I met Sanjeev Arora as part of the RWJ crowd at TEDMED last year and was pretty impressed with his approach–especially given the lack of access to care in poor and minority regions. Now there’s proof his approach works —Matthew Holt
On June 1 the New England Journal of Medicine published a study about how primary care providers can treat very sick patients who previously did not have access to specialty care. The piece described Project ECHO, a disruptive model of health care delivery based on collaborative practice that has the potential to transform health care. Supported by Robert Wood Johnson’s Pioneer Portfolio and based at the University of New Mexico Health Sciences Center (UNMHSC), Project ECHO was developed by Sanjeev Arora, M.D., a hepatologist at UNMHSC and leading social innovator.
The ECHO model organizes community-based primary care clinicians into disease-specific knowledge networks that meet through weekly videoconferencing to present patient cases. These “virtual grand rounds” are led by specialists at academic medical centers who train providers to provide specialized care, share best practices and co-manage complex chronic illness care for patients with the local care team. Under this model, primary care providers treat patients in their own communities – burdens on academic center capacity are reduced, poor access to care is eliminated (patients are no longer limited by geography when seeking quality care), and the health care systems’ capacity to provide high quality care to more patients, sooner, is dramatically expanded.
In the NEJM study, patients with hepatitis C treated by primary care clinicians working through Project ECHO achieved results that were identical to patients treated by UNMHSC specialists. The evaluation also showed that the ECHO model can reduce racial and ethnic disparities in treatment outcomes.
Project ECHO offers promise as a game-changer for how patients with complex illnesses are treated. Dr. Arora describes the power of ECHO’s knowledge networks as a “force multiplier,” which “transforms the dynamics and the capacity of health care delivery and the spread of best practices.”
In an accompanying editorial, Thomas D. Sequist, M.D., associate professor of medicine and of health care policy at Harvard Medical School and Brigham and Women’s Hospital, said Project ECHO “represents an important step forward” in addressing barriers to accessing specialty care. He notes that the NEJM study raises several issues, including the need for adequate health information technology to implement the ECHO model successfully, the critical role of academic medical centers in supporting the model and the potential for meeting local community health care needs by extending the model to additional chronic diseases.
Sequist makes excellent points, and Project ECHO is already addressing them head-on.
The ECHO model harnesses communications technology to form truly collaborative provider partnerships that permit care in home communities. It connects the wealth of knowledge and expertise housed at academic medical centers and the desire of primary care providers to do more for their patients. And although the findings from the NEJM evaluation focus on hepatitis C, the Project ECHO model has spread to include asthma, mental illness, chronic pain, diabetes and cardiovascular risk reduction, high-risk pregnancy, HIV/AIDS, pediatric obesity, rheumatology and substance abuse.
ECHO represents a fundamental rethinking of how we use our limited supply of physicians, how we engage a full care team in chronic disease management, how we teach best practices and how we provide access to quality care for all. We know we have physician shortages, an aging population and 32 million more Americans who are going to become insured in the coming years. Dr. Arora has developed a disruptive innovation that addresses these challenges.
Through ECHO, providers – not just doctors, but nurses, nurse practitioners, physician assistants and community health workers – are teamed to work together to the benefit of patients who receive accessible, high quality care.
Isn’t that what we all are striving to deliver?
Brian Quinn is the Pioneer Portfolio team leader, Robert Wood Johnson Foundation.
As the Region 5 Public Health Director for the 10 counties in southwest New Mexico, I can honestly say that our association with Dr. Arora and Project ECHO since June 2003 has been a wonderful journey in so many positive ways for our staff, our organization, and the diverse communities we serve. Our weekly participation in telehealth sessions started with hepatitis C, but it now includes addiction and HIV. This DOH-UNMHSC collaboration has enabled us to internally integrate service delivery for infectious and chronic diseases with behavioral disorders while externally differentiating ourselves among healthcare consumers and providers in our border area to become a highly valued secondary care or specialty provider to receive referrals for these three public health priorities. Project ECHO has offered our workforce the opportunity to grow and develop professionally, to have more competence, confidence, and comfort to survive, and even thrive, in the changing healthcare environment of today and the future. With Dr. Arora’s leadership and support, we have been able to incrementally innovate over the years to the point that the cumulative effect is “disruptive” for a governmental entity like ours.
