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September 19, 2014

US project echoes with potential

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Dr Sanjeev Arora launched Project ECHO

Catherine Reilly investigates why Minister for Health Dr James Reilly is interested in a US project that uses telehealth in a primary care setting to improve outcomes, cuts hospital outpatient waiting lists and advance access to care.

Last June, in a fascinating video conference, Minister for Health Dr James Reilly conversed with a specialist in gastroenterology and hepatology at the University of New Mexico Health Sciences Centre based at the University of New Mexico, Albuquerque, US.

By all accounts the Minister listened very intently — and asked lots of questions — as Dr Sanjeev Arora outlined a model of primary care-based healthcare for common and complex conditions that can improve outcomes, cut hospital outpatient waiting lists and advance care access in a cost-effective way. It was, as a Ministerial advisor recently remarked to Irish Medical Times, a model that appeared to “recommend itself”.

Dr Arora launched Project ECHO (Extension for Community Healthcare Outcomes) as a pilot in 2003. It utilises telehealth technology through which primary care providers from underserved areas receive training, advice and support from specialists in delivering best-practice care.

Due to the success of the pilot programme, the model received a US federal grant from the Agency for Healthcare Research and Quality (part of the US Department of Health and Human Services) and a grant from the New Mexico State legislature. It grew from there and has attracted funds from a range of sources.

Project ECHO has expanded to dozens of sites in the US and its hubs include, among others, the University of Washington, the Veteran’s Administration Health System and the Beth Israel Deaconess Medical Centre, Boston, which is a Harvard Medical School Teaching Hospital. The model is delivering for a range of conditions/treatment areas including chronic pain, HIV, addiction, nephrology, diabetes mellitus and ADHD.

The model has also been replicated internationally, in the state of Parra, Brazil (HIV); New Delhi (HIV and HCV); Lucknow (autism), India; and Uruguay (liver disease). Chile and Mexico are expected to launch Project ECHO in 2013 and IMT understands that two pilots backed by the health service are due to be established in Northern Ireland during this year.

Frustration was the mother of invention for Dr Arora, in that he established the initiative because many patients from rural New Mexico with the hepatitis C virus (HCV) infection presented at his clinic at too late a stage. In fact, a number of factors were converging to severely limit patients’ ability to get specialised care, including poor access to specialists, a limited number of specialists and inadequate medical insurance.

The project therefore linked healthcare providers from rural clinics, the Indian Health Service, and prisons with specialists at the University of New Mexico through e-health tools such as teleconferencing and video-conferencing; Internet-based assessment tools; online presentations; and telephone, fax, and e-mail communications. The primary care providers are trained and mentored by specialists using videoconferencing and case-based learning.

HCV research

Research co-authored by Dr Arora and published in the New England Journal of Medicine has shown that the model is a very effective way of treating HCV infection in underserved communities. The paper, ‘Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers’ (2011;364:2199-207), involved a prospective cohort study comparing treatment for HCV infection at the University of New Mexico (UNM) HCV clinic, with treatment by primary care clinicians at 21 Project ECHO sites in rural areas and prisons in New Mexico. A total of 407 patients with chronic HCV infection who had received no previous treatment for the infection were enrolled and the primary end point was a sustained virologic response.

Dr David Vaughan, Director of Leadership, HSE

The study found that 57.5 per cent of the patients treated at the UNM HCV clinic (84 of 146 patients) and 58.2 per cent of those treated at Project ECHO sites (152 of 261 patients) had a sustained viral response. Among patients with HCV genotype 1 infection, the rate of sustained viral response was 45.8 per cent (38 of 83 patients) at the UNM HCV clinic and 49.7 per cent (73 of 147 patients) at Project ECHO sites. Serious adverse events occurred in 13.7 per cent of the patients at the UNM HCV clinic and in 6.9 per cent of the patients at Project ECHO sites.

Participating providers in each of the Project ECHO partner sites included a lead clinician (a physician, nurse practitioner, or physician’s assistant) and a nurse or medical assistant who helped manage patient care. None of the community practice sites had treated patients with HCV infection before joining the Project ECHO network.

Community providers took part in weekly HCV clinics or “knowledge networks” by joining a videoconference or calling into a teleconference line. They presented their cases by sharing patients’ medical histories, laboratory results, treatment plans and individual challenges and asked questions about best practice. Specialists at the UNM Health Sciences Centre in the fields of hepatology, infectious diseases, psychiatry and pharmacology provided advice and clinical mentoring during these clinics.

The paper suggested a number of potential explanations for the success of Project ECHO, including patient-centred care proximate to patients and the potential for greater patient trust in local providers who tended to be culturally competent, with such factors potentially enhancing adherence to treatment. As a result, local providers may have been better able to comply with best-practice protocols, ensure close assessment of the results of laboratory tests, offer patient-tailored education, and provide better and timelier management of side effects. The fact that the primary care of the patient and the management of hepatitis were provided by the same clinician ensured better co-ordination of care and fewer communication challenges.

Irish ECHO?

