SPECIAL ARTICLE
ECHO PROJECT
(Extension for Community Healthcare Outcomes)
Sanjeev Arora, MD* & Nick Shroff
The Extension for Community Healthcare Outcomes
(ECHO) Model is a platform that delivers complex
specialty medical care to underserved populations through
an innovative educational model that consists of team-
based inter-disciplinary development.
Using technology, best practice protocols, and case
based learning; ECHO trains and supports primary care
clinicians to develop knowledge and self-efficacy on a
variety of diseases, enabling them to deliver best possible
care for complex health conditions in communities
where specialty care is unavailable. The model has broad
applicability to improve healthcare in India for chronic
complex diseases.
INTRODUCTION:
A number of strategies have been used worldwide to
increase access to health care in underserved areas. While
these efforts have reduced barriers, specialty care for complex
and chronic health conditions remains limited in rural and
semi urban areas around the world.
A potential solution is an innovative paradigm to allow
specialized medical resources of Academic Medical Centers
(AMC) to be accessible outside of urban areas. Expanding
knowledge and skillsets of local providers allows rural patients
equal access to expertise care.
Most rural areas cannot afford the broad range of disciplines
and specialty medical training needed to deliver best practice
care for even a small number of complex and chronic health
conditions. It is not feasible to provide a full range of specialty
care in outlying areas using current strategies and available
options. Given the existing financial and infrastructure
barriers, broader access can only be achieved through
innovative strategies and technology such as the ECHO
Model that allows rural and small town clinicians to utilize
centralized expertise.
26 Spring 2011 sAAPI Journal
By providing consultation and case-based learning using
an inter-disciplinary team at an AMC, this model responds
directly to key unmet needs. The purpose of the model is
“force multiplication” defined as a logarithmic increase in
capacity of care for complex diseases in rural areas.
BACKGROUND:
The idea for Project ECHO grew out of New Mexico’s
severe hepatitis C problem. Prior to Project ECHO, fewer
than 1,600 New Mexicans had received treatment for hepatitis
C and chronic liver disease, although an estimated 34,000
residents had the disease. Hepatitis C is curable, but the
treatment regimen is grueling and requires twelve to eighteen
visits with a specialty provider over the course of a year. For
patients who live great distances from academic medical
centers or other major hospitals, or who lack transportation
or face other access barriers, it can be difficult to impossible
to see a specialist. For patients who are poor, uninsured, or
underinsured, a number of other social, cultural, linguistic,
and financial barriers may stand in the way of care.
However, few rural practitioners are prepared to deal
with treatment side effects, drug toxicities, treatment-induced
depression, and co-occurring conditions. These can include
mental health issues and substance abuse, both of which are
common among hepatitis C patients. Optimal management
of hepatitis C requires consultation with highly trained
specialists from multiple areas, including gastroenterology,
infectious disease, psychiatry, and addiction medicine.
Rural primary care providers who are treating patients in
their home communities may want to consult with specialists,
but they typically have limited access to such specialists or other
difficulties in doing so. If they choose to refer their patients
to specialists, the severe shortages of specialty providers in
rural areas means that people with complex conditions such
as hepatitis C often have to wait months to get treatment.
Primary care physicians may then have few options but to
refer patients to the closest academic medical center or other
major hospital--which, as noted, may not be close at all. Not
surprisingly, given the numerous barriers they may face, such
patients often forgo treatment or wait until they have severe
complications before seeking help.
THE ECHO MODEL AND HOW IT WORKS:
The ECHO Model uses technology, such as webcams,
custom software and clinical management tools, to train and
support primary care providers from underserved areas to
develop knowledge and self-efficacy so they can deliver best
practice care for complex health conditions.
When a new partner site--a primary care practice in
a rural area, for example--joins the network, ECHO staff
members first conduct a two-day, in-person orientation
in Albuquerque. The orientation explains the hepatitis C
treatment protocol as well as the communications technology
and the case-based presentation format for the weekly two-
hour telemedicine clinics. Next, primary care clinicians--
including physicians, nurses, and physician assistants--are
organized into disease-specific learning networks that meet
weekly via videoconference to present cases. A team of
University of New Mexico Health Sciences Center specialists
who review and discuss cases with primary care providers
leads these “virtual grand rounds” or “teleclinics”.
The hepatitis C team from the University of New Mexico
includes a hepatologist, a pharmacist, a psychiatrist, and a
nurse. These specialists do not assume the care of the patient;
in fact, the team from the Health Sciences Center never even
sees the patient. Instead, through a guided practice model, the
primary care provider retains responsibility for managing the
patient, operating with increasing independence as his or her
skills and self-efficacy grow.
