The Guam Department of Public Health and Social Services has to cope with a very serious tuberculosis problem.

THE PROBLEM
Guam has an extremely high rate of TB: In 2017, the case rate of TB in Guam was 50.2 per 100,000 residents, compared to the mainland U.S. rate of 2.8 per 100,000 residents.

Directly observed therapy, or DOT, is the practice of watching a patient take every dose of medication. It is endorsed by the U.S. Centers for Disease Control and Prevention and is the standard of care for TB treatment in the United States. Patients with TB were having to receive their medication via daily visit to or through an in-home visit from the health department.

In Guam, concerns of both staff safety and stigma have previously limited directly observed therapy's success in the region.

"Guam also is no stranger to the effects of some of nature's most destructive forces, including earthquakes and typhoons; during these disasters, TB patients are given medicine doses to self-administer because traditional directly observed therapy becomes a challenge due to the risk involved in having community health aides going out to administer traditional DOT during these natural disasters," explained Chima Mbakwem, tuberculosis/Hansen Disease Control Program manager, bureau of communicable disease control, Guam Department of Public Health and Social Services.

Guam also has a huge number of non-U.S.-born citizens on TB treatment who travel back and forth to their original countries of birth, and there is need to monitor treatment when they are off island.

PROPOSAL
To help overcome the challenges it faced with directly observed therapy, the Guam Department of Public Health and Social Services turned to a healthcare technology from emocha Mobile Health.

"Patients use emocha, a HIPAA-compliant mobile application, on their smartphone to video record themselves taking their medication, report side effects and receive medication reminders," Mbakwem said. "They have access to two-way, HIPAA-secure messaging to communicate with their healthcare provider. DPHSS healthcare workers can assess the data collected on the secure emocha web portal, engage directly with their patients, and intervene swiftly in the event of reported symptoms, side effects or medication non-adherence."

MARKETPLACE
There are many vendors on the market today offering telemedicine technology, including American Well, Avizia, GlobalMed, MDLive, Novotalk, SnapMD, Teladoc, TeleHealth Services and Tellus.

MEETING THE CHALLENGE
The community health aides in the TB program monitor the patient ingesting their TB medicine to ensure adherence by reviewing videos submitted by patients who use the technology.

The asynchronous technology provided by emocha empowers the patient to use self-administered therapy for TB treatment in those extreme weather conditions. And it made it easy to monitor patients on treatment who travel off island to ensure adherence to treatment. There is also cost savings in staff time, gas and drive time around the island.

"DPHSS healthcare workers can assess the data collected on the secure emocha web portal, engage directly with their patients, and intervene swiftly in the event of reported symptoms, side effects or medication non-adherence."

Chima Mbakwem, Guam Department of Public Health and Social Services

"Patients who are confirmed to be infected with TB are offered the option of using the vDOT, Traditional DOT or In-house DOT where they have to visit the Public Health Clinic daily to ingest their medication," Mbakwem explained. "The vDOT option is most popular due to feedback from patients by a survey administered by the program and the increased adherence by patients on vDOT."

RESULTS
Patients were enrolled in emocha using a list of comprehensive criteria, ranging from two weeks of previously completed in-person DOT to an understanding of the need for TB treatment. Confirmed doses were calculated based on the number of accepted videos during this period; staff time, gas and total cumulative amount of driving time saved were additionally calculated.

"Between August 2018 and January 2019, the program fostered a series of successes," Mbakwem said. "The implementation of asynchronous video DOT not only increased staff capacity to perform DOT under constraints while maintaining high medication adherence and patient satisfaction, but also generated significant cost savings."

The program has served as a model for other initiatives in the region, and demonstrated how the technology can potentially help with other conditions on the island, such as diabetes, Mbakwem added.

Hard results include:

• 1,417 confirmed medication doses from 35 unique patients.
• $21,255 in staff time savings.
• $3,457 in savings from gasoline.
• 700 hours of saved driving time.

ADVICE FOR OTHERS
"Due to the availability of smartphone technology and the cost savings involved in the use of vDOT, I would suggest that healthcare provider organizations consider using such technology to reduce costs, enhance patient care, serve the people in remote locations and also consider the fact that patients will have complete control over their treatment outcome with little or no interference," Mbakwem advised.