Weitzman 2013: Project ECHO


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Dr. Sanjeev Arora talks about Project ECHO at the 2013 Weitzman Symposium

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  • Project ECHO is the Brain child of SanjeevArora & started in 2003. Vision is the energy behind every effort and the force to push thru problems that we are encounteredFor ECHO Global Connections we hope to engage the health-care community by fostering communications and identifying common themes affecting health issues, in India. Health Care professionals work in vastly different environments, yet we all face many of the same challenges. With this presentation we offer various perspectives and expect to provoke thoughtful discussion.
  • WHO estimates that 170 million persons or 3 % of the world’s population are infected with hepatitis C and 3 to 4 million persons are newly infected each year. The prevalence of HCV in some countries in Africa, the Eastern Mediterranean, South East Asia and Western Pacific is high compared to some countries in Europe and North America.According to the National Health and Nutrition Examination Survey of 1988 to 1994, the NHANES survey, and other population-based surveys, nearly 2% of Americans test positive for the hepatitis C antibody. This prevalence corresponds to an estimated 4 million Americans infected with HCV.
  • NM 2 M people……………. is larelgy rural just like India, 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUAs)
  • Arora S, Geppert CM, Kalishman S, et al: Acad Med. 2007 Feb;82(2): 154-60.4 principles #2 is caring sharing and Improving by using Best practices and Reduce variation4 is tracking outcomes on InternetBecause lectures to Dr’s is not enough, but university students learn by guided practice. U prof becomes a mentor
  • Knowledge comes but wisdom lingers. Guide lines and process alone not enough expert modify criteria…roll w the punchesAlgorithm gene + ve 1 ,RX for 1 yr GuidelineCk list 16 wk do 16 cks all, instead of 12 Process…who does what, what can nurse does, because Dr does not have time, he delegatesKnowledge comes but wisdom lingers. Guide lines and process alone not enough expert modify criteria…roll w the punchesAlgorithm gene + ve 1 ,RX for 1 yr GuidelineCk list 16 wk do 16 cks all, instead of 12 Process…who does what, what can nurse does, because Dr does not have time, he delegates
  • Knowledge learning means they will learn from U prof, from each other and then learning by doing to become expert
  • Outcomes x Provider skills improvement, pt overall satisfaction, efficacy of RX1 is no skill and 7 is expert start from 2.4 before and in 1 yr 5.6
  • 94 % pts GP say this was v. beneficial
  • When we ask prof competence is 4.4 out of 5
  • Weitzman 2013: Project ECHO

    1. 1. WORKING TO BRING SPECIALTY HEALTHCARE TO ALL PEOPLESanjeev Arora MDProfessor of Medicine (Gastroenterology/Hepatology)Director of Project ECHO®Department of MedicineUniversity of New Mexico Health Sciences CenterTel: 505-272-2808Fax: 505-272-6906sarora@salud.unm.edu
    2. 2. The mission of Project ECHO® is toexpand the capacity to provide bestpractice care for common and complexdiseases in rural and underserved areasand to monitor outcomes.Supported by N.M. Dept. of Health, Agency for Health Research and Quality HIT Grant 1UC1 HS015135-04, New Mexico Legislature, and the Robert Wood Johnson Foundation.
    3. 3. U.S.A.4 MSOUTHAMERICA10 MAFRICA32 MEASTMEDITERRANEAN20MSOUTH EAST ASIA30 MAUSTRALIA0.2 MSource: WHO 1999WESTEUROPE9 MFAR EAST ASIA60 MHepatitis C: A Global Health ProblemOver 170 Million Carriers Worldwide, 3-4 MM newcases/year
    4. 4. • Estimated number is greater than 28,000• In 2004 less than 5% had been treated– 2,300 prisoners were HCV positive (~40% of thoseentering the corrections system), none weretreated• Highest rate of chronic liver disease/cirrhosisdeaths in the nation; 25% higher incidencethan the next highest state• Ten times more prevalent than HIVHepatitis C in New Mexico
    5. 5. 02040608010042%-46%70%-80%Genotype 1 Genotype Non-1Adapted from Strader DB et al. Hepatology. 2004;39:1147-1171.Sustained Viral Response (Cure) Rates withPegIFN/RBV According to Genotype
    6. 6. • Good News• Curable in 45-81% of cases• Bad News• Severe side effects:– anemia (100%)– neutropenia >35%– depression >25%• No Primary Care Physicians treating HCVHepatitis C Treatment
