Using Mobile Phones to Monitor and Improve Adherence to Tuberculosis Medications In collaboration with: Central TB Division

Topics Covered What is 99DOTS Features and Benefits of 99DOTS Benefit to Patient Benefit to Field Staff Benefit to District Supervisors 99DOTS Workflow in TB only patients 99DOTS Dashboard Workflow

Goal: to provide 99% of the benefits of DOTS at a fraction of the cost and inconvenience to patients Anti-TB drugs are wrapped in envelopes which are printed with hidden numbers behind the pills When patients dispense a dose, they reveal a hidden TOLL FREE number which they call This call gets reflected on the 99DOTS dashboard and the 99DOTS Android Mobile App immediately as a taken dose

99DOTS: Accurate Monitoring at Very Low Cost

How can the Patient data be accessed? Different ways of accessing the patient data – Web dashboard (www.99dots.org) Every center will be given their own login ID and Password to access their patients Different logins for ART center, DTC and field staff (with limited permissions) Mobile app (For Android phones) Most of the functions that you can do on the Web dashboard can be done through the mobile app SMS Alerts for Staff and Treatment Supporters to take immediate action

Calendar View of Adherence

New patient (740XXXXXX) enrolled, Yelahanka district SMS Alerts from 99DOTS Reminders to Patients Alerts to Staff [0000] Two of your patients have missed doses SMS Message: SMS Message: [0000] Please Two of your take pills Please patients have missed doses today: Raj & take pills Om Raj (979XXXXXX) & Om (812XXXXXX) Notification of new patients Analytics and Reports for Program New patient (740XXXXXX) enrolled, Yelahanka district SMS Message: [0000] Please take pills

Features of 99DOTS Calls are completely free for patients Calls can be made even when the patient has no pre paid balance or the mobile is in roaming area Any call from a registered patient number is marked as a dose taken (personal, shared, land line) Numbers are not unique, but appear in an unpredictable sequence – ensures pill-in-hand adherence When patients call, they hear “Thank you” Calls immediately show up in the dashboard as taken doses Automatic alerts and reminders to patients and supervisors for non-adherent patients Adherence records available to field staff, medical officers, district staff and all other stakeholders in the program Two of your patients have missed doses Raj (979XXXXXX) & Om (812XXXXXX) SMS Message: today: Raj & Om

Field Staff/Supervisors Benefits of 99DOTS Less travel Increased convenience Patients Focused and more efficient care Field Staff/Supervisors Easy monitoring Accurate reports Program Officers

99DOTS Workflow for TB only patients

99DOTS: Workflow - Summary Patient’s sputum is sent for testing Medical evaluation for evidence of TB Patient visits TU with symptoms of TB Cough, Fever, Night sweats, Weight loss Continuous monitoring and follow up by RNTCP staff Patient registered on 99DOTS website and counseled on adherence Patient identified positive for TB

TB Medication Regimen Most patients undergo treatment for 6 months FDC Intensive Phase (IP): 2 months (Isoniazid, Rifampicin, Ethambutol, and Pyrazidamide) – 4FDC Continuation Phase (CP): 4 months (Isoniazid, Rifampicin, and Ethambutol) – 3FDC FDC Pills/Day based on weight band Daily regime – easy with FDC If patient takes full course, near certain-cure After 2-3 weeks: feeling better After 6 months: negligible chance of relapse/resistance 4FDC 3 FDC

Does not receive FDCs or 99DOTS FDC Drugs by Weight WEIGHT CLASS # OF PILLS # STRIPS FOR 28 DAYS < 25 kgs Does not receive FDCs or 99DOTS 30 – 39 kgs 2 pills per day 2 40 – 54 kgs 3 pills per day 3 55 – 70 kgs 4 pills per day 4 > 70 kgs 5 pills per day 5 FDCs wrapped in custom 99DOTS envelopes based on weight (diagrams to follow)

99DOTS Envelopes – Weight Band Wise Envelope features Background color for weight band Label color for IP/CP Call symbol to assist pills / day Direction arrows to assist order for dosing 3 and 5 pills / day overlap blisters 2 pills / day 3 pills / day 4 pills / day 5 pills / day

99DOTS Envelopes – Universal Each patient gets the same sleeve, regardless of weight band Counselor/pharmacist should write number of pills/day patient should take on the envelope Every day, a patient will take prescribed number of pills and reveal 1, 2, or 3 hidden phone numbers Patient should call any one they reveal that day Patient should start at pill 1 and move in sequence (1,2,3…28), completing each column, and starting from the top at each row

Patient counseling of 99DOTS Explain 99DOTS, and importance of adherence (how many pills, every day, make free call) 6 months medication Call is free, even without balance and can be done free even when roaming Patient should follow path of pills Patient should come back every 28 days when pills are finished If patient has phone, administer first dose and make first call

Patient monitoring by RNTCP Login to 99dots.org or 99DOTS Mobile app to see patient adherence/notes Follow up with patients with low adherence Respond to SMS alerts, and 99DOTS requests to follow up with patients DOTS+ Supervisor/RNTCP team to review adherence at regular meetings Add notes on patient behavior to log follow ups

99DOTS Website and App Workflow NOTE: For detailed information on how to use the 99DOTS Website or the 99DOTS Mobile app to perform various tasks, see the respective guides available on the Training Materials page. https://www.99dots.org/Info

Snapshots of 99DOTS Website Dashboard

Snapshots of 99DOTS Mobile App

99DOTS Dashboard Workflow Step 1 Maintain Staff Details at District and TU level using the Staff Details menu in the 99DOTS Website and also configure alert frequency for the staff to receive SMS alerts Step 2 Register Patient using the Add Patient menu in the 99DOTS Website Step 3 Link TU staff to some or all patients of the TU using the Staff Details menu in the 99DOTS Website. Step 4 Monitor patients for adherence using the Calendar menu in the 99DOTS website. Add Notes/Tags after interacting with patients, and perform various patient management tasks from the patient details page.

99DOTS Dashboard Workflow STEP 1: Staff Details STEP 2: Add Patient Add District and TU staff details. These staff will get SMS alerts for patients listed under their district and Tus TUs based on the alert frequency configured in this step. Register Patient on 99DOTS. When registering patient, select the correct District and TU to which the patient belongs. STEP 5: Patient Management STEP 4: : Link Patients to TU Staff S Perform various on-going patient management tasks such as: Edit Patient Details, Edit Attention Required, Adding Notes and Tags, Editing Treatment Center, Marking Manual Dosage, Closing and Reopening a Case, Downloading Treatment Cards, Reports From the Staff Details menu, link patients of a particular TU to the respective TU staff. TU staff can be linked to all patients of the TU or some patients of the TU. The TU staff will get SMS alerts for the patients they have been linked in this step.

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