In addition to the praise that precedes this post, I would add that you don’t have to be a rural practitioner to benefit from ECHO or to feel overwhelmed by the complexity of medical advances in Hepatitis C or opiate addiction/mental health. One of the features of the ECHO team is that is promotes a real sense of collegiality without the pretensions of many tertiary medical centers. ECHO really aims to please as well as inform. Keith Barton, MD, Oakland, CA
Having worked in the opiate addictions field as the State Opioid Treatment Authority for New Mexico, I have to say it is pretty impressive to attend a Project Echo Integrated Addiction and Psychiatry Clinic. There is always a stimulating clinical presentation prior to the case consultation segment. Attendees represent, among other specialities, primary care, behavioral health, pharmacy, Corrections, medical school, and psychiatry, and it is not unusual for participants to bring in perspectives from outside New Mexico.
Dr. Miriam Komaromy sets an attentive and thoughtful tone for the high- level proceedings. As a clinician it inspires me to know that other professionals are devoting two hours on Fridays to improve their care of a (mostly) uninsured and (greatly) ignored population of opiate abusers. Project Echo is one of the essential anchors in our efforts to make significant inroads in a serious public health problem. Thank you Dr. Arora, Dr. Komaromy and the entire Echo staff.
As a primary care ECHO provider in a rural community,and as the medical director of a Community Health Center network, and as a clinician who has been part of a unique University Medical School Innitiative I have been able to witness the wonder of Project ECHO from many vantage points. My providers are thrilled and excited to be able to serve our patients through Project ECHO, it has helped us both recruit and retain a superb group of primary care providers who are providing cutting edge care right on the front line in underserved communities. A unique character of Dr. Arora is the care which he shows for each of the providers who participate and through that for each of the patients we serve. It continues to be a moving experience to witness the gratefullness expressed by patients who are receiving exceptional care and often a cure for what are some devastating diseases. Thank you Dr. Arora and the ECHO team!
I became a Community Health Extension Agent almost 4 years ago with Project Echo, working in treatment of Hepatitis C, Addiction Medicine and Psychiatry, and Chronic Pain. In those few years working in Northern New Mexico where resources are few, patients are poor but often very patient, I have been transformed through the power of Project ECHO. Though I have worked in public health for many years, there has been no work that has touched my heart and served my soul like this. Thank you, Dr. Arora, for allowing the world to see what strengths can come from one idea, and how far reaching we “force multipliers” can be. You and your staff continue to train us well, and for that our patients will forever be grateful. We are saving lives in Northern New Mexico that may not have been saved from Hepatitis C, and a great debt is owed to Project ECHO.
Project ECHO has been an amazing thing for the state of New Mexico. I am a family physician in northern New Mexico who has participated in Project ECHO since early on. I started off treating hepatitis C, then learned how to treat opiate dependence with the assistance of the Integrated Addiction and Psychiatry clinic. They trained me well enough that I now help precept the clinic. I have seen patients get very complicated care throughout all parts of rural New Mexico that they never would have had access to if not for Project ECHO. It has also been wonderful for me as a primary care clinician. It can be very hard to stay up to date in the hinterlands. ECHO has allowed me to stay on the front edges. ECHO has made a huge difference to me. I will forever be grateful that Dr. Arora got his insight that the best way for him to treat hepatitis C was to stop treating it himself and start training the rest of us. Thank you, Dr. Arora! You have accomplished more than I ever imagined possible when I first heard of this program, and I hope it continues to expand across the country and around the world.
Brian is spot on. The beauty of Project ECHO is that it is a familiar format for many physicians and very unobtrusive, secure technology is available. We’ve been using Project ECHO in the Pacific Northwest for 2 yrs and have had similar “life-changing” and “game-changing” experiences, for both patients and isolated, burnt-out primary care clinicians in the rural frontier. When will Medicare and 3rd party payors reimburse for this activity?