This is discussion about Project ECHO: Knowledge Networks for the Treatment of Complex Diseases in Remote, Rural, Underserved Communities.
This model is indeed one that we find necessary in many underserved communities. Could you expound a bit more in terms of the incentive structure for specialists? Aside from addition exposure to more cases and increasing their field of knowledge, are there any other incentives offered to the specialists? What has been their response to their participation?
Thank in advance for your response!
Our project reimburses specialists for time they serve as experts on the knowledge networks. What we are also offering is a work environment with more opportunities for intellectual stimulation, more opportunities for learning, more opportunities for interaction with colleagues, and a greater range of experience with patients of different backgrounds than may ordinarily be seen by the specialists. What a program like ECHO offers is a chance to expand our horizons, interact with others, to enjoy the satisfaction of teaching, and to continue learning. We have had a very positive response from specialists with many more approaching us every month to set up new knowledge networks.
Thank you for the stimulating questions. If you have additional questions or if you'd like me to expand on any of these issues, please let me know. We look forward to further discussions.
Sanjeev Arora M.D.
Professor of Medicine,
Executive Vice Chairman,
Department of Internal Medicine,
University of New Mexico School of Medicine
2211 Lomas NE, Albuquerque NM 87131
Dear Dr. Arora:
Although the model you provide with telemedicine is not a completely novel idea, it being practiced for the past 15-20 years. What is indeed innovative is that your program has worked to address a specific need in New Mexico and it has filled a knowledge gap there. By empowering primary physicians to treat this disease with new, somewhat complex medications (ribavirin and Pegylated interferon, we are presuming), the diffusion of knowledge has occurred with likely beneficial outcomes.
Applied to an even larger problem like diabetes or hypertension in rural New Mexico, this model could have a large impact. The question is whether your organization has the institutional plan and wherewithal to make it happen. Could you provide us with more information on how they set up the conferences and what technology they use? How would you apply their program to giant issues like Diabetes? Would you use subspecialist consultants, or expert primary care physicians who see a lot of diabetic patients? How would you achieve primary care physician buy-in on issues that are often the domain of primary care (like diabetes) as opposed to subspecialties (like hepatitis C infection)?
More specifically, what is your scale-up plan in greater detail?
We thank you in advance for your response!
The Changemakers Team
Dear Ms. Ahn and Changemakers Team,
Thank you for your comments! Yes, the disruptive innovation here is not the technology but our model for efficient dissemination of information from specialists to generalists. Three other components of the model are best practice protocols, case based learning and outcomes tracking. The ECHO Knowledge Network is a fully-connected, one-to-many communication processing consisting of bi-directional connections between a single specialist and multiple primary care providers and, longitudinally, connecting the primary care
givers to each other. The crucial element is this: There are weekly meetings connecting a specialist (or specialist team) with multiple primary care givers and connecting the care providers to each other. In these meetings, the flow of knowledge is 3-directional: the generalists learn from the specialist, the specialist gains practical experience with a wider range of patients of different backgrounds and circumstances, and the primary care providers learn from each other's experiences. Throughout the rest of the week, the primary-care providers disseminate this information to all of the patients in their care, thus multiplying the effectiveness of the specialist provider. (Please see Academic Medicine paper
http://echo.unm.edu/publications.shtml for some graphics and more detailed description
of the concept.
These meetings may take place in the same room or, through the leveraging power of technology,
we can meet with health care providers scattered all over the world. Video teleconferencing
provides us with the widest bandwidth long distance communication, allowing for power point presentations, nonverbal cues such as facial expressions and gestures in parallel with the spoken voice, but it is not a
requirement for this model and in fact, we use simple telephone connections and email to reach those communities that are not yet equipped with the infrastructure to support teleconferencing.
Applied to an even larger problem like diabetes or hypertension in rural New Mexico, this model
could have a large impact. The question is whether our organization has the institutional
plan and wherewithal to make it happen.
Yes, the ECHO concept enjoys a broad base of support ranging from the University of New Mexico
Health Sciences Center (http://hsc.unm.edu/), the New Mexico Department of Health (whose newly
appointed Secretary of Health is a primary care physician who was one of the early adopters of ECHO), the New Mexico state legislature, as well as strong support from our congressional delegation in Washington DC.
