An initial challenge was to find an appropriate location for videoconferencing equipment in rural clinics. Participating sites often installed the equipment in conference rooms or in common areas such as kitchens or break rooms. Unfortunately, this prevented quiet, confidential consultations in which clinicians had ready access to patient charts. We therefore installed software on desktop computers in clinicians’ offices, adding a webcam and a microphone. This created a more intimate user experience, and cost much less than previous layouts. Another challenge was the lack of administrative support for clinician participation and the overriding demand on clinicians to see more patients. Despite the videoconferences being held in the middle of the day, clinicians reported seeing fewer patients on the day of the videoconference. In response, we made the case to site administrators that clinicians were receiving continuing medical education and were more satisfied in their jobs because of project participation, thus reducing the chance of clinician turnover. This was accepted as a reason to permit participating clinicians to see fewer patients than non-participating clinicians. Nonetheless, eight participating clinicians left rural sites. In over half of these cases, the clinic continued its participation because an entire team was involved, and another member of the same team became the point of contact with the project.
Another problem was the reluctance of some participating clinicians to present cases. In interviews with participants, we found a variety of reasons for this hesitancy. First, some rural participants were intimidated by the number of experts attending and felt they would be revealing their lack of expertise in public. Second, clinicians were too busy to complete the intake forms. Lastly, rural participants occasionally found that there were simply too many opinions provided, some of which were contradictory. We therefore reduced the number of academic specialists at the UW and visited sites more often. During these visits, we encouraged clinicians to present their cases in order to establish trust and open dialogue. We have worked to make both the intake form and the discussions more concise and to give concrete recommendations before moving onto the next case presentation.
A final and continuing challenge is financial sustainability. The project has been funded almost exclusively by grants and eventually these monies will run out. Accordingly, we have worked with third-party payors, such as Medicare and Medicaid, to reimburse both the academic medical centre and participating sites. In New Mexico, several Medicaid managed care organizations have agreed to reimburse both UNM Project ECHO (at a rate of $400 per case) and each participating rural site (at a rate of $150 per case). We continue to work in this area, both to estimate the cost savings and return on investment and to develop a long-term business plan.