National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 

Division of Tuberculosis Elimination

Implementing an Electronic Directly 

Observed Therapy (eDOT) Program: 

A Toolkit for Tuberculosis (TB) Programs
Contents

I. Background. 

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

II. Introduction. 

What is eDOT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

What Technologies Can be Used to Administer eDOT? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Is eDOT Right for Your Program and Your TB Patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Benefits of eDOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Challenges of eDOT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Security and Patient Privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

III. Preparing for Implementation. 

Convene an eDOT workgroup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Identify resources and technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Develop eDOT policies and protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Train staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

IV. Implementation. 

V. Monitoring and evaluation. 

VI. Appendices. 

Appendix A: Technology Options for 

Electronic Directly Observed Therapy (eDOT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Appendix B: Patient Electronic Directly 

Observed Therapy (eDOT) Agreement Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Appendix C: Loaner Agreement for Electronic 

Directly Observed Therapy (eDOT) Device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Appendix D: Health Care Provider Script for 

Electronic Directly Observed Therapy (eDOT) Real-Time Encounter . . . . . . . . . . . . . . . . . . . 13

Disclaimer of Medical and Legal Advice: The following toolkit is provided for information 

only. The information does not represent legal or medical advice. Additionally, this toolkit 

is not an endorsement for the use of eDOT in the treatment of latent TB infection or TB 

disease. Further studies are required to evaluate the effectiveness of eDOT.
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

I. Background

Background

Directly observed therapy (DOT) is the most effective strategy for ensuring that tuberculosis (TB) 

patients adhere to treatment. DOT means that a health care worker or another designated person

watches the TB patient swallow each dose of the prescribed drugs. However, because DOT can

be time and resource intensive, some TB programs have expressed an interest in alternative, costefficient methods of delivering DOT for both TB disease and latent TB infection (LTBI). Electronic

DOT (eDOT) is an alternative method to in-person DOT in which a patient is remotely observed 

(e.g., over a smartphone) taking his or her TB medicati

Purpose

The purpose of this toolkit is to assist TB programs in developing and implementing a TB eDOT 

program. There are a wide variety of eDOT programs throughout the United States. These eDO

programs have been designed to meet their respective TB program’s patient needs, utilize available 

resources, and meet management and regulation concerns. Because eDOT programs can be very

diverse to accommodate individual TB program needs, this toolkit will provide general information 

that can be tailored to fit your program needs

Acknowledgements

The following health departments were instrumental in aiding staff in developing this toolkit. The

health departments shared their eDOT knowledge and documents, reviewed draft materials, and 

provided feedback on what they thought would be helpful to others in starting an eDOT program:

 Boulder County Public Health, Colorado 

 Clark County Public Health, Washington

 Kentucky Tuberculosis Prevention and Control Program

 New York City Department of Health and Mental Hygiene 

 New Jersey Department of Health

 Public Health Seattle-King County, Washington

 Snohomish Health District, Washington

 Tacoma-Pierce County Health Department, Washington

 Washington State Department of Health
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

II. Introduction 

What is eDOT? 

eDOT is the use of electronic technologies to remotely monitor TB patients ingesting their 

medication, either in real-time or recorded. In addition to eDOT, this type of DOT is sometimes

referred to as virtually observed therapy (VOT), mobile DOT (mDOT), remote DOT, video DOT 

(VDOT), and video-enhanced therapy (VET)

What Technologies Can be Used to Administer eDOT?

There are multiple technologies available to administer eDOT. Some patients will use their own

personal device, as long the technology is compatible with the health department’s technology and 

patient security and privacy are not compromised

Depending on the resources of the program, the following are some examples of the types of 

communication devices that can be used:

 Smartphone

 Tablet

 Computer with webcam

With each of these devices, there are a multitude of different software programs that can be 

used to provide eDOT (please refer to Appendix A for a list of technologies). Additionally, eDOT

encounters can either be live or recorded. During a live eDOT visit, the health care worker and

the patient schedule a specific day and time to meet virtually, and the health care worker watches 

the patient take his or her medication in real-time. This allows for the health care worker to ask

the patient how he or she is feeling, check the medications before they are taken, ask the patient 

if he or she is experiencing any side effects, and answer any questions the patient may have. It

also allows for the health care worker to continue to build rapport with the patient. In contrast,

recorded eDOT is when the health care worker and the patient do not set a specific time to meet, 

and the patient records himself or herself taking the medications. The patient then saves the

recording and sends it to the health department for review. This option may be useful when patient

schedules do not align with the health department, and the health care worker is unable to watch 

the patient live
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

Is eDOT Right for Your Program and Your TB Patients?