More importantly, ECHO is a collaborative partnership among several organizations throughout the state. We have already established partnerships with 21 of the federally-qualified rural health clinics, the
Indian Health Service, the New Mexico Department of Corrections, and the Primary Care Association.
Given our broad base of support, our extensive network of partners, and our experiences with
HCV, rheumotology and substance abuse, we are very well positioned to make a large impact on
other chronic diseases such as diabetes or hypertension.
Could you provide us with more information on how
they set up the conferences and what technology
We are using teleconferencing equipment from Polycom (http://www.polycom.com). We have a full time IT specialist as part of the ECHO team who runs the technical side of the teleconferences, and assists new rural sites to set up the system and provide training, and interacts with our collaborative partners.
How would you apply their program to giant issues like Diabetes? Would you use subspecialist
consultants, or expert primary care physicians who see a lot of diabetic patients? How would you
achieve primary care physician buy-in on issues that are often the domain of primary care (like diabetes) as opposed to subspecialties (like hepatitis C infection)?
We have recently started a cardiac risk reduction initiative which covers Diabetes, Obesity, Hypertension, Lipid Disorders, Nutrition, Smoking Cessation and Exercise physiology. In this project specialist experts in the above areas interact with primary care physicians from around the state. Thre is an explosion of medical inforamtion in these “primary care diseases” and primary care doctors find it difficult to keep up with best practices. The one-to-many fan out of the ECHO model allows a single specialist to assist multiple primary care providers who, in turn, assist multiple patients, having a multiplicative effect. We have the facilities to handle additional knowledge network sessions (two dedicated video and teleconferencing rooms) that can be used 40 hours a week if necessary.
Regarding the buy-in by primary care providers in rural areas, one of the biggest challenges faced by physicians in remote rural areas is a sense of professional isolation. The ECHO model does more than provide consultations with specialists; it also connects rural physicians with their (geographically separated) professional peers. In a metropolitan hospital, this kind of discussion occurs naturally and easily in the
corridors and offices. When individuals are separated by large distances, this kind of informal learning and professional interaction can be mediated by technology. To quote from a letter to Senator Domenici from Dr Leslie Hayes, a primary care physician in Española New Mexico: " The benefits of the ECHO project are not only for the patients, though. I have also gotten several things from it personally. One of the problems with rural practice is a sense of stagnation. It is hard to learn new things and keep up. With the ECHO project, I have been able to learn a huge amount about a disease that I see every day. I feel a sense of pride that I am actually at the forefront of knowledge about hepatitis C. When I first met Dr. Arora, my comment on the program at the time was that in medical school, it is all learning and no actual work, and being an actual practitioner is all work and no learning. I don't think either is the proper balance for physicians, who are, by our very nature, people who want to work and learn both. ECHO has been an enjoyable way for me to
extend my learning. One other benefit of the program has been the chance to get to know several specialists. One problem in rural health care is that there are often no specialists immediately available. The
ECHO project has introduced me to a gastroenterologist, a psychiatrist, and an infectious disease specialist who I have been able to call for help with patients other than hepatitis C.
The ECHO project has been a huge success for us here in Española. Anything that you could do to help expand the program nationally would be a boon for healthcare."
Ther primary strategy is to disseminate the concepts and our results so that other organizations can emulate the model. Our model is both simple and powerful and can be quickly apprehended and implemented by other academic medical centers or other organizations that could act as hubs for new Knowledge Networks. The ECHO Knowledge Network can serve as a model, as a turn-key "franchise" that other organizations can adopt, learning from our experience and outcomes. We would be happy to communicate with other centers interested in setting up an ECHO Knowledge Network. We can talk to you by telephone, make a power point presentation, or refer you to our publications.
We also welcome you to participate in one of our weekly clinics (contact us to arrange for access codes or to arrange a visit to Albuquerque).
ECHO seems to hit all the right notes by:
* Using a commonly available technology (telephone & televideo over Internet)
* Starting out in an underserved overlooked market (rural, uninsured or prison population)
* Side-stepping many of the regulatory barriers and privacy concerns by organizing their knowledge networks as specialist-to-generalist health care *professionals*, rather than specialist-to-patient conferences.
