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ECHO Project

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Sanjeev Arora , made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (2.6 MB).

Slide 1

ECHO Project

Sanjeev Arora M.D., FACG
Professor of Medicine
Executive Vice Chairman
Department of Medicine
Director of Project ECHO
University of New Mexico School of Medicine
sarora@salud.unm.edu
505-272-2808

Slide 2

Mission

The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.

Note: Supported by Agency for Health Research and Quality Health Information Techology (Health IT) grant 1 UC1 HS015135-04, and Minority Research Infrastructure Support Program (MRISP), R24HS16510-02 and the New Mexico Legislature.

Slide 3

Hepatitis C: A Global Health Problem

The slide shows a map of the world's continents marked with the number of known cases of Hepatitis C.

U.S.A.: 4 million.
South America: 10 million.
West Europe: 9 million.
East Mediterranean: 20 million.
Far East Asia: 60 million.
South East Asia: 30 million.
Africa 32 million.
Australia: 0.2 million.
170 Million Carriers Worldwide, 3-4 MM new cases/year.

Note: Source: World Health Organization (WHO) 1999

Slide 4

Hepatitis C in New Mexico

Estimated number is greater than 28,000.
Less than 5% had been treated.
Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths.
2300 prisoners diagnosed in corrections system (expected number is greater than 2400)—None treated.
Highest rate of chronic liver disease/cirrhosis deaths in the nation.

Slide 5

Rural New Mexico

Underserved Area for Healthcare Services.

121,356 sq miles.
1.83 million people.
42.1% Hispanic.
9.5% Native American.
17.7% poverty rate compared to 11.7% nationally.
>22% lack health insurance.
32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUA's).
14 counties designated as Health Professional Shortage Areas (HPSA's).

Slide 6

Health Care in New Mexico

20% practice in rural or frontier areas.

Note: New Mexico Physician Survey 2001.

Slide 7

Goals

Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes.
Develop a model to treat complex diseases in rural locations and developing countries.

Slide 8

Partners

University of New Mexico School of Medicine Dept of Medicine, Telemedicine and CME [Continuing Medical Education] (UNMHSC).
NM Department of Corrections.
NM State Health Department.
Indian Health Service.
Community Providers with interest in Hepatitis C and Primary Care Association.

Slide 9

Method

Use Technology (telemedicine and internet) to leverage scarce healthcare resources.
Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing "best practices."
Case based learning: Co-management of patients with UNMHSC specialists.
Centralized database Health Insurance Portability and Accountability Act (HIPAA) compliant to monitor outcomes.

Slide 10

Steps

Train providers, nurses, pharmacists, educators in Hepatitis C.
Install protocols and software on site.
Conduct telemedicine clinics—"Knowledge Network."
Initiate co-management—"Learning loops."
Collect data and monitor outcomes centrally.
Assess cost and effectiveness of programs.

Slide 11

Benefits to Rural Providers

No cost CME's and Nursing continuing education units (CEU's).
Professional interaction with colleagues with similar interest.
- Less isolation with improved recruitment and retention.
A mix of work and learning.
Obtain hepatitis C virus (HCV) certification.
Access to specialty consultation with gastrointestinal (GI), hepatology, psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator.

Slide 12

The slide shows a photograph of televised individuals participating in a videoconference on a closed-circuit television.

Slide 13

The slide shows a photograph of participants sitting around a table at a videoconference, viewing both a power point presentation and a closed-circuit television.

Slide 14

Solution Functional Capabilities

Comprehensive Electronic Medical Record.
Patient Care Management Workflow (ECHO Clinics).
Dynamic Forms.
Patient Presentation and Case study.
User and Site Management.
Reporting & Search.
Patient Health Surveys.
Patient Registration.

Leads to:

Comprehensive Patient Demographics.
Health History, Physical Examination, Review of Systems.
Allergies.
Vitals.
Labs.
Medications.
Diagnosis (Medical Conditions).
Surgical Procedures.
Imaging.

Slide 15

Disease Selection

Common diseases.
Management is complex.
Evolving treatments and medicines.
High societal impact (health and economic).
Serious outcomes of untreated disease.
Improved outcomes with disease management.

Slide 16

Building Bridges

The slide shows four, blue, vertical bars being crossed by three, blue, horizontal bars. The four vertical bars represent "UNM HSC;" "State Health Department;" "Private Practice;" and "Community Health Centers." The three horizontal bars represent "Hepatitis C;" "Asthma and COPD;" and "Substance Use and Mental Health Disorders."

Paretto's Principle

Slide 17

Force Multiplier

The slide shows a duplicate copy of the illustration from the previous slide. The four vertical bars represent "Specialists;" "Primary Care;" "Physician Assistants;" and "Nurse Practitioners." The three horizontal bars represent "Hepatitis C;" "Asthma and COPD [Chronic Obstructive Pulmonary Disease];" and "Substance Use and Mental Health Disorders."

Use Existing Community Providers.

Slide 18

Community Health Extension Agent

The slide presents a Venn diagram consisting of three circles:

Blue circle: University of New Mexico.
Green circle: State Department of Health.
Yellow circle: Community Providers.
CHEA represents the area where they overlap.

Slide 19

Force Multiplier

The slide shows a duplicate copy of the illustration from slides 16 and 17. The four vertical bars represent "Primary Care;" "Nurse;" "Medical Assistant;" and "Community Health Worker." The three horizontal bars represent "Hepatitis C;" "Asthma and COPD;" and "Substance Use and Mental Health Disorders."

Chronic Disease Management is a Team Sport.

Slide 20

A Knowledge Network Is Needed

The slide presents a graph depicting that over time there is an increasing gap between the rapid upswing of "Medical Knowledge" and the slower rate of "Learning Capacity."

