Project ECHO has the potential to be a significant disruptive innovation in three major areas: 1) access to specialty health care, 2) expanded delivery of evidence-based best practice care, and 3) a new paradigm for team-based interdisciplinary professional development. It contributes to these three areas by using its model of case-based, iterative learning in an environment employing technology to support inter-disciplinary community providers in provision of quality care for patients with chronic, complex diseases.
ECHO provides attention to other needs of community providers as well. Providers develop confidence in their ability to provide safe and effective care, value being part of a community of practitioners dedicated to improved care for complex patients, and appreciate being valued by their peers. They receive professional satisfaction and acknowledgement through their close collaboration with respected experts at an AMC. Ongoing learning and development contributes to a feeling of professional satisfaction that can promote retention in rural and underserved communities that otherwise offer limited opportunities for professional engagement.
The project also demonstrates that technology and inter-disciplinary collaboration can be used to leverage scarce health care resources. Many telemedicine projects link specialists with remotely located patients. ECHO inverts that process and uses technology to build knowledge and skills among remotely located providers who in turn care for patients with chronic disease within their home communities.
Communication between primary care providers and AMC specialists is often suboptimal. Primary care providers may not receive feedback about patients they have referred, and specialists may not know the history of patients when they begin care. ECHO can streamline and enhance such care coordination, with primary and specialty care providers working together to care for patients using the ECHO model.
Hepatitis C was an ideal condition for which to pilot the ECHO model because it is a complex disease that requires experts from multiple specialties, mental health experts and substance abuse professionals to achieve optimum management. Few primary care practitioners, particularly in rural and underserved areas, have the broad knowledge to manage emerging drugs and treatment options, treatment side effects, drug toxicities, treatment-induced depression, and substance abuse issues are common among hepatitis C patients.
As a result of the success of the ECHO model for hepatitis C, there has been significant demand to treat other complex and chronic diseases. ECHO has now expanded to provide telehealth clinics for 13 distinct disease “arms” for challenging and common health issues as broadly divergent as substance use disorders, mental health disorders, cardiac risk reduction (including diabetes, hypertension, hyperlipidemia, obesity, smoking cessation, nutrition and exercise physiology), prevention of teenage suicide, rheumatology and childhood obesity.
While ECHO was developed and piloted in New Mexico where the primary barriers to care are socioeconomic and geographic, it is now being replicated in urban areas and outside of the United States. These efforts will help determine the broader applicability of the model. In addition to the hepatitis C program in New Mexico, a similar HCV program is being replicated for rural residents of Washington State in cooperation with the University of Washington with funding from the Robert Wood Johnson Foundation. India is launching an ECHO effort to respond to disproportionately high rates of HIV/AIDS. These efforts will be studied to investigate whether ECHO is as effective in poor, urban areas or international communities where there are shortages of health care providers.
To expand this model of care delivery, AMCs will need financial incentives. Today, academic health centers focus on research, training, and tertiary care. Federal and state governments could provide funds to promote an additional mission for AMCs to help and build capacity among primary care providers to treat complex, chronic conditions. This incentive would allow models such as ECHO to expand access to best practice care for underserved populations, build communities of practice to enhance professional development and satisfaction of primary care clinicians, and expand sustainable capacity for care by building local centers of excellence.
In summary, ECHO enhances chronic disease management in a number of ways, not just through its innovative use of new technology. In New Mexico and other underserved areas, there are multiple, common, chronic, and complex diseases for which there are too few specialists. Examples include rheumatoid arthritis, hepatitis C, and chronic pain. Collaboration among specialty and primary care providers is an inexpensive way to increase the capacity to provide complex, chronic care even in communities not considered geographically remote. ECHO links these collaborative teams with existing community clinicians and gives them the expertise and confidence to be able to treat these diseases.
In addition to patient care, the technology used in ECHO has demonstrated its utility in educating clinicians through co-managed care of rural and underserved patients throughout the state. The geographic isolation of many communities in New Mexico precludes ongoing on-site professional education or consultation. While there are a variety of educational programs and media available at this time, most online venues do not involve face-to-face interactions with colleagues and do not address their professional isolation. In contrast to typical “telemedicine” services where specialists directly see patients using similar technology, ECHO uses technology to link these specialists with community-based clinicians. Therefore, it empowers and educates these providers through iterative, co-managed case based care to become equivalent to academic specialists in the quality of patient care they provide, a disruptive and innovative healthcare outcome. ECHO focuses on the needs of community providers and underserved patients in supporting best practice care for complex patients, while meeting the larger societal needs within the state to better address expensive chronic diseases growing at unsustainable rates.