Project ECHO: Knowledge Networks for the Treatment of Complex Diseases in Remote, Rural, Underserved Communities
Location
The U.S. Dept of Health and Human Services’ Healthy People 2010,was one of the first programs to identify the elimination of health disparities as a national health goal. Rural, uninsured, and underserved populations represent three of the most significant sectors of inequality in the provision of health care in the U.S. system. Additionally, many patients in rural and underserved areas with chronic complex diseases such as HCV, substance use and mental health disorders face difficulties in accessing the specialty treatment they need. The ECHO model addresses this problem by giving physicians who specialize in treating complex and chronic conditions like HCV access to technology, enabling them to share knowledge about best practice protocols using a case-based learning approach to co-manage patients with primary caregivers in rural communities and prisons in New Mexico. Conservative estimates suggest that approximately 34,000 New Mexicans, including 2500 prisoners are infected with HCV, and the state leads the nation in deaths from chronic liver disease and cirrhosis. Prior to the launch of project ECHO, less than 1600 rural residents and no prisoners had received treatment for chronic liver disease. Since its inception in June 2004, Project ECHO has established 21 HCV treatment centers in rural New Mexico and at prisons around the state, resulting in an addition 3500 patients are receiving treatment during this time who were otherwise unlikely to have received any treatment at all. Given the success of the model to date, additional ECHO clinics have been launched for rheumatology, substance use and mental health disorders. Empowering primary caregivers at rural clinics has several long term effects. Rural physicians gain expertise, earn required continuing education credits, and are encouraged to remain in remote communities by having one of their highest priority needs answered: an opportunity to continue learning and to interact with professional colleagues.
About You
Location
Project Street Address
Project City
Project Province/State
Project Postal/Zip Code
Project Country
Your idea
Focus of activity
Service/process
Year the initiative began (yyyy)
2003
Positioning of your initiative on the mosaic diagram
Which of these barriers is the primary focus of your work?
Monopolies of knowledge
Which of the principles is the primary focus of your work?
Push work down the chain of command
If you believe some other barrier or principle should be included in the mosaic, please describe it and how it would affect the positioning of your initiative in the mosaic:
Although we selected "Push work down the chain of command", this does not fully capture the spirit of what we strive to achieve in our project. Perhaps a category like "Rapid Knowledge Diffusion" would better capture the spirit of our model. We like to describe project ECHO (Extension for Community Healthcare Outcomes) model as a "Knowledge Network" in which "Learning Loops" lead to rapid increases in expertise of primary care providers. The idea is to share the knowledge of one specialist with several generalists (who then apply that knowledge in treating large numbers of patients). The case based knowledge flow is NOT unidirectional; the generalists are also feeding results and experience back to the specialists.
Name Your Project
Project ECHO: Knowledge Networks for the Treatment of Complex Diseases in Remote, Rural, Underserved Communities
Describe Your Idea
The U.S. Dept of Health and Human Services’ Healthy People 2010,was one of the first programs to identify the elimination of health disparities as a national health goal. Rural, uninsured, and underserved populations represent three of the most significant sectors of inequality in the provision of health care in the U.S. system. Additionally, many patients in rural and underserved areas with chronic complex diseases such as HCV, substance use and mental health disorders face difficulties in accessing the specialty treatment they need. The ECHO model addresses this problem by giving physicians who specialize in treating complex and chronic conditions like HCV access to technology, enabling them to share knowledge about best practice protocols using a case-based learning approach to co-manage patients with primary caregivers in rural communities and prisons in New Mexico. Conservative estimates suggest that approximately 34,000 New Mexicans, including 2500 prisoners are infected with HCV, and the state leads the nation in deaths from chronic liver disease and cirrhosis. Prior to the launch of project ECHO, less than 1600 rural residents and no prisoners had received treatment for chronic liver disease. Since its inception in June 2004, Project ECHO has established 21 HCV treatment centers in rural New Mexico and at prisons around the state, resulting in an addition 3500 patients are receiving treatment during this time who were otherwise unlikely to have received any treatment at all. Given the success of the model to date, additional ECHO clinics have been launched for rheumatology, substance use and mental health disorders. Empowering primary caregivers at rural clinics has several long term effects. Rural physicians gain expertise, earn required continuing education credits, and are encouraged to remain in remote communities by having one of their highest priority needs answered: an opportunity to continue learning and to interact with professional colleagues.