    7. 7. • 121,356 sq miles• 1.83 million people• 42.1% Hispanic• 9.5% Native American• 17.7% poverty ratecompared to 11.7%nationally• >22% lack healthinsurance• 32 of 33 New Mexicocounties are listed asMedically UnderservedAreas (MUAs)• 14 counties designated asHealth ProfessionalShortage Areas (HPSA’s)Underserved Area for Healthcare ServicesRural New Mexico
    8. 8. practice in rural orfrontier areasNew Mexico Physician Survey 2001Health Care in New Mexico20%
    9. 9. • Develop capacity to safely andeffectively treat HCV in all areas of NewMexico and to monitor outcomes• Develop a model to treat complexdiseases in rural locations anddeveloping countriesGoals of Project ECHO®
    10. 10. • University of New Mexico School of MedicineDept of Medicine, Telemedicine and CME• NM Department of Corrections• NM Department of Health• Indian Health Service• FQHCs and Community Clinics• Primary Care AssociationPartners
    11. 11. • Use Technology (multipoint videoconferencing andInternet) to leverage scarce healthcare resources• Disease Management Model focused on improvingoutcomes by reducing variation in processes of careand sharing “best practices”• Case based learning: Co-management of patientswith UNMHSC specialists (learning by doing)• HIPAA compliant web-based database to monitoroutcomesArora S, Geppert CM, Kalishman S, et al: Acad Med. 2007 Feb;82(2): 154-60.Methods
    12. 12. What is Best Practice in Medicine• Algorithm• Check Lists• Process• Wisdom Based on Experience
    13. 13. • Train physicians, mid-levelproviders, nurses, pharmacists, educators in HCV• Train to use web based software — “iHealth”• Conduct telemedicine clinics — “KnowledgeNetwork”• Initiate co-management — “Learning Loops”• Collect data and monitor outcomes centrally• Assess cost and effectiveness of programsSteps
    14. 14. • No cost CMEs and Nursing CEUs• Professional interaction with colleagues with similarinterest‒ Less isolation with improved recruitment and retention• A mix of work and learning• Obtain HCV certification• Access to specialty consultation withGI, hepatology, psychiatry, infectious diseases, addictionspecialist, pharmacist, patient educatorBenefits to Rural Clinicians
    15. 15. NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G
    16. 16. • Videoconferencing Bridge (Polycom RMX 2000)• Videoconferencing Recording Device (Polycom RSS 2000)• You Tube-like Website (Polycom VMC 1000 )• Webcam Interfacing Capacity (Polycom CMA 5000)• iHealth• Webinar• Customer Relation Management Solution- iECHOTechnology
    17. 17. How well has model worked for Hepatitis C?• 500 HCV TeleECHO Clinics have been conducted• >5,000 patients entered HCV disease managementprogramCME’s/CE’s issued:• >6,000 CME/CE hours issued to ECHO® Clinicians forHep C‒ Total CME hours 27,000 at no cost• 280 hours of HCV Training conducted at rural sites• National Recognition as Model for Complex DiseaseCare
    18. 18. scale: 1 = none or no skill at all 7= expert-can teach othersCommunity CliniciansN=25BEFOREParticipationMEAN (SD)TODAYMEAN (SD)PairedDifference(p-value)MEAN (SD)EffectSizefor thechange1. Ability to identify suitablecandidates for treatmentfor HCV.2.8 (1.2) 5.6 (0.8)2.8 (1.2)(<0.0001)2.42. Ability to assessseverity of liver disease inpatients with HCV.3.2 (1.2) 5.5 (0.9)2.3 (1.1)(< 0.0001)2.13. Ability to treat HCVpatients and manage sideeffects.2.0 (1.1) 5.2 (0.8)3.2 (1.2)(<0.0001)2.6Project ECHO® CliniciansHCV Knowledge Skills and Abilities (Self-Efficacy)(continued)
    19. 19. Community CliniciansN=25BEFOREParticipationMEAN (SD)TODAYMEAN (SD)PairedDifference(p-value)MEAN (SD)EffectSizefor thechange4. Ability to assess and managepsychiatric co- morbidities inpatients with hepatitis C.2.6 (1.2) 5.1 (1.0)2.4 (1.3)(<0.0001)1.95. Serve as local consultantwithin my clinic and in myarea for HCV questions andissues.2.4 (1.2) 5.6 (0.9)3.3 (1.2)(< 0.0001)2.86. Ability to educate andmotivate HCV patients. 3.0 (1.1) 5.7 (0.6)2.7 (1.1)(<0.0001)2.4(continued)Project ECHO® CliniciansHCV Knowledge Skills and Abilities (Self-Efficacy)
    20. 20. Community CliniciansN=25BEFOREParticipationMEAN (SD)TODAYMEAN (SD)PairedDifference(p-value)MEAN (SD)EffectSizefor thechangeOverall Competence(average of 9 items)2.8* (0.9)5.5*(0.6)2.7 (0.9)(<0.0001)2.9Cronbach’s alpha for the BEFORE ratings = 0.92 and Cronbach’s alpha for the TODAY ratings = 0.86 indicating ahigh degree of consistency in the ratings on the 9 itemsArora S, Kalishman S, Thornton K, Dion D et al: Hepatology. 2010 Sept;52(3):1124-33Project ECHO® CliniciansHCV Knowledge Skills and Abilities (Self-Efficacy)
