Teaching by telementoring

Ten years ago, liver specialist Dr. Sanjeev Arora faced this challenge: How could he build the capacity to serve more patients with hepatitis C, given that many of the people he treated lived in underserved areas of New Mexico, and some waited as long as eight months to see him?

The solution was Project ECHO (Extension for Community Healthcare Outcomes), a new form of continuing medical education based at the University of New Mexico Health Sciences Center in Albuquerque. It pairs specialists at academic medical centers with primary-care physicians and other clinicians via video teleconferencing so primary-care providers can learn how to treat complex, chronic conditions. Unlike traditional telemedicine that relies on technology to connect physicians with patients, Project ECHO applies what Arora calls the “forced multiplier” effect, which increases capacity and spreads best practices among clinicians.

“It's a brand-new model for continuing education,” says Arora, director of Project ECHO. “We think it's one of the best models. It's case-based learning and really improves quality of care,” he says, adding that in New Mexico, Project ECHO has provided about 57,000 hours in continuing medical education for healthcare clinicians in the past 10 years.

Clinicians who provide the training are not compensated on a fee-for-service basis, according to Arora, who says Project ECHO will typically pay the clinician's respective medical center for his or her time. Arora says he's trying to build relationships with commercial insurers that, in turn, would cover part of the specialists' salaries to provide the consultation.

The model has already been replicated at other academic medical centers in the U.S., including the University of Washington, University of Chicago, Beth Israel Deaconess Medical Center, the University of Utah and the University of South Florida, and others are in the planning stages.

The CMS Center for Medicare & Medicaid Innovation awarded Project ECHO a three-year $8.5 million healthcare innovation grant. Meanwhile, this summer, the Robert Wood Johnson Foundation provided $5 million in funding to establish the new Project ECHO Institute through 2016. That grant money is to be used for replicating the model within the U.S., and Arora says he is currently looking for funding to expand it internationally.

Launched in 2003, Project ECHO uses “telementoring” to train primary-care providers on how to treat chronic conditions such as hepatitis C, asthma, diabetes, mental illness and pain issues.

“The treatment of hepatitis C has been changing, so it's hard to keep up with the best treatment and safety of medications,” says Dr. Shobha Joshi, director of hepatology research at Ochsner Health System in New Orleans, which is working to replicate Project ECHO to serve remote areas of Louisiana. “All of that requires a lot more expertise than what a small rural provider site can do—whether they're clinics, small hospitals or private practitioners who treat these patients.”

When the findings of a Project ECHO evaluation were published in the New England Journal of Medicine two years ago, Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation, said the model has the “potential to transform healthcare as we know it,” and that what began as a “truly disruptive innovation in New Mexico for treatment of hepatitis C has the capacity to re-engineer healthcare delivery and training across the healthcare system.”

In addition to Ochsner in New Orleans, the University of Texas MD Anderson Cancer Center in Houston also has expressed interest in copying the model. Arora says he expects representatives from MD Anderson to visit the institute for an orientation this fall, and clinicians from Ochsner visited this summer.

Joshi was one of the Louisiana health system's two representatives to attend a one-day orientation at the University of New Mexico in July. She says the day included presentations from speakers about how the model can help providers and patients in rural communities. And the conference also showed attendees how to set up “teleECHO,” which she describes as the video conferencing capability between the “hub”—in her case, Ochsner—and participating clinics. There also was a two-hour hepatitis C treatment consultation, where she could see about 10 to 12 other sites participating.

“It helps providers learn how to take care of these patients and provide good advice,” says Joshi, who adds that she expects it will cost Ochsner about $15,000 for a one-time setup of the large screens and video-conferencing capabilities to serve as the hub site. The individual providers in outlying communities will need only a laptop and video camera, and it's free for them to participate.

