Project ECHO opens up access to medical learning through technology

Gathered around a conference table on a recent February morning in Phoenix are a team of hepatologists — experts on liver function, disease and abnormalities. Projected on a big screen across the room are the faces of a local primary care provider, several medical students, doctors and related subject area experts from Arizona State University, all connecting to this meeting via Zoom. On the docket is the case of a patient presenting with jaundice and malaise.

Based on the patient’s personal information, the team concludes she likely has alcoholic hepatitis, a condition of the liver caused by heavy alcohol consumption over an extended period of time.

The group spends the next 30 minutes discussing treatment options, along with the causes, risk factors and signs of alcohol abuse. Matthew Martin, a clinical assistant professor at ASU’s College of Health Solutions who specializes in behavioral health integration, describes the best way to approach the topic of alcohol consumption with a patient who is less than forthcoming. One medical student comments that she has never heard about using that kind of approach before, but that she’d like to try it out and see how it goes.

This collaboration is a testament to the importance of having multidisciplinary teams address complex medical issues. 

This isn’t telemedicine. This is telementoring.

It’s the whole philosophy behind Project ECHO, a new model of medical education and health care delivery that relies on the sharing of knowledge across disciplines and physical space — a factor more important now than ever.

It operates via a “hub and spoke” model in which a small team of specialists at a hub site connect virtually with primary care providers (the spokes) in communities across their state or region to train them in the delivery of specialty care services, thereby increasing access to specialty treatment and care in rural and underserved areas. 

ASU’s College of Health Solutions has served as a hub site since spring 2019, linking specialists within the college and partner institutions with primary care providers in local Arizona communities. Each hub site can host any number of programs focused on topics from diabetes to bone health.

At the College of Health Solutions, two programs, one focused on liver disease and one focused on behavioral health integration, have been up and running for a year. In February, the college added a program focused on medication-assisted treatment (MAT) for opioid use disorders, and in March it added another, focused on veterans’ health.

Over the past couple of weeks, all of these programs have turned their focus toward responding to the COVID-19 crisis within their areas of expertise, and the response from the health care community has been huge — the MAT program alone went from roughly 30 participants to 245 — demonstrating how crucial such distance-learning programs are at this moment.

A series of serendipitous events

The way College of Health Solutions Lecturer Adrienne White tells it, Professor Keith Lindor was wandering the halls one day a few years ago, looking for junior faculty to co-teach with, asking if there were any takers. She could hardly believe her ears and jumped at the chance.

“I have a world-renowned hepatologist saying, ‘Hey, want to teach a class with me?’” White said. “So I'm like, ‘Yes!’” 

If it seems like there are a lot of hepatologists in this story, it’s because Project ECHO got its start with one: Sanjeev Arora at the University of New Mexico.

White had been using Project ECHO as a case study in her courses to teach students about alternate methods of health care delivery for a couple of years.

“I just thought it was a really cool way of rethinking something that we've done for so long one way and doing it differently,” she said.

And when she brought up Project ECHO to Lindor in a discussion of the syllabus for her health care system and design course, she learned that he knew Arora.

“I should've known (they knew each other),” White said, chuckling. “It's a small world in hepatology.”

So Lindor gave him a call, and Arora agreed to visit ASU.

One day in fall 2017, Arora participated in a speaker series at ASU, spoke to College of Health Solutions graduate students and attended some meetings around Phoenix to talk about Project ECHO with leaders of various organizations.

At the end of that day, Arora suggested to White that the College of Health Solutions become a replicating partner of Project ECHO.

Meanwhile, Martin had just joined the faculty at the college and was eager to use his new position to address the lack of expert knowledge he’d become aware of in the field of integrative care. He did some research and discovered Project ECHO. Intrigued by its teaching model and philosophy of knowledge sharing, he reached out to the University of Mexico to get in touch with Arora but learned someone from ASU already had. It was, of course, White. 

Soon after, they formed a team, with White taking on the role of director of ASU Project ECHO and Martin taking charge of its first program in behavioral health integration​.

Medical knowledge for all

The main factor that attracted both White and Martin to Project ECHO was Arora’s belief in the democratization of medical knowledge.

