Project ECHO Replication in Semi-urban India: Force Multiplication to Improve Care for Chronic Diseases

Project ECHO^® (Extension for Community Healthcare Outcomes) is an innovative model of healthcare transformation applicable for semi-urban and underserved urban populations. It uses technology to leverage scarce healthcare resources and has the potential to improve healthcare delivery.

Project ECHO (http://echo.unm.edu/) started in New Mexico, USA in 2003 with the management of Hepatitis C (HCV) but has expanded to address various other health conditions since then. These include diabetes, cardiovascular risk reduction, high-risk pregnancy, HIV/AIDS, chronic pain, and rheumatological conditions.

Sanjeev Arora, MD is the founder and director of Project ECHO and has been instrumental in all studies that are part of this innovative health delivery system.  ECHO has now been successfully replicated in 29 US states and three countries.  ECHO has the developed processes, training curricula, and software resources to support replication initiatives worldwide.

Introduction

The motivation for Project ECHO stems from severe shortages of specialty trained expert physicians in rural areas, as people suffering from complex diseases often have to travel long distances or wait months to get treatment. Given these barriers, such patients are often forced to wait until complications become severe or life threatening.

ECHO utilizes case-based learning, disease management techniques, and technology, using the Internet and videoconferencing. It expands access to care for patients with chronic, complex conditions by improving the capacity of community healthcare providers to optimize management.  Specialists help guide rural community providers to apply best practices to manage care. The community providers build their knowledge and expertise in specific conditions and come to serve as expert consultants in their regions. The principal goal of Project ECHO is “force multiplication”--achieving a logarithmic increase in capacity to deliver best practice care for complex diseases.

ECHO in India

The purpose of ECHO-Gujarat is to pilot the successful application of the ECHO model for diabetes and cardiovascular risk reduction. We will thereby demonstrate that the model is effective in enhancing the care for common, complex conditions for the people of India. This will be accomplished by increasing the capacity of primary care clinicians, nurses, and community health care workers in underserved areas to provide best practice care for complex diseases.

Target Population and Disease Categories

The project will first be implemented in the state of Gujarat and will roll out in three phases:

These clinical conditions are targeted because they are common, require complex treatment, and have a significant impact in terms of health and economic consequences. In addition, best practice care for these conditions has been shown to help. 

Methodology

The proposed project will incorporate four key elements of the ECHO model:

Community providