Wednesday, August 23, 2017

Project ECHO—Share the Knowledge

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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