Dr. Leslie Hayes, a family physician at El Centro Family Health, a community health center in Espanola, N.M., heard Arora speak at her clinic in 2005 and began participating in video conferences with Project ECHO the following year to learn more about treating patients with hepatitis C. She also learned from specialists about prescribing buprenorphine, which is used to treat patients with opioid addictions—a huge problem in her community, which she says has the highest heroin overdose rate in the country. After being trained in these specialties for about two years, Hayes began leading the video conferencing for other primary-care providers in the state.

“Physicians are people who really like to learn, and the problem is, when you get into practice, you usually don't do much learning anymore,” Hayes says. “And I like the process of working and learning.”

And it's that concept of providers teaching other providers that sets Project ECHO apart, according to Col. Kevin Galloway, director of the Army Pain Management Program under the U.S. Army Medical Command in the Defense Department, which began working with Project ECHO two years ago.

“Frequently there is a misunderstanding that this was telemedicine,” says Galloway, a U.S. Army Nurse Corps officer, who added that the Army and other branches of the military have used telemedicine for decades. “ECHO is an educational initiative,” he says, adding, “We like to call it, 'teaching a man to fish, instead of giving a man a fish.' ”

In 2010, an Army pain-management task force completed its work and released a report with more than 100 recommendations on how to restructure pain management across the VA and Defense Department. As Galloway's team began to implement the recommendations, they learned about Project ECHO, which he says is a model that helps the Defense Department treat patients all over the world while also addressing the need to build capacity for care in remote areas. And because the Defense Department already had what Galloway calls a “robust capability to provide audio and video teleconferencing,” the department's relationship with experts at the University of New Mexico centered more on implementing Project ECHO's concept of telementoring.

As Galloway explains, the U.S. Army Medical Command has medical centers that have interdisciplinary pain-management clinics, as well as smaller medical treatment facilities that don't have the capacity for specialty care. The ECHO hub runs the clinics within its given region, and the Army sent a group from that hub to the University of New Mexico for specialized training.

Because of fiscal constraints, Galloway's team set up what he calls a “virtual boot camp” for the Pacific region in May, which meant the hub in Hawaii learned about Project ECHO through video conferencing, rather than through training in Albuquerque. Clinicians at the European hub at Landstuhl Regional Medical Center in Kaiserslautern, Germany, will participate in a similar boot camp this week, he says.

Replicating the Project ECHO model to help primary-care physicians learn more about pain management is also the goal for Dr. Andrea Furlan, a pain specialist at the Toronto Rehabilitation Institute in Ontario, Canada. She learned about Project ECHO early this year and has since received a planning grant totaling about $21,000 from the Canadian Institutes of Health Research—Canada's equivalent to the National Institutes of Health—to replicate the model in Ontario. The grant helped fund travel expenses for five people to attend a two-day orientation at the University of New Mexico in August, while another five used either hospital funding or their own funding to attend.

The grant is only to plan the replication of the Project ECHO model, and Furlan says she still needs the official approval of the Canadian government to copy it.

“They understand the importance of doing this,” she says of the Canadian government, which was represented at the University of New Mexico visit by a Ministry of Health official. “We are seeking government funding for replication of ECHO for chronic pain.”

And similar to Galloway, Furlan also views Project ECHO as vastly different from traditional telemedicine.

“ECHO is different because I communicate with the physician treating the patient,” she says. “They will be able to ask me questions, and, whatever the physician learns in that one case, he or she will be able to practice with many other of his or her patients,” she says, adding that another benefit is it allows several primary-care groups to watch and learn about a complex case simultaneously, which helps build the capacity to care for patients.

As she explains, about 90% of patients who live with chronic pain should be treated by a primary-care physician. But because primary-care physicians often don't feel comfortable treating this condition, they send their patients to specialists like Furlan—who has patients who wait as long as 14 months to see her. She hopes the Project ECHO model will help primary-care physicians diagnose, treat, manage and follow up with patients who have chronic pain, which will allow her to see only the most complex cases.

“We hope that with ECHO,” Furlan says, “we will spread this knowledge.”

Follow Jessica Zigmond on Twitter: @MHjzigmond