Skype Observed Therapy: New Technology for Tuberculosis Control

State: NY Type: Model Practice Year: 2013

Nassau County Department of Health (NCDOH) serves 1.36 million people located east of New York City (NYC). The demographics of Nassau County (NC) have changed considerably in the last ten years according to Census data, with the Asian population increasing by 62%, the black population increasing by 11%, the white population decreasing by 8% and the Hispanic population increasing by 47%. NC is home to immigrants as its proximity to NY’s largest international airport is located seven miles from the border. Twenty percent of Nassau’s population is foreign born (2010 US Census). As described by New York State Department of Health (NYSDOH), tuberculosis (TB) is caused by Mycobacterium tuberculosis (MTB) and is annually responsible for nearly two million deaths worldwide. NYS has the sixth highest incidence rate of TB (4.9/100,000), in particular because of the high rate of TB in NYC. Three metro area counties, Nassau, Suffolk and Westchester report over half of the cases of TB in the state, exclusive of NYC. In 2010, the rate of TB in NC was 3.6/100,000 and the rate of TB in the rest of the state was 2.2/100,000. Seventy-seven percent of NC cases are foreign born, comparable to the percent in NYS including NYC. In 2008, the rate of Hispanics with TB exceeded non-Hispanics (12.0/100,000 compared to 2.3/100,000) and Asians had the highest rates of TB compared to whites and blacks (22.0/100, 00 vs. 3.7/100,000 and 2.3/100,000, respectively). TB is a grave public health threat because of a significant increase in multiple-drug-resistant TB and complication with HIV. Individuals with HIV are more likely to acquire TB and can activate latent TB infection. In order to diminish the spread of TB, active cases must be treated with multiple combinations of antibiotics over the course of six to nine months on a daily basis. To best assure compliance of drug regimen, Directly Observed Therapy (DOT) is considered the standard of care. DOT is an adherence-enhancing strategy in which a health-care worker observes ingestion of each dose of medication. The DOT process is time consuming and costly because it requires transportation to a mutually agreed upon location, typically the patient’s home or workplace. Furthermore, cases in NC have included recent immigrants with nontraditional working hours and settings for example, manual laborers and babysitters, and therefore are either not available during NCDOH hours of operation; or, are not at a suitable location for DOT during those hours. With the difficult work schedules, settings among patients and persistent limited resources within health department, consistent DOT can be challenging to achieve. NCDOH sought to use innovative technology to assist and supplement DOT. The goal was to use Skype to address three objectives: 1) Develop and acquire the technology and capability of the NCDOH to provide Skype Observed Therapy (SOT); 2) Implement remote, confidential and consistent observed therapy by Skype to reduce non-observed therapy; 3) Improve efficiency of staff through decreased cost and decreased travel time. The overall goal of the practice was to maintain vigilant compliance of the drug regimen for the patient’s well being and to protect the public. Initial evaluation indicates that Skype technology is an excellent solution to the challenges described and may be easily replicated in other health departments with adequate guidelines and training. Internet coverage within the community must be strongly considered. SOT was introduced as a pilot program in NC in July of 2012. Prior to its implementation, it was researched, developed, evaluated and modified all with participation and support by NYSDOH. Costs were minimal ($2373) and included onetime purchase of 2 laptop and 3 net book computers ($1918), corresponding protective cases ($155 total), 5 additional webcams with built-in microphones ($140 total) and 4 mobile high speed wireless broadband USB devices, which were free with monthly subscription to mobile broad band service ($40/device/month). Initial outcomes include equipment capacity, SOT guidelines and contracts, high success and cost savings. While these objectives have been met, this practice is still subject to modification as NCDOH continues to learn new lessons. The success of this practice is attributed first and foremost to NCDOH TB Control Staff, both case managers and field staff, who are committed to their patients’ care and follow up, and to their expertise to assess the patients’ clinical status and circumstances. Furthermore, NYSDOH has provided financial and guiding support to this effort.
