Electronic Directly Observed Therapy (eDOT)

Funded by the California Health Care Foundation, CCHP worked in conjunction with the University of California San Diego to help improve the policy and reimbursement environment for the use of telehealth to control tuberculosis and other infectious diseases.

Tuberculosis (TB) is a deadly airborne infectious disease that is spread when an infected person coughs, sneezes or talks close to someone, and requires strict adherence to treatment.  Patients who take their medications inconsistently or stop early are at risk for disease progression and death, transmission of the disease to others, and development of drug resistant strains of the TB bacteria that are much harder and more expensive to treat.

Through “directly observed therapy” (DOT), an individual’s ingestion of medication is observed by a designated person, usually a public health worker or medical professional. The use of DOT for strict adherence of ingestion of TB medication is labor intensive and can be a highly inefficient use of the public health worker’s time and challenging for the infected individual to be accessible every time he or she is taking the medication. Electronic Directly Observed Therapy (eDOT) is an alternative method of delivering DOT for TB treatment. Asynchronous Video Directly Observed Therapy (AVDOT) may offer greater flexibility for both parties while still providing the level of care and maintenance needed for the treatment program. 

CCHP conducted a literature review of published eDOT studies, examined current reimbursement policy, procedures and practices regarding TB management on a state and federal level, and conducted key informant interviews and two surveys (one to attendees at the 2015 Annual California Tuberculosis Control Association (CTCA) conference and the other disseminated online by the National Tuberculosis Control Association (NTCA) in December 2015). In addition, CCHP and UCSD worked collaboratively with the California TB Controllers Association (CTCA) and the California Department of Public Health (CDPH) to develop guidance on using electronic Directly Observed Therapy (eDOT) in California, which were approved in early September 2016.  

 
As a result of the project, CCHP released a White Paper on the use of telehealth for DOT in treating TB entitled “Using Telehealth for Directly Observed Therapy in Treating Tuberculosis”, followed by a final report on the results of the project.

CCHP concluded that eDOT shows great promise in medication adherence and patient acceptance due to the flexibility offered by the technology. Encouraging data on potential cost efficiencies were also noted by making better use of staff time and reducing travel.  Concerns centered on technology failures, privacy and security issues, reimbursement and lack of guidelines or materials for effectively building an eDOT program.  A scan of relevant state and federal laws and policies confirmed an absence of the policy in statutes or regulations that pertained to the use of eDOT in combating TB.  No law or regulation to prohibit the use of telehealth in delivering DOT therapy was found under California law whether via live video or asynchronous video. In-person DOT is reimbursed under the Medi-Cal program as a fee-for-service. However, some Medi-Cal telehealth policies conflict with the opportunity to utilize eDOT and be reimbursed for it, causing some county health departments to hesitate in utilizing the technology. Additionally, existing DOT policies and provisions from the CDC and the US Department of Health and Human Services (HHS) were outdated and did not include technology when discussing DOT procedures. 

To address the barriers to utilizing eDOT in TB patients, CCHP recommended the following: 

National Level

  • CDC Guidelines for DOT should be updated to include the use of eDOT.
  • Guidelines should also be developed that address HIPAA, privacy, security, and confidentiality concerns when utilizing eDOT.
  • There is a need for more studies focused on the use of eDOT on other infectious diseases in addition to TB, such as HIV/AIDS.

California Level

  • Medi-Cal’s list of eligible providers for reimbursement should be expanded to include DOT providers, who most commonly include community health workers and/or public health nurses.
  • Expand Medi-Cal’s list of eligible locations for reimbursement to allow for the home to qualify when a healthcare provider is not present.
  • Medi-Cal and other payers should provide reimbursement for eDOT.

 

To learn more about this project, see CCHP's final report on this project, Challenges and Recommendations on Using Telehealth for Directly Observed Therapy in Treating Tuberculosis, released in September 2016.