There are many considerations when deciding to develop and implement an eDOT program. It

should first and foremost be used only when it has been determined that patients’ health will not 

be at risk

Benefits of eDOT

The benefits to having an eDOT program include convenience for patients and staff, in addition to 

reduced staff travel cost and time. It is important to note that eDOT is not a complete replacement

for in-person DOT. In other words, it doesn’t have to be an all or nothing approach; it may work

for some patients, but not all, and it may work for some part of treatment, but not all. Additionally, 

it is likely that a patient will behave the same whether on eDOT or receiving in-person DOT. If the

patient has issues around reliability, honesty, substance abuse, or any other behavior that might 

interfere with adherence, these behaviors may not change just because he or she switches from an 

in-person DOT to an eDOT program.

Challenges of eDOT

Monitoring adverse reactions to TB medications is a major concern when using eDOT. Patients at

risk for adverse effects should have clinical evaluations at least monthly to identify possible adverse 

reactions to medications, assess adherence, and determine treatment efficacy. Patients should be

instructed to look for symptoms associated with the most common and most serious reactions to 

the medications they are taking

Other challenges to using eDOT could be the lost opportunity of building rapport with the patient 

through in-person visits. Some patients thrive on personal contact and may not be motivated to

remain adherent to treatment by eDOT. Building a personal connection with the patient to support

treatment completion is vital regardless of the mode of delivering DOT

Security and Patient Privacy

Security and the protection of a patient’s privacy are of paramount importance when using 

eDOT. There are legal, ethical, and moral issues at stake when patients transmit private health

data, either in real-time or recorded. For information about the legal permissibility of eDOT, TB

programs may want to refer to The Network for Public Health Law, which conducted an analysis 

of the legal permissibility of eDOT in several states: www.networkforphl.org/the_networ

blog/2015/01/21/538/video_directly_observed_therapy_for_tuberculosis_legal_and_practical_issues

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides national 

standards for protecting the privacy of health information. The Privacy Rule regulates how

organizations and health care workers use and disclose certain individually identifiable health 

information. Health departments should be well aware of HIPAA requirements. Because eDOT i

a relatively new method of health care delivery, there are aspects of it that may not have been 

considered when HIPAA was passed. Having both an information technology (IT) representative

and a legal representative on your workgroup (see workgroup information below) is crucial in 

understanding both the state and federal laws that will govern your choice to implement your own 

eDOT program
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

III. Preparing for Implementation

To implement an eDOT program, it can be helpful to follow the steps below:

1. Convene an eDOT workgroup 

2. Identify resources and technologies

3. Develop eDOT policies and protocols

4. Train staff 

1. Convene an eDOT Workgroup

One of the first steps to starting an eDOT program is to establish an eDOT workgroup with 

representatives from the health department’s IT, clinical, legal, outreach, and training and 

education staff. Representatives should have decision-making authority to enhance the ability

of the workgroup to develop and implement the program. Having representatives from all the

departments involved creates a sense of ownership, provides an opportunity to problem solve, and 

increases the chance for success

2. Identify Resources and Technologies

While trying to establish an eDOT program, TB programs will need to research available 

technologies that are compatible with their agency’s security needs, as well as allow for the level 

of privacy needed to secure patient information. Thus, TB programs should work with their IT

departments to identify technologies that can both be used on health department equipment, as 

well as technologies that are HIPAA compliant

When researching technologies, the following factors may be useful to consider:

 Is the technology HIPAA compliant?

 What type of communication device is needed (e.g., can the technology be used o

a phone, computer, or tablet?)

 How much are the initial costs of the software?

 How much are the annual costs (e.g., licensing

 What are the IT requirements (e.g., bandwidth, data

 How easy is the program to use?