ResponsivenessThe public health issue the practice addressesAs described by NYSDOH, TB is caused by the bacterium Mycobacterium tuberculosis and is annually responsible for nearly two million deaths worldwide. A third of the world's population is currently infected with the TB bacillus, and more than eight million new cases are diagnosed each year. In NC, 77% of its TB cases are in foreign born individuals where TB is endemic. TB is a grave public health threat because of a significant increase in multiple-drug-resistant TB and complication with Human Immunodeficiency Virus (HIV) and M. tuberculosis infection. Individuals with HIV are more likely to acquire TB and can activate latent TB infection, as well. TB is only treated by on-going, often daily, antibiotic therapy that can last for six to nine months. If the patient does not take his/her medication correctly and consistently, the patient risks relapsing or antibiotic resistance. Multi-drug resistant TB is very difficult to treat and therapy can last up to 24 months. DOT is the standard of care in TB treatment to ensure that patients complete their drug therapy. Most patients will comply with the regimen of treatment once educated about the risks of TB. However, for some patients DOT scheduled appointments may be difficult to keep as work schedules are irregular or not conducive to DOT. For other cases, DOT appointments may be difficult to schedule because health department staff is limited and therefore is limited to travel times. Skype Observed Therapy (SOT) allows remote face-to-face observation of patients’ therapy in lieu of relying upon patients’ recall. The practice of SOT addresses the public health concern of TB spreading in the community. Process used to determine the relevancy of the public health issue to the communityThe process used to determine whether SOT would be relevant to the community required four steps: The first step was to consider the community’s support and investment in its success. The control of any communicable disease is a priority for the community, and its members rely primarily on government to ensure their safety. Efforts to improve efficiency in the control of TB would be embraced by the community, both in prevention of disease and in better use of government resources. The second step was to determine how widely used Skype technology is. According to industry news Skype had 663 million registered users in 2010 compared to 474 million users a year earlier. In 2009, Skype accounted for 12% of the world’s international calling minutes, a 50% increase over 2008 when it accounted for 8% of international calling, according to TeleGeography Research. Therefore, data indicates the growth of Skype as a global method of communication. The majority of TB cases are foreign born and often seek to maintain communication with their home country. The third step was to determine if patients with TB understood the gravity of the disease. Staff spends a large proportion of time educating cases on the seriousness of untreated TB and the importance of maintaining adherence to TB medication. This process is not straightforward, but requires cultural competency and trust to evolve over time. During this time, DOT schedules are agreed upon. For some patients, time is limited because of either the work schedule or setting of the patient or the work schedule and caseload of the DOT staff. Throughout this effort, field staff can assess whether or not the patient understands the critical nature of TB and likewise DOT. The fourth step was to determine if Skype might be an acceptable method to the patients’ circumstances. NCDOH assessed if these cases were technologically savvy or had an aptitude for computer use and might be good candidates for SOT. Staff questioned and surveyed the patient’s home or workspace. When asked about interest in participation with Skype, cases that were deemed candidates were overwhelmingly eager. How the practice addresses the issueResponding to the evolution of technology by seeking a more efficient practice, SOT directly addresses tuberculosis and the adherence to a curative regimen of therapy. SOT as described is not different from DOT in that health department staff can talk to the patient, and then observe the patient ingest his/her medications. The only difference between SOT and DOT is that the health department staff is not in the same room with the patient. Remote DOT is advantageous because it allows unaligned work schedules on the part of the patient and the health department staff to find five minutes to interact. Video chatting is an excellent forum for congenial hellos, updates on the patient’s health and visual and technological connection with the patient. Aside from observing compliance to therapy, SOT allows an efficient time and cost effective use of resources on the part of the health department and patients. On a typical day at the health department, one field staff may visit 10 cases that live a potential of 23 miles from each other. With congested traffic that exists in NC, this mileage can take the entire work day. In some instances, those 10 patients cannot be seen in one day and staff must make phone calls to confirm medication use. Phone calls cannot adequately substitute for a face-to-face meeting. However, SOT can substitute for such limitations. Cost for DOT includes salary spent on travel time as well as cost of mileage. In most cases, performing DOT translates to 75% of field staff salary spent in the car. Skype offers an alternative to the high cost of DOT because staff can perform the same objective for 10 cases, but from one location and in one hour.   