Innovation
Define the innovation
The U.S. Dept of Health and Human Services’ Healthy People 2010,was one of the first programs to identify the elimination of health disparities as a national health goal. Rural, uninsured, and underserved populations represent three of the most significant sectors of inequality in the provision of health care in the U.S. system. Additionally, many patients in rural and underserved areas with chronic complex diseases such as HCV, substance use and mental health disorders face difficulties in accessing the specialty treatment they need. The ECHO model addresses this problem by giving physicians who specialize in treating complex and chronic conditions like HCV access to technology, enabling them to share knowledge about best practice protocols using a case-based learning approach to co-manage patients with primary caregivers in rural communities and prisons in New Mexico. Conservative estimates suggest that approximately 34,000 New Mexicans, including 2500 prisoners are infected with HCV, and the state leads the nation in deaths from chronic liver disease and cirrhosis. Prior to the launch of project ECHO, less than 1600 rural residents and no prisoners had received treatment for chronic liver disease. Since its inception in June 2004, Project ECHO has established 21 HCV treatment centers in rural New Mexico and at prisons around the state, resulting in an addition 3500 patients are receiving treatment during this time who were otherwise unlikely to have received any treatment at all. Given the success of the model to date, additional ECHO clinics have been launched for rheumatology, substance use and mental health disorders. Empowering primary caregivers at rural clinics has several long term effects. Rural physicians gain expertise, earn required continuing education credits, and are encouraged to remain in remote communities by having one of their highest priority needs answered: an opportunity to continue learning and to interact with professional colleagues.
Context for Disruption:
Project ECHO (Extension for Community Healthcare Outcomes) is an innovative, collaborative partnership of an academic medical center with a network of rural health clinics, Public Health Service, and the Department of Corrections for the delivery of health care and clinical education in the management of complex, common and chronic diseases in underserved areas, using hepatitis C (HCV) as a model.
The key component of the ECHO model is a disruptive innovation called a Knowledge Network. In a one-to-many knowledge network, the expertise of a single specialist shared with several primary healthcare providers, each of whom sees numerous patients. The flow of information in a Knowledge Network is NOT unidirectional; the specialist and community-based primary care providers gain invaluable feedback and case-based experience through weekly consultations.
Telemedicine and internet connections enable specialists in the program to co-manage patients with complex diseases using best practce protocols, case-based knowledge networks and learning loops. Learning loops are case-based educational experiences in which community providers learn through three main routes: (1) longitudinal co-management of patients with specialists, (2) other primary care providers on the network via shared case-management decision making and, (3) short didactic presentations on relevant topics, such as vaccination for hepatitis A and B and diagnosis of depression. These learning loops create deep domain knowledge about the area in question—here HCV—among rural providers, enabling them to provide the highest quality treatment for their patients Systematic monitoring of treatment outcomes is an integral aspect of the project. We believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes. The primary beneficiaries of this innovation are patients in underserved areas.
Delivery Model
Project ECHO uses teleconferencing and videoconferencing; Internet-based assessment tools; online presentations; and telephone, fax, and e-mail communications to connect specialists with primary care providers in prisons and rural areas and to promote the use of identified best practices. Telemedicine and Internet connections enable specialists and primary care providers to co-manage patients with HCV infection, increasing the capacity of rural clinicians to provide treatment for HCV. Project ECHO participants must have access to the internet and telephone service (including a fax machine and a speaker phone). Video conferencing is optional but enhances the interaction between the partners and specialists and requires broadband access and a video camera. Project ECHO network partner organizations are recruited through statewide health care conferences, presentations, and partner contacts. Project ECHO network clinicians include pharmacists, nurse practitioners, primary care physicians, and physician assistants. Once a provider organization joins the Project ECHO network, members of the UNM HCV team visit the site to conduct a 1-day training workshop. After completing orientation and training, network clinicians present and discuss their HCV patients during weekly 2-hour telemedicine clinics. The clinics use a standardized, case-based format that includes discussion of treatment complications and psychiatric, medical, and substance use issues. During these clinics, network clinicians collaborate with specialists in gastroenterology, infectious disease, psychiatry, substance use, and pharmacology, as well as with other network clinicians.
Project ECHO is designed to develop network clinicians’ skills so that they can deliver the highest quality HCV care with less need for specialist assistance. Because specialists have limited time available, a project based only on consultations with the UNM specialists would have limited ability to expand HCV care.
Key Operational Partnerships
The University of New Mexico (UNM) provides project leadership, specialist expertise, technology and outcomes evaluation.
