Smartphone technology has given San Diego County health officials a less invasive way to monitor the treatment of tuberculosis patients.
Through a partnership with the University of California, San Diego (UCSD) and Verizon, the county is distributing a number of smartphones to TB patients. The users record themselves taking their daily prescriptions and then wirelessly transmit the videos to the county for review.
Called Video Directly Observed Therapy (VDOT), the program has been around for a few years. The first smartphones were introduced to the program in 2010, giving patients the ability to take their medicine and record video at their convenience. That ended a couple of years ago. A recent grant from Verizon has funded a new trial of the program, which includes various improvements to the system.
The system’s backend architecture has been upgraded so that multiple health departments can feed information into the same database. The new version also has expanded data fields for health workers watching the videos and the program now works on multiple types of Android-based smartphones.
County workers have in the past have used landline-based phones and still photos to evaluate patient TB treatment. That evaluation method, along with in-home visits continues, but requires patients to take their medication on the schedule of health officials, normally during business hours.
According to experts, while TB patients are not required to be observed taking their medicine, poor overall compliance with lengthy, year-long treatment regimens has led to observation being recommended. Patients typically need to take from six to 12 pills per day, some of which produce unwelcome side effects, including upset stomach.
Kathy Moser, director of the TB and refugee health branch in San Diego County, felt the flexibility of smartphone video as opposed to real-time phone conversations and pictures or in-home visits has been a benefit for both staff and patients.
“Patients feel like someone isn’t watching them and no one is coming to their homes, so it’s had that advantage,” Moser said of the VDOT system. “And our staff like it, especially for people who live quite some distance away. We’re a big county, so if you have someone in the furthest reaches, it’s quite a bit of travel time.”
The VDOT system was created by Richard Garfein, a professor with the Department of Medicine at UCSD and developers from Calit2, a research and development arm of the university.
The initial development work on the VDOT smartphone system was funded through a $275,000 NIH grant. The smartphone app and backend programming took approximately six months to develop, but the entire process took about two years. It was pilot tested from 2010-2011 with 43 patients in San Diego County and nine in Tijuana, Mexico.
Garfein said he got the idea of using smartphones from observing Washington State and San Diego’s nine-month pilot study involving 33 patients in 2004. That pilot used landline phones and photos to evaluate patients. Garfein noted that governments were able to save approximately 28,000 miles of transportation and 800 hours of manpower during the study, which translated to about $25,000 in savings.
At first Garfein wanted to continue doing live interactions with patients, envisioning the use of Skype or other real-time video. But there were a number of advantages to using recorded video as opposed to live video.
“One, patients can take their medications at any time and two, if the phone is out of cellular or Wi-Fi range, the video can still be made and stored in the phone until it encounters a signal,” Garfein said. “Then the video will automatically be uploaded to our secure server.”
For security purposes, if a patient records a video and is out of communication range, it’s stored on the phone until a signal is detected. Once connectivity is established and the video is transmitted, it is deleted off the patient’s phone. In addition, health workers are permitted to stream patient videos off a secure server, but the system doesn’t allow them to download it to their computer.
Smartphones for the new trial period are now being distributed to patients. Verizon awarded the program a $300,000 grant in addition to phones and cloud computing service valued at approximately $2.5 million. The trial will run until Sept. 30, 2014.
In the future, Garfein wants to deploy the VDOT system as “widely as possible,” to health departments throughout the United States. He added that the development team is also working with University College London in England on a project to see if VDOT can work with patients that are difficult to track, such as homeless people.
Garfein envisions VDOT having two parts in the future.
“One component would be utilization as a service for health departments in the U.S. and abroad,” he said. “The other would be a research component or components that are [also] designed to see if we can improve adherence to treatment by adding motivators or different types of reminder systems to help the patient to remember to take their pills.”
In addition, Garfein said he’d also like to make the app available for use on personal smartphones. Right now, it’s restricted to just program-provided phones.
While the technology may seem like a no-brainer for both patients and county health officials, a number of obstacles had to be overcome — and need to be hurdled in the future as well — for the system to really take root in San Diego County permanently.
Moser explained that some people just aren’t technology-savvy and aren't interested in using technology. In addition, because patients are often required to stay at home in the early stages of treatment, they prefer daily contact with someone.
Another hurdle could be future funding. Garfein is using the current trial to estimate the costs of maintaining the program without grant money. Moser added that as far as she knows, insurance companies aren’t reimbursing for VDOT services. So while the county saves travel and staff time using VDOT, if the IT cost ends up being higher, some decisions will have to be made.
“Certainly health departments will need to decide whether they can finally take on this technology,” Moser said. “Technology has a way of creeping up in cost at times. There’s maintenance, phones, service and we’re just going to have to sort of go down the road and hopefully it will be cost-effective.”