Johns Hopkins Physician Improves Standard of Care for Tuberculosis through Patient-centered Technology
Maunank Shah, an infectious diseases specialist, has developed mobile health tools now used nationally.
When Maunank Shah provides a tour of the surprisingly diverse landscape of his career, he sometimes pauses to make sure he’s not leaving anything out.
It’s a daunting task: Since 2007, when he began his fellowship in infectious diseases at Johns Hopkins, the professor of medicine has developed an acclaimed suite of mobile health tools to improve public health control and the clinical care of tuberculosis (TB) and HIV.
He serves as co-director for the microbiology and infectious diseases curriculum for students at the Johns Hopkins School of Medicine, and as co-director of the clinical core for the Johns Hopkins Tuberculosis Research Advancement Center.
Now president of the National Society of Tuberculosis Clinicians, Shah also helped create the online IDCrowd e-consultation platform adopted by the Centers for Disease Control and Prevention-funded TB Centers of Excellence to support TB care in the U.S.
And he manages all of these commitments while serving as medical director for the Baltimore City Health Department’s TB program, where he oversees clinical care for all individuals with TB disease or infection in Baltimore as well as directs contact investigations and public health surveillance for tuberculosis in the area. Additionally, he provides education and consultation for clinicians throughout the region for the Maryland Department of Health’s tuberculosis control and prevention program.
“Maunank’s breadth and depth and his ability to do so many different things is truly remarkable,” says Amita Gupta, director of the Division of Infectious Diseases at the Johns Hopkins University School of Medicine. “To be innovating apps and educational tools, while also getting research funding to do clinical trials and also taking care of patients and managing people in our local city clinic, is pretty amazing.”
At the moment, the Elkridge resident may be best known as the co-inventor of a mobile health tool called video directly observed therapy (vDOT), which he developed to help ensure that tuberculosis patients take their medications every day. In part for recognition of this work, he was awarded the Robert Koch Award by the National Tuberculosis Controllers Association for outstanding contributions to clinical, epidemiological or academic focus by a TB researcher.
Tuberculosis kills 1.5 million people annually across the globe, according to the World Health Organization. Shah’s invention, which allows patients to record themselves taking their medication, is widely acknowledged to have changed the standard of care for the world’s most deadly infectious disease. The vDOT platform Shah created and licensed to Scene Health (formerly emocha Health) is now used in more than 700 public health departments across the country.
“What Maunank and team have achieved is actually unprecedented,” says Sebastian Seiguer, CEO of Scene Health, the company that spun out of Johns Hopkins University as emocha Health and developed the technology. “When the CDC recommended asynchronous video as equivalent to in-person directly observed therapy this past March, it marked the very first regulatory allowance in health care of parity between a recorded video and a live in-person meeting between a patient and a clinician.”
The achievement also marks another Hopkins milestone in a history of TB research and treatment that leads back to founding professor William Osler, says Richard Chaisson, director of Johns Hopkins University Center for Tuberculosis Research.
Over the past two decades, work by faculty in the center has led to new, shorter regimens for treating and preventing tuberculosis that are endorsed by the World Health Organization; novel diagnostic tests that reduce the time needed to detect tuberculosis from three weeks to less than three hours; an improved understanding of the impact and management of tuberculosis in pregnancy; and major advances in treating people with HIV infection and tuberculosis. Laboratory studies in the center have advanced the understanding of the pathogenesis of tuberculosis, as well as identified better therapeutic regimens.
Medication Adherence Prevents Spread of Tuberculosis
The best practice for treating tuberculosis — and preventing its spread — requires patients to take medication daily, often for many months. However, many patients are apt to stop taking their medicine when they feel better.
In the 1990s, a study by Chaisson and C. Patrick Chaulk, another Hopkins infectious diseases specialist, proved that the best way to ensure such adherence to treatment was through directly observed therapy — a standard approach that either required public health patients to come to the clinic so clinicians could see them take their medication, or to meet with a public health nurse at their home or workplace.
Although highly successful at curing the disease, the method was also highly inconvenient and stigmatizing.
“We’ve seen over and over that some people have challenges adhering to their treatment or negative impact on their lives because of all the logistical challenges associated with requirements for in-person directly observed therapy,” Shah says. “That was the genesis of the idea: Is there a more patient-friendly, patient-centered way that we could still achieve our public health goals of verifying daily TB treatment and supporting adherence? And could we do this in a way that was HIPAA compliant?”
After Shah took over as medical director of Baltimore City’s TB clinic in 2010, he developed a video-based approach that could allow patients to prove their compliance remotely through a smartphone application.
He recalls how the parents of a toddler video-recorded mashing up her medication, putting it into chocolate sauce, then feeding it to her. The method proved successful, allowing the mother to keep her job because the child could be treated at a time in the evening that was convenient for the family, which was outside the times the health department could offer traditional directly observed therapy.
Before long, the state of Maryland expanded its adherence guidelines to include vDOT, following a pilot National Institutes of Health-funded study led by Shah at multiple local clinics in which the technology was found to be both effective and more acceptable to selected patients than traditional approaches.
Following a series of steps, patients can now record themselves taking their medication on their mobile phones and upload the video to a secure server. After reviewing it, health department professionals can either accept it or follow up with the patient.
Shah says overall, treatment adherence has stayed the same or even improved, because vDOT is more patient-centered and easy to monitor on weekends and holidays. In particular, patients experience fewer disruptions to their work and travel since they can record videos wherever and whenever is convenient, rather than having to fit health department business hours.