Innovation Evidence based strategies used in developing this practiceA review of the literature indicates that DOT therapy has been supplemented by other forms of technology. Telemedicine was shown to be effective in the following studies. DOT via videophone was researched and implemented in Washington State: html, and analyzed for cost-effectiveness: In the five years of videophone use, a total of $139,546 was saved in staff salaries, benefits and travel costs. The average cost savings per patient was $2,448. The studies concluded in positive compliance outcomes as well as obvious proven cost-effectiveness. Mobile phone video transfer was piloted in Kenya with good results: The studies all noted their technologic limitations with respective telecommunication devices as a weakness and anticipated further capabilities for the future. No other documented technology was found in the recent literature review. NCDOH does understand that several other counties in NYS may be considering implementation, but to date, none have. This practice is new to the field of public health Process used to determine that this practice is new to the field of public healthTechnology to achieve directly observed therapy alternatives is not new to public health. However, specifically using SOT to achieve remote real time observation is new as applied in this suburban county. Other agencies have tried to address the issue of reaching target populations who suffer from tuberculosis. Innovative scheduling programs have included overtime staffing requirements and adjusted schedules to provide DOT to patients with scheduling challenges. However, with limited resources this becomes difficult. Other pilot programs have shown that videophone observed DOT was promising, but in reality, came with technical difficulties that can be overcome by Skype technology (see above links). Aside from these three published articles, multiple PUBMed searches using permutations and combinations of terms such as: “tuberculosis” and “technology” and “directly observed therapy” and “video” and “skype”, the NCDOH TB Control could not identify any other programs. See attached literature citations. Certainly, the experience at NCDOH represents the use of innovative technology in a highly populated suburban county with a relatively large population of immigrant cases whose occupations demand nontraditional hours and settings. In addition, conference calls with NYSDOH confirm that SOT is not implemented in other counties to date. How the practice differs from other approaches used to address the issueSOT differs from other approaches because other than DOT, there is no other standard of care considered. DOT is the gold standard. The practice differs from DOT because DOT reflects the old-fashioned public health method whereby nurses and public health sanitarians would visit homes to inspect, investigate, identify and treat communicable disease to household members and their contacts. Skype Observed Therapy retains the face-to-face interaction between health department staff and case to view ingestion of medications as well as retain the personal interactions between health department staff and case to discuss adverse effects or address questions. Skype Observed Therapy allows for a quick meeting each day, and for an observation that can adjust to inconsistent daytime schedules and settings and distant visitations, as well as save staffing costs. Approaches used to address the inefficiency of DOT have included self-administration techniques, such as self-administered flow sheets. Flow sheets are unreliable as patients record their own information about pill consumption. The videophone system is outdated because of the advent of internet video chatting. Historically, videophone-DOT necessitated not only the purchase, but also the installation of a videophone by the health department into the patients’ home. Aside from not being cost-effective, this is considered an antiquated practice with today’s technology. SOT is the most efficient of any non-directly observed therapy techniques as it allows for personable interactions coupled with the presence of internet-capable devices and the nearly universal ease of access to the internet.