    21. 21. BenefitsN=35Not/MinorBenefitsModerate/MajorBenefitsEnhanced knowledge aboutmanagement and treatment of HCVpatients.3%(1)97%(34)Being well-informed aboutsymptoms of HCV patients intreatment.6%(2)94%(33)Achieving competence in caring forHCV patients. 3%(1)98%(34)Clinician Benefits(Data Source; 6 month Q-5/2008)
    22. 22. N=17 Mean Score(Range 1-5)Project ECHO® has diminished my professional isolation. 4.3My participation in Project ECHO® has enhanced my professionalsatisfaction.4.8Collaboration among agencies in Project ECHO® is a benefit to myclinic.4.9Project ECHO® has expanded access to HCV treatment for patients inour community. 4.9Access, in general, to specialist expertise and consultation is a majorarea of need for you and your clinic. 4.9Access to HCV specialist expertise and consultation is a major area ofneed for you and your clinic. 4.9Project ECHO®Annual Meeting Survey
    23. 23. T h eHepatitis C Trial
    24. 24. • To train primary care clinicians in rural areasand prisons to deliver Hepatitis C treatmentto rural populations of New Mexico• To show that such care is as safe andeffective as that give in a university clinic• To show that Project ECHO® improvesaccess to Hepatitis C care for minoritiesOBJECTIVES
    25. 25. • Study sites– Intervention (ECHO)• Community-based clinics: 16• New Mexico Department of Corrections: 5– Control: University of New Mexico (UNM) LiverClinic• Subjects meeting inclusion / exclusion criteria– Community cases seen by primary care physicians– Consecutive University patientsParticipants
    26. 26. • Prospective cohort study– Participation determined by available technology– Randomization by patient, Clinician, or site notfeasible• Advantages– Uniform eligibility criteria– Standardized treatment– Prospective measurement of end-points• Limitation: groups unbalanced with respect topatient covariatesStudy Design
    27. 27. • Sustained Viral Response (SVR): nodetectable virus 6 months after completionof treatmentPRINCIPLE ENDPOINT
    28. 28. • 407 hepatitis C patients met inclusion andexclusion criteria– Age: 43.0 ± 10.0 years– Men: 63.3%– Minority: 65.2%– Genotype 1: 57.0%– Log10 viral load: 5.89 ± 0.95– Treatment sites• UNMH: 146• ECHO site: 261Developing New Standards ofPractice for Hepatitis C
    29. 29. TREATMENT OUTCOMESOutcome ECHO® UNMH P-valueN=261 N=146Minority 68% 49% P<0.01SVR* (Cure)Genotype 150% 46% NSSVR* (Cure)Genotype2/370% 71% NS*SVR=sustained viral responseNEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G
    30. 30. • Rural primary care Clinicians deliverhepatitis C care under the aegis of ProjectECHO® that is as safe and effective as thatgiven in a University clinic.• Project ECHO® improves access to hepatitisC care for New Mexico minorities.Conclusions
    31. 31. 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 diseasemanagement
    32. 32. Bridge BuildingUNM HSCStateHealthDeptPrivatePracticeCommunityHealth CentersPareto’s PrincipleChronic PainRheumatoid Arthritis + Rheumatology ConsultationSubstance Use and Mental Health Disorders
    33. 33. Force MultiplierUse Existing Community CliniciansSpecialistsPrimaryCarePhysicianAssistantsNursePractitionersChronic PainRheumatoid Arthritis + Rheumatology ConsultationSubstance Use and Mental Health Disorders
    34. 34. Successful Expansion intoMultiple DiseasesMon Tue Wed Thurs Fri8-10a.m.Hepatitis C• Arora• ThorntonDiabetes &Cardiac RiskReduction• ColleranGeriatrics/Dementia• HermanPalliative Care• Neale10-12a.m.Rheumatology• BankhurstChronic Pain• KatzmanIntegratedAddictions &Psychiatry• KomaromyComplex Care• Neale &Komaromy2-4p.m.HIV• Iandiorio &ThorntonPrison PeerEducatorTraining• ThorntonWomen’sHealth &Genomics• Curet
    35. 35. Integrated Addictions andPsychiatry Clinic• Focus on treating opiate addiction (heroin, pain pills) withpsychosocial support + effective medication• Only 32 physicians in New Mexico certified to prescribeBuprenorphine in 2007• Trained/certified 225 physicians statewide in use ofbuprenorpine/Suboxone, 274 total clinicians trained
    36. 36. TimeIncreasing Gap“Expanding the Definition of Underserved Population”TRANSFORMING PRIMARY CARE WITHKNOWLEDGE NETWORKS
    37. 37. Primary CareNurseMedicalAssistantCommunityHealthWorkerChronic Disease Management is a Team SportForce MultiplierDiabetes and Cardiac Risk ReductionAsthma and COPDSubstance Use and Mental Health Disorders
    38. 38. Community Based Care forCardiac Risk Factor Reduction was moreEffective than Enhanced Primary CareBecker Circulation. 2005:111:1298-1304.
