Project ECHO: Extension for Community Healthcare Outcomes (New Mexico)

Project Final Report (PDF, 1.59 MB) Disclaimer

Project ECHO: Extension for Community Healthcare Outcomes - 2008

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS04-011: Transforming Healthcare Quality through Information Technology (THQIT)
  • Grant Number: 
    UC1 HS 015135
  • Project Period: 
    09/04 – 08/08, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,455,258
  • PDF Version: 
    (PDF, 50.2 KB)


Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve the quality and safety of medication management via the integration and utilization of medication management systems and technologies.

Business Goal: Knowledge Creation

Summary: Project ECHO (Extension for Community Healthcare Outcomes) involves a partnership of academic medicine, public health offices, corrections departments, and community clinics dedicated to providing best practices and protocol-driven specialty health care in rural and underserved areas. This specific research project focused on using health information technology to provide improved treatment of hepatitis C virus (HCV). Project ECHO’s weekly scheduled telemedicine clinics, which are hosted by University of New Mexico (UNM) specialists in the areas of HCV, use telemedicine pathways and Internet-based access to provide community health care practitioners with the opportunity to present cases, which are discussed among the network participants to jointly reach treatment decisions. This particular form of case-based learning, called “learning loops,” allow community providers to learn from the experience of co-managing patients with specialists and their peer providers around the State. In these case-based learning clinics, partners rapidly gained deep domain expertise in HCV as they collaborated with university specialists in hepatology, infectious disease, psychiatry, and substance abuse in co-managing their patients. Expansion of this telehealth model to other chronic, complex diseases is underway.

Specific Aims

  • Co-manage ECHO HCV patients by partnering urban specialists with community physicians. (Achieved)
  • Develop and expand access to treatment for HCV and eventually other complex diseases (diabetes, asthma, etc.) by building treatment capacity in New Mexico among rural medical providers. (Achieved)
  • Create a model for treatment of complex, chronic diseases in rural and/or underserved populations in New Mexico. (Achieved)
  • Provide extensive professional health care no-cost education through use of telemedicine technologies. (Achieved)
  • Develop Patient and Provider Outcomes Program. (Achieved)
  • Expand telehealth access and infrastructure. (Achieved)

2008 Activities: In 2008, Dr. Arora continued to offer teleconference clinics for HCV (during the first 8 months of 2008, 5,993 patient consultations were provided), while expanding to offer clinics for rheumatology, integrated addiction/psychiatry, child psychiatry, psychodynamic psychotherapy, gestational diabetes/high-risk pregnancy, cardiovascular risk reduction, pediatric obesity, asthma/pulmonary disease, HIV, occupational medicine, medical ethics, and chronic pain.

Impact and Findings: Provider outcome data demonstrated increased provider knowledge, self-efficacy in treating HCV patients, decreased professional isolation, and enhanced professional satisfaction. Preliminary patient outcome data analysis confirms co-managed HCV treatment by rural providers is as safe and effective as treatment delivered in an academic medical center HCV clinic.

Selected Outputs

Berkley EM, Leslie K, Arora S, et al. Chronic hepatitis C in pregnancy. Obstet Gynecol 2008 Aug;112(2: Pt 1):304-10.

Geppert CM, Arora, S. Widening the door: the evolution of hepatitis C treatment in patients with psychiatric disorders. Hepatology 2007 Oct;46(4):957-9.

Gish RG, Arora S, Rajender RK, et al. Virological response and safety outcomes in therapy-naive patients treated for chronic hepatitis C with taribavirin or ribavirin in combination with pegylated interferon alfa-2a: a randomized, phase 2 study. J Hepatol 2007 Jul;47(1):51-9.

Arora S, Thornton K, Jenkusky S, et al. Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Public Health Rep, 2007;122(S2):74-7.

Arora S, Geppert C, Kalishman S, et al. Academic health center management of chronic diseases through knowledge networks: Project ECHO. Acad Med 2007 Feb;82(2):54-60.

Arora S, O’Brien C, Zeuzem S, et al. Treatment of chronic hepatitis C patients with persistently normal alanine aminotransferase levels with the combination of peginterferon alpha-2a (40 kDa) plus ribavirin: impact on health-related quality of life. J Gastroenterol Hepatol 2006 Feb;21(2):406-12.

Geppert CM, Arora S. Ethical issues in the treatment of hepatitis C. Clin Gastroenterol Hepatol 2005 Oct;3(10):937-44.

Sulkowski M, Wright T, Rossi S, et al. Peginterferon alfa-2a does not alter the pharmacokinetics of methadone in patients with chronic hepatitis C undergoing methadone maintenance therapy. Clin Pharmacol Ther 2005 Mar;77(3):214-24.

iHealth Electronic Clinical Management Tool: Real-time remote entry and access to patient-specific information is needed for co-management and during consultative clinics. An outside vendor, Infosys Technologies, Inc., completed a new Web-based clinical management database, iHealth (trademark application pending), in May 2008. This allowed all partners to access information even from remote sites, with HIPAA-compliant controlled access to protect confidentiality. Clinical personnel from ECHO Partner Sites continued to receive iHealth instruction. This database will ultimately be utilized by all ECHO Partner Sites that treat HCV patients.

Grantee’s Most Recent Self-Reported Quarterly Status:This project has been completed. Project ECHO will continue to offer clinics and services to rural New Mexico physicians. The project’s success has spurred further interest as well as funding from additional sources, and its methodology will be expanded to other diseases while using the same infrastructure developed with this grant.

Milestones: Progress is mostly on track.

Budget: On target.

Project Details - Ended

Project Categories

Summary:

The University of New Mexico Health Sciences Center (UNM HSC) developed an innovative and widely applicable model to provide treatment for patients with chronic, common and complex diseases who do not have direct access to specialty health care providers. This knowledge-on-demand model is called Project ECHO - Extension for Community Healthcare Outcomes. Conceived as a means to treat HCV-infected patients in New Mexico's rural communities and prison system, Project ECHO can assist in diagnosing and successfully treat many other chronic illnesses and conditions. Project ECHO connects urban medical center disease experts with rural general practitioners and community health representatives over a telehealth network. This enables them to effectively treat patients on site who would otherwise have to travel to urban healthcare facilities for specialty treatment. Project ECHO has enormous potential as an affordable healthcare intervention in rural communities where certain chronic diseases have reached epidemic levels and healthcare resources and personnel are scarce. The purpose of Project ECHO was to educate, train, and support rural general practitioners or other available healthcare representatives on the best practice treatment protocols for complex diseases they encounter in their communities. This model focused on the principles of case-based learning and disease management using the telemedicine infrastructure and internet-based technologies to co-manage patients in community-based practices. The ultimate goal of Project ECHO was to provide the same level of healthcare to rural patients with chronic diseases as can be obtained in an urban setting. A secondary goal was to provide rural healthcare practitioners with a level of interaction and support commensurate with their urban counterparts to enhance their technical competence and decrease their feelings of professional isolation.

Project ECHO: Extension for Community Healthcare Outcomes - Final Report

Citation:
Arora S. Project ECHO: Extension for Community Healthcare Outcomes - Final Report. (Prepared by the University of New Mexico at Albuquerque under Grant No. UC1 HS015135). Rockville, MD: Agency for Healthcare Research and Quality, 2008. (PDF, 1.59 MB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Medical Condition: 
This project does not have any related resource.
This project does not have any related survey.

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.

This project does not have any related emerging lesson.