Notes on Project ECHO

The New Year marks the start of "Better Ideas in Action," a blog that highlights
innovative approaches to chronic disease care. Today's entry about Project ECHO marks the
first post. I look forward to your comments, and to learning about your better ideas in
action.

Having returned from a visit to Project ECHO in the wide open spaces of New Mexico, I
came away with the impression that it’s not the technology that’s transformative, but the
relationships it supports.

Developed by Dr. Sanjeev Arora and colleagues at the University of New Mexico (UNM), the
ECHO (Extension for Community Healthcare Outcomes) model is an Internet/telemedicine-
based method of providing specialty support to primary care practices. The goal is to
increase the ability of primary care providers to act as local specialists by creating a
“virtual practice community.”

How are they doing things differently?  

• Learning is not didactic, but through the co-management of specific patients in these primary care practices (case-based learning).
• In exchange for co-management support, primary providers are expected to become the local specialists for these conditions in their community (and also receive free CME). 
• The specialty interdisciplinary team (e.g., pharmacist, psychiatrist, hepatologist) virtually “rounds” with the primary practices, so that all practitioners simultaneously learn best practices (as they implement them) and become a practice ‘community.’ 
• Clinical outcomes are centrally captured and shared.

Key requirements: 

• The “de-monopolization” of specialty expertise-- finding specialists (and subspecialists) who inherently believe that complex conditions can be managed in the primary care setting.
• Interested primary care providers willing to spend the extra time (2 hours weekly) to participate in an ECHO and provide consultations to other local providers.
• The condition should be common, require complex management, with evolving treatments/medications, high societal impact (health and economic), serious outcomes of untreated disease, and ability to significantly improve outcomes with disease management.
• Initial outcomes are promising, as evidenced by their recent NEJM article, which demonstrated similar Hepatitis C treatment outcomes in the community when compared to the tertiary care center (almost unheard of).

The model is being spread to: addiction management (via buprenorphine), rheumatology,

pain management, diabetes care, severe hypertension, chronic kidney disease management,
and CHF.  It also has been used to also train medical assistants, peer support staff; and,  the infrastructure, once in place, can be used for rapid dissemination of information (e.g., H1N1 information).

The most aggressive adopters are the VHA and DoD.Most replication sites are rural, but the University of Chicago is using the model with local federally qualified health centers (FQHCs) to support hypertension care.Even UNM is using ECHO to better support care in their local FQHCs and feel that they are now much more effective at triaging patients into specialty care visits.

To date, however, the model seems to be implemented in settings where specialists are salaried and play an active role as educators.