* Addressing the demanding needs of complex diseases (such as HCV) without requiring the patients to travel hundreds of miles each way to reach a specialist or to change where they live
* Utlizing many, less-costly people to assist in the work of centralized specialists and to meet the needs of an under-served markets
What I like about this idea is that it a less costly and more convenient way to enable under-served populations to access the best in current care for a disease that was, in many cases, going untreated in these populations. But even better than that, it is a fairly straightforward model that could be easily replicated in other areas for the treatment of other diseases and the "fan out" of the network would make it less expensive and more convenient even for the more affluent, city-dwelling population. Plus, they have a proof-of-concept program already running and strong partnerships in place that ensure longterm sustainability.
In the past, telemedicine has often been used to connect specialists directly with patients, but I find that model problematic, not only from a privacy point of view, but also because it doesn't increase the efficiency (and may actually be *more* costly as a result).
I've also seen lots of proposals for using "less costly" health providers to serve rural populations, but putting less expensive (and less extensively trained) individuals out in the field and leaving them on their own seems to suggest that the underserved populations get a lower quality of care. What I like about this proposal is that, although they are utlizing non-specialist providers out in the field, they are also providing them with regular access to a specialist and to continuing training. This is more efficient and less costly than sending the specialist out to every rural clinic, *without* compromising the quality of care afforded to the rural communities. It also provides a quick path for new information to get out to those isolated communities.
Dear Ms Bahait,
Thank you for your kind comments. You have captured the essence of our program.
Sanjeev Arora M.D.
We would like to commend you on setting an excellent example of telehealth-telemedicine. Your model not only provides remote consultation but also provides this knowledge to the general practitioners who can utilize this knowledge for all of their patients. Do you have plans to perhaps target other regions within the United States? The other ailments and diseases that you seek to focus on in the future, do they pose different challenges to this system?
Thank you in advance for your response!
Dear Ms Ahn and the Changemakers Team,
Thank you for your questions.
Yes, we do have plans to expand in New Mexico and other regions of the United States.
Expansion Plans in New Mexico:
Other ECHO clinics in various stages of implementation in rural New Mexico are HIV care, rheumatology consultation, autism, cardiac risk reduction, high risk pregnancy, occupational health disorders, childhood obesity, and prevention of teenage suicide. We also plan to start an Asthma knowledge network. Over the next two years we plan to develop the network of Centers of Excellence so that all regions of New Mexico have access to this expertise.
These knowledge networks have the potential to impact hundreds of thousands of patients in New Mexico. For example our cardiac risk reduction clinic has experts in diabetes, hypertension, lipid disorders, obesity, smoking cessation, exercise and nutrition. More than 30% of the population can benefit if primary care providers have better expertise in this area.
Expansion plans in other states in the US:
In July 2007, members of the ECHO Team conducted a
training session in Nevada Corrections Department imparting to them
the essentials of the ECHO model and providing initial training of
nurses and IT support technicians for the treatment of Hepatitis C. This initiative has the potential to bring access to treatment to thousands of inmates.
We have recently established a partnership with the University of North Carolina (UNC), division of Gastroenterology. Later this year the chief of hepatology at UNC will launch an ECHO program for Hepatitis C in North Carolina.
We envision the spread of the ECHO model as one of expanding
concentric rings, with the Albuquerque-based ECHO Team training one
set of centers to serve as Knowledge Network Hubs and each of those
Hubs training the next set of centers, and so on. We hope to
organize an annual ECHO meeting (physical or virtual) of all ECHO
hubs in order to share experiences, learn from each other, and help share best practices.
Within the US, our plan is to focus on federally qualified health centers in rural areas and the prison population. We work closely with the Primary Care Association (PCA), a national organization of primary care doctors working in rural and underserved communities. Since the education and empowerment of primary caregivers is such a large part of the ECHO
model, and since PCA already serves many of the same target
populations, it makes sense for us to work together and to expand to
other regions of the United States where PCA is active.
We also plan to focus on correctional facilities. Such facilities with high population densities generally are found to be incubating several potentially epidemic diseases including HCV, HIV AIDS, and Hepatitis B. Access to best practice care is difficult in these settings. Once these individuals are released from prison, these diseases are being spread to spouses, children and to the general population.