Slide 21

How well has model worked?

305 HCV Telehealth Clinics have been conducted.
- 3016 patients entered HCV disease management program.
CME's/CE's issued:
- 3631 CME/CE hours issued to ECHO providers at no-cost.
- 205 hours of HCV Training conducted at rural sites.
National Recognition as Model for Complex Disease Care.

Slide 22

Project ECHO Annual Meeting Survey

The table presents the mean scores, ranging from 1-5, for the following survey questions:

Project ECHO has diminished my professional isolation.
- Mean Score: 4.3
My participation in Project ECHO has enhanced my professional satisfaction.
- Mean Score: 4.8
Collaboration among agencies in Project ECHO is a benefit to my clinic.
- Mean Score: 4.9
Project ECHO has expanded access to HCV treatment for patients in our community.
- Mean Score: 4.9
Access to in general to specialist expertise and consultation is a major area of need for you and your clinic.
- Mean Score: 4.9
Access to HCV specialist expertise and consultation is a major area of need for you and your clinic.
- Mean Score: 4.9

Note: N=17

Slide 23

Project ECHO Providers: HCV Knowledge Skills and Abilities (Self-Efficacy)

The table presents the results for "Before Participation MEAN-SD;" "Today MEAN-SD;" "Paired Difference MEAN-SD/p-value;" and Effect Size for the Change" for "Community Providers, N=25."

Ability to identify suitable candidates for treatment for HCV.
- Before Mean / SD: 2.8 / 1.2
- Today Mean / SD: 5.6 / 0.8
- Paired Difference MEAN / SD / p-value: 2.8 / 1.2 / less than 0.0001
- Effect Size for the Change: 2.4
Ability to assess severity of liver disease in patients with Hepatitis C.
- Before Mean / SD: 3.2 / 1.2
- Today Mean / SD: 5.5 / 0.9
- Paired Difference MEAN / SD / p-value: 2.3 / 1.1 / less than 0.0001
- Effect Size for the Change: 2.1
Ability to treat HCV patients and manage side effects.
- Before Mean / SD: 2.0 / 1.1
- Today Mean / SD: 5.2 / 0.8
- Paired Difference MEAN / SD / p-value: 3.2 / 1.2 / less than 0.0001
- Effect Size for the Change: 2.6

Note: Scale: 1 = none or no skill at all 7 = expert-can teach others.

Slide 24

Project ECHO Providers: HCV Knowledge Skills and Abilities (Self-Efficacy)

Ability to assess and manage psychiatric co-morbidities in patients with Hepatitis C.
- Before Mean / SD: 2.6 / 1.2
- Today Mean / SD: 5.1 / 1.0
- Paired Difference MEAN / SD / p-value: 2.4 / 1.3 / less than 0.0001
- Effect Size for the Change: 1.9
Serve as local consultant within my clinic and in my area for HCV questions and issues.
- Before Mean / SD: 2.4 / 1.2
- Today Mean / SD: 5.6 / 0.9
- Paired Difference MEAN / SD / p-value: 3.3 / 1.2 / less than 0.0001
- Effect Size for the Change: 2.8
Ability to educate and motivate HCV patients.
- Before Mean / SD: 3.0 / 1.1
- Today Mean / SD: 5.7 / 0.6
- Paired Difference MEAN / SD / p-value: 2.7 / 1.1 / less than 0.0001
- Effect Size for the Change: 2.4

Slide 25

Project ECHO Providers: HCV Knowledge Skills and Abilities (Self-Efficacy)

Ability to assess and manage substance abuse co-morbidities in patients with Hepatitis C.
- Before Mean / SD: 2.6 / 1.1
- Today Mean / SD: 4.7 / 1.1
- Paired Difference MEAN / SD / p-value: 2.1 / 1.1 / less than 0.0001
- Effect Size for the Change: 1.9

Slide 26

Project ECHO Providers: HCV Knowledge Skills and Abilities

(Self-Efficacy)

Overall Competence-Average of 9 items.
- Before Mean / SD: 2.8* / 0.9
- Today Mean / SD: 5.5* / 0.6
- Paired Difference MEAN / SD / p-value: 2.7 / 0.9 / less than 0.0001
- Effect Size for the Change: 2.9

Note: Cronbach's alpha for the BEFORE ratings = 0.92 and Cronbach's alpha for the TODAY ratings = 0.86 indicating a high degree of consistency in the ratings on the 9 items.

Slide 27

Ashoka and Robert Wood Johnson Changemaker Award

Applications sought for Disruptive Innovations in Healthcare—New Models that would change healthcare nationally and globally.
307 Applications from 27 countries.
9 finalists selected by a panel of Judges.
Project ECHO selected one of three winners by worldwide online voting.

Slide 28

Vision for the Future

The slide shows a calendar presenting a schedule for specific programs.

Slide 29

The slide shows a map of the state of New Mexico with specific cities highlighted with color-coded bands.

Slide 30

Potential Benefits of the ECHO Model

Quality and Safety.
Access for Rural and Underserved Patients.
Workforce Training and Force Multiplier.
Improving Professional Satisfaction/ Retention.
Cost Effective Care—Avoid Excessive Testing and Travel.
Integration of Public Health.

Slide 31

Use of telemedicine, best practice protocols, co-management of patients with case based learning (the ECHO model) is a robust method to to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.

Note: Supported by Agency for Health Research and Quality Health IT grant 1 UC1 HS015135-04, and MRISP, R24HS16510-02 and the New Mexico Legislature.

Current as of January 2009

Internet Citation:

ECHO Project. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090908slides/Arora.htm