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Project ECHO® (Extension for Community Healthcare Outcomes)Connect with Expert Medical Specialists to Build Capacity in Primary Care and Reduce Health Disparities

Learning Objectives
1. Describe the Project ECHO® model and its benefits
2. Identify a topic area where there is a need or interest for increased access to specialty care
3. Describe how to participate in a teleECHO™ clinic session
0.5 Credit CME
How Will This Module Help Me?

  1. Presents 5 STEPS to incorporate the Project ECHO model in your practice.

  2. Answers commonly asked questions about adopting the model.

  3. Provides tools and resources to help your team increase access to care for your patients.

Introduction

Primary care physicians (PCPs) and other clinicians can provide excellent specialty care directly to patients from their own practices. Project ECHO (Extension for Community Healthcare Outcomes) is a model originally developed at the University of New Mexico, creating a bridge between primary care clinics and specialist teams at academic medical centers through weekly virtual meetings, called TeleECHO clinic sessions. The goal of these sessions is to build a community of practice, learning, and support by sharing knowledge to increase treatment capacity.1 This approach saves time, adds convenience, and improves treatment adherence for patients. In doing so, it simultaneously increases the knowledge, mastery, and joy of medical practice for clinicians.

Since the launch of Project ECHO, initial results and responses have been enthusiastic. In 2016, the U.S. Congress passed the ECHO Act (Pub. L. 114-270) with strong bipartisan support to further federal study of the intervention. In February 2019, the U.S. Department of Health and Human Services released a Report to Congress evaluating Project ECHO.2 As identified in the report, Project ECHO has spread far beyond New Mexico; there are now more than 160 sites across the country and internationally, covering a wide variety of health conditions that “many clinicians feel under-equipped to address”.2 The ten most common health content areas covered are mental health, opioid and other substance use disorders, chronic pain management, hepatitis C, autism spectrum disorders, cancer care, palliative care, HIV/AIDS, and diabetes.

Five STEPS to Incorporate Project ECHO in Your Practice

  1. Learn More About the Project ECHO Model.

  2. Identify Topics That Are Unique to Your Practice or Patient Population.

  3. Connect with Project ECHO and Join a TeleECHO Session.

  4. Present Patient Cases in a TeleECHO Clinic Session.

  5. Apply What You've Learned to Treat Patients in Your Practice and Continue Participation.

Step 1 Learn More About the Project ECHO Model.

Quiz Ref IDProject ECHO was initiated in 2003 in response to extremely long waits for hepatitis C care and a lack of specialty clinicians in the state of New Mexico. A prospective cohort analysis of the initial Project ECHO hepatitis C virus (HCV) program demonstrated that the model is a viable and an effective mechanism for treating HCV infection in underserved communities.3

Project ECHO has become a lifelong learning and guided practice model developed precisely to address these types of concerns. The model has expanded to hundreds of partners across the United States and internationally, covering more than 60 clinical topics.3

The model is a low- or no-cost, high-impact intervention that links primary care clinicians with expert interdisciplinary teams in other specialties through TeleECHO clinics. Experts mentor their primary care colleagues to manage complex patient cases. Expertise is shared via case-based learning, guidance, feedback, and education.

“ECHO is really the main inspiration I have in my professional life today.”

—Henry Cohen, MD, Uruguay

Four principles comprise the Project ECHO model. The combination of these principles results in a unique and successful approach for improving clinician satisfaction, enhancing clinician knowledge and self-efficacy, and improving patient satisfaction and outcomes:

  1. Use technology to leverage the expertise of a multidisciplinary team.

  2. Share best practices to reduce disparities and standardize care.

  3. Leverage case-based learning and guided practice to master complex cases.

  4. Apply web-based tools to monitor outcomes.

Project ECHO is not just a learning and mentoring network; it is also a professional community. Participants are encouraged to ask questions, provide input and guidance to one another, and engage actively in discussions, both during and after a TeleECHO clinic session.

Box Section Ref ID

To learn more about the Project ECHO model and how to can apply it in my practice, join a free Project ECHO introduction to learn more about the model and how it has been applied in the U.S. and worldwide, and to start thinking about how it might address health care challenges in your own clinic. The introduction gives an overview of the Project ECHO model, the rationale for its development, evidence showing the benefits to patients and clinicians, a review of the methods and principles of the model, and thoughts about how to apply it in your practice, based on the experiences of the ECHO partners around the world.

Project ECHO can exponentially increase a practice's workforce capacity to provide specialty care by moving knowledge rather than moving patients. Over time, primary care clinicians operate with increased independence as their knowledge, skills, and self-efficacy grow. Implementation of this model has also revealed that when patients are treated in their local communities by clinicians they know and trust, it enhances their adherence to treatment and follow-up care. The Project ECHO model has also been shown to improve clinician professional satisfaction.

Recommended Video: Changing the World, Fast: Dr. Sanjeev Arora at TEDxABQ

Box Section Ref ID

Q&A

  • Why Project ECHO?

    In some regions, patients often wait weeks or even months to see a specialist. Visiting a specialist may require patients to travel great distances. In some situations, patients may be unable to travel and therefore do not receive the additional specialty care they need. This can be incredibly frustrating and disheartening for both clinicians and patients, particularly when patients with chronic conditions might need to see a specialist several times a year.