Primary StakeholdersThe primary stakeholders are the local health department, boards of health, the state health department, the individuals with active tuberculosis, the medical community and the community at large. LHD roleThe local health department is required for this practice, as it is the local health department which must implement Directly Observed Therapy for its active cases of tuberculosis. DOT occurs each day for up to nine months of therapy. In Nassau County, the health department identified the need for an alternative approach to DOT, and with guidance, developed protocol for implementation. Throughout the process of developing this practice, Nassau County sought the guidance of NYS DOH Tuberculosis Control. Because of NYS DOH’s expertise, Nassau County Health Department benefited from the state’s contribution to the plan and valued its emphasis on issues such as confidentiality and patient care. Nassau County’s Board of Health also provided encouragement to the process and update on its development. This Board includes past Commissioner of Health who herself is an expert in tuberculosis and so her investment in the process was advantageous. The medical community is responsible for the medical management of the patient and treatment regimen. The health providers are invested in the success of SOT implementation. Nevertheless, the partner that is most committed to the success of this program is the patient. He/she must be a reliable participant who meets the criteria for program inclusion. As part of the protocol for Skype, the patient must sign a consent agreement and fully understand the guidelines. But regardless, the patient’s reliability on a continuous basis remains the essential factor in this stakeholder’s role. Otherwise, the patient will lose the opportunity to Skype for DOT. NCDOH has a long history of community collaboration and provides outreach services. In many cases, communities in the county which have high burden of disease also suffer from poor access to health care. The geographic distribution of TB in NC is disproportionately prevalent in these communities as well. NCDOH Tuberculosis Control has endeavored to provide education to faith based institutions in these neighborhoods. Furthermore, Spanish speaking staff to address issues of cultural competency is essential to community collaboration. NCDOH representatives sit on various boards and outreach committees. These organizations provide outreach to the community as well as provide resources to the residents. The Health Department seeks to infuse resources and access to health information often in communities with both high disease burden and concomitant high poverty rates. NC cases of tuberculosis are concentrated in communities of high need, high rates of immigration and where governmental services already exist. Therefore, the familiarity between NCDOH staff and the residents allows for a trustful relationship. While the community collaboration is fostered through these health department programs in sectors of the county at a macro level, the relationship that each field staff has with his or her patient in the community is specific and unique and bares further explanation. NCDOH Tuberculosis Control staff is strongly connected, compassionate and genuinely invested in the improved health of its patients. In some instances, once the staff has established a relationship with the patient and educated him/her on the importance of taking doses correctly, other health and social issues may also be identified. In these cases, patients may ask about additional governmental services that can assist needs. In some instances, the DOT staff is the only individual outside the patient’s family with whom the patient can confide. Therefore, each specific DOT relationship can foster continuance of therapy and likewise the potential to use SOT. The goals with either are the same: adherence to medication therapy and return of patient’s health and improved health of the community at large. Lessons learnedBarriers to collaboration with community members include cultural competency, language differences, distrust of government. To overcome these obstacles, the health department trains its staff in cultural competency. Furthermore, the health department endeavors to pair Spanish speaking TB staff with Spanish speaking TB patients. In some cases with female TB patients, female TB staff was recruited to facilitate the relationship. These specific cultural issues are resolved with SOT similarly as DOT. Specifically with TB, issues of confidentiality must be addressed. With some of our cases, SOT provides a better method of confidentiality. The case does not have to explain a visitation to his/her home, for example if the patient does not want curious neighbors to know what is transpiring. Or, cases may be able to maintain confidentiality in the workplace if he/she can Skype with the health department on a break or during lunch time. To further maintain such confidentiality, the health department has used a pseudonym as a Skype screen name to avoid onlookers or cyber community. While barriers to effective DOT will always exist, they may be circumvented by culturally sensitive personnel who can also employ SOT.   