Thirteen federally-qualified rural health clinics are currently partnered with the University of New Mexico to set up centers of excellence for HCV care for residents of rural communities.
The Indian Health Service currently provides care for Native Americans in the state and has established a center to treat patients with HCV.
Eight prisons in the New Mexico Department of Corrections have partnered with project ECHO. Primary care physicians and other health providers participate in clinics and treat prisoners who have HCV and HIV.
The Primary Care Association is a principal partner and represents over 50 federally-qualified health clinics through a statewide network linked by T1 lines.
The New Mexico Department of Health also provides funding for Project ECHO, acts as a consultant on the network, and has established a treatment site in Las Cruces.
These partnerships are the core of the collaborative project and are essential for its success. The primary objective of the project is to enhance the ability of the UNM partners to provide best practice care for common, chronic and complicated illnesses to rural and underserved patients throughout the state.
Impact
Financial Model
The cost of health care in the United States is higher and continues to increase faster than in other developed countries. Yet a commensurate gain in quality of care and patient satisfaction is not being obtained. (Anderson, Reinhardt et al. 2003; Reinhardt, Hussey et al. 2004) Despite higher spending in the U.S., Canada and the European Union have consistently earned higher patient satisfaction scores on cross-national surveys. (Blendon, Benson et al. 1995) A central factor in the disparity between health care expenditures and outcomes in the area of complex disease management is the relative lack of collaboration between the public, the government, and the academic and private sectors in the U.S. The most effective interventions to improve health care delivery to rural areas are those that support the education of primary care physicians, increase the flow of providers to rural areas, strengthen and support rural health care institutions and integrate rural health care into larger regional systems. The ECHO model principles are designed to help achieve these objectives in rural America and the developing world.
The traditional fee for service system does not have an adequate reimbursement methodology for education and training of primary care physicians to enhance collaborative care for underserved populations. To overcome this barrier, ECHO has adopted a public health model of funding. In this model federal and state governments absorb the cost of disseminating best practices by funding academic health centers to start "knowledge networks" for chronic, complex disease care. In the future we anticipate large integrated healthcare systems and health maintenance organizations to set up "knowledge networks" to empower primary care physicians.
To address HIV treatment in many of the developing countries in Africa, the cost of setting up "knowledge networks" requires funding by international agencies and foundations.
What is your annual operating budget?
1.3 m
What are your current sources of revenue? (please list any sources that are foundation grants)
The project is supported by a federal grant from the Agency of Healthcare Research and Quality, Deparatment of Health and Human Services: 1 UC1 HS015135-03
We also receive funding from the New Mexico Legislature and New Mexico Department of Health
Effectiveness
Since June 2004 we have conducted 205 HCV "knowledge network" clinics and provided 2316 consultations for HCV patients. 21 HCV centers of excellence have been established around New Mexico and thousands of high risk patients have been screened for the disease and eligible patients have received a 6-12 month treatment regimen with interferon and ribavirn under the remote supervision of UNM specialists. 71% of rural patients and 74% of prisoners treated were minorities. Outcome studies have demonstrated that the care provided in rural areas and prisons is as safe and effective as that provided in a university-based clinic. Many of these patients are now free of the HCV virus. Without the ECHO project these patients would have suffered the long term effects of HCV including liver cancer or cirrhosis and might have required a liver transplant.
Primary care providers have received more than 3000 continuing medical education credits for participation. Outcomes research to evaluate effectiveness of the education model has revealed that physician competence and professional satisfaction is enhanced rapidly in a highly statistically significant way.
As a result of the success of the HCV ECHO model there has been significant demand to treat many other complex and chronic diseases, and we now have ECHO clinics for substance use disorders, mental health disorders, cardiac risk reduction (diabetes, hypertension, hyperlipidemia, obesity, smoking cessation, nutrition and exercise physiology), prevention of teenage suicide, rheumatology and childhood obesity.
The University of New Mexico has adopted this model as an important way to fulfill its mission to improve the health of all New Mexicans.
Which element of the program proved itself most effective?
The most effective part of the program has been increased provider knowledge and self efficacy regarding care of HCV which has enhanced capacity for care in rural areas and prisons. The impact on provider knowledge and self-efficacy in treating complex health conditions is assessed through intensive written surveys administered at baseline and repeated every six months. In a survey of 24 participating providers, almost all have reported moderate or major improvements in their knowledge and self-efficacy about a variety of treatment issues.
