Earlier this year, the World Health Organization reported that its goal of eliminating viral hepatitis as a global public health threat by 2030 has come well within reach, with 194 governments committed to hepatitis elimination; drastic price reductions in medicines through the use of generics; and effective harm reduction, screening, and treatment approaches currently available. Close to 3 million people have been able to access treatment for hepatitis C over the past 2 years, and 2.8 million people started lifelong treatment for hepatitis B in 2016 alone. Yet yearly rates of new infections continue to increase worldwide. Rapid global scale-up of screening, prevention, and treatment services – putting knowledge of those services into the hands of the frontline healthcare providers who serve communities and patients most at risk – is crucial if the dream of eliminating hepatitis is ever to be fully realized.1
Project ECHO (Extension for Community Healthcare Outcomes) is an innovative tool for the dissemination of medical knowledge to providers in medically underserved areas, which has the potential to tip the scales of worldwide efforts to halt the advance of hepatitis. It is not “telemedicine,” wherein a specialist assumes the care of a patient; rather, it enables primary care providers to care more effectively for patients in their own communities.
Project ECHO was initially developed in 2003 by Dr. Sanjeev Arora, a liver specialist in the Department of Internal Medicine at the University of New Mexico Health Sciences Center, to address disparities in access to hepatitis C treatment among New Mexico’s rural populations. At the time, while over 28,000 patients in New Mexico were diagnosed with hepatitis C, fewer than 5% had received treatment with interferon and ribavirin (best practice at that time). The waiting list at Dr. Arora’s clinic in Albuquerque was 8 months long. Many of his patients had to travel hundreds of miles to get care, resulting in lost work time and income, childcare expenses, and travel costs. Low-income patients would often delay seeking care (and develop increased complications) or not seek treatment at all. People were dying from a curable disease.
In response, Dr. Arora devised the ECHO model as a solution to the problem of inadequate access to hepatitis C care in New Mexico’s rural and underserved communities. He based the ECHO model on four principles:
· Use of technology (multipoint videoconferencing and the internet) to leverage scarce healthcare resources, in this case Dr. Arora and the expert pharmacists and psychiatrists at the University of New Mexico
· Sharing of clinical best practices and guidelines for treatment
· Case-based learning: learners receive guided practice and support from a multidisciplinary expert team and master issues of complexity
· Evaluation of outcomes
Dr. Arora and his team set up 21 hepatitis C Centers of Excellence across New Mexico (16 in community health centers, 5 in state prisons), each run by primary care providers committed to becoming experts in hepatitis C prevention and treatment. Using a simple videoconference platform, Dr. Arora’s hepatitis C ECHO program connected his team of specialists at UNM (the “hub”) with those providers (the “spokes”) for weekly two-hour teleECHO sessions in which the hub team guided the spoke participants through didactic presentations and discussion of participants’ deidentified patient cases.2 The case presentations and shared discussions highlighted another key aspect of the ECHO model: all-teach, all-learn. The primary care clinicians presenting cases and the hub specialists were all viewed as experts in their own right, helping to contribute knowledge and understanding that lead to better patient care.