PROJECT ECHO: Bringing Specialty Care to Rural New Mexico

Sanjeev Arora, MDIn the remote towns and sparsely populated counties of New Mexico, specialized care for chronic diseases has always been difficult to get, if not impossible.

But over the past three years, a project funded by the Agency for Healthcare Research and Quality (AHRQ) has started delivering state-of-the-art care via the Internet to those who need it most: rural, low-income, often uninsured patients.

Project Extension for Community Care Outcomes-known as Project ECHO-began in 2003 by helping rural doctors and nurses in New Mexico attack widespread, untreated hepatitis C. In 2006, ECHO has launched programs in mental health disorders, substance abuse, gestational diabetes and rheumatologic diseases. Treatment for diabetes and obesity will be added soon.

Chronic diseases account for much of the illness and mortality in the U.S. -- and much of its health care spending. Effective treatment usually requires long-term, complex management-ideally involving the use of newer therapies and medicines. However, access to disease management specialists and the latest drugs is typically constrained in rural areas and beyond the reach of many low-income patients.

In New Mexico, Project ECHO offers a promising solution by linking primary care clinics in rural areas with the University of New Mexico's School of Medicine in Albuquerque over an Internet-based, audio-visual network. Unlike most telehealth initiatives, which mainly connect patients with doctors, Project ECHO focuses on training rural doctors, nurses, physician's assistants, and other clinicians, and helping them stay current with advances in treating chronic disease.

"AHRQ funding allowed us to set up these Internet systems and support rural sites, and that paved the way for an ongoing state-funded program," said Sanjeev Arora, M.D., vice chairman of the Department of Medicine at UNM Medical School, who has been the driving force behind the creation of Project ECHO. "The AHRQ grant also enables us to share our data with other people."

Project ECHO's primary goal is to provide the same level of care in rural areas that is available in cities with specialty medical practices by bringing rural doctors and UNM disease specialists together online to co-manage chronic disease patients.

"Project ECHO brings academic medicine to this part of the state," notes Ray Stewart, director of a regional public health office in Las Cruces that oversees state efforts in 10 counties. His staff supports primary care and preventive services in community health centers, detention centers, and nonprofit clinics throughout southern New Mexico.

"We are 225 miles south of Albuquerque. This project has brought expertise to us in a very economical way, so we can consult and do the training we need. It's probably the most significant single event for the good of public health in our area. Now people don't have to travel three to four hours to Albuquerque for specialized services."

When a rural clinic joins Project ECHO, its staff receives initial care management training at UNM in Albuquerque; UNM experts help the clinic install and use care management and data reporting software; then clinic staff join a disease-specific "knowledge network" that meets online each week for case presentations and discussion. Doctors participating in project knowledge networks earn CME credits; nurses and physician assistants can earn treatment certification for hepatitis C.

"We use Project ECHO to share best practices with all of our partners on the network," Arora points out. "We show them how specialized treatment is done and how to manage their patients."

The ECHO network currently links the UNM medical school with more than 20 partner clinics based in public health departments, prisons, Indian Health Service sites, community health centers, and rural primary care practices around the state. In many locations, clinics have big-screen TVs hooked up to the network so participants all over the state can see each other as well as the team at UNM.

"It's a big deal for me," says April Grisetti-Nail, a physician's assistant at the El Centro Family Health Clinic in Espanola, a small town north of Albuquerque. "Every week we sit inon a two-hour teleconference and present our cases. People from all over the state learn from each other, and we get directions from medical school experts on complicated cases we have here."

Participating in Project ECHO has given Grisetti-Nail the training and expertise to educate and treat patients with hepatitis C, which afflicts an estimated 32,000 people in the state. Less than 7 percent of those who have the disease have been treated in New Mexico, which has the nation's highest rate of chronic liver disease and cirrhosis deaths.

Arora and his team chose hepatitis C to field-test Project ECHO because the disease is common, has a significant impact on public health and is treatable. But managing treatment, he notes, is not easy. It requires a year-long regimen of weekly injections with advanced drugs like Interferon and often causes side effects such as anemia and depression, which then have to be treated by specialists as well. As a result, most doctors in rural areas didn't want to treat the disease, because they didn't have the expertise.

That's changing fast. "Project ECHO has made a huge difference," reflects Leslie Hayes, M.D., a family practitioner at Espanola's El Centro Clinic, which is less than hour's drive from Santa Fe -but too far for many of her patients.

"We weren't treating these patients at all before. If they had good insurance and transportation, we'd refer them to Santa Fe to get treated, but only about 10 percent of my patients could do this on a regular basis."

Since its launch in 2003, Project ECHO has conducted more than 100 online disease-specific clinics involving case presentation and management for more than 1,400 patients. The effort has drawn support from major drug companies, which have donated more than $6 million in drugs for uninsured patients involved in the project.

Project ECHO not only gives patients in rural areas a chance to get more sophisticated care; it also has important personal benefits for rural doctors, nurses and other health professions who feel isolated from their peers.

"Once you get out of residency you don't learn a lot new out here," says Hayes. "ECHO has allowed me to keep learning, to connect with physicians around the state who are interested in treating these diseases.

"Being in a rural area, we don't have a gastroenterologist locally; we don't have a psychologist locally; we don't have an infectious disease specialist locally. Through ECHO, I have gotten to know these specialists, and I now have people I can call when I'm stuck and not sure where to go. That's been wonderful."

Her experience highlights a major goal for Project ECHO: providing rural doctors with a wide range of specialized knowledge on demand.

"We're developing our knowledge networks so that every doctor can provide best practice care without being an expert in all chronic diseases," Arora says. "By co-managing patients with UNM specialists, we're bringing case-based learning back into the lives of rural providers."

Arora and other experts expect that the Project ECHO model for treating chronic disease will lead to higher retention of skilled health care professionals in rural areas. A recent survey shows that most professionals participating in Project ECHO believe it is helping them do a better job treating patients.

An important component of the project is the collection and analysis of patient outcome data. An AHRQ-funded evaluation, currently being conducted by Arora and his colleagues at the University of New Mexico, should help determine the project's impact on patients.