- Knowledge about HCV management and treatment Major: 96% Moderate: 0%
- Symptoms of HCV patients in treatment Major: 79% Moderate: 13%
- Achieved competence in caring for HCV patients Major: 92% Moderate: 8%
- Belief in own ability to treat HCV (self-efficacy) Major: 71% Moderate: 17%
Providers perceived that these benefits of participation in ECHO were achieved through a number of different elements of its provider learning strategy as well as through its inter-disciplinary team of experts.
- Access to expertise in behavioral/mental health Major: 84% Moderate: 8%
- Access to expertise in pharmacology Major: 67% Moderate: 21%
- Collegial discussions with peers about HCV patients Major: 71% Moderate: 17%
• 29 provider surveys were completed at the project’s annual meeting in February 2006. These providers reported a moderate to high degree of change via ECHO participation in their approach to patient education (72%). Most providers (86%) reported access to ECHO specialists when needed. Most (76%) found that collaboration with ECHO was of benefit to their clinic or organization. One additional benefit was that 65% of providers reported that ECHO diminished their professional isolation.
Number of clients in the last year?
ECHO Community Clinics:
1) Number of clinical sessions with HCV patients by ECHO site providers - 4282
2) Number of ECHO patients receiving HCV education (Incl. Non-PCP, such as nurse, health educator, etc.) during office, class, or home visits- 7124
3) Number ECHO patients referred to psych/mental health services- 510
4) Number of CME/CEU issued for professional HCV training sessions- 1306
5) Number of community members educated during HCV educational events-815
6) Number of ECHO patients referred for substance use counseling and/or treatment (Including Opiate Replacement Therapy)- 381
7) Number of case presentations during ECHO Tele-Health Clinics- 757
ECHO Prison HCV Program:
1) Number of HCV positive prison inmates enrolled in Hepatitis C Chronic Care Clinic Program in NMCD - 2214
2) Number of Hepatitis C Chronic Care Clinic sessions clinic visits/encounters with inmates in NMCD-3410
What is the potential demand?
HCV, the exemplar in Project ECHO, exhibits the six characteristics we have identified for making a disease amenable to treatment utilizing knowledge networks:
1. The disease is common.
2. The disease has complex management.
3. Treatment for the disease is evolving.
4. The disease has high societal impact.
5. There are serious outcomes of failing to treat the disease.
6. Improved outcomes can be obtained with best practices.
Common diseases such as HCV, cardiovascular disease, and mental health disorders account for the majority of morbidity and morality in the United States. Improving outcomes for these diseases can thus have a disproportionately greater impact on quality and quantity of life in this country.
These common conditions are also complicated to manage, and effective treatment is beyond the training or experience of most primary care providers. The treatment of these diseases is rapidly evolving with new research constantly dictating changes in disease management, making it nearly impossible for a primary care provider to keep up with the latest developments of one, much less a multitude, of chronic health conditions.
The Global Burden of Disease Study reports that in 2020, the 5 leading causes of death worldwide will be ischemic heart disease, unipolar major depression, traffic accidents, cerebrovascular disease, and chronic obstructive pulmonary disease. Through the use of state-of-the-art technology and best practices for the management of such diseases, substantially improved outcomes in quality of life, cost-effectiveness of care, and survival can be achieved.
Project ECHO principles can also be applicable for training and education of a geographically disparate work force to address other endemic problems in developing countries. Knowledge networks can be used to continuously disseminate best practices in diverse fields such as secondary education, population control, environmental pollution, and agriculture.
Scaling up Strategy
We envision a system in which large urban tertiary healthcare centers and academic health centers worldwide will form the hubs of "knowledge networks" each supporting numerous rural centers of excellence to provide care for chronic, common, complex diseases.
Our primary goal is to disseminate these concepts worldwide so that other healthcare systems and nations can use the principles for enhancing healthcare for underserved populations. Our efforts to date include:
1) The publication of two peer reviewed articles on the model.
A) Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico: Arora S, Thornton K, Jenjusky SM, Parish B, Scaletti JB: Public Health Rep. 2007;122 Suppl 2:74-7
B) Academic health center management of chronic diseases through knowledge networks: Project ECHO: Arora S, Geppert CM, Kalishman S et al: Acad Med. 2007 Feb;82(2):154-60
2) The project was selected as a success story by AHRQ (Agency of Healthcare Research and Quality) and highlighted on the Health and Human Services web site: tinyurl.com/27xa3w
3) The project was featured in a public television series "Remaking American Medicine"
4) The project director has given more than 50 oral presentations at national and international meetings including presentations in Japan, Vietnam and India.