  • How does Project ECHO work?

    Quiz Ref IDA TeleECHO clinic session is, essentially, a virtual grand rounds. Participation is usually offered free of charge and clinicians from multiple locations connect at regularly scheduled times with a multidisciplinary team of specialists using low-cost, multi-point videoconferencing. During TeleECHO clinic sessions, PCPs and other clinicians present patient cases to the specialist expert team, who then mentors the clinicians on the management of patients with common complex conditions. Everyone learns from each other's cases, similar to what would occur in a grand rounds.

    These case-based discussions are supplemented with short instructive presentations to improve subject understanding and knowledge and share evidence-based strategies. Clinicians can connect to a TeleECHO clinic that focused on a complex condition that is of interest to them.

  • How much does it cost to participate? Is Project ECHO cost-effective?

    Participation in a TeleECHO clinic is usually free, you generally only need to have standard internet connections and a computer.

    Several studies have demonstrated the cost-effectiveness of this model, particularly in treating hepatitis C.5 Recent internal analyses by various Project ECHO partners have demonstrated cost-effectiveness generally and for chronic pain specifically. These studies were conducted as part of a successful effort to convince state Medicaid officers and a state legislature to expand support for the project. Several Project ECHO partners are currently evaluating the cost-effectiveness and return on investment of the model, as well as its financial benefits in an accountable care organization setting.

  • Why is Project ECHO a unique approach to developing the skills to provide additional specialty care in my practice?

    The heart of the Project ECHO model is its sharing networks that are led by expert teams who use videoconferencing to conduct virtual clinics with community clinicians. Primary care physicians, nurses, and other clinicians learn to provide excellent specialty care in areas of interest or need to patients in their own communities. They can connect on a regular basis to build a community of practice, learning, and support, while developing professional relationships that can last a lifetime.

  • How is the Project ECHO model different from traditional telemedicine?

    This model is not “traditional telemedicine” where the specialist assumes care of the patient, but instead is a guided practice model where the PCP retains responsibility for managing the patient. Specialists serve as mentors, training PCPs to deliver care in areas outside their expertise. Over time, PCPs operate with increased independence as their knowledge, skills, and self-efficacy grow.

Step 2 Identify Topics That Are Unique to Your Practice or Patient Population.

Create a planning committee or team that will identify areas where there is a need for increased access to specialty care within your practice. The committee should include clinicians from various disciplines, as well as administrators who can work with your practice or organizational leaders to identify access shortage areas. It is very important that clinician special interests be included in this planning phase, as Project ECHO is a learner-centric model. Once the planning committee has identified a particular clinical need or target area, you can connect to Project ECHO and join a learning network in your topic area of interest and in your geographic region. You can find a list of all of the TeleECHO programs in the United States by visiting their interactive and searchable program database.

There are currently more than 430 ECHO Programs, covering topics from behavioral health to cancer diagnosis, endocrinology to neurology, military health to rheumatology, and many more.

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Q&A

  • How often should my practice's planning committee meet and what should we cover?

    Quiz Ref IDThe committee should plan to meet for approximately one hour a month for the first two to three months to review potential areas of need, plan who will participate in the TeleECHO clinic sessions, discuss any existing data, and respond to new opportunities or stresses within the clinic.

  • How do I make Project ECHO work if I have a smaller practice?

    If you have a solo or small practice, participating in one TeleECHO clinic that is of interest to you personally may be a better option. This will allow you to gain knowledge and develop expertise in one area and to test and perfect your participation in the Project ECHO model. If you have a partner, he or she could choose a different topic area to expand the services offered by your practice.

  • Is the Project ECHO model also applicable in urban and suburban settings?

    While Project ECHO has typically been applied in rural settings, where the nearest academic medical center can be many hundreds of miles from a patient's home, it has also been shown to be effective in urban and suburban settings where access to specialty care is limited. The University of Chicago, for example, is using the model to link clinicians in affiliated community health centers in Chicago and throughout Illinois with specialists. They are operating TeleECHO clinics in risk-based approaches to women's healthcare, hepatitis C, geriatric medicine, child and youth epilepsy, childhood obesity, pediatric ADHD, and resistant hypertension.

Step 3 Connect with Project ECHO and Join a TeleECHO Session.

Project ECHO offers virtual TeleECHO clinics in specific areas of interest and in your geographic region. They can answer questions and provide you with more information to help you decide if they fit your practice needs. Project ECHO has a wealth of resources available to help you connect to more than 100 TeleECHO clinics across the US and around the world, each offering different specialty areas.

“I think the idea of being part of a movement that's going to reach a billion people is lofty. I know there's a huge need out there and just understanding that the current tools that we have are not sufficient to meet the demand, the demand of expanding medical knowledge and expanding need, is daunting. ECHO is probably the best idea to meet that demand.”

