Sanjeev Arora, MD is professor of medicine, director of Project ECHO, and executive vice-chair of the Department of Internal Medicine at the University of New Mexico Health Sciences Center, Albuquerque, NM.
Please give me an overview of Project ECHO.
Project ECHO stands for Extension for Community Healthcare Outcomes. Our mission is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. It’s funded by the Agency for Healthcare Research and Quality, the New Mexico legislature, and the Robert Wood Johnson Foundation.
We started this project about five and half years ago to treat hepatitis C, which is a global health problem affecting 170 million people worldwide, of which 3-4 million are in the US. In New Mexico, we had 28,000 patients who had hepatitis C. In 2004, less than 5% had been treated because there weren’t enough specialists in rural areas to treat them. There were 2,300 prisoners who were diagnosed with hepatitis C and none had been treated. We had the highest rate of chronic liver disease/cirrhosis deaths in the nation, so it’s twice the national average.
The disease was treatable and it can be cured. Hepatitis C has six main kinds of virus. If people had Genotype 1, we could cure them about 45% of the time. If they had other kinds of genotypes, we could cure them about 80% of the time. The problem was that if patients were given this kind of treatment, which consisted of weekly injections and daily pills, they got severe side effects.100% of patients became anemic. Their white cell count went down. About a quarter of them got depressed.
Primary care doctors didn’t feel comfortable treating this disease. There weren’t any specialists in the rural areas and in prison. That was the problem that we were trying to solve.
Rural areas of New Mexico are a very underserved area for healthcare services. Thirty-two of 33 New Mexico counties are listed as Medically Underserved Areas. Fourteen are designated as a Health Professional Shortage Areas. We said we could use this new model to develop the capacity to safely and effectively treat hepatitis C in all areas in New Mexico and to monitor outcomes. We felt, if we could do that, then we would have a model to treat complex diseases in rural locations and developing countries.
We developed a partnership between the University, the prisons, health department, Indian Health Service, and community clinicians who were willing to treat hepatitis C in rural areas. ECHO’s model is based on four key ideas.
One is the use of technology to leverage scarce healthcare resources which may exist only at a university or in a tertiary care center.
We use a disease management model, where we focus on improving outcomes by reducing variation and processes of care. We create a best practice protocol for treating hepatitis C and then we share it widely with our partners. We all manage off the same label. This is to improve quality.
The third key idea is case-based learning. That’s when a rural provider goes to medical school or residency. They learn from real patients and mentors. When they go to the rural area and a new disease like hepatitis C gets discovered in 1989, they’re expected to read books and then treat this disease. They don’t feel comfortable because it’s a very complicated disease. So we said, “Why should we not bring case-based learning back into the lives of the rural provider by co-managing patients with them? We have a centralized database to monitor outcomes.”
We train physicians, nurses and pharmacists in hepatitis C. Then we conduct these telemedicine clinics, which we call Knowledge Networks. Many rural clinicians sign on simultaneously onto an interactive video network with specialists from the university. One by one, they present patients with hepatitis C to experts at the university. The specialists at the university help them manage these patients, tell them what to do, what tests to order, what treatments to take, and help them manage side effects of treatment.
They come every week, once a week, for a couple of hours and present their patients. This creates a learning system which we describe as a Learning Loop, where these clinicians learn from each other as much as they learn from university specialists. They also learn from short didactic presentations.
We give the rural providers no-cost CME credits. We give nurses credits for participation because they are learning from experts at the university. We like to improve their professional satisfaction and we give them access to multiple specialists at the same time.
Everybody gets the chance to present their patients. We use all different kinds of technology, including videoconferencing bridges, videoconferencing recording devices, and electronic records to enhance communication. We described this first for hepatitis C, but it’s applicable to any disease that is common, management is complex, new treatments are coming, high societal impact, if there’s a serious outcome of a untreated disease, and if there’s effective treatment.
We have a few concepts that make Project ECHO work. One is we are trying to provide the same level of care at a community health center as we give at a university. We can do this by means of technology, best practice protocols, and case-based learning.
From the Pareto Principle, the 80/20 rule, if you create Knowledge Networks for just a few diseases, you can have a huge impact on healthcare. You don’t need to have Knowledge Networks for 500 diseases to have a huge impact. A few diseases account for most of the morbidity and mortality.
We use the concept of a Force Multiplier. Because of the specialist shortage in rural areas, we can use existing community clinicians like nurse practitioners and physician assistants and enable then to provide the same level of care as specialist, therefore multiplying the capacity for specialty care in rural areas.