Web-based disease management tools facilitate consults,
and specialists and primary care providers jointly manage
complex chronic illness care for patients, who are treated right
in their home communities. A secure, centralized database
monitors patient outcomes.
The knowledge network consists of (continued on page 28)
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regularly scheduled conference calls over regular landlines
or cell phones and web cam based online clinics that bring
together expert inter-disciplinary specialists from the AMC
and multiple community-based partners. These partners learn
best practices through “learning loops” in which they co-
manage diverse patients in real world situations and practice.
Over time, these learning loops create deep knowledge,
skills and self-efficacy. Provider evaluation results reported
in peer-reviewed journals have shown both a positive impact
on provider knowledge and self-efficacy while enhancing
professional satisfaction and reducing professional isolation.
Patient outcome studies have confirmed that the safety and
efficacy of HCV care provided by primary care clinicians
through ECHO collaboration and consultation are as good as
traditional care delivery at an AMC.
EXPANSION TO OTHER CHRONIC
DISEASES AND OTHER GEOGRAPHIES:
After initial success ECHO has expanded beyond HCV
and now covers 12 additional disease areas that include
chronic pain, rheumatology, pulmonary disease, high-risk
in India to develop centers of excellence for prevention,
evaluation and treating Diabetes and the metabolic syndrome.
Community health workers and medical assistants will be
trained to become diabetes educators so they can become
a part of the disease management team at these centers of
excellence.
India like most developing nations lacks a fully developed
infrastructure, often limited broadband connectivity between
rural and urban areas. However, many towns (including
smaller ones) have access to broadband connectivity through
the national telephone carrier MTNL for less than Rs 1500
per (30 USD) month. Clinics will be chosen for the project
based on availability of broadband connectivity of 512 Kbps
per location. Project ECHO will provide the webcams and
software necessary for areas that have the required broadband
Internet access so that they may access the clinics via video-
conference.
As part of this process, the project will determine the
resources, support, expert leadership team, partners and
sustainability plans required to bring ECHO to other areas.
PREGNANCY()6!)$3ANDCARDIOVASCULARRISKREDUCTION!S The proposed project will incorporate four key elements of
of September 2011, 305 partner teams across New Mexico
have collaborated on more than 11,000 specialty care
consultations for multiple chronic diseases. The project has
been successfully replicated at the University of Washington,
University of Chicago and in India for treatment of HIV.
Over 15,000 hours of Continuing Medical Education (CME)
and Nursing Continuing Education Units (CEUs) have been
issued to community-based primary care providers at no cost
to individual providers.
ECHO received international recognition as one of three
winning entries out of 307 world-wide applications from 27
countries in the 2007 Ashoka Changemaker’s competition for
Disruptive Innovations in Health and Health Care nationally
or globally.
THE PROPOSED PROJECT IN INDIA:
We propose a replication of the ECHO model in India
for cardiac risk reduction by setting up centers of excellence
for effective management of Diabetes, Hypertension, Lipid
Disorders, Obesity, and Smoking Effective education on diet,
exercise, weight loss, smoking cessation and use of low cost
treatments such as insulin and oral anti diabetic medications
can save millions of lives. However the specialized expertise
to educate patients and treat these disorders does not exist
in villages and many small towns of India. Primary care
physicians currently working in AAPI sponsored clinics in
India will collaborate with an Academic Medical Center
28 Spring 2011 sAAPI Journal
the ECHO model:
1) Case-based learning and learning loops delivered through
a knowledge network.
2) Best practice protocols for management of Diabetes,
Hypertension and Lipid Disorders
3) Tracking and evaluation of patient and provider outcomes
and
4) Five types of technology that make distance learning,
consultation, and evaluation feasible including: a) webcams
linked to a video conferencing bridge for consultative clinics,
b) a web based electronic disease management tool (iHealth- to
be developed for Diabetes by March 2011) that allows remote
entry of patient and outcome information for co-management
and outcome evaluation, c) fax machines for data exchange
where internet access is poor, e) webinar capacity to allow
delivery of didactic and interactive education to hundreds
of users simultaneously and e) a dedicated online video site
(similar to “You Tube”) that allows providers to directly access
recorded educational sessions at any time.
We will measure the number of patients treated, the
efficacy of treatment in small towns and compare that
to published literature and assess our ability to deploy
technology in India. Success of the project will demonstrate
the effectiveness of ECHO as an innovative paradigm for
providing best practice care for multiple complex diseases in
India.