In an effort to build the capacity for the NCDOH to use innovative technology and develop SOT (Objective 1), NCDOH Tuberculosis Control sought approval from NYS DOH to use grant funds to support the purchase of the additional technology. Steps were necessary to ensure that computer and software would be able to have internet capability for Skype. This process was complicated by the fact that this county has firewalls and is connected with the NYS DOH system. Finally, training was provided to staff to use Skype technology. Criteria for patient selection, administrative guidelines were drafted, tested and modified. To implement the practice (Objective 2), the patient must be assessed for Skype use and meet specific criteria clinically, socially and technologically. The patient must be assured confidentiality whether at work or at home. The patient and staff agree upon an appointed time for Skype. The patient must demonstrate with staff that he/she can perform Skype and that there is an adequate internet connection. Within the implementation effort, it is extremely clear that if NCDOH staff finds the patient to be unreliable for any reason (including technical failure), in person DOT will resume. Finally, SOT documentation is completed for each appointment. Specific steps are outlined are below. To achieve Objective 3 to reduce time in the field and cost, NCDOH has incrementally expanded the use of Skype. This effort is done slowly so as to evaluate each case on an individual basis and not capriciously use Skype. However, evaluation of cost and estimation of time saved is made on an ongoing basis. Timeframe:Capacity building for Skype Observed Therapy time frame takes approximately three months, but is variable depending on staff resources. The research necessary to purchase compatible equipment, purchase and receive equipment can take some time depending on fiscal constraints and governmental logistics. Once equipment is in hand, training and practice with Skype must also be conducted with staff. This time frame is thus dependent on numbers of staff who need to be trained and number of trainers. Development of protocol and procedures for Skype was conducted internally with staff and then required submission to the state and follow-up phone calls. Implementation of Skype Observed Therapy is incremental. The time to establish if cases are reliable and understand the gravity of their condition varies. Therefore, specific time constraints cannot be applied. On average, most patients can be well assessed between two and three weeks, but this is not a rigid determination. Once SOT has been implemented, efficiency is maximized. Actual time spent on Skype lasts approximately 5 minutes per case. The travel distance is reduced to zero miles. The analysis for calculating cost and mile differences occurs at the end of each month. Objective 1: Capacity Building for Skype Observed Therapy A. Include equipment in budget proposal B. Identify laptop computers, internet service provider, additional webcams C. Purchase equipment D. Meet with staff on protocol for Skype E. Conference call with NYS DOH regarding protocol and procedures of draft documents Objective 2: Implement Skype Observed Therapy A. DOH: a. Assess patient and setting where Skype will occur b. Assure languagec. Review privacy and confidentiality d. Discuss usage with patient e. Obtain consent f. Schedule time appointment for SOT visit g. Document each SOT visit h. NCDOH will provide microphone and webcam if necessary B. Patients: a. Must be tolerating therapy well and low risk for adverse effects b. Must have a good understanding of their disease c. Must live in a stable environment or must identify a stable location for Skype d. Must be have a computer and reliable access to internet C. SOT will be discontinued if: a. Patient has adverse side effects b. Patient’s clinical situation worsens c. Patient is not reliable or compliant d. There is recurrent technical failure Objective 3: Efficient Use of Time and Cost A. Use SOT when appropriate for Patient B. Use SOT in lieu of telephone calls C. Use SOT in lieu of self-administered documentation of medication D. Use SOT in lieu of not being able to perform DOT NCDOH has learned several methods for improving SOT. In regards to building capacity to perform SOT, NCDOH TB Control learned that firewalls inhibited the use of Skype from desktop, NYSDOH imaged, computers. Lack of Wi-Fi in the building also contributed to the need to purchase laptops, notebooks and mobile broadband USB modems for internet access. This could be used within the health department building and anywhere in the community where 3G coverage was available. NCDOH also learned that the protocol could not be rigidly defined in terms of patient criteria. NCDOH needed the flexibility to assess each patient for as long as needed (not a predetermined time) to make sure the patient was reliable for SOT. Staff training was essential in use of SOT and trouble shooting. Finally, field staff learned where in the community was best for making connections through the 3G network. Where 3G coverage was sparse, libraries and coffee shops where patient confidentiality could be maintained were good candidates for SOT due to their existing free Wi-Fi networks. Cost of implementationBudget for this practice is the following: One time cost of 2 laptops @ $534/each =$1068 One time cost of 3 netbooks @ $284/each = $850 One time cost of cases =$155 One time cost of webcams @$28/each =$140 Monthly cost of 4 mobile high speed wireless broadband USB devices @$40/each =$160 Start Up Cost =$2373 These costs reflect current county contracted costs with Sprint and identification of lowest cost products that meet specifications. In Kind Cost and Funding: NCDOH TB Control staff are paid through NYSDOH grant funding for the purposes of controlling the spread of TB. All equipment was also purchased under the same grant.
