Project ECHO: Improving access to specialist-level care, leveraging both specialist expertise and the community care infrastructure

By Alina Hsu

Ten years ago Dr. Sanjeev Arora, a hepatologist at University of New Mexico Health Sciences Center (UNMHSC), was frustrated: Patients with hepatitis C typically had to wait months for treatment, and fewer than 1,600 New Mexicans were being treated out of an estimated 34,000 residents with hepatitis C.  Furthermore, the specialists were located in urban areas.  New Mexico has a high proportion of residents who are poor and uninsured, and two-thirds of the population lives in rural areas. 

At the same time, rural physicians and community health centers were frustrated by their inability to provide the complex, multi-specialty care their hepatitis C patients required.  And the patients were probably the most frustrated of all. 

Dr. Arora thought that a program of virtual consultations would vastly extend the reach of the urban specialists, and act as a “force multiplier”.  Local healthcare providers attend two days’ training in the management of hepatitis C, and have two hours a week of “virtual rounds” or “teleclinics” via videoconference which include other rural providers as well as all the relevant specialists.   

Project ECHO (Extension for Community Healthcare Outcomes) explicitly aims to improve the access of minorities and other underserved populations to best-practice care, initially for hepatitis C.  A recent article in the New England Journal of Medicine demonstrates its effectiveness in extending specialty care to rural and prison populations.  The model also works for rapidly disseminating changes to the protocol, and to guide local responses to epidemics, as described in an article in Health Affairs.  It is enormously flexible, and has already been expanded to asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions and mental illness.

The response of the community clinicians has been overwhelmingly positive.  Not only does the model enable community care of complex diseases, it also reduces the disconnection and isolation that many rural physicians experience.   

One major problem the Project ECHO group sees is the financial sustainability of the model.  It has been generously funded thus far by AHRQ, the Robert Woods Johnson Foundation, and the State of New Mexico, but this won’t continue indefinitely.  On the one hand, the model would seem to represent the kind of innovation the Affordable Care Act is supposed to encourage and reward:  it provides high-quality care at the lowest possible cost, while improving equity and access.  On the other hand, there are no mechanisms to reimburse this kind of co-management of complex chronic conditions.  The authors see ACOs as the best fit, since their focus is on (and payments to them are based on) health outcomes for a defined population. 

I also wonder about possible decreases in quality over time and/or as a function of scale.  One-to-many partnerships between an academic health center and community healthcare providers of many types and sizes may provide new challenges for the Process Improvement professional.  The basic relationship is mentor-mentee, or expert-trainee, only now one-to-many or even many-to-many.  In hospitals, this kind of relationship is no guarantee of (1) having solid evidence-based standards and protocols agreed on by all of the “experts”, (2) valuing the comments and perspectives of the “trainees” and other members of the care team, (3) collaborating well across clinical specialties, or (4) ensuring that standards are in fact followed (or that something is modified such that the standards can be followed).  Case-based learning is the norm in hospitals, but this is not necessarily correlated with a culture of respect, a culture of safety, or a culture of quality.  Will Project ECHO over time demonstrate all of the kinds of quality and safety issues that we see in hospitals?  If not, what would protect it from experiencing these issues?  To continue our analogy, if Dr. Arora provides the leadership of a hospital CEO, it may turn out that the success of new Project ECHO initiatives is very sensitive to the quality of leadership. 

The fact that hepatitis C treatment delivered by rural primary care providers can be just as effective as that provided in an academic medical center may be too low a bar, given the persistent quality and safety problems that we are all aware of.  Ultimately, though, when the alternative for a significant proportion of the 59 million Americans in rural areas is effectively no care at all for complex chronic illnesses, the Project ECHO model is a much-needed breakthrough in access to and delivery of care.