AAPI_Fall Journal_firstproof_lr ECHO PROJECT P26-28 by AAPIUSA on Scribd

Dr. Nick Shroff – Chairman, AAPI Charitable Foundation
Dr. Sanjeev Arora – AAPI Charitable Foundation

The Extension for Community Healthcare Outcomes (ECHO) Model is a platform that delivers complex specialty medical care to underserved populations through an innovative educational model that consists of team based inter-disciplinary development.

Using technology, best practice protocols, and case based learning; ECHO trains and supports primary care clinicians to develop knowledge and self-efficacy on a variety of diseases, enabling them to deliver best possible care for complex health conditions in communities where specialty care is unavailable. The model has broad applicability to improve healthcare in India for chronic complex diseases.

A number of strategies have been used worldwide to increase access to health care in underserved areas. While these efforts have reduced barriers, specialty care for complex and chronic health conditions remains limited in rural and semi urban areas around the world. A potential solution is an innovative paradigm to allow specialized medical resources of Academic Medical Centers (AMC) to be accessible outside of urban areas. Expanding knowledge and skillsets of local providers allows rural patients
equal access to expertise care.

Most rural areas cannot afford the broad range of disciplines and specialty medical training needed to deliver best practice care for even a small number of complex and chronic health conditions. It is not feasible to provide a full range of specialty care in outlying areas using current strategies and available
options. Given the existing financial and infrastructure barriers, broader access can only be achieved through innovative strategies and technology such as the ECHO Model that allows rural and small town clinicians to utilize centralized expertise.

By providing consultation and case-based learning using an inter-disciplinary team at an AMC, this model responds directly to key unmet needs. The purpose of the model is “force multiplication” defined as a logarithmic increase in capacity of care for complex diseases in rural areas.

The idea for Project ECHO grew out of New Mexico’s severe hepatitis C problem. Prior to Project ECHO, fewer than 1,600 New Mexicans had received treatment for hepatitis C and chronic liver disease, although an estimated 34,000 residents had the disease. Hepatitis C is curable, but the treatment regimen is grueling and requires twelve to eighteen visits with a specialty provider over the course of a year. For patients who live great distances from academic medical centers or other major hospitals, or who lack transportation or face other access barriers, it can be difficult to impossible to see a specialist. For patients who are poor, uninsured, or underinsured, a number of other social, cultural, linguistic, and financial barriers may stand in the way of care. However, few rural practitioners are prepared to deal with treatment side effects, drug toxicities, treatment-induced depression, and co-occurring conditions. These can include mental health issues and substance abuse, both of which are common among hepatitis C patients. Optimal management of hepatitis C requires consultation with highly trained specialists from multiple areas, including gastroenterology, infectious disease, psychiatry, and addiction medicine. Rural primary care providers who are treating patients in their home communities may want to consult with specialists, but they typically have limited access to such specialists or other difficulties in doing so. If they choose to refer their patients to specialists, the severe shortages of specialty providers in rural areas means that people with complex conditions such as hepatitis C often have to wait months to get treatment. Primary care physicians may then have few options but to refer patients to the closest academic medical center or other major hospital–which, as noted, may not be close at all. Not
surprisingly, given the numerous barriers they may face, such patients often forgo treatment or wait until they have severe complications before seeking help.


The ECHO Model uses technology, such as webcams, custom software and clinical management tools, to train and primary care providers from underserved areas to develop knowledge and self-efficacy so they can deliver best practice care for complex health conditions. When a new partner site–a primary care practice in rural area, for example–joins the network, ECHO staff members first conduct a two-day, in-person orientation in Albuquerque. The orientation explains the hepatitis C treatment protocol as well as the communications technology and the case-based presentation format for the weekly two hour
telemedicine clinics. Next, primary care clinicians–including physicians, nurses, and physician assistants—are organized into disease-specific learning networks that meet weekly via videoconference to present cases. A team of University of New Mexico Health Sciences Center specialists who review and discuss cases with primary care providers leads these “virtual grand rounds” or “teleclinics”.

The hepatitis C team from the University of New Mexico includes a hepatologist, a pharmacist, a psychiatrist, and a nurse. These specialists do not assume the care of the patient; in fact, the team from the Health Sciences Center never even sees the patient. Instead, through a guided practice model, the
primary care provider retains responsibility for managing the patient, operating with increasing independence as his or her skills and self-efficacy grow.

