By Dan Paloski, Communications Specialist, AHA’s Physician Leadership Forum
Imagine being stricken by hepatitis C, a curable disease, yet one that can be fatal if left untreated. Now imagine living in a rural area, with no immediate access to a specialist to help you treat your disease. Instead, you have to travel hundreds of miles to a large city to receive care, and in the case of hepatitis C, you’ll have to make this trip anywhere from 12-18 times for up to a year. This is contingent on your even getting an appointment. Most specialists have a months-long waiting list. The treatment regimen can be grueling, not to mention other barriers (social, economic, cultural, etc.) that may stand in the way of receiving treatment.
The above scenario is one that used to play out on a daily basis in the state of New Mexico. All told, it led to few people actually receiving treatment for the disease. Sanjeev Arora, MD, a liver disease specialist who ran a clinic treating hepatitis C at the University of New Mexico, knew there had to be a better way for people to receive care. What he came up with was Project ECHO (Extension for Community Healthcare Outcomes), an innovative health care model that would help bring education and delivery to underserved areas.
Project ECHO began in the summer of 2003. At the time, an estimated 34,000 New Mexicans suffered from hepatitis C. Dr. Arora estimates that less than 5% were receiving treatment or had access to it. To combat this, Project ECHO created 21 centers of excellence for treating hepatitis C all over New Mexico. Because of a lack of liver specialists in rural New Mexico, each center is run by a primary care clinician. Clinicians receive a crash course from University of New Mexico Health Sciences Center specialists in the treatment of hepatitis C. Weekly “virtual grand rounds” are led by this same team of specialists, who review and discuss cases with the primary care clinicians. By partnering with the specialists, the primary care clinicians benefit from case-based learning. They receive guided feedback and ongoing learning as well as have a chance to learn from each other through the network’s provider interaction and shared decision-making. All of this creates a continuous learning loop for the primary care clinicians based on common interests and concerns regardless of physical location.
Project ECHO is partly funded by an $8.5 million grant from the Center for Medicare and Medicaid Innovation. Other funding is provided by the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality, the state of New Mexico legislature, and the New Mexico Department of Health. Long term, Dr. Arora says funding will be transferred to managed care organizations that have a strong interest in improving quality while reducing costs.
According to Dr. Arora, results for Project ECHO have been positive. He said clinicians participating in the clinics report high levels of satisfaction, reductions in feelings of professional isolation, improvement in self efficacy in taking care of this complex problem, and enhancement of access to care for their patients. The most pleasant surprise, however, is that when compared to the university specialist clinic, the 21 ECHO clinics were able to cure hepatitis C at the same rate. Dr. Arora speculates this may be because of better patient adherence to treatment protocols due to the relationship they already have established with their primary care clinician and the increased ease in being treated closer to home.
Dr. Arora says the biggest challenge with Project ECHO has been the time involved in training primary care clinicians to become experts on hepatitis C. This training time takes away from their productive time, which is seeing patients. He said one of the goals of Project ECHO is force multiplication, where the primary care clinicians become so adept at treating the disease that they need less intervention from the university specialists, thus cutting the overall cost to treat the disease. Despite this challenge, Dr. Arora says primary care clinicians are so interested in working for Project ECHO that they are able to convince their leadership how important this is for them and find time in their busy schedules to attend training. In the future, Dr. Arora hopes there is some way to recognize this learning and the value created through some sort of reimbursement mechanism for these primary care clinicians.
The success of Project ECHO can be seen all over. It has been replicated across a number of different specialty areas (HIV/AIDS, diabetes, and rheumatology to name a few) and at a number of different institutions around the country including the University of Washington, the University of Chicago, and Beth Israel Deaconess Medical Center in Boston. According to Dr. Arora, The Department of Veterans Affairs is replicating Project ECHO in 11 regions across seven different disease categories. The Department of Defense is also replicating the program worldwide to treat chronic pain. Project ECHO has even expanded into developing countries. For example, in India the model is being used for HIV and viral hepatitis. Dr. Arora envisions other developing countries using Project ECHO to treat tuberculosis or malaria.
Dr. Arora feels the need for Project ECHO-like clinics will continue to grow, not only in developing countries but also in the United States as health care reform takes shape and millions of new patients enter the market. In order to use this model, he says six criteria must be met:
- The disease is common
- Management is complex
- New treatments are emerging
- There is a high societal impact in terms of health or economic impact
- There are serious outcomes of untreated disease
- Effective treatments exist
Project ECHO is one of the models transforming the way health care is delivered to those who lack access. It breaks down the barriers between primary and specialty care and leverages technology, limited resources, and expertise to treat complex conditions. Thus far within the scope of specific disease approaches, it has proven to be a cost-effective model that delivers high-quality care while containing costs.
For more information on Project ECHO, visit http://echo.unm.edu.