Additionally, health departments will need to determine what type of communication device to use 

with the eDOT program, as well as who will supply the device. For example, health departments

will need to determine whether patients can use their own devices or whether the health 

department will provide a device to the patient. If the health department provides one, they

should consider having the patient sign a loan agreement form which explains their responsibilities 

for the general care and security of the device, as well as how the patient may or may not use it 

for their own personal use (sample patient agreement forms are provided in Appendices B and C)

In contrast, if the patient is allowed to use his or her own device, the health department may need 

to explain to patients that the health department will not cover excess data charges as a result of 

participation in eDOT, or they may want to provide a small monetary incentive to cover any 

excess charges
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

3. Develop eDOT policies and protocols 

Health departments should develop their own policies and protocols on the use of eDOT with their 

TB patients. The eDOT policy should be written to reflect the health department’s philosophy on

the use of eDOT. Below is a sample policy statement

The state will offer electronic directly observed therapy (eDOT) to patients receiving treatment 

for suspected or confirmed TB disease who meet enrollment criteria. eDOT is an alternative 

method of ensuring that patients adhere to treatment. Patients may choose in-person DOT, 

eDOT, or a combination. Continued participation in the eDOT program will depend on 

adherence and monthly medical follow-up visits. 

Below are some samples of patient criteria used by other health departments

Examples of inclusion criteria

 Stabilized on treatment for at least 

2 weeks and noninfectious 

 Motivated patient (as determined by 

case manager) 

 Demonstrated adherence to treatment 

 English speaking or ability to 

effectively communicate with the 

health care worker 

 Drug-susceptible disease 

 Converted sputum smear and culture 

to negative 

 No current alcohol or drug use 

 Managing physician accepts the 

eDOT approach 

 Proficiency in using a smartphone 

or other technology

 Able to accurately identify each 

medication

Examples of exclusion criteria

 Infectious patients 

 Adherence issues 

 Language barriers 

 Multidrug-resistance 

 Minors without accompanying adult 

 Immunocompromised 

 Patient experiences adverse reactions 

 Patients at risk for hepatic 

complications while receiving 

anti-TB medications 

 Patients with disabilities that prevent 

full participation in eDOT such as 

hearing or vision disabilities, or 

physically challenged 

Additionally, health departments will need to determine where and when their staff can administer 

eDOT encounters. For example, will staff only provide eDOT during regular business hours while

at the office, or can staff provide eDOT outside of regular business hours? To make this decision, 

health departments should consider the privacy of patients. During eDOT encounters, staff need to

be aware of his or her surroundings. For example, during eDOT encounters, other people should

not be able to hear the patient’s voice coming through the speaker or see the patient’s face on the 

screen. To help maintain privacy, headphones should be worn and encounters should be done in

a place that allows for privacy. Some locations have set up privacy screens to hide the computer

monitors from others
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

4. Train Staff

Staff should be trained on how to use the technology, as well as how to conduct an eDOT 

encounter

The following steps outline the general real-time eDOT process: 

 Prior to each eDOT visit, the health care worker should review the patient information (e.g.

chart, medications, notes, appointment date and times)

 Contact the patient at the specified time (See Appendix D for a sample script for a real-time 

eDOT encounter)

 Ask the patient if he/she is having any adverse reactions, address any concerns, and advise 

the patient to seek medical care if necessary

 Ask the patient to verify his/her medications with a verbal and visual pill count

 Observe the patient ingest all of the medication

 Have the patient confirm verbally that he/she has taken all of the medication and by opening 

their mouth for a visual inspection

 Confirm the next eDOT visit date and time, and any upcoming in-person clinic visits

 Remind the patient to call the health care worker if they experience any adverse reactions; 

ensure the patient knows who and how to contact regarding adverse reactions

For recorded eDOT the steps are similar to the steps for real-time eDOT, with a few exceptions

The patient records himself or herself and there is no live interaction with the health care worker

The patient logs into a secure system approved by the health department, identifies each pill by 

name and number of pills being taken, takes the medication, states when the next recording is 

due, and then sends the recording to the health department. The staff member then views the

recording to ensure that the appropriate medication was taken. For recorded eDOT, as with other

forms of eDOT, it is important that patients continue to comply with regularly scheduled in-person 

appointments to assess for any adverse reactions
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IV. Implementation

