Implementing an Electronic Directly Observed Therapy …

1 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis EliminationImplementing an Electronic Directly Observed Therapy (eDOT) Program: A Toolkit for Tuberculosis (TB) ProgramsContentsI. Background ..1 Background ..1 Purpose ..1 Acknowledgements ..1II. Introduction ..2 What is eDOT? ..2 What Technologies Can be Used to Administer eDOT? ..2Is eDOT Right for Your Program and Your TB Patients? ..3 Benefits of eDOT ..3 Challenges of eDOT ..3 Security and Patient Privacy ..3 III. Preparing for Implementation ..4 Convene an eDOT workgroup ..4 Identify resources and technologies ..4 Develop eDOT policies and protocols ..5 Train staff.

2 6IV. Implementation ..7V. Monitoring and evaluation ..8VI. Appendices ..9 Appendix A: Technology Options for Electronic Directly Observed Therapy (eDOT) ..10 Appendix B: Patient Electronic Directly Observed Therapy (eDOT) Agreement Form ..11 Appendix C: Loaner Agreement for Electronic Directly Observed Therapy (eDOT) Device ..12 Appendix D: Health Care Provider Script for Electronic Directly Observed Therapy (eDOT) Real-Time Encounter ..13 Disclaimer of Medical and Legal Advice: The following toolkit is provided for information only. The information does not represent legal or medical advice. Additionally, this toolkit is not an endorsement for the use of eDOT in the treatment of latent TB infection or TB disease.

3 Further studies are required to evaluate the effectiveness of FOR DISEASE CONTROL AND PREVENTION | NATIONAL CENTER FOR HIV/AIDS, VIRAL HEPATITIS, STD, AND TB PREVENTIONIMPLEMENTING AN Electronic Directly Observed Therapy (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMSI. BackgroundBackgroundDirectly Observed Therapy (DOT) is the most effective strategy for ensuring that tuberculosis (TB) patients adhere to treatment . DOT means that a health care worker or another designated person watches the TB patient swallow each dose of the prescribed drugs . However, because DOT can be time and resource intensive, some TB programs have expressed an interest in alternative, cost-efficient methods of delivering DOT for both TB disease and latent TB infection (LTBI).

4 Electronic DOT (eDOT) is an alternative method to in-person DOT in which a patient is remotely Observed (e .g ., over a smartphone) taking his or her TB medication . PurposeThe purpose of this toolkit is to assist TB programs in developing and Implementing a TB eDOT program . There are a wide variety of eDOT programs throughout the United States . These eDOT programs have been designed to meet their respective TB program s patient needs, utilize available resources, and meet management and regulation concerns . Because eDOT programs can be very diverse to accommodate individual TB program needs, this toolkit will provide general information that can be tailored to fit your program needs.

5 AcknowledgementsThe following health departments were instrumental in aiding staff in developing this toolkit . The health departments shared their eDOT knowledge and documents, reviewed draft materials, and provided feedback on what they thought would be helpful to others in starting an eDOT program: Boulder County Public Health, Colorado Clark County Public Health, Washington Kentucky Tuberculosis Prevention and Control Program New York City Department of Health and Mental Hygiene New Jersey Department of Health Public Health Seattle-King County, Washington Snohomish Health District, Washington Tacoma-Pierce County Health Department, Washington Washington State Department of Health2 CENTERS FOR DISEASE CONTROL AND PREVENTION | NATIONAL CENTER FOR HIV/AIDS, VIRAL HEPATITIS, STD, AND TB PREVENTIONIMPLEMENTING AN Electronic Directly Observed Therapy (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMSII.

6 Introduction What is eDOT? eDOT is the use of Electronic technologies to remotely monitor TB patients ingesting their medication, either in real-time or recorded . In addition to eDOT, this type of DOT is sometimes referred to as virtually Observed Therapy (VOT), mobile DOT (mDOT), remote DOT, video DOT (VDOT), and video-enhanced Therapy (VET) . What Technologies Can be Used to Administer eDOT?There are multiple technologies available to administer eDOT . Some patients will use their own personal device, as long the technology is compatible with the health department s technology and patient security and privacy are not compromised . Depending on the resources of the program, the following are some examples of the types of communication devices that can be used: Smartphone Tablet Computer with webcamWith each of these devices, there are a multitude of different software programs that can be used to provide eDOT (please refer to Appendix A for a list of technologies).

7 Additionally, eDOT encounters can either be live or recorded . During a live eDOT visit, the health care worker and the patient schedule a specific day and time to meet virtually, and the health care worker watches the patient take his or her medication in real-time . This allows for the health care worker to ask the patient how he or she is feeling, check the medications before they are taken, ask the patient if he or she is experiencing any side effects, and answer any questions the patient may have . It also allows for the health care worker to continue to build rapport with the patient . In contrast, recorded eDOT is when the health care worker and the patient do not set a specific time to meet, and the patient records himself or herself taking the medications.

8 The patient then saves the recording and sends it to the health department for review . This option may be useful when patient schedules do not align with the health department, and the health care worker is unable to watch the patient live . 3 CENTERS FOR DISEASE CONTROL AND PREVENTION | NATIONAL CENTER FOR HIV/AIDS, VIRAL HEPATITIS, STD, AND TB PREVENTIONIMPLEMENTING AN Electronic Directly Observed Therapy (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMSIs eDOT Right for Your Program and Your TB Patients?There are many considerations when deciding to develop and implement an eDOT program . It should first and foremost be used only when it has been determined that patients health will not be at risk.

9 Benefits of eDOTThe benefits to having an eDOT program include convenience for patients and staff, in addition to reduced staff travel cost and time . It is important to note that eDOT is not a complete replacement for in-person DOT . In other words, it doesn t have to be an all or nothing approach; it may work for some patients, but not all, and it may work for some part of treatment, but not all. Additionally, it is likely that a patient will behave the same whether on eDOT or receiving in-person DOT . If the patient has issues around reliability, honesty, substance abuse, or any other behavior that might interfere with adherence, these behaviors may not change just because he or she switches from an in-person DOT to an eDOT program.

10 Challenges of eDOTM onitoring adverse reactions to TB medications is a major concern when using eDOT . Patients at risk for adverse effects should have clinical evaluations at least monthly to identify possible adverse reactions to medications, assess adherence, and determine treatment efficacy . Patients should be instructed to look for symptoms associated with the most common and most serious reactions to the medications they are taking .Other challenges to using eDOT could be the lost opportunity of building rapport with the patient through in-person visits . Some patients thrive on personal contact and may not be motivated to remain adherent to treatment by eDOT . Building a personal connection with the patient to support treatment completion is vital regardless of the mode of delivering DOT.