Supplemental Information for Video Directly Observed Therapy (vDOT) Recommendations
Key Points
- Video directly observed therapy (vDOT) can help people with TB complete treatment.
- vDOT is a type of electronic DOT (eDOT) that uses a video-enabled device (e.g., smart phone, tablet, computer) to facilitate treatment observation.
- Evidence presented in Recommendations for Use of Video Directly Observed Therapy During Tuberculosis Treatment — United States, 2023 demonstrates that vDOT is associated with a higher proportion of TB medication doses being observed, and similar proportions of cases with treatment completion and microbiologic resolution, when compared with traditional in-person DOT. Based on this evidence, CDC has updated the recommendation for DOT during TB treatment to include vDOT as an equivalent alternative to in-person DOT.
- This webpage provides considerations, concerns, and limitations as supplemental to content published in Recommendations for Use of Video Directly Observed Therapy During Tuberculosis Treatment — United States, 2023.
vDOT can decrease expenses and save time.
TB programs and patients can save money and time with the use of vDOT. 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 that can be requested by TB programs to 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 decreased travel, clinic wait times, need for dependent care, and less time off from work.
vDOT can support treatment adherence and greater patient satisfaction with care.
Video DOT that uses either live (synchronous) or recorded (asynchronous) videos can provide patients greater flexibility and autonomy as they undergo treatment.
- Recorded vDOT can facilitate medication monitoring outside of normal clinic hours, such as on nights, weekends, and holidays. Depending on the software application being used, patients can record their medication ingestion and forward the videos to the TB program when they have internet or Wi-Fi access.
- Live vDOT can facilitate medication monitoring when patients travel.
This flexibility and autonomy may improve patient satisfaction.
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. Recorded video sessions can also be viewed again as needed to verify medication ingestion.
TB programs can implement vDOT as a component of case management in most settings where traditional in-person DOT is used, including for:
- 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
vDOT is not advised if a TB patient, or their daily caregiver, is unable to demonstrate comfort with or proficiency in using the vDOT platform or is unable to communicate effectively. Caution and clinical judgment are advised 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 provide additional assistance and support in treating people with TB disease.
Clinical judgment should be used to individualize DOT to each patient’s clinical status and social, emotional, mental health, environmental, and financial circumstances.
vDOT can begin at the start of outpatient treatment or shortly after outpatient treatment has been initiated.
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 for vDOT
- Regular access to the internet or Wi-Fi
- Plans to change their phone or internet service provider while on vDOT
- A device and current data plan that can accommodate the TB program’s selected vDOT app
- Concerns about paying monthly phone or internet costs related to vDOT
At the start of vDOT, TB programs should provide the patient with training 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, the teach-back method can be used to confirm if patients understand vDOT. If vDOT is initiated after in-person DOT has begun, TB programs may consider offering training on vDOT during in-person DOT sessions.
During educational sessions, it is important to discuss with the patient the circumstances that would lead to the discontinuation of vDOT and switching to in-person DOT.
Additionally, potential out-of-pocket costs related to the patient’s data plan on their personal phone and usage fees should be discussed, as appropriate.
While the patient is receiving TB treatment, incentives and enablers can be used to support adherence to therapy. Incentives are inexpensive rewards given to patients to encourage them 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, reimbursement for internet services). Incentives and enablers should be chosen according to each patient’s needs and are frequently offered along with DOT.
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.
Establishing vDOT Software
TB programs will need to research available vDOT software compatible with their agency’s security needs, as well as allow for the level of privacy needed to secure patient information. Thus, TB programs should work with their IT departments to identify technologies that can be used on health department equipment, and are 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 are the:
- languages that the software can accommodate
- ability for the software to store and forward videos (i.e., perform asynchronous vDOT) if patients are in areas where internet access is weak or intermittent
- compatibility of the software to work with different types of devices and operating systems
Training TB Program Staff
TB programs should develop their own policies and protocols on the use of vDOT, including training requirements for their TB program staff. Training might be needed on:
- vDOT software operations from the perspective of the program and patients
- Troubleshooting the software application
- Troubleshooting common audio and video problems on devices
- Assessing a device’s compatibility with a software application
- Protocols for vDOT sessions
- Patient education on TB and vDOT
- Protecting patient confidentiality
- Working with interpreters
- Case management and vDOT
- Local laws and regulations relevant to vDOT
- Selecting the appropriate DOT method for patients
- Reverting to in-person DOT
- TB medication administration to patients who may require assistance (e.g., infants and small children)
Addressing Potential Difficulties
TB programs implementing vDOT might experience technical challenges while using vDOT software (e.g., 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 also engage their local IT staff and the developers of the vDOT software to proactively address any potential issues.
Patients might also experience difficulties using the vDOT technology (e.g., unable to remember how to use the app, no phone service, low battery). Patient education, educational materials (e.g., brochures with instructions and pictures), and practice vDOT sessions at the start of and during vDOT can help lessen potential difficulties.
As with in-person DOT, TB programs implementing vDOT will need to establish procedures to confirm that the TB 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 TB patient does not adhere to treatment, treatment difficulties can arise (e.g., sputum smear reversions, delayed culture conversions, development of drug-resistant TB).
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 videos stopping immediately after pills are placed in a patient’s mouth, a patient spending time out of camera view or being only partially visible on screen, or a patient covering their mouth while ingesting medications. Potential solutions include watching the patient continuously from the time each pill is given to the time he or she swallows it and asking the patient to show inside their mouth while moving their tongue from side-to-side.
TB programs will also need to ensure that the TB patient can report any concerns or symptoms of side effects that they may have. Examples of side effects include fever, rash, vomiting, nausea, upset stomach, changes in eyesight or hearing, yellow skin or eyes, aching joints.
- Patients using vDOT should be taught which medication side effects should be reported immediately, and how to contact health care workers without delay.
- During live video sessions, staff should inquire about any potential side effects.
- Patients using recorded vDOT should be instructed to report any concerns or symptoms to their health care worker at the start of each recorded vDOT session. If a patient using recorded vDOT does not acknowledge whether they have any health concerns or symptoms, TB program staff should call the patient and ask about any possible problems.
If any symptoms of serious side effects are reported, a new drug supply should not be given; the patient should stop taking medication immediately. The health care worker should arrange for the patient to see their TB clinician as soon as possible.
Reporting vDOT Data
The 2020 Report of Verified Cases of Tuberculosis (RVCT) collects data on the administration of TB medications for all TB patients. vDOT is reported under electronic DOT (eDOT). This is because vDOT is a type of eDOT that uses a video-enabled device (e.g., smart phone, tablet, computer) to facilitate observation of medicine ingestion through a remote interaction between patients and health care workers.
Additional types of eDOT might include other electronic methods to document adherence to a medication regimen (e.g., pill bottles with medication event monitoring systems [MEMS], text message reminders, sensor-embedded pills). CDC did not review or make a recommendation for electronic methods other than vDOT, because video was considered 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.
For information on reimbursement from private insurance companies, TB programs should check with the individual insurance company to determine if they offer reimbursement for vDOT.