Dr Arora shared this success story from the deserts of New Mexico, and beyond, with Irish audiences when he visited in March 2012 as part of ‘Change Nation’, an event organised by Ashoka Ireland, whereby 50 of the world’s leading social entrepreneurs suggested their solutions to Ireland’s greatest societal challenges.

Senior figures in the HSE were among those who spoke with Dr Arora during and after his visit, setting in train a series of events that led to the video conference with Minister Reilly. IMT understands that the Minister subsequently asked the HSE to examine the possibility of implementing the model, in some manner, in Ireland.

Sharon Keilthy, a management consultant with a company in Dublin, and Rebecca Kilbane, a consultant with Ashoka Ireland, were involved in Change Nation and have been volunteering their time to promote the idea of Project Echo in Ireland. They have met with a range of interested parties including senior HSE representatives, consultants and the CEO of the RCSI, Prof Cathal Kelly. There are promising leads, according to Keilthy, but nothing concrete has been finalised just yet. Yet there are a few ways it could happen and an obvious route would centrally involve the HSE.

Keilthy understands that the Executive is very eager to leverage the availability of expert diagnosis in mental health, for example, and she feels Project ECHO would be an ideal modus operandi.

However, she underlined that there are various options in terms of how Project ECHO in Ireland could begin and what conditions it could cover. The key factors are that the treated conditions are common and complex and the patient population is underserved (e.g. due to waiting lists).

Right model

Dr David Vaughan, Director of Leadership and Quality Improvement, HSE, said the principle and technology associated with Project Echo “fit very well into what the HSE wants to do”. He told Irish Medical Times: “[The HSE] is very interested and the clinical care programmes are the route to go, but we’ve been trying to find the right clinical programme at the right stage of development that it fits in with.”

Dr Vaughan added that the costs associated with the Project Echo model would be “minimal”.

Identifying the right disease model is easier said than done, he said. People working in Irish healthcare are extremely busy and it takes time to process, analyse and make a call on a relatively new concept of health delivery for Ireland.

Challenges rest in presenting it to the people who would use and implement the model and in finding a disease or disease group that best fits into Project ECHO in an Irish healthcare context, he added. “The model that Sanjeev Arora uses in New Mexico is essentially a consultant specialist in a big teaching hospital working with GPs on hepatitis, in his case. In my opinion — and it is just my opinion — it is less clear whether that’s a model that would work as well here, or does it need some modification?”

Specifically, it needs to be established if a model in Ireland would be best led by a specialist consultant in a major hospital who would liaise with GPs, or by a greater number of consultants in smaller hospitals linking in with GPs.

Asked if the Minister for Health had pledged any specific support, Dr Vaughan indicated that it would be better for “a proposal to come back to the HSE and the Department saying ‘this is what we need and this is what we can deliver’”.

GP buy-in

In terms of buy-in from GPs, the model would also need to be framed so that the benefits were clear. Data collected by Dr Arora suggested that GPs’ participation enhanced professional satisfaction and benefited their clinics. Dr Vaughan commented: “GPs are outstanding professionals, but it needs to be presented in a way that it makes sense to them… everyone is working hard and no-one wants more work in a challenging environment.”

Telemedicine in Irish healthcare does not have a huge back-story, but its successful use in treating acute stroke at some centres underlines how impactful it can be. Dr Vaughan said a significant development regarding the HSE’s potential involvement in Project Echo could happen tomorrow or in six months’ time. “These things just take longer than anyone likes sometimes.”

As Sharon Keilthy predicted, someone, somewhere just needs to say ‘yes’ and it will snowball. “Sanjeev [Arora] talks about the way that Project Echo happens, in that an academic medical centre just decides to do it and runs a pilot of it with one specialty, maybe with one consultant who is just game,” she said. The consultants who have been approached “get it”, she said, and are “excited” by the idea.

“The New England Journal of Medicine is a prestigious journal and they see that the clinical outcomes were really good, so it comes across to them as credible.”

Keilthy preferred not to name the consultants who have been approached, but said they work in specialties with the longest outpatient waiting times. She said such areas included mental health, especially in the public system, neurology, including for the private system (due to the lack of consultants), rheumatology and diabetes. “But basically anywhere you are short of consultants… because what [Project Echo] does is, it de-monopolises the consultants’ expertise.”

Private drive

It is also possible that a private hospital could adopt Project Echo as “a way of building its market share, if you want to be business-like about it”. On the latter point, Keilthy expanded: “[A private hospital] would get a reputation for being innovative; it would have great relationships with the GPs. GPs would have great relationships with the specialists, and so then they would be more likely to refer to you.” In a competitive market, these would be real incentives.

In general, she said the public-private split in the Irish health system has made the whole process of identifying and securing stakeholders a little bit more “complex”.

Meanwhile, GPs would be key players if the model was adopted, but thus far Keilthy and Kilbane have been more focused on sharing the idea with consultants, as they are the conduits through which a programme could begin. The time commitment for all concerned would be a subject for discussion, she concluded.