One challenge that comes up is that there is not only a shortage of specialists in rural areas, there’s also a shortage of primary care doctors. This is the next generation of Force Multiplier, which essentially shows you that we are training now community health workers and medical assistants and nurses also in these chronic diseases so they can be part of the chronic disease management team to help the primary care clinicians.
Existing methodology for training and development of widely distributed learners has major limitations. They tend to be expensive and out of sight, out of mind. You call them in for a conference into your city, spend thousand of dollars, they go back, and they forget what you have taught them.
In our model, we help them apply this knowledge and, using technology, we can do this training at a much lower cost. Also, we don’t have the problem of knowledge obsolescence because it’s a weekly interaction where we are slowly making them experts.
We also have a prison peer education program where we train prisoners in New Mexico to teach other prisoners about hepatitis C.
We have 15 separate areas in which we have Project ECHOs going on: hepatitis C, cardiac risk reduction, asthma, rheumatology, chronic pain, substance abuse, high-risk pregnancy. Some are supported by the Robert Wood Johnson foundation. We have many others. Overall, we have more than 140 programs around the state.
With hepatitis C, we have done 375 HCV Telehealth Clinics. More than 3,500 patients have entered the HCV disease management program. We have provided thousand of hours of CME credit at no cost to clinicians.
We’ve taken community clinicians and assessed their skills and abilities on different domains of hepatitis C care. On the question of, “What is your ability to treat Hepatitis C patients and manage side effects?”, on a scale of one to seven, they were two out of seven when they started and it went up to 5.2 in 12 months alone. So, very major improvements occur as they engage with us in this learning process.
Asking if they could serve as a local consultant for hepatitis C in their clinic and area, it went from 2.4 to 5.6. Overall competence went from 2.8 to 5.5. When asked if this kind of activity is of moderate or major benefit to them, it ranged from 94% to 98%.
Subsequently, we did a hepatitis C trial in which we compared the care in the university to the care in the rural areas and prisons by primary care clinicians. Rural primary care clinicians deliver hepatitis C care that is as safe an effective as a university clinic. We can also improve access to care for minorities. Almost 69% of our patients in the ECHO groups are minorities, versus much fewer in the university.
The potential benefits of the model are improved quality and safety, improved access for rural and underserved patients, workforce training and force multiplier, improving professional satisfaction and retention, cost effective care by avoiding excessive testing and travel, preventing cost of untreated disease, for example, liver transplant, and integration of public health.
In 2007, applications were sought for disruptive innovations in healthcare, new models that would change healthcare nationally and globally. This was sponsored by ASHOKA Foundation and Robert Wood Johnson Foundation in a disruptive innovations contest. Project ECHO was selected a winner among 307 applications from 27 countries. We were one of three winners selected.
Using technology, best practice protocols, and co-managing patients with case-based learning is an effective way to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to minor outcomes.
This is the first program I’ve heard of where the goal wasn’t just to turn over patients to experts sitting on the other end of a monitor, but rather to educate and make local practitioners self-sufficient. Has anybody else done that?
We don’t know of anybody that has done it the way we do it. Basically, that is why it was selected, probably, as the most disruptive innovation in healthcare.
Commonly, technology has been used specifically in healthcare by telemedicine, where there’s a specialist at the university and there’s somebody in the rural area connected by camera. That doesn’t lead to the force multiplication that we’re talking about. We’re interested in long-term capacity expansion of care.
In the passage of time, these healthcare providers become less and less dependent on us as they become good at it. We are not aware of this model anywhere.
Healthcare reform always talks about who’s going to pay and who will be covered, but nobody has addressed the issue of having enough practitioners of the right types in the right places. Are you getting interest from the government or insurance companies about how they might use this model?
We have not focused so far on publicizing at all. This is the first initiative. We got a very large grant from Robert Wood Johnson Foundation and they hired a PR firm, which I think reached you. So I think that this is just the beginning, really.
Very few people know about this program in the way you have just learned about it. We have treated tens of thousands of patients through this methodology, but our focus has been on service, not so much on policy work or convincing healthcare providers. But we hope that some of the work you and your colleagues will do will help us get there.
We think that this is a very valuable tool for healthcare reform because we can train, not only primary care physicians, but community health workers to become experts in very common diseases like obesity and hypertension and diabetes.
Because of the shortage of primary care clinicians, how do you take care of all the chronic disease that is going on everywhere? We thought, if we trained the teams of the primary care clinicians in these very common problems, we’ll do a better job.
