A telemedicine platform developed about 15 years ago in New Mexico is now helping thousands of doctors across the country learn from specialists and manage care for patients with complex conditions.
Project ECHO (Extension for Community Health Outcomes) uses a hub-and-spoke model to connect rural and remote practitioners with specialists to discuss cases that would otherwise be sent to large — and distant — health systems. It’s now in use in more than 130 hubs across the United States, at health systems from Hawaii to Florida, as well as 23 other countries.
The basic model places an academic medical center or large health system at the hub and provides telemedicine links to primary care providers, clinics and federally qualified health centers who participate in teleECHO clinics, which can take place weekly, bi-weekly or monthly. Through a secure teleconferencing platform, primary care providers present their patient cases for review by specialists, discuss new trends and techniques, and gather advice from their peers on how to treat their patients.
“Essentially, ECHO® creates ongoing learning communities where primary care clinicians receive support and develop the skills they need to treat a particular condition, such as hepatitis C or chronic pain,” the Project ECHO model explains. “As a result, they can provide comprehensive, best-practice care to patients with complex health conditions, right where they live.”
A Model for Better Hepatitis C Care
Project ECHO was launched in 2003 at the University of New Mexico School of Medicine by Sanjeev Arora, MD, a liver disease doctor based in Albuquerque who wanted to improve care management and coordination for patients with hepatitis C. At that time it was estimated that only 5 percent of hep C patients in the state were receiving proper treatment.
While working in one of only two clinics in the state who were treating hep C patients, Arora created an online platform by which specialists like himself could share their knowledge with rural doctors, who could then treat their own patients. His goal was to both empower doctors to treat more of their own patients and reduce the heavy workload on specialists, who might have wait times for appointments of several months.
“Within a year of Project ECHO’s launch all these people had become expert,” says Arora, whose own wait times for appointments dropped from eight months to two weeks. “We were seeing exponential improvement in capacity to treat.”
From that hep C program, Arora saw a model — he calls it telementoring, not telemedicine — for treating other diseases and chronic conditions that might otherwise handcuff the rural practitioner or community clinic. In New Mexico alone, more than 3,000 providers are now treating more than 6,000 patients through ECHO programs in such areas as cardiology, bone health, chronic pain and opioid management, dementia, endocrinology, HIV and AIDS, substance abuse, cognitive rehabilitation and mental health.
The initial program’s success was detailed in a 2011 study posted in The New England Journal of Medicine, in which Arora and his team found that the ECHO model to be “an effective way to treat HCV infection in rural and underserved communities.”
Studying the effects of the program on some 5,000 case presentations made by 16 community sites and five prisons connected via Project ECHO, Arora and his colleagues found that patients treated by doctors trained via ECHO had similar success rates as those treated at an academic medical center, while they also sustained far fewer “serious adverse events.”
In explaining the results, Arora and his colleagues also noted the Project ECHO programs can be especially impactful to community-based health centers and providers.
“Community providers, particularly community-based health centers, provide coordinated, patient-centered care in facilities proximate to their patients,” they wrote. “Patients are likely to have greater trust in local providers, who tend to be culturally competent with respect to their specific communities. This may enhance patients' adherence to treatment and allow for greater direct contact with the clinician, including more frequent visits.”
“As a result, local providers may be better able to comply with best-practice protocols, ensure close assessment of the results of laboratory tests, offer education tailored to the patient, and provide better and more timely management of side effects,” the study concluded. “In addition, the fact that the primary care of the patient and the management of Hepatitis are provided by the same clinician ensures better coordination of care and fewer communication challenges.”
Project ECHO Across the Country
Project ECHO programs can now be found throughout the country, with programs launched by the MD Anderson Cancer Center at the University of Texas, the University of Massachusetts Medical School, the Oregon Health Sciences University, the University of Idaho, the University of Chicago and countries like Northern Ireland, Uruguay, India and Canada, to name a few.
One of the more extensive ECHO programs in the US is run out of the Missouri Telehealth Network and the University of Missouri Health System. Appropriately titled Show-Me ECHO, the four-year-old program offers telementoring for asthma care and education, autism, child psychology, chronic pain management, community health programs, dermatology, hepatitis C, opioid abuse and even healthcare ethics (a new, once-a-month program developed in a partnership[ with West Virginia healthcare officials).
“We’ve been doing telemedicine for more than 20 years,” says Rachel Mutrux, Senior Program Director for the University of Missouri and Show-Me ECHO Director. “We really thought that we were spreading knowledge, but once we saw the ECHO program we realized we weren’t doing it as well as we could.”