Challenges posed by other diseases and ailments.
Yes, we have no doubt that the other diseases and ailments will each
pose unique challenges and twists. However, we are convinced that
the basic ECHO model is flexible and interactive enough to adapt to these differences as they arise. The weekly meetings between primary care providers and specialists are essential for this process to be successful. In addition to sharing best practice information on disease management, these weekly discussions serve as interactive forums for process improvement and problem solving. We can quickly adapt to changes in the current best practice models as well as respond to concerns and feedback from the remote sites.
We welcome further discussion and collaboration.
It seems to be a great concept. Health care Education, its dissemination and empowerment of the Patient and Primary care provider is a must for any country or state.
After returning from the US I have been working in Bihar, India one of the poorest places on earth with a literacy rate of around 30%, and feel that with the right technology and systems in place we could bring about a sea change in the status of health here. Must have seen hundreds of Hepatitis cases , but am unable to confirm HCV since the testing is beyond the reach of the average bihari where the per capita income is a meagre 150$.
We could though use your model for disseminating information on a host of other diseases such as TB, Leishmaniasis, Malaria, Diarrhoea etc. Wonder if we could join your network and use your protocols and use radio, instead of the Internet to reach the rural poor.
Keep up the good work.
Uday Pathak MD
Mahavir vatsalya aspatal
Thank you for your kind comments about our project. We have also found that HCV treatment is not a practical application of the ECHO model in developing countries because of the prohibitive costs of testing and treatment. The ECHO model is likely to have bigger impact on treatment of HIV disease, TB, Leishmaniasis, Malaria, Diarrhoea etc. We have not used radio as a communication medium but have had excellent success with teleconferencing using cellular phones. It would be an honor to discuss a possible collaboration with you.
Sanjeev Arora M.D.
This program has brought life and hope to so many patients and their family and wish if such care could continue for ever.
"Getting world class treatment at our door steps". we thank every member of the project for their dedicated efforts.
We would love if a simillar thing is done For Indian villages great project.
My vote goes to Dr.Sanjay, gr8 concept
Dear Dr. Sanjeev,
This project is no doubt the best.It can bring life to so many needy patients in the poor areas of any country or any state,the areas which are often forgotten and where it is needed the most!And also it will guide our colleagues from the medicine profession to understand these problems from a little closer aspect and help everyone to have a healthier world.Would really like to thank everyone involved in this project.Well done & All The Best.Please keep up the good work.
DEAR DR. ARORA,
WELL I am from India , and who better then me would know the importance of such a programme,nevertheless it requires, exceptional human endurance, patience and motivation to work upon such a movement, my best wishes to u and all team members. few lines to what we human beings can do.
Life, I know not what thou art,
But know that thou and I must part,
And when,or how , or where we met,
I own to me' s a secret yet.
Life!we've been long togather,
Though pleasant and through cloudy weather,
'Tis hard to part when friends are dear-
Perhaps'twill cost a sigh, a tear:
Then steal away, give little warning,
Choose thine own time ,Say not good night-but in brighter clime
Bid me good morning.
My vote goes to this project, with appreciation of its creativity and importance in improving the quality of life everywhere.
Dear Dr. Sanjeev Arora,
Your project is really impressive. I feel that such a set up would be a boon during epidemics in remote areas. Many rural far off and/or deserted places will have community medicine or Primary Health Care Centers for treating the uninsured, and deserving but left-out populace, but it is not possible to have a Medico specialist in these village based clinics operative in remote locations. ECHO Program takes care of this deficit and provides on line consultation with a qualified and specially trained Doctor, etc., to attend to any emergency (be it Malaria or a Snake Bite).
I wish you succeed and may the eternal one grant all your wishes. You are doing your bit for community and for the greater good for larger populace.
Divyang K Chhaya
Advocate Supreme Court
Dear Mr Chhaya,
Your comments regarding epidemics are very insightful. Phone based "knowledge networks" should be able to rapidly bring best practices even to remote areas at very low cost. Best wishes
This has been an incredible lifeline for SW NM. Thank you.