Web-based disease management tools facilitate consults, and specialists and primary care providers jointly manage complex chronic illness care for patients, who are treated right in their home communities. A secure, centralized database monitors patient outcomes.

The knowledge network consists of regularly scheduled conference calls over regular landlines or cell phones and web cam based online clinics that bring together expert inter-disciplinary specialists from the
AMC and multiple community-based partners. These partners learn best practices through “learning loops” in which they comanage diverse patients in real world situations and practice.

Over time, these learning loops create deep knowledge,skills and self-efficacy. Provider evaluation results reported in peer-reviewed journals have shown both a positive impact on provider knowledge and self-efficacy while enhancing professional satisfaction and reducing professional isolation.Patient outcome studies have confirmed that the safety and efficacy of HCV care provided by primary care clinicians
through ECHO collaboration and consultation are as good as traditional care delivery at an AMC.

After initial success ECHO has expanded beyond HCV and now covers 12 additional disease areas that include chronic pain, rheumatology, pulmonary disease, high-risk  of September 2011, 305 partner teams across New Mexico have collaborated on more than 11,000 specialty care consultations for multiple chronic diseases. The project has been successfully replicated at the University of Washington, University of Chicago and in India for treatment of HIV. Over 15,000 hours of Continuing Medical Education (CME)
and Nursing Continuing Education Units (CEUs) have been issued to community-based primary care providers at no cost
to individual providers.

ECHO received international recognition as one of three winning entries out of 307 world-wide applications from 27 countries in the 2007 Ashoka Changemaker’s competition for Disruptive Innovations in Health and Health Care nationally or globally.


We propose a replication of the ECHO model in India for cardiac risk reduction by setting up centers of excellence for effective management of Diabetes, Hypertension, Lipid Disorders, Obesity, and Smoking Effective education on diet, exercise, weight loss, smoking cessation and use of low cost treatments such as insulin and oral anti diabetic medications can save millions of lives. However the specialized expertise
to educate patients and treat these disorders does not exist in villages and many small towns of India. Primary care physicians currently working in AAPI sponsored clinics in India will collaborate with an Academic Medical Center in India to develop centers of excellence for prevention, evaluation and treating Diabetes and the metabolic syndrome. Community health workers and medical assistants will be trained to become diabetes educators so they can become a part of the disease management team at these centers of excellence.

India like most developing nations lacks a fully developed infrastructure, often limited broadband connectivity between rural and urban areas. However, many towns (including smaller ones) have access to broadband connectivity through the national telephone carrier MTNL for less than Rs 1500
per (30 USD) month. Clinics will be chosen for the project based on availability of broadband connectivity of 512 Kbps per location. Project ECHO will provide the webcams and software necessary for areas that have the required broadband Internet access so that they may access the clinics via videoconference.
As part of this process, the project will determine the resources, support, expert leadership team, partners and sustainability plans required to bring ECHO to other areas.

The proposed project will incorporate four key elements of the ECHO model:

1) Case-based learning and learning loops delivered through a knowledge network.

2) Best practice protocols for management of Diabetes, Hypertension and Lipid Disorders

3) Tracking and evaluation of patient and provider outcomes and

4) Five types of technology that make distance learning, consultation, and evaluation feasible including: a) webcams linked to a video conferencing bridge for consultative clinics,
b) a web based electronic disease management tool (iHealth- to be developed for Diabetes by March 2011) that allows remote entry of patient and outcome information for co-management and outcome evaluation, c) fax machines for data exchange where internet access is poor, e) webinar capacity to allow
delivery of didactic and interactive education to hundreds of users simultaneously and e) a dedicated online video site (similar to “You Tube”) that allows providers to directly access recorded educational sessions at any time.

We will measure the number of patients treated, the efficacy of treatment in small towns and compare that to published literature and assess our ability to deploy technology in India. Success of the project will demonstrate the effectiveness of ECHO as an innovative paradigm for providing best practice care for multiple complex diseases in India.

Dr. Nick Nipan Shroff
 – Chairman, AAPI Charitable Foundation nickshroff@gmail.com
Dr. Sanjeev Arora – AAPI Charitable Foundation sarora@salud.unm.edu

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