Mutrux says remote and rural healthcare providers across the Show Me State “want to join this program because of who they are.” These providers are all committed to providing the best care possible for their patients, she maintains, and that also means helping those patients avoid long waits for specialist care and long and expensive trips to distant hospitals or clinics.
“When they get into this, they quickly realize how little they know about a certain [condition] and they want to do a better job,” she says. For example, one rural doctor has joined four different Project ECHO programs. “They want to be care providers. They’re really willing and eager to learn, and they’re learning from the best.”
The challenge, as always, lies in funding the programs. An ECHO program can run up costs of $250,000 a year. Much of the cost is covered in federal and state grants targeting specific healthcare issues (e.g., opioid dependency or pediatric health). Some funding can be found in higher education budgets or even corporate donations.
“Planning out a new Project ECHO program is a huge deal right now,” says Mutrux, adding that some past programs have been discontinued. Recently, she says, the state secured an $8 million grant over two years for a new asthma ECHO program, based primarily on preliminary Medicaid claims data.
“How best do you evaluate these programs if they don’t directly affect the patient care model?” she asks. “We know what Project ECHO is doing and why it’s working for us, but how do you measure it? How do you measure autism, for example?”
That said, Mutrux has a long list of subjects she’d like to see included in future ECHO programs, topics that remote doctors and nurses could and should learn more about.
“The biggest benefit is definitely access to care,” she says. “We’re giving doctors access to the information they need to treat their patients, and we’re giving [underserved populations] better access to the care they need.”
At the University of Rochester Medical Center in New York, Michael Hasselberg, MS, PhD, admits that the health system “kinda fell into” the ECHO program about four years ago, when officials asked him to create a new platform to help reduce the eight-month wait time for specialist services.
“There was a traditional telemedicine model, but we weren’t so excited about traditional telemedicine,” says Hasselberg, Director of both the ECHO Program and UR Medicine’s Telepsychiatry Program and an assistant professor of psychiatry and clinical nursing.
“I was pessimistic at first,” he adds. “How would we convince primary care doctors to attend education session every two weeks and not get paid for it? It’s time-consuming, complex and there’s not a lot of reimbursement going on.”
After flying down to New Mexico to check out the ECHO Program, Hasselberg came back with a plan. He forged partnerships with several groups, ranging from HMOs to health systems, and launched a geriatric mental health ECHO program in 2014. Within a short period of time, he was training some 500 primary care providers across 32 counties.
URMC now runs several ECHO Programs targeting autism, eating disorders, palliative care, and psychiatry as well as geriatric mental health in long-term care.
“Folks are satisfied with this model,” Hasselberg says of the primary care providers across the state logging on to learn more about complex cases and treatments. “They feel more job satisfaction. They’re doing what they were trained to do — deliver healthcare.”
Akin to Mutrux, Hasselberg recognizes that a new ECHO program takes a lot of time and effort to develop. The right specialists have to be found and convinced to take the time to share their expertise, and remote and rural general practitioners have to buy into the concept of care coordination and management of complex, often-high-cost patients.
“We tell them, ‘This is an opportunity for you to have access to specialists,’” he says.
In organizing the programs, Hasselberg says finding good facilitators to keep the conversation going is important. He also recommends limiting the size of each program — URMC sets a limit of 30 participants — and dividing the program into cohorts if there is a lot of interest.
Going Too Far Too Fast?
Not everyone is on board with the idea of replacing specialist care with what critics say is essentially enhanced primary care. Some say Project ECHO hasn’t proven anything yet.
“Continuing education as a path to improved health outcomes is an attractive theory, especially to experts in a field who have gone through years of additional training to get their expertise. They imagine that if others had gone through their training, that things would get better,” Christopher Langston wrote in a January 2017 blog in Health Affairs.
“However, the evidence for the benefits of continuing education on outcomes is less than clear,” he continued. “More subtle and less modifiable forces also play a role -- interest, design of the practice setting, and incentives.”
Admitting that he felt like “a skunk at a party to critique Project ECHO,” Langdon argued that the model hasn’t proven itself beyond the hepatitis C case study, and that it may not work as well on other disease or conditions. He also cited the enormous costs in setting up an ECHO program and the current lack of funding or reimbursement for providers launching such a model.
“These are big bets with still little evidence of benefit and good reason for concern,” he wrote. “It is important not to get carried away by the hope of a seemingly simple intervention that fits our preconceptions. ECHO has substantial costs in expert and PCP time and without better evidence of its effects on patient outcomes, doubling down on our investments is premature.”
Hasselberg also senses that concern. He’s also worried that supporters of the ECHO model are moving too far too fast.