I would like to congratulate you for creating such a wonderful project. Its really a boon for the class which actually needs a thought. It is that part of our society which is often neglected. But this project may actually prove to be a new life for these people. You are doing a wonderful job. All the best. Wishing you all the success.
Dear Dr Arora & the ECHO Team,
Thank you for your dedicated effort in helping the underprivileged. Providing healthcare to rural areas a real challenge at the best of times, and you have shown the way as to how to do it. Your concept also has a tremendous potential in the underdeveloped and the developing countries especially India. I am aware that the maiden venture by ECHO in Lucknow (India) regarding Child Autism was a phenomenal success: it clarified the doubts and changed the way the people who handle it, think! I wish your Team all success, and hope you can bring it to India one day. Dr Kumud rai
I would like to congratulate on your wonderful project. It is that part of our society which is often neglected. You are doing a wonderful work. All the best.
The idea is superb but alldepends upon the proper implementation of the project. I wish to congratulate the team and hope to see it through.
dr suresh chintamaneni
Congratulations to Dr Arora and his team. Reaching out to poor and underserved population both in rural and urban settings should be the goal of this project going forward. Personally after my return from USA where I practiced as a Surgeon in rural Mississippi, I was saddened at the health delivery sysytem for people in rural India. With blessings of our President Hon Abdul Kalam, I started the first rural telemedicine/ rural out reach program for the underserved in India. I can imagine the pleasure your team derives when you see the smile of hope and gratitude in these patients and am sure you all are now indespensible to the doctors and patients whose lives you all have touched.
I wish you all the best and continue your good work.
Dr Suresh Chintamaneni
Having had the opportunity to attend an ECHO Clinic, it is clear that this disruptive technology is having a measurable and significant impact on healthcare services. I congratulate Dr. Arora on this innovative programme.
I am amazed by the vision that Dr Arora has for the future of health care. Especially tackling with complex diseases and coming up with innovative ideas to serve the under-privileged population is one of the great thoughts that would make the world a better place to live in.
Congratulations to Dr Arora on Project ECHO and sure it will go a long way serving the person kind!
"It's not enough to have lived. We should be determined to live for something. May I suggest that it be creating joy for others, sharing what we have for the betterment of personkind, bringing hope to the lost and love to the lonely."
— Leo Buscaglia, author and university professor (1924-1998)
ECHO has done a major ground work for bringing the latest aspects of treatments to the rural underserved area. MY question is that can this be used in terms of bringing the early educational behavior modifications in our rural schools too. Can we use this heath care model to educate and monitor the out come in school based interventions for many chronic disease including childhood obesity??? Also, how good is the sustainebility of such programs if you cant get active pariticpation by the stake holders including communities and governments???
Uni of New Mexico
Thank you for your comment. We have an ECHO project in partnership with the Envision New Mexico to reduce childhood obesity. You have correctly concluded that for such a project to thrive a partnership with communities and governments are required.
As a health care provider in a small, northern New Mexico town, and a current Project ECHO participant, I can testify to the benefits of a program like Project ECHO. Communities like ours often feel isolated and are always underserved. Not only do we lack specialty care, but most of the patients we see at our community health center are uninsured or underinsured. Before Project ECHO, our patients, many of whom lack reliable transportation, were expected to travel for hours to find appropriate care. Now, we are able to dial-in to Project ECHO specialists to provide our patients with high quality services and resources that we would not have otherwise. We started by using ECHO to offer hepatitis C screening and treatment and have since joined forces with ECHO's substance abuse specialists to help patients overcome opiate abuse, which in our community is usually in the form of intravenous drugs, the primary method of transmission for the hepatitis C virus. This has made us more confident in our abilities to contribute to risk reduction, while still maintaining a strong hepatitis C program. We are thankful to be in a network that connects us with ECHO Psychiatrists and other specialists who help us direct our patient care. Kudos to a great vision that will help rural communities in limitless ways, and I can only hope to see it expand exponentially!
April Grisetti-Nail PA-C
Congratulations to you and your team.
The ECHO project is such an innovative way to get specialized medical care to patients that would not other wise have access. Your delivery model is innovative yet direct.
As I read through all the discussion comments, I am struck by a recurring theme.