    39. 39. • Live in Community• Understand culture• Appreciate economic limitations of patientand know community resources available topatient• Often know family and can engage othersocial resources for patient• Spend more time with patientWhy is a CHW Intervention Effective?
    40. 40. • CHW Specialist Training– CREW: Diabetes, Obesity, Hypertension,Cholesterol, Smoking Cessation, ExercisePhysiology– CARS: Substance Use Disorders– ECHO Care: Complex Multiple Diagnoses• Prison Peer Educator TrainingECHO ® CHW Training — Multiple Tracks
    41. 41. • Use low-cost technology to take specialty training toCHWs, Promotoras, CHRs, Medical Assistants where they live• Narrow Focus — Deep Knowledge• Standardized Curriculum– 3 Day Onsite– Webcam/Weekly Video Based Clinics• Diet• Exercise• Smoking Cessation• Motivational Interviewing• Gentle Nudges• Finger Stick• Foot Exam– Ongoing support via knowledge networks– Part of Disease Management Team– Warm HandoffSpecialty CHW Program
    42. 42. Community Health Workers in PrisonThe New Mexico Peer Education ProgramPilot training cohort, CNMCF Level II, July 27-30, 2009Photo consents on file with Project ECHO and CNMCFFirst day of peer educator training
    43. 43. Graduation Ceremony of First CohortThe New Mexico Peer Education ProgramPilot training cohort, CNMCF Level II, July 27-30, 2009Photo consents on file with Project ECHO and CNMCFGraduation as Peer Educators
    44. 44. • Quality and Safety• Rapid Learning and best-practice dissemination• Reduce variations in care• Access for Rural and Underserved Patients, reduced disparities• Workforce Training and Force Multiplier• De-monopolize Knowledge• Improving Professional Satisfaction/Retention• Supporting the Medical Home Model• Cost Effective Care- Avoid Excessive Testing and Travel• Prevent Cost of Untreated Disease (e.g.: liver transplant ordialysis)• Integration of Public Health into treatment paradigmPotential Benefits of ECHO® model toHealth System
    45. 45. • University of Washington (HCV, Chronic Pain, HIV, Addiction)• University of Chicago (HTN, Cancer, ADHD)• Veteran’s Administration Health System (Chronic Pain, DM,Heart Failure, HCV, Women’s Health, Nephrology) – 11 regions• US Department of Defense• University of Nevada (DM)• University of Utah (HCV)• University of South Florida, ETAC (HCV/HIV Co-Infection)• Florida and Caribbean, AETC (HIV/AIDS)• Harvard, Beth Israel Deaconess Medical Center (HCV, Dementia)• Community Health Center, Inc. (HIV, HCV, Chronic Pain)• LA NetECHO® Replication in US:
    46. 46. • India: New Delhi (HIV and HCV), Lucknow(Autism)• Uruguay (Liver disease)ECHO® Replication Sites worldwide:
    47. 47. The ECHO® Team
    48. 48. • Excellence in Clinical Research Award, University of New Mexico Health SciencesCenter, 2012• New England Journal of Medicine Article, “Outcomes of Treatment for Hepatitis C VirusInfection by Primary Care Providers” named one of the Most Influential Research Articlesof 2011 by the Robert Wood Johnson Foundation, 2012• 21st Century Awards for Best Practices in Distance Learning from the United StatesDistance Learning Association (USDLA), 2010• ASHOKA Fellowship for Social Entrepreneurship, 2009• Lemelson Fellow for Using Technology to help Humanity, 2009• Leadership in Distance Learning Program Administration Award from the United StatesDistance Learning Association (USDLA), 2009• eHealth Initiative Award: “Transforming Care Delivery at the Point of Care,” 2008• Robert Wood Johnson Foundation/Ashoka Foundation Changemakers CompetitionWinner: “Disruptive Innovations in Health and Healthcare--Solutions People Want,” 2007Awards for ECHO® Team
    49. 49. Use of multipoint videoconferencing, bestpractice protocols, co-management ofpatients with case based learning (the ECHOmodel) is a robust method to safely andeffectively treat common and complexdiseases in rural and underserved areas andto monitor outcomes.WORKING TO BRING SPECIALTY HEALTHCARE TO ALL PEOPLE