“This is a model that … needs evidence,” he says. “You’ve got all these ECHOs starting up, but they’re not doing good, solid evaluations of their efforts. These folks need more evidence to be able to move forward.”
The ECHO Act
Project ECHO gained national exposure in late 2016 with unanimous Congressional approval of the Expanding Capacity for Health Outcomes (ECHO) Act, which calls for a national study on the Project ECHO program with a goal of eventually making it a federally funded service.
“We’re now one step closer to supporting new ways to train health providers and deliver health care,” Senator Brian Schatz (D-Hawaii), co-sponsor of the legislation with Senator Orrin Hatch (R-Utah), said in a press release. “Technology is changing the way medical professionals connect with each other and their patients. Our bill capitalizes on this technology to give health professionals in hard-to-reach areas the specialized training they need and help them reach more patients.”
The legislation drew support from a wide variety of healthcare organizations.
“Because health centers are all located in medically underserved urban and rural areas or serve medically underserved populations, they regularly become the medical home for patients with complex needs and chronic conditions,” Dan Hawkins, Senior Vice President of Public Policy And Research at National Association of Community Health Centers, said following the bill’s passage.
The need is often amplified in rural areas which may have higher rates of chronic diseases and less access to specialty providers. By connecting specialists with primary care providers, the Project ECHO model allows for patients to access quality care close to home and creates opportunities for primary care physicians to manage complex needs in their own health centers.
Under the ECHO Act, the Department of Health and Human Services (HHS) and Health Resources and Services Administration (HRSA) are conducting an analysis of federally funded ECHO programs, including analyzing how they impact provider capacity and clinical outcomes. At the same time, the Government Accountability Office (GAO) is preparing a separate report on “opportunities for increased adoption of such models, efficiencies and potential cost savings from such models, ways to improve health care through such models and field recommendations to advance the use of such models.”
Eventually, HHS will present both reports to Congress, “including ways such models have been funded by HHS and how to integrate these models into current funding streams and innovative grant proposals.”
“Through today’s rural health initiatives, healthcare providers across the country can overcome miles of physical isolation through the utilization of telehealth, mentorship and collaboration projects,” Sheri Stoltenberg, founder and CEO of Stoltenberg Consulting, wrote in a January 2017 analysis of the legislation for mHealthIntelligence.com. “And in doing so, they'll have better opportunities for financial reimbursement, improved population health treatment and a more educated pool of connected community-care providers.”
While they appreciate the passage of the ECHO Act, Arora and colleagues involved in the programs contend the legislation fell far short of what they wanted. They note there was no federal funding included in the legislation, and only federally funded ECHO programs are being studied.
“There are very few of them around,” says Mutrux. “They’re missing out on many programs.”
Transforming How Healthcare is Delivered
ECHO Programs will likely pin their success on healthcare reform, according to Hasselberg.
“ECHO doesn’t fit into a fee-for-service reimbursement mechanism,” he says. “This will catch on as the nation moves to a quality-based system.”
“I’m not satisfied,” adds Arora. “We don’t want this to become another fee-for-service program. We want to make this a model for support.”
That’s the conclusion drawn by David Hutton, PhD, an associate professor specializing in health management and policy at the University of Michigan School of Public Health. Hutton was part of a team analyzing the cost-effectiveness of Project ECHO in hep C treatment.
Their study, published in the December 2017 issue of Gastroenterology, found that such a program involved a substantial investment up front, but could lead to “a cost-saving public health intervention” over time.
“We conducted this analysis to determine if financing this additional investment is worth the cost. We think government, private insurance and health system policy makers are interested in understanding how valuable these investments are,” Hutton told Medical Economics. “That’s why we feel the results of this analysis may help encourage this type of investment. With that in mind, it may take time to roll out new hubs and spokes for Project ECHO.”
“We have shown that the Project ECHO model to expanding care is a financially worthwhile one that could successfully reward implementers under a properly structured value-based system of payments,” he added. “Projects like this do not need researchers, but invested primary care clinicians who are willing to try out something new and engage with new models of care delivery, such as Project ECHO. Without the many clinicians in the field willing to go the extra mile for their patients, Project ECHO would never have worked.”
Arora, meanwhile, sees a bright future for ECHO.
“The principal idea is to democratize the knowledge of experts, rather than monopolizing it,” says Arora, who now travels across the globe to help health systems launch Project ECHO programs. “With Project ECHO, we’ve only scratched the surface.”
“We want to transform how healthcare is delivered in the US and elsewhere,” he concludes. “We want to change the way that knowledge is distributed.”