William Hull
RN, BSN
PhD Student,
College of Nursing
University
of Utah
Background
Historically care is and has been delivered in primary care
settings by primary care physicians. As healthcare has advanced and science has
marched forward, heath care has become increasingly complex. This complexity
has led to a fragmentation of medical knowledge as care has been delegated to a
number of sub-specialties—gate keepers of advanced specialty treatment
knowledge. This has created a complicated situation for many rural patients
diagnosed with illnesses requiring specialty care. First, specialists may often
have large patient loads and extensive wait times which can delay treatment and
consultation, often for months. Furthermore, to receive care, these patients
may have to drive long distances—at a cost of time, lost work, and pay. Then, depending
on the diagnosis, patients may have to travel a number of times per month or
year to receive appropriate care. Finally, in this model, patients interact
with unknown physicians—void of prior relationships of trust. These barriers to
receipt of optimal healthcare services in the current system, result in poorer health
outcomes for rural patients.1
Source: Blackbird
Studios – Jodi Hull
Assumptions of the Existing Paradigm
Under the aforementioned primary care model, it is assumed
that specialty care cannot be delivered without a specialist. In the model, the
specialist holds the knowledge for treatment and acts as the gatekeeper. The
assumption is that If care were to be delivered outside of the physician
specialty model, treatment would be ineffective, subpar, and potentially
detrimental to the patient.
The Birth of Project ECHO
Dr. Sanjeev
Arora and the University of Mexico health science center in Albuquerque observed
this problem first hand in New Mexico. As a practicing Hepatologist, Dr. Arora
had an eight month wait time for consultation with many of his patients driving
100-250 miles to be treated for Hepatitis C. Patients over the course of
treatment made as many as 20 (average of 18) visits to academic medical centers
resulting in many patient burdens, such as high travel cost, cost of specialty
care consultation, and a loss of work time. Observing this problem, Dr. Arora
developed project Extension for Community Healthcare Outcomes (ECHO).2
What is Project ECHO
Project ECHO utilizes teleconferencing technology to connect
specialist with rural area physicians. Community based rural providers learn
from specialists via “learning loops” as they co-manage patients utilizing the
concepts of case based learning.3
ECHO enables rural providers with knowledge to treat complex patients with a
variety of diseases that historically would be considered to fall outside of
their scope of practice. In this regard ECHO departs from the standard
telehealth model—the rural provider maintains stewardship of the patient as the
specialist acts as a knowledge broker and mentor.4
Source: Blackbird
Studios – Jodi Hull
Potential Impacts
The initial project ECHO for Hepatitis C demonstrated safe
and effective treatment with equal cure rate to those treated at the academic
medical center.2
Other benefits to the patient include decreased cost of travel, decreased wait
times, and care from a trusted and familiar provider. Further, aside from
developed knowledge and demonstrated competence in managing patients requiring
specialty care, rural care providers exhibited increased job satisfaction and
reduced sense of professional isolation. These additional benefits may lead to
better provider retention in rural areas.3
Today ECHO operates from 120 locations treating 60 conditions in 23 countries.5
Created Using Google
Sheets and Project ECHO Location Information6
Why is this change necessary?
There is a worldwide shortage of specialty physicians. In
New Mexico alone, there were 30,000 patients with hepatitis C with two specialty clinics in the entire
state where these patients could receive treatment. Of these hepatitis C patients,
only 1,600 were receiving treatment for chronic liver disease.1
This is not an isolated problem only
relevant to New Mexico and hepatitis C patients. According to the
Centers of Disease control and Prevention, currently 15% of the U.S.
population live in rural areas. Furthermore, a recent CDC study demonstrated
that rural Americans are more likely to die from potentially preventable disease
than their urban counterparts.7
Barriers to adoption
Although ECHO has demonstrated promising results barriers
exist to widespread implementation. These barriers include: lack of access to necessary
technology, lack of reimbursement and/or financial incentives, and lack of
provider time.8 Scott, J., et al., cited financial
sustainability as a pivotal challenge in continuing the Project ECHO project in
the northwest.3
This may be in part due to a lack of research that demonstrates fidelity for
reproduction of the project in other locations. Furthermore, high-fidelity
methodologies—randomized control trials—and further studies of cost
effectiveness continue to be needed to measure the effectiveness of the project.8
Recommended readings/viewings:
References
1. Arora
S, Kalishman S, Thornton K, et al. Expanding access to hepatitis C virus
treatment--Extension for Community Healthcare Outcomes (ECHO) project:
disruptive innovation in specialty care. Hepatology.
2010;52(3):1124-1133.
2. Arora S, Thornton K, Murata G, et
al. Outcomes of treatment for hepatitis C virus infection by primary care
providers. N Engl J Med. 2011;364(23):2199-2207.
3. Scott JD, Unruh KT, Catlin MC, et
al. Project ECHO: a model for complex, chronic care in the Pacific Northwest
region of the United States. J Telemed
Telecare. 2012;18(8):481-484.
4. Arora S, Thornton K, Jenkusky S,
Parish B, Scaletti JV. Project ECHO: Linking university specialists with rural
prison-based clinicians to improve care for people with chronic hepatitis C in
New Mexico. Public Health Reports. 2007;122(Supplement
2):74-77.
5. UNM School of Medicine Project ECHO.
Our story. 2017; http://echo.unm.edu/about-echo/our-story/.
Accessed July, 13, 2017.
6. UNM School of Medicine Project ECHO.
ECHO Hubs & Superhubs: Global. 2017; https://echo.unm.edu/locations-2/echo-hubs-superhubs-global/.
Accessed August, 1, 2017.
7. Rural Americans at higher risk of
death from five leading causes. Demographic, environmental, economic, social
factors might be key to difference. 2017; https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html.
Accessed July 13, 2017, 2017.
8. Zhou C, Crawford A, Serhal E,
Kurdyak P, Sockalingam S. The Impact of Project ECHO on Participant and Patient
Outcomes: A Systematic Review. Acad Med. 2016;91(10):1439-1461.
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