When a community health worker is used as a sole diabetes educator — that is, no doctor, no nurse, no certified diabetes educator — HbA1c can drop by 15%. Comparing the care provided by a community health worker and a nurse practitioner in the community versus a university-based primary care clinician, the community-based care does twice as good.
We asked ourselves, “Why is this community health worker intervention effective?’ These people live in the community. They understand the culture. They walk two moons in the patient’s moccasins. They appreciate the economic limitations of the patient and they often know family and can engage other the social resources. But most importantly, they spend more time with the patient.
If you are trying to change a diabetic or and obese patient’s behavior and doctor spends four 15-minute sessions with them over the course of a year, it’s hard to do that, whereas somebody like community health worker can spend seven one-hour sessions for one-tenth of the cost and actually make a bigger impact.
We have developed two tracks. The first one has already launched, the second one is in preparation. The first one we call the CHW Specialist Training Track, where we take these community healthcare workers and train them in diabetes, obesity, hypertension, cholesterol, smoking cessation, and exercise physiology. Then, over time, they start interacting with us on these Knowledge Networks until they really become experts in a very narrow area. This specialty CHW program uses low-cost technology to take specialty training to CHWs, promotoras, CHRs, and medical assistants where they live. It has a very narrow focus but deep knowledge, standardized curriculum.
We give them ongoing support via Knowledge Networks. They become part of the disease management team. Basically, the point that I was trying to make to you with reference to your question is, in healthcare reform, we have to train a much larger health workforce so that doctors work in teams, rather than individuals trying to solve the big problem.
I’m interested in your statistic on how well the community-based caregivers were able to do what they do. Do you think that would be true outside your population of the underserved or on a Indian reservation? Is it translatable to the rest of the United States?
There are some places in the United States where you have a highly trained work force, for example, Manhattan or Boston. There are hundreds of certified diabetes educators. So the moment somebody comes to you, you can refer them to a nutritionist, diabetes educator, or podiatrist. You don’t need a community health worker — you’ve got super experts doing all this work.
But when you go to a prison, a rural area, an Indian Health Service facility, there aren’t any certified diabetes educators. They don’t exist. The nurses there are not experts and there’s a shortage of primary care clinicians who are trying to see 25 patients a day and do it all themselves. In that setting, or in inner city areas whether it be south of Chicago or Bronx … I think where there’s a shortage of these healthcare resources, these models are particularly effective. We’re not trying tot change healthcare where there’s doctors on every street corner and every other health professional fully supplied. Our mission is to provide world class healthcare in cost effective ways in areas where there isn’t enough healthcare workforce.
It seems that there’s not much ego involved. You’re not saying that your organization or your doctors have to get all the credit. You’re just saying, “We’re going to help you and help the patients.” It must be hard to convince people that you don’t have a vested interest.
I think the fundamental issue with Project ECHO, as you have alluded to, is that we have to be willing to break the monopoly of knowledge that exists. The knowledge gets monopolized otherwise. Breaking that monopoly and sharing it freely for public benefit, without necessarily charging anybody for it, doing it at low cost on public dollars, would be much more cost effective.
What if President Obama came to you and said, “This works. This is where we want to go. We want to take this national.” How would you go about doing that and what would it cost?
I think the first thing that would happen is one would have to create some kind of a federal granting mechanism to academic medical centers around the country, in which we would essentially ask them to consider a different mission.
Right now, academic medical centers do three or four things. They basically provide very high quality tertiary care, but they also train doctors and nurses. These federal grants that would be provided to these academic medical centers would ask them to essentially refocus their mission to training a much larger workforce in America to manage chronic disease in a highly cost-effective way.
That is, finding out what is the lowest cost person who can be trained to provide education, behavioral change, and foot exams to diabetics in rural areas without having to have them travel. Right now, people in New Mexico have to travel sometimes five hours to come to an academic medical center.
Most of the academic medical centers are being financed right now by the clinical revenue generated by all these patients travelling. If you redirect clinicians, these highly educated specialists, from providing direct care one on one to instead enabling the workforce around the state in their rural areas to provide world class care by setting up these Knowledge Networks, you can actually get a much more cost effective healthcare system and get much better outcomes at much lower cost.
It means re-thinking how we do healthcare, so it would mean reconfiguration. In order for the federal government to be able to support such an effort, they would need to support this transition in the mission of academic medical centers. I think if federal granting mechanisms were available, large numbers of institutions like ours would jump at the opportunity because they want to do this kind of work if they are made financially whole.