One of the biggest challenges of primary healthcare is ensuring frontline providers receive necessary guidance for managing complex and chronic health problems, especially as advances in treatment change rapidly.
This need is particularly acute when treating poor and underserved populations. But a new tool that leverages technology to link specialists with primary care providers is making big inroads, with the hope of reaching 1 billion people by 2025.
Project ECHO has emerged as a powerful tool to build communities of learners. Project ECHO (Extension for Community Healthcare Outcomes) is a dynamic, case-based approach to continuing medical education that leverages technology and helps manage chronic and complex diseases. It has the potential to drive significant change in healthcare delivery globally.
Ten years ago in New Mexico, there was only one specialist with expertise in treating hepatitis C who was willing to see patients without insurance or with only state-funded Medicaid coverage. While these patients could receive expert primary care from local community health centers, they struggled to get specialty care for their life-threatening hepatitis. Long waits, long drives and poor outcomes were the predicable result.
However, Dr. Sanjeev Arora, a specialist in the management of hepatitis, realized that others could learn to do what he did and that — by using technology to enhance his ability to coach and consult with the primary care providers — he could create a force multiplier and spread his knowledge to many. The result of this simple idea was Project ECHO, a weekly videoconference in which primary care providers from across the state presented their cases to a multidisciplinary team of experts in hepatitis C treatment from the University of New Mexico.
In 2011, the Project ECHO team published a lead article in the New England Journal of Medicine demonstrating the results of this innovation. Specifically, patients cared for by the primary care providers who attended weekly ECHO sessions and managed their own hepatitis C cases achieved clinical outcomes that were as good or better than those obtained by specialists at the academic medical center in Albuquerque.
Since then, Project ECHO has grown into a national and international movement aimed at replicating the model and using it as a tool to extend knowledge to all the places where it is needed to improve patient’s outcomes. ECHO clinics are now available for conditions ranging from complex hypertension management to pain management to pediatric behavioral health. Centers from Washington State to Connecticut have replicated the ECHO model and are using it to strengthen the infrastructure of primary care systems. The GE Foundation has funded a grant to support ECHO Access focused on integrating mental health and substance abuse treatment into primary care.
At Community Health Center, Inc. in Middletown, Connecticut, we have been using the ECHO model focused on four chronic and complex health issues; hepatitis C, HIV, buprenorphine management and chronic pain. At the center — where we care for 130,000 patients, mostly living in poverty — we act as a regional hub connecting our clinicians and other similar safety net providers in seven states across the country.
As the hub, we connect primary care providers to a panel of expert specialists on each condition. Before each virtual teleECHO clinic, providers post de-identified data regarding the patient so the expert panel can be prepared. During the video conference, hosted by ZOOM, frontline providers summarize their presentation. The specialists —behavioral health, nursing, pharmacy, or others as appropriate — engage in guiding the practitioner using the latest evidenced-based strategies.
While ECHO masterfully helps us manage chronic and complex diseases, we have started to apply it not just to disease states, but to organizational problems within the primary care setting.
We’ve realized that often our frontline clinical staff take valuable information gleaned from the technical ECHO sessions back to their teams and sites, only to find that ineffective delivery systems limit their impact. A well-trained provider working in a suboptimal delivery system can only accomplish so much. To address this issue, our Health Center has invested in training coaches on improving process management and quality, using tools from the Dartmouth Institute, GE Foundation, and the Institute for Healthcare Improvement.
We support these coaches using a modified version of Project ECHO called Project ECHO Coaches International. This ECHO is focused on applying formal quality improvement and system redesign approaches to healthcare delivery. It features expert improvement faculty from CHCI’s Weitzman Institute who support frontline improvement coaches from Washington State, Connecticut and Sheffield Hospital System in England.
These coaches are not the experts on clinical content like primary care providers — rather, they are the experts on process, and they help us ask the right questions about how we deliver care. For frontline primary care providers around the globe treating special populations, team-based care requires as much focus on workflow, process and communication as it does on knowing about the latest medical evidence-based intervention. Project ECHO Coaches International provides a forum for staff from all over the country and the world to discuss quality improvement and learn new ways to improve the delivery of healthcare.
Primary care is in crisis. Despite the clear and urgent need for a strong and vibrant primary care infrastructure to lead us out of the healthcare crisis, medical students are not choosing careers in primary care, and quality measures continue to demonstrate wide gaps in outcomes.
Project ECHO is a powerful tool that can re-energize primary care. Through simple application of technology, primary care providers can be connected with specialists across the country and the world to share knowledge, spread best practices and improve the quality of care.
People in need deserve a world-class primary care system informed by best practices — embracing Project ECHO can help us get there.
Mark Masselli is Founder, President and CEO of Community Health Center, Inc., the largest Federally Qualified Health Center in Connecticut. CHC focuses on providing world-class primary care to underserved populations. Under his direction, the health center has led the way in transformational health care innovations. Daren Anderson, M.D. is VP/Chief Quality Officer of Community Health Center, Inc. In this role, Dr. Anderson is responsible for ensuring that CHC delivers the highest possible quality of care to its patients, developing a strong quality improvement infrastructure across CHC, promoting research and development, and supporting CHC’s mission to become a nationally recognized center of world-class healthcare.