“One thing I like about this kind of work is that it's very tangible,” he says. “Sometimes you don't get to see the impact of your research because you're doing foundational work, or because the progress is incremental. When you build something that actually immediately changes patients’ lives, it’s a lot of fun to see that final product.”
Now, vDOT is being used with other infectious and chronic conditions such as asthma, diabetes, hypertension, heart failure and opioid use disorder.
Resources for Physicians
Shah says he became interested in TB and HIV — tuberculosis is the leading cause of death for people living with HIV in the late 1990s, when he was a medical student at the University of California, San Francisco. Subsequently he worked as chief resident at Emory University in Atlanta, Georgia, where he spent time at Grady Hospital on an infectious diseases unit focused on HIV.
After he came to Hopkins in 2007, he earned his Ph.D. in clinical investigation and public health, with expertise in decision analysis, epidemiology and biostatistics from the Johns Hopkins Bloomberg School of Public Health.
Shah’s technological work helps not only patients but also physicians. He co-founded HIV-ASSIST, a free online and app-based interactive tool that supports providers to make individualized, patient-centered decisions on antiretroviral therapy (ART) regimens for their patients living with HIV. The educational tool, which incorporates national guidelines from the Department of Health and Human Services and The International Antiviral Society-USA, summarizes relevant scientific literature pertinent to individual patient scenarios, and integrates a number of resources (drug interactions, drug-resistance evaluation) into a single platform.
Using a multiple-criteria analysis to weigh thousands of factors, HIV-ASSIST evaluates and ranks all possible treatment options to help select the optimal regimen for each patient.
“While HIV has essentially become more of a chronic disease, the actual management has gotten infinitely more complex,” Shah says. “Fifteen years ago, there were only a few drugs. Now there are at least 30, and you can use them in lots of combinations. In an era where we should be making tailored HIV treatment and medication choices, the guidelines now comprise hundreds of pages.”
And, as more people with HIV live well into their retirement years — a period of life that often requires treating more than one condition — Shah says the number of doctors and nurses actually trained in HIV medicine is rapidly declining. The same applies to physicians trained in up-to-date treatment of tuberculosis.
In addition to HIV-ASSIST, he developed IDCrowd, an online e-consultation and discussion system that facilitates rapid, efficient consultation for TB care. The CDC now uses it as the core platform for its international TB consultation service.
Shah also led efforts to develop the Johns Hopkins Epidemiologic and Economic Model, a mathematical model now available as an interactive online tool that helps policymakers decide which public health interventions are most likely to reduce incidences of HIV disease in their geographic areas, and be cost-effective.
Such resources also help Hopkins trainees and first-year medical students. Shah performed a randomized trial at Hopkins that gave 10 very complicated cases to roughly 150 medical students and trainees with very little HIV background. Then he gave the same 10 cases to the world's leading HIV experts at Hopkins, Harvard and UCSF.
Using HIV-ASSIST, the students made the same choices as the world’s leading experts more than 90% of the time.
HIV-ASSIST is now managed and distributed globally through HIV-ASSIST Inc., a registered nonprofit organization.
“With vDOT, so many patients tell us how great and useful it is. And with HIV-ASSIST, providers let us know how much it has helped their own clinical practice,” Shah says. “That’s what motivates me: Being able to move the needle on helping to control or manage TB or HIV just makes life a little bit better.”
Under a license agreement between emocha Health and The Johns Hopkins University, Shah and the university are entitled to royalties related to technology described in the study discussed in this article. Also, the University owns equity in emocha Health. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. JHU assigned the rights to HIV-ASSIST to Shah and the co-founder, who have in turn granted a free perpetual license to a registered 501c3 non-profit organization, HIV-ASSIST Inc., for free global distribution. Shah is the executive director for HIV-ASSIST Inc., but takes no financial payment, and no royalties.
A Suite of Mobile Health Tools.
vDOT (video directly observed therapy): Initially created in 2014 by Johns Hopkins emocha Health, now Scene Health, Shah co-developed a platform whereby patients use their phones to record themselves taking their daily dose of medication, then upload it to a secure server where it’s reviewed by health department personnel. Recommended by the CDC, the Scene Health vDOT system replaces a burdensome in-person reporting requirement and is now used in roughly 700 health departments throughout the country.
HIV-ASSIST: The first interactive support tool to help physicians make decisions about what anti-retroviral (ARV) medications are best for their patients with HIV. Treatments can be tricky, particularly for physicians who don’t specialize in infectious diseases such as HIV and TB. The free online platform uses a multi-criteria decision analysis calibrated and updated with current guidelines and input from HIV experts. The use of HIV-ASSIST has shown to improve ARV selection among trainees. It is also available as a mobile smartphone app.
IDCrowd: An online discussion system that facilitates rapid, efficient consultation for management of TB and latent TB infection.
Latent Tuberculosis Decision Support (LTBI-ASSIST): The first interactive decision-support tool for the management of latent TB, a condition when TB bacteria are present in the body but not active. Unless it is treated, latent TB poses a threat to those who are immunocompromised. Developed with the CDC and regional TB Center of Excellence, this tool presents clinicians with more than 200 pages of latent TB guidelines, offering a patient-driven approach and expert clinical recommendations.
HIV Public Health Model: Shah created a mathematical model to explore the impact and cost-effectiveness of new interventions along the HIV care continuum. Through work led by internal medicine fellow Anthony Todd Fojo, the model is an interactive online tool that helps local decision-makers determine which HIV public health interventions are most likely to lead to reductions in incidence in their area.