Around 2003, Arora and one other physician were the only ones in New Mexico treating hepatitis C, a viral infection of the liver that can be fatal. The treatment at the time was a drug called interferon, which was similar to chemotherapy in that it required several rounds of treatment and was very expensive. No primary care physicians would touch it. That meant only about 2% of those in New Mexico who needed it were getting treatment. Those going untreated generally came from lower-income households and lived in rural areas.

That only 2% of people with a disease that had a 70% cure rate were getting treatment was unacceptable to Arora. He figured there had to be a simple way to share his expert knowledge with the primary care providers already living and working in rural and underserved areas to improve health outcomes there. 

And so Project ECHO was born.

It now has hubs in 38 countries around the world, with nearly 800 distinct programs, yet it has no revenue generation whatsoever. Arora calls it “a project of the willing."

“It's very much made up people who just get it, who see the benefit of it, who believe in it,” White said.

The initiative is gaining support, though. In 2016, Congress passed the ECHO Act, requesting that the Secretary of Health and Human Services evaluate the efficacy of the ECHO model in the U.S., with strong bipartisan support. Three years later, the ECHO 2019 Act was passed, again with strong bipartisan support, to begin driving funding and resources toward Project ECHO in the form of grants, technical assistance, equipment, curriculum development and whatever else is needed.

That support for the program attracted partners like Blue Cross Blue Shield, which is providing funding for an entire year of ASU’s new medication-assisted treatment ECHO program. It was born out of the need surrounding the current opioid crisis, which Arizona Gov. Doug Ducey declared an emergency in 2017, and will operate in partnership with Honor Health and the Center for Applied Behavioral Health Policy at ASU’s Watts College of Public Service and Community Solutions.

Specialists and primary care providers alike are recruited to participate in ECHO programs through such grassroots efforts as cold calls, letters and face-to-face meetings that prioritize relationship building.

“One thing that we look for with our participants are providers who want to become champions within their clinic,” White said. “It's really easy to use an ECHO program to come and get advice from an expert panel for that one patient you're having challenges with. But we want to create champions who become experts themselves, who become the go-to person in their clinics, who are willing to take that knowledge and pass it on.”

Project ECHO programs welcome providers of any level — from physician’s assistants to social workers to community health workers — and offer continuing education credit, free of charge.

“There's huge potential,” White said. “Anybody can be involved.”

White’s goal by the end of 2020 is to have 200 provider participants from all 15 counties in the state enrolled across ASU’s four ECHO programs. She and her team will also be making more targeted recruitment efforts.  

Education, continued

At a panel at ASU’s Downtown Phoenix campus in January, Martin hosted Project ECHO Chief of Staff Elizabeth Clewett, Christopher Abert, director of the Southwest Recovery Alliance, and Isabel Kozak, assistant chief of staff for community medicine at the Phoenix VA Health Care System, for an overview of the initiative’s progress at ASU so far, and a look to the future with the addition of the medication-assisted treatment and veterans-focused programs.

“We’re really growing exponentially, which is good because we have a big goal,” Clewett said.

Both Kozak and Abert, who were on hand to represent two of the organizations ASU has partnered with for the two new programs, expressed an eagerness to get the ball rolling.

“It’s unnecessarily complicated right now to prescribe MAT because of stigmatization,” Abert said. “I’m excited to help practitioners navigate an unnecessarily difficult process in hopes that one day it won’t be difficult.”

Already, about 50 providers across Arizona are participating in ASU’s medication-assisted treatment ECHO program.

ASU’s Veteran Community Care Collaborative ECHO aims to address the need for primary care providers to better understand veteran populations.

“We’re very excited to partner with ASU ECHO at the VA, because doctors sometimes don’t understand vets,” Kozak said, referring to veteran-specific health concerns that not all primary care providers are knowledgeable in, such as PTSD.

Martin pointed out that the ECHO teaching model has great prospects for use outside of health care as well, and is already being used in such industries as policing and at ASU’s Mary Lou Fulton Teachers College to train future educators.

“I’m hoping that the ECHO model or something like it can become the future of continued education,” he said. “Because the experience of participating in an ECHO program is so much richer.”