5) We have established a collaboration with the National AIDS Control Organization of the Govt of India to use the ECHO model as part of the HIV control program .
Future funding will be used to demonstrate the effectiveness of the model for HIV care in India
Stage of the initiative:
1
Expansion plan:
Our short term plan is to expand the ECHO model for care of other common, chronic, complex diseases in rural New Mexico and prisons. In April 2006 we initiated a program to increase access to chemical dependency treatment for underserved residents across the state of New Mexico. Because New Mexico leads the nation in the incidence of death from heroin overdose the initial focus for the substance use clinic has been on opiate dependence; over the next year we will expand to include alcohol and other substance use disorders. The ECHO substance use clinic has provided Buprenorphine training (8 hours of face-to-face training per provider) and federal certification at no cost to 60 physicians, more than doubling the number of providers in New Mexico who can prescribe Buprenorphine for opiate addiction. We plan to develop 10 additional Centers of Excellence throughout the state for the treatment of substance abuse and associated behavioral health disorders (similar to what is being accomplished for treatment of HCV).
Other ECHO clinics in various stages of implementation are HIV care, rheumatology consultation, autism, cardiac risk reduction, high risk pregnancy, occupational health disorders, childhood obesity, and prevention of teenage suicide.
Over the next year we plan to partner with the government of India to use the EHCO model for expanding access to anti retroviral treatment for HIV in rural India
Origin of the Initiative
In 2003 we developed the ECHO model in response to a major community need. Estimates suggest that 34,000 people in New Mexico are infected with HCV. More than 40% of these patients are uninsured and many live in remote rural, and underserved communities with no access to treatment. Most rural clinics do not have the expertise to treat these patients and the only University clinic in New Mexico lacked the capacity to provide treatment, which requires first weekly and then monthly physician and nurse visits for 12 months. Additionally, the round trip distance to/from the centrally located clinic in Albuquerque can be as high as 500 miles for many patients. Project ECHO began with the goal to expand access to HCV treatment for all patients in New Mexico by using technology, best practice protocols, and case based learning to leverage scarce specialist resources in the treatment of HCV.
This Entry is about (Issues)
Sustainability
What are your two main challenges to finance the growth of your initiative
One main challenge in expanding project ECHO is provider turnover in rural areas and prisons. When provider turnover occurs at a Center of Excellence, the University project ECHO staff have to start from scratch and retrain new providers. Provider staff in rural areas and prisons are often overworked and therefore are pulled in many directions. Therefore the project works best if some funding can be provided to rural sites to hire additional staff.
The main challenge in expanding to other countries is the absence of adequate healthcare infrastructure and teleconferencing equipment. In some cases, infrastructure improvements such as reliable power and high speed internet connections are required.
An additional $500,000 per year of operating costs will allow us to pilot the project in India.
How did you hear about this contest and what is your main incentive to participate?
Dr Scaletti, Associate Director of ECHO discovered this contest on the internet. Our main motivation is to raise awareness of the ECHO model, to make contacts with potential partners and have the opportunity to apply for future funding for our international expansion.
The Story
Do you have an annual financial statement?
No. We are a part of the University of New Mexico financial system.
Do you currently have an annual financial statement that tracks profit/loss?
In the Department of Internal Medicine we have active monitoring of financial information including all revenue and expenses at the Department Level. Project ECHO is treated as a separate cost center with full financial reporting capability.
Please describe the amount (and/or type) of funding you need to implement your initiative, at year 1 and at year 5.
Funding will be used for the following expenses:
1) Salaries for program staff in India
2) Cost of internet and videoconferencing for knowledge network clinics in India
3) Personnel costs at the University of New Mexico
4) Travel and supplies
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| Agenda.doc | 47 KB |
| barbara.doc | 25.5 KB |
| april.doc | 24.5 KB |
| clinic_medium.JPG | 182.4 KB |
| Lesley to Senator Domenici1.doc | 28.5 KB |
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Comments
Dr. Arora:
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!
Changemakers Team
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
sarora@salud.unm.edu
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
they use?
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."
More specifically, what is your scale-up plan in greater detail?
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.
http://echo.unm.edu/publications.shtml
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).
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
sarora@salud.unm.edu
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.
Dear Dr. Arora:
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!
Changemakers Team
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.
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
sarora@salud.unm.edu
Dear Sanjeev,
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
Director
Mahavir vatsalya aspatal
Patna, Bihar
INDIA
91-612-2277529
Dear Uday,
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.