—John Scott, MD, MSc, University of Washington

CME from TeleECHO activities may be available from the sponsor site for each TeleECHO clinic session attended, and some institutions are now offering maintenance of certification (MOC). For example, Johns Hopkins University School of Medicine offers MOC for a Sickle Cell TeleEcho Conference Series. Cincinnati Children's Hospital Medical Center offers MOC for an online course entitled STORM TeleECHO, for Sickle Treatment and Outcomes research in the Midwest. These course offerings may change over time, as more organizations begin to offer MOC for physician participation in the work.

To connect with Project ECHO and join a TeleECHO clinic, visit the Project Echo website. The Join an ECHO page has all the information that you will need.

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Q&A

  • How is patient confidentiality protected?

    Patient confidentiality is a pillar of Project ECHO. All the patient cases presented in a TeleECHO clinic session are de-identified. A HIPAA announcement is given prior to the start of each session to remind both specialists and clinicians about the importance of preserving patient confidentiality. In addition, the teleconferencing system and other tools and resources used for TeleECHO clinics must be HIPAA-compliant.

  • What if I have specialty expertise and want to participate by teaching others?

    If you are at an academic medical center and want to share your specialty knowledge with a wide audience through a structured, easy-to-use format, this model is for you. By participating, you can build capacity among community physicians and help patients access the care they need. Visit the Project ECHO website to learn more about becoming a Project ECHO teaching center.

Step 4 Present Patient Cases in a TeleECHO Clinic Session.

Quiz Ref IDProject ECHO links expert specialist teams at an academic hub with primary care clinicians in local communities. Primary care clinicians then become part of a learning community, where they receive mentoring and feedback from specialists. Together, they manage patient cases so that patients get the care they need.

Many benefits exist for physicians and their practices once they join a TeleECHO Clinic Session, as detailed below in Table 1.

All TeleECHO clinic sessions are case-based, so each will use a disease-specific or topic-specific case presentation template to assist you in structuring and presenting your complex patient case. Most TeleECHO clinic sessions are held for 1-2 hours per week depending on the clinical topic area.

You may want to watch some brief instructional videos on the best way to present patient cases in a TeleECHO clinic session.

Recommended video: The Correct Way To Conduct An ECHO Patient Presentation

Recommended video: Project ECHO: Sample Weekly TeleHealth HCV Clinic

You may also want to review some examples of preparation forms and presentation templates used by participants in their TeleECHO sessions:

Box Section Ref ID

Q&A

  • Who should participate in TeleECHO clinics?

    Individual clinicians of all levels are welcome and highly encouraged to participate in TeleECHO clinic sessions, including physicians, physician assistants, nurse practitioners, registered nurses, psychiatrists, social workers, community health workers, and pharmacists. Team participation is encouraged, as team-based care is the ideal model for enabling higher-level care delivery and task shifting.

  • What issues or challenges have practices and clinicians faced in participating in TeleECHO clinic sessions?

    Quiz Ref IDTime constraints have been identified as one of the most significant challenges for practices and clinicians. The specialist teams often schedule TeleECHO clinic sessions either before office hours or during lunch to avoid taking away from patient-clinician time.

Step 5 Apply What You've Learned to Treat Patients in Your Practice and Continue Participation.

After participating in several TeleECHO clinic sessions, you will have the skills and knowledge to help many of your patients yourself or to discern when their conditions are so complex that they will need to be referred. Through your Project ECHO partners, you will have access to specialists in your region, which is helpful for triaging the most urgent and complex patients.

Project ECHO is a self-paced learning model whose target audience is comprised of primary care clinicians and multidisciplinary care teams in the community. Individuals participate in TeleECHO clinic sessions on a regular basis, often for many months or years, especially in rapidly evolving, complex disease areas. Over time, participating community clinicians begin to receive referrals from other community clinicians, creating an effective triaging system in their region.

“I enjoy ECHO immensely. I enjoy seeing all of the nurses and being able to talk to them all and to find out problems or issues maybe with patients that they have not otherwise brought to our attention. Now that we are doing ECHO, I don't know how we did it without ECHO.”

—Deborah Isaacs, Nurse Consultant, New Mexico Department of Health
Conclusion

Project ECHO moves specialty knowledge into the community to help primary care clinicians care for patients with complex health conditions, expanding the care these patients can receive from the clinicians they know and trust. The interactive virtual learning platform, TeleECHO, brings expertise to clinicians where they practice so they can grow their skill set and increase workforce capacity to provide best-practice specialty care and reduce health disparities.5

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclaimer: The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

ABMS MOC Statement: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Additional Information: About the AMA Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Renewal Date: August 22, 2019

References
1.
 Project ECHO® The University of New Mexico. Our Story. https://echo.unm.edu/about-echo/ourstory. Accessed May 18, 2019.
2.
U.S. Department of Health and Human Services.  Report to Congress: Current State of Technology-Enabled Collaborative Learning and Capacity Building Models. https://aspe.hhs.gov/system/files/pdf/260691/ECHOAct-ConsolidatedReportToCongress.pdf Published February 2019.
3.
 Project ECHO®  The University of New Mexico.
6.
Citation in conclusion: https://echo.unm.edu
7.
 Project ECHO: Spreading Access to Specialty Healthcare. http://www.youtube.com/watch?v=2lBfyOlL4_s. Accessed May 7, 2016.
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