Once all the planning, decision making, and trainings have been completed, the program can begin 

enrolling patients in eDOT

The health care worker should discuss the option of eDOT with patients who meet the criteria

The patients who choose to enroll should sign all necessary paperwork. The next step would be to

teach the patients how to use the technology (e.g., how to log into the system, and how to recor

or live stream)

Additionally, health care workers should teach patients the best way to conduct an eDOT visit

For example: 

 The patient should be in a well-lit space

 The health care worker must be able to see the patient’s face

 The patient should have a glass of water nearby to take their pills

 The patient should show each pill before taking it; state the name of the medication, shape, 

size, color, and the number of pills he/she is taking

 The health care worker should ask how the patient is feeling to assess adverse reactions, 

and advise the patient to seek care if necessary

 The health care worker should confirm the day and time for the next eDOT visit

All eDOT encounters (and attempts) should be documented by the health department

There may be a need to re-assess the patient’s ability to participate in eDOT if the patient 

becomes non-adherent, experiences adverse reactions, communication equipment is lost, or 

clinical status worsens
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

V. Monitoring and Evaluation

When evaluating an eDOT program, staff should look at: 

 Completion rates 

 Specifically, TB programs can assess the number of patients who 

• Complete treatment

• Are lost to follow-up 

• Refuse further treatment

• Transfer or move

• Experience treatment failure

• Die (with death attributable to TB)

 Adherence to treatment

 Patient satisfaction with eDOT 

 To assess patient satisfaction with eDOT, programs can assess

• Frequency and reasons patients discontinue eDOT

• Patient perceptions of quality of care and overall satisfaction with eDOT and patient-staff 

relationships/rapport, and patients’ confidence in their ability to adhere to treatment

 Cost analysis 

 To assess the cost of eDOT, programs can look at

• Staff time and transportation costs for eDOT versus in-person DOT

• Cost of hardware/equipment

• Cost of software and licenses
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

VI. Appendices

Appendix A: 

Technology Options for Electronic Directly Observed Therapy (eDOT)

Appendix B: 

Patient Electronic Directly Observed Therapy (eDOT) Agreement Form

Appendix C: 

Loaner Agreement for Electronic Directly Observed Therapy (eDOT) Device

Appendix D: 

Health Care Provider Script for Electronic Directly Observed Therapy (eDOT) 

Real-Time Encounter
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

Appendix A: Technology Options for Electronic Directly 

Observed Therapy (eDOT)

The Centers for Disease Control and Prevention (CDC) has not made any endorsement for the use of 

electronic directly observed therapy (eDOT) and does not endorse any particular product or application 

for use in eDOT. These options are provided for review and consideration at the individual TB program

level, and should be reviewed with input from local public health staff and local legal counsel. This list is

not comprehensive; and due to the rapid change in technology, we recommend that programs conduct 

further research to ensure they have the most current options available. In addition, CDC has made no

assessment on whether these products are compliant with state or federal privacy laws, including HIPAA

 AiCure: (https://www.aicure.com

 Emocha: miDOT (https://www.emocha.com/solutions/midot

 FaceTime (https://support.apple.com/en-us/HT204380

 Fuze (www.fuze.com

 HipaaBridge (http://hipaabridge.com)

 ooVoo (www.oovoo.com

 Skype www.skype.com/

 SureAdhere (http://sureadhere.com)

 Tango (www.tango.me

Adapted from the Minnesota Department of Health
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

Appendix B: Patient Electronic Directly Observed 

Therapy (eDOT) Agreement Form

Date: ____ / ____ / ____ 

Patient Name: ___________________________________

Provider Name: __________________________________

I, _________________________________ , understand that I have been diagnosed with tuberculosis (TB) 

and have been prescribed medication by a physician to treat this disease. If my disease goes untreated,

there may be serious consequences: 

 My illness may last longer or become more severe 

 I may spread TB to others 

 I may develop and spread drug-resistant TB 

 I may die from TB 

During my treatment, observation will be performed remotely using electronic directly observed therapy 

(eDOT). This may be done using a smartphone or a computer. I understand that the equipment provide

to me (if any) is property of the Health Department. I agree to return all the equipment to the Health