The following are the three primary objectives for the overall public health practice goal of maintaining vigilant compliance of the drug regimen for the patient’s well being and to protect the public: 1) Develop and acquire the technology and capability of the NCDOH to provide Skype Observed Therapy (SOT); 2) Implement remote, confidential and consistent observed therapy by Skype to reduce non-observed therapy. Non-observed therapy is patient self report; 3) Improve efficiency of staff through decreased cost and decreased travel time. In assessing the overall value of the identified public health practice, it is important to consider each objective and its respective performance measures, relevant data, evaluation results and ensuing feedback. Objective 1) Develop and acquire the technology and capability of the NCDOH to provide Skype Observed Therapy (SOT). Outcome performance measures for this objective: • Final NYSDOH supported contract between NCDOH and patient for SOT • Final NYSDOH supported administrative guidelines for patient selection of SOT • Final NYSDOH approved budget modification to purchase equipment • Equipment purchased • Imaging of new equipment (computers) by Nassau County information technology staff • 4 staff trained to use technology • Creation of 3 NCDOH skype accounts (1 for each of 2 outreach workers, and 1 for in office) Process performance measures for this objective include: • Budget meetings (conference calls and emails) with NYSDOH for approval of budget modification to purchase equipment • 3 drafts of patient contract to skype submitted to NYSDOH for support with corresponding meetings and emails to discuss drafts • 3 drafts of administrative guidelines for patient selection of SOT submitted to NYSDOH with corresponding meetings and emails to discuss drafts • Internet and in store research of equipment needed to be purchased • 3 meetings with Nassau County IT to finalize equipment selection and corresponding emails • 5 draft purchasing orders submitted • Scheduling Nassau County IT to image 5 computers • Planning staff trainings for each staff member and practice using skype Data for outcome performance measures were collected by the Director of TB control at the NCDOH.Data sources are the following final documents:? Patient Contract of SOT ? Administrative Guidelines for Patient Selection of SOT ? Approved Budget Modification ? Purchase Order ? Packaging slips of equipment received ? 5 imaged computers ? 4 staff members trained to conduct SOT ? 3 active Skype accounts Data for process performance measures were also collected by Director of TB Control. Data sources were in the form of email correspondence with IT and NYSDOH, meeting minutes of meetings with IT and NYSDOH, drafts of documents submitted by NCDOH to NYSDOH and documentation of feedback given, documentation of internet and in store research regarding equipment to be purchased, drafts of purchase orders submitted, packaging slips of purchases received and Skype between TB staff to demonstrate knowledge of use. Evaluation Results: Through this evaluative process, we learned that due to firewalls, we were required to purchase new equipment, not hardwired into our existing County and State Network; so that internet access could come from a cellular mobile broadband subscription. In addition, we learned that comfort with Skype varies among individuals and that hands-on training, practice and demonstration of understanding is essential for staff so that implementation is successful. All implementation activities were achieved and the objective was met. Feedback: Evaluation results were received by the Director of TB Control who made the necessary modifications after consulting with 6 experts from NYSDOH TB Control and 2 Nassau County IT staff members and 1 NCDOH Fiscal manager. Conversation with NYS DOH TB Control led alterations within guideline and contract. Additional lessons learned included collaborating with NYSDOH regarding language in documents. Furthermore, NCDOH learned that additional time should be devoted to the start-up process as unanticipated obstacles occur. Objective 2) Implement remote, confidential and consistent observed therapy by Skype to reduce non-observed therapy. Non-observed therapy is patient self report (telephone, flow sheets, etc.). Outcome performance measures for this objective: • Number of individuals on SOT from inception, June 28, 2012 to September 30, 2012 ? 