The mission of Project ECHO™ (Extension for Community Healthcare Outcomes) is to develop the capacity to safely and effectively treat chronic, common, and complex diseases in rural and underserved areas, and to monitor outcomes of this treatment.

Problem

The Need Patients who live in rural, underserved areas and prisons lack access to specialty care to manage chronic and complex diseases, such as Hep C. Community-based primary care physicians, especially in Federally Qualified Health Centers, are not trained to deliver treatment to Hep C patients, more than 50 percent of whom are uninsured and rely on these Centers for care. In the case of Hep C, treatment consists of a highly customized weekly chemotherapy regimen with serious side effects lasting up to a year, with at least six months of follow-up. Without treatment, six thousand New Mexicans would develop cirrhosis and many hundreds would develop liver cancer. With the rapid advancement of science and the exponential growth of medical knowledge American medicine has become increasingly specialized. Many cannot afford these specialists’ services or even get to them physically. Adding insult to injury, there is also a shortage of primary care physicians, fewer medical school students are going into primary care, and fewer still are willing to serve in places like rural New Mexico. Those who do are isolated, have few opportunities for meaningful professional development, and cannot effectively treat many of the patients with chronic, complex diseases they see in their practice. While traditional telemedicine has helped in a few isolated cases, it is fraught with reimbursement problems and is not scalable.

Solution

The Solution Project Echo has created as new way of delivering specialized medical care, replacing monopolies of knowledge that pull treatment away from the underserved with knowledge networks that send it back out. Project Echo shows ECHO patients are not only benefiting by receiving treatment, but that they have as good or better outcomes than if they were seen by a specialist in person. The “better” care comes, in part, from having multiple specialists in most ECHO clinics (e.g. Hep C has a hepatologist, psychiatrist, psychologist, and pharmacist), which would be impossible in an in-person consultation in a rural area. Project Echo uses software to track this by collecting data in both the teleclinic and a small in-person clinic population that Sanjeev sees once a week. Project ECHO, enhances the experience of remote healthcare providers in order to keep them where they are most needed: in underserved communities. ECHO offers them a hands-on, fulfilling way to earn the continuing education credits they need, and breaks their isolation by engaging them in a statewide force of medical professionals. ECHO convenes an annual conference where providers learn from ECHO specialists while also having a chance to network among themselves. Many providers eventually treat the diseases without ECHO clinics, though they usually stay in the network for professional growth, or occasionally rejoin to present a particularly difficult case or to seek assistance from the network The result is a greatly improved sense of professional growth and satisfaction that causes many to stay in their rural posts longer than anticipated, or even permanently. ECHO has recently begun to train peer educators in prison in order to reduce Hep C infection rates, improve general health literacy among prisoners, and help some of them gain employment as community health workers upon release. The ECHO Addictions & Psychiatry clinic is also working with the county jails and Albuquerque Healthcare for the Homeless to train healthcare providers to administer bupenorphine to heroin addicts in detention, and to arrange a warm hand-off for them to a community provider upon discharge, in order to reduce recidivism by treating opiate dependence while in detention, and to ensure continuity of care upon discharge.

Exemple

The Model Using video-conferencing technology and case-based learning, primary care providers from rural and underserved areas and prisons are trained and mentored by ECHO's medical specialists to deliver best-practice management of complex health conditions in their communities or correctional institutions. A key component of the ECHO model is an innovation known as Knowledge Networks, in which the expertise of a single specialist is shared with numerous primary providers through telehealth clinics, thereby increasing access to care in rural areas without having to recruit, retain and fund additional providers. Knowledge Networks create what Sanjeev calls a ‘force multiplier’. The expansion of specialist service capacities means up to 10 times as many patients can be effectively treated and educated about managing their diseases and chronic pain. The primary physicians are given the opportunity to upskill and to learn by doing which increases their work satisfaction. Through participation in Project Echo they gain the competency and confidence to diagnose chronic diseases. The Project Echo model diffuses information through three main routes: Longitudinal co-management of patients with specialists; Communication with other primary providers on the network via shared case-management decision-making; Presentations from specialists or experts on relevant topics. The Echo model has expanded to treat 14 other diseases including: HIV, pediatric obesity, asthma and high-risk pregnancy. Since its first clinic launched in 2003, Project Echo has provided 4,050 patients access to expert support throughout the 21 centers in New Mexico focused in Hepatitis C virus (HCV) alone. Sanjeev decided to replicate his model nationally. ECHO is currently being replicated at the University of Washington and at the University of Chicago resulting in the operation of 255 treatment sites in the United States. In 2010 Sanjeev decided to expand Project Echo globally. He developed an Echo model that the National AIDS control organization in India. Currently ECHO Projects in India include HIV, autism and treatment of organo phosphorous poisoning.