Many of the comments are suggesting that your delivery model be expanded to include other diseases and other countries that are of particular interest to each of them.
When others seek to imitate, they are offering you their sincerest form of flattery.
I wish you continued success.
An outstanding project with world changing potential.
Its simply a mind-blowing project.Congratulations for giving life to such a wonderful project
An awesome proposal that would need absolute grit and passion . It is truly disruptive innovation as it would really crumble the age old traditional method of health delivery or at least be on par with it. God Speed!
The ECHO model of healthcare delivery-plus-education in combination with the PointCare CD4-count technology would be a truly revolutionary combination in the treatment of HIV AIDS (and potentially other diseases) in resource-poor or isolated regions anywhere in the world.
We wish to congratulate you on the success you have had so far and want to let you know that you have our support and hopefully the underserved and sick population that this is aimed at will be able to access the kind of healthcare that has long been out of reach.
Parul Aneja MD,
Anil Chopra MD,
Pallavi Aneja MD
Dear Sanjeev must congratulate u and ur team for an excellent innovative concept to improve health care in rural,remote underserved areas in India -but the basic problem remains of the absence of health care providers in these areas without adequate basic amenities-lack of financial &professional motivation to reach out and be there to take the professional help and guidance your project can offer.The primary health centres remain grossly understaffed and hardly offer anything by way of health care specially in Bihar ,Uttar Pradesh &Jharkand etc.Except for the few Uday Pathaks,Chintamanis and the minuscle few who have had the luxury of being in the USA for many years and now back to give back their knowledge and expertise to the underserved areas -u can find very few motivated people to take up the job of a rural physician.Some incentive to get the health provider there will make the difference.Am sure it will work out and wishing u all the best in your endeavour.ECHO will stimulate many people to participate and make it a very viable prog.
My understanding of the ECHO model is that they rely, in large part, on training and assisting the primary caregivers who are *already* living in the rural areas (in some instances primarcy care docs but when this is not possible, they are educating and assisting other primary care givers). One of the disincentives to living in a rural area is professional isolation, and ECHO goes a long way towards meeting this rarely articulated need; this makes the rural clinic more attractive to healthcare professionals. In other words, I think part of the genius of this model is that they do not try to 'bribe' doctors to move to rural areas. Instead, they work with people from those areas, empowering and educating them and providing ongoing training through the Knowledge Network--enriching their professional lives and making it more attractive to remain in the area.
This project has my vote. Thank you for this innovative work.
This project has great potential in collaborating with NMCHWA in training promotoras in rural areas of New Mexico regarding prevention and intervention where health services are not readily accessible for high risk patients. In 2006, during the 11th annual NMCHWA conference, participants told us that they would take the training information they received to over 30,000 clients. We provide training for community health workers on a quarterly basis and during the annual conference. CHW programs have limited funding for training and travel, utilizing telemedicine would enable more CHWs to access much needed training.
It was my honor to have served with you on the ECHO Project when it was in its early stages. I was thrilled to hear how much it has grown in the past 2 years. I have been working with state and county human service providers to develop a network like this to get psychiatric expertise to rural communities in Wisconsin because I really believe that the model works. I have seen it in action in New Mexico. Thank you for your dedication to the underserved and often forgotten healthcare consumers. And thank you for sharing your knowledge with others like me who wish to "pay it forward."
This project definitely gets my vote. As a member of the Navajo Nation there seems no end to the economic and social devastation on many, many reservations. The long distances between health care services and people that need specific services is great. Add to this the high cost of resources to those that have very little - a vehicle, gas, someone to drive the distance, food, etc. - just to get to the hospital.
The implemention of technology would help the health care providers such as IHS provide more cost efficient services to those in rural areas especially at a time IHS is suffering from budget cuts due to the wars the United States insists on funding. This project needs to happen so people on New Mexico reservations and other rural areas can benefit If this project is successful then it can serve as a model for other health care providers in other states such as Arizona.
This project has my Vote
Dr Sanjeev Arora, Congratulations to you and your team for these bold initiatives.
Keep it up!!!
This is great and wonderful project with significant community impact and also training and mentorship of community members. For those Schools who advocate comunity empowerement and closing of health disparities this project has many lessons to learn from.
Dr Simeon Mnining