6 • Percent of cases offered SOT who agreed and signed contract ? 100% (6/6) • Percent of TB cases on SOT ? 4% (1/23) in July ? 13% (3/24) in August ? 19% (5/27) in September • Per patient on SOT (in order of recruitment) percent Skype success and percent non-observed therapy. ? Patient #1 – 86% (12/14) Skype success, 14% (2/14) non-observed therapy ? Patient #2 – 97% (38/39) Skype success, 3% (1/39) non-observed therapy ? Patient #3 – 81% (30/37) Skype success, 19% (7/37) non-observed therapy ? Patient #4 – 86% (6/7) Skype success, 14% (1/7) non-observed therapy ? Patient #5 – 92% (11/12) Skype success, 8% (1/12) non-observed therapy ? Patient #6 – 56% (5/9) Skype success, 44% (4/9) non-observed therapy Patient #6 is a child whose primary care giver was not able to participate in any form of direct therapy for cultural reasons. Initially, there was a problem scheduling observed therapy at a time in which the other care giver was present to administer medication. SOT allowed more flexibility in scheduling, therefore increased overall success. Data for outcome performance measures were collected primarily by field staff responsible for DOT, who now also conducts SOT. In cases of absence, other TB Control staff members covering SOT collected data. The primary data source was an internal access database used to track patient drug regiment and DOT schedule. This database provides a daily account on all DOT, including success, failure, and failure reason. Data is entered by DOT worker on a daily basis. Evaluation Results: Of those patients that were deemed good candidates for SOT (reliable, tech savvy, difficult daily schedule, etc.), all were eager to participate and willingly signed contract. It is apparent that given the option, people are open to this technology and are excited to partake. Our evaluation also revealed that SOT is effective and efficient in reducing lost opportunities for observed therapy. As apparent by patient #6, SOT does not mitigate all potential scheduling conflicts. It does, however allow for more flexibility in scheduling, as it does not need to be on a set daily schedule and does not require the advanced coordination as is true of DOT. Therefore, activities to support objective were achieved and the objective was met. Feedback Evaluation results were received by the Director of TB Control at NCDOH and shared with NYSDOH. More real-time training was required by staff to learn to troubleshoot technical issues, such as video and microphone failure. These lessons were then incorporated into continuous training efforts. Objective 3) Improve efficiency of staff through decreased cost and decreased travel time. Outcome performance measures for this objective: • Savings in cost of mileage from June 29, 2012 to September 28, 2012 – (total $1061.78) ? Patient #1 – 13.69 miles round trip x 12 days SOT x $.55 = $90.35 ? Patient #2 – 17.07 miles round trip x 38 days SOT x $.55 = $356.76 ? Patient #3 – 25.81 miles round trip x 30 days SOT x $.55 = $425.87 ? Patient #4 – 26.88 miles round trip x 6 days SOT x $.55 = $88.70 ? Patient #5 – 7.39 miles round trip x 11 days SOT x $.55 = $44.71 ? Patient #6 – 20.14 miles round trip x 5 days SOT x $.55 = $55.39 • Savings in staff travel time – (total 63 hours) ? Patient #1 – 39 minutes round trip x 12 days SOT ÷ 60 = 7.8 hours ? Patient #2 – 36 minutes round trip x 38 days SOT ÷ 60 = 22.8 hours ? Patient #3 – 40 minutes round trip x 30 days SOT ÷ 60 = 20 hours ? Patient #4 – 52 minutes round trip x 6 days SOT ÷ 60 = 5.2 hours ? Patient #5 – 20 minutes round trip x 11 days SOT ÷ 60 = 3.7 hours ? Patient #6 – 41 minutes round trip x 5 days SOT ÷ 60 = 3.4 hours Similar to Objective 2, the primary data source for these outcome performance measures was the internal access database used to track patient drug regimen and DOT schedule. Again this data is entered by the DOT worker on a daily basis or other TB Control staff members in cases of absence. TB Control staff epidemiologist used Mapquest to calculate round trip mileage between patient home address and NCDOH. Round trip travel time was calculated in the same way. These estimates do not account for additional time spent in traffic or face-to-face visit time of DOT. Therefore, these numbers are an underestimate of time and money saved. The per-mile amount of $.55 is the County reimbursement rate. Evaluation results: NCDOH TB Control Program learned that SOT is a highly