with parental or guardian support
• Patients in rural areas
• Patients in institutional locations, if the institutional setting regulations support patient privacy and permit the use of electronic devices

TB programs need to maintain in-person DOT capability and availability to monitor TB treatment. In-person DOT is likely the best option for:

• Patients who are prescribed injectable medications
• Patients who are medically fragile and need close clinical monitoring
• Patients who are non-adherent to treatment with vDOT
• Patients who prefer in-person DOT

Do not use vDOT if a TB patient, or their daily caregiver, is unable to:

• Demonstrate comfort with or proficiency in using the vDOT platform or
• Communicate effectively.

Use caution and clinical judgment for patients with:

• Prior side effects to TB drugs,
• Drug resistance, or
• For whom treatment failure or poor adherence (e.g., persons with memory impairment, psychiatric illness, history of non-adherence) is a concern.

State TB Control Offices and TB Centers of Excellence for Training, Education, and Medical Consultation can assist in treating people with TB disease.

Preparing a patient to use vDOT

vDOT can begin at the start of outpatient treatment or shortly after.

When preparing a TB patient to use vDOT, TB program staff should assess if the TB patient or the patient's caregiver has:

• Knowledge of the prescribed medication regimen and potential side effects
• Awareness of how to respond to and report side effects
• Capacity to take (or administer) medications
• Regular access to a video-enabled phone, tablet, or computer and the internet
• Plans to change their phone or internet service provider while on vDOT
• A device and current cellphone data plan that supports the vDOT software application
• Concerns about paying monthly phone or internet costs related to vDOT

Patient education

At the start of vDOT, TB programs should train the patient on how to download and use the vDOT technology. Patient education and practice sessions can help patients learn vDOT protocols before sessions begin. During patient education, using the teach-back method can help to confirm if patients understand vDOT. If a patient starts on DOT and switches to vDOT, TB programs may consider offering vDOT trainings during the in-person DOT sessions.

During educational sessions, it is important to discuss with the patient:

• Circumstances that would lead to discontinuing vDOT and switching to in-person DOT, and
• Potential out-of-pocket costs (e.g., patient's cellphone data plan and usage fees).

Incentives and enablers

TB programs can use incentives and enablers to support the patient in adhering to TB treatment. Incentives are inexpensive rewards to encourage patients to take their medications or to keep DOT or clinic appointments. Enablers are things that help the patient receive treatment (e.g., cash assistance, reimbursement for cellphone data plans and internet services). TB programs should choose incentives and enablers according to each patient’s needs.

vDOT logistics for TB programs

Implementing an Electronic Directly Observed Therapy (eDOT) Program: A Toolkit for Tuberculosis (TB) Programs can assist TB programs in developing and implementing a TB eDOT program. To implement vDOT, TB programs will need to obtain vDOT software. TB programs should develop their own policies and protocols on the use of vDOT.

Selecting vDOT Software

TB programs will need to research available vDOT software that:

• Is compatible with their agency's security needs, and
• Allows for the level of privacy needed to secure patient information.

Thus, TB programs should work with their IT departments to identify technologies that are:

• Compatible with the health department equipment, and
• Compliant with the Health Insurance Portability and Accountability Act (HIPAA).

TB programs should also consider their program needs and budget when selecting vDOT software. A few additional key features to consider for the software are the:

• Language options
• Ability to store and forward videos later if patients are in areas with little or no internet access
• Compatibility with different types of devices and operating systems

Training TB program staff

TB programs should develop their own policies and protocols on using vDOT, including the training requirements for TB program staff. Staff may need training on:

• Operating the vDOT software from the perspective of the program and patients
• Troubleshooting the software application and common audio and video problems
• Assessing a device's compatibility with a software application
• Implementing protocols for vDOT sessions
• Educating patients on TB and vDOT
• Protecting patient confidentiality
• Working with interpreters
• Managing TB cases while using vDOT
• Understanding local laws and regulations relevant to vDOT
• Selecting the appropriate DOT method for patients
• Reverting to in-person DOT
• Administering TB medication to patients who require assistance (e.g., infants and small children)

Addressing potential challenges

TB programs implementing vDOT might experience challenges while using vDOT software.

Technical challenges

Technical challenges may include:

• Software-specific malfunctions,
• Internet connection issues,
• Patient's audio or video not working,
• Poor quality recordings,
• Inadequate memory on the device.

TB program staff should receive training on how to use the vDOT software before implementing vDOT. TB program staff should engage their local IT staff and the vDOT software developers to proactively address any potential issues.

Patients might experience challenges using the vDOT technology (e.g., unable to remember how to use the software application, no phone service). Patient education, educational materials, and practice vDOT sessions at the start of and during vDOT can help lessen potential challenges.

Challenges taking the medication

As with in-person DOT, TB programs implementing vDOT should establish procedures to confirm that the patient ingests the prescribed medicine. Some patients might hide pills in their mouth and spit them out later, hide medicine in clothing, or vomit the pills. If a patient does not adhere to treatment, treatment difficulties can arise (e.g., sputum smear reversions, delayed culture conversions, development of drug-resistant TB disease).

It might be difficult for the health care worker to ensure that a patient has ingested their medicine completely, especially during recorded vDOT sessions. Signs that a patient might not have ingested their medication completely include:

• A patient stopping videos immediately after putting pills in their mouth,
• A patient spending time out of camera view or being partially visible on screen, or
• A patient covering their mouth while ingesting medications.

Potential solutions include:

• Watching the patient continuously until he or she swallows the medicine and
• Asking the patient to show inside their mouth while moving their tongue from side-to-side.

Medication side effects

TB programs need to ensure that patients can report any concerns or side effects that they may have. Examples of side effects may include:

• Fever,
• Rash,
• Vomiting,
• Nausea,
• Upset stomach,
• Changes in eyesight or hearing,
• Yellow skin or eyes, or
• Aching joints.

TB programs should teach patients using vDOT which medication side effects to report immediately. Patients should know how to contact health care workers without delay.

During live video sessions, staff should inquire about any potential side effects.

TB programs should teach patients using recorded vDOT to report any concerns or symptoms at the start of each recorded vDOT session. If a patient using recorded vDOT does not acknowledge whether they have any concerns or symptoms, TB program staff should call the patient and ask about any possible problems.

If a patient reports any symptoms of serious side effects, do not give a new drug supply. The patient should stop taking the medication immediately. The health care worker should arrange for the patient to see their TB health care provider as soon as possible.

Reporting vDOT data

The Report of Verified Cases of Tuberculosis (RVCT) collects information on the administration of TB medications for all patients. TB programs report vDOT under eDOT.

Additional types of eDOT might include other electronic methods to document adherence to a medication regimen, for example:

• Pill bottles with medication event monitoring systems [MEMS],
• Text message reminders, and
• Sensor-embedded pills.

CDC did not review or recommend electronic methods other than vDOT for published recommendations. The researchers considered video critical to observing medication ingestion.

Jurisdictions that intend to implement vDOT should review their data collection systems to ensure compatibility to report eDOT data.

Determining reimbursement for vDOT

Medicaid coverage and reimbursement varies from state to state. For more information, see the National Policy Center – Center for Connected Health Policy list of current state laws and reimbursement policies.

TB programs should check with the individual private insurance company to determine if they offer reimbursement for vDOT.

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