Department at the end of my treatment or upon request. I agree to allow the Health Department staff

watch me take my medicines via eDOT at a prearranged time

To complete my treatment and protect my family and friends, I will: 

1. Come to the health department clinic to give sputum specimens when request

2. Keep all appointments for medical evaluation and x-ra

3. Participate in eDOT at the agreed upon time with the health care worker. If for any reason I 

unable to keep an appointment, I will notify the health department as soon as possible to set up 

another appointment

eDOT Day(s): _____________________ Time: _________________________

I understand that I may switch back to standard in-person DOT at any time during my treatment

I have read this agreement and understand the following (initial each box): 

❏ My adherence to this treatment regimen is very important

❏ I am responsible for the three tasks mentioned above

❏ If I fail to complete these tasks, legal action may be taken to make sure I complete treatment

Patient Signature: ___________________________________________ Date: ____ / ____ / ____

Health Department 

Representative Signature: _____________________________________Date: ____ / ____ / ____

Adapted from the CDC Self-Study Modules on Tuberculosis, Module 6: Managing Tuberculosis Patients and Improving Adherence
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

Appendix C: Loaner Agreement for Electronic Directly 

Observed Therapy (eDOT) Device

Patient Name: ______________________________________ Date of Birth: ____ / ____ / ____

Device (Phone/Tablet/Computer) Type: __________________________Device Number: _______________

Date Device Received: ____ / ____ / ____ Expected Date of Return: ____ / ____ / ____ 

I agree to the statements below: 

 I received this device to use for my electronic directly observed therapy (eDOT). The device and its

accessories are property of the health department; I agree to return all equipment to the health 

department by the date specified above

 If the device or its accessories are lost or damaged, I may be responsible for the cost of repair or 

replacement

 I will take all reasonable steps to keep the device and its accessories safe and working. I will

• Not loan the device to others

• Protect the device from extreme temperatures

• Use the protective case when carried, and take care to not damage the screen

• Never leave the device in an unsecured area or visible in a locked or unlocked vehicle

• Not share passwords with unapproved persons

 I am responsible for using good judgment about acceptable use of the device, and I am responsible 

for any additional software, apps, or other files loaded onto the device

Unacceptable use: Unacceptable uses include, but are not limited to: 

 Engaging in illegal or offensive online activity such as sending or receiving abusive, pornographic, 

sexually explicit, violent, or threatening material

 Sending or receiving of material that violates state or federal laws is not allowed. This includes,

but is not limited to, confidential information, copyrighted material, online piracy, and threatening 

material

 Introducing harmful code such as viruses, worms, spyware, malware, and adware

Patient / Legal Representative: _________________________________ Date: ____ / ____ / ____

Health Department 

Staff Member Signature: ______________________________________Date: ____ / ____ / ____

Adapted from Clark County Public Health (Washington State)
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IMPLEMENTING AN ELECTRONIC DIRECTLY OBSERVED THERAPY (EDOT) PROGRAM: A TOOLKIT FOR TUBERCULOSIS (TB) PROGRAMS

Appendix D: Health Care Provider Script for Electronic 

Directly Observed Therapy (eDOT) Real-Time Encounter

1. Staff and patient connect at the scheduled time using the agreed upon technolo

2. “Hello, this is ______________________________ (health care provider

3. “Can you please confirm that I am speaking to ______________________________ (patient)

4. “Have you had any negative reactions to the TB medicine?

If yes, follow your health department’s protocol to ensure the patient receives medical attention

If no adverse reactions, then proceed with step #5

5. “Show me each pill separately and say the name of each medicatio

6. “Put each pill in your mouth and drink at least 4 ounces of fluid after you take your pill

7. “Please open your mouth and show me that the pills were swallowe

8. “Let’s confirm the time and date for the next eDOT appointment (or in-person clinic appointmen

if upcoming). Your next eDOT appointment is tomorrow at (time). Your next in-person clini

appointment is scheduled for (day) at (time).

9. “Do you have any other concerns

10. “Thank you. I look forward to talking with you tomorrow at (confirmed time of next ca

Good-bye.

Adapted from the New Jersey Department of Health