cost-effective and efficient means of conducting observed therapy. Implementation of SOT has been highly successful and we continue to expand SOT activities. The start-up costs and monthly subscription to mobile broadband service will pay for itself within two to four months depending on patient recruitment. The amount of staff time that was saved is equivalent to nine 7-hour work days. In that additional time, staff can address additional responsibilities such as follow up on contacts and cases more timely as well as attend to data entry more efficiently. We have been 100% successful in meeting our goal to improve efficiency of staff through decreased cost and decreased travel time. Feedback: Evaluation results were received by NCDOH Director of TB Control and shared with the Commissioner of Health. Results of this objective were extremely favorable. Therefore, on a case to case evaluation, the practice will be expanded to include more TB patients. There are no plans to further modify practice at this time.  
Stakeholder CommitmentThe community at large is committed to decrease the spread of tuberculosis, for personal as well as public health reasons. Clearly, no one wants to get infected with tuberculosis. Furthermore, in the current economic climate, the resident tax payer will support cost savings that do not sacrifice community health; but actually improve it. The patients are eager to use SOT as an alternative to DOT when their schedules are unsuitable. They appreciate the flexibility in use and the time it saves from their perspectives. NCDOH TB staff and resources are limited. Therefore, staff is committed to this process as long as patient reliability and confidentiality remains. Staff, then has time to conduct additional contact investigations, keep data entry up to date and continue to review cases’ progress timely. Furthermore, SOT may be applicable for individuals with latent TB infection (LTBI). Currently, NCDOH does not conduct DOT for such non-contagious contacts. But with this innovation, it may be included in the future. If LTBI therapy can be observed, perhaps one day, TB can be eradicated. NC Board of Health supports the concomitant cost and time savings along with the endeavor to find new ways to diminish disease in the community. Doctors and clinic staff who see patients on SOT are assured that these patients have taken their medications. Patient management becomes more efficient and less uncertain regarding adherence to their prescribed regimen. And finally, NYSDOH continued support and communication is steadfast as apparent from its genuine effort to improve patients’ health and protect the public. NYSDOH will foster efforts to improve adherence of therapy as long as NCDOH meets grant deliverables, and work plans reflect necessary steps to diminish the spread of TB. The sustainability of SOT is self-propagating. SustainabilityPlans to sustain SOT are clear and comprehensive. It includes meeting deliverables and fulfilling the work plan to receive support from NYDOH. NYSDOH will support new technologies to achieve diminished disease in the community as long as patients’ care and the public’s health remain paramount. SOT can fulfill DOT alternatives such as patient self administered flow sheets of medication therapy. Locally, NCDOH is committed to the small cost of $40/device/month. The savings in time and cost clearly outweigh the program’s expense in mobile broadband USBs. As long as internet coverage is available, this program can continue and expand. Furthermore, NCDOH continues to evaluate and test quality of program on a monthly basis. This includes review of compliance of SOT and review of cases’ progress. NCDOH includes technical training of SOT on consistent bases as an important aspect to planning. Training on patient assessment must also be reviewed monthly and with each individual case. Once a patient fits criteria and administrative guidelines are followed, SOT is simple to conduct. Ease of use further enables its sustainability over time. With the support of the staff and patient along with doctors and governing entities, SOT may be the future standard of care across multiple local health jurisdictions. It fulfills observational therapy; it maintains continuity of care; it is confidential; it is convenient to the patient’s schedule; it saves money; it saves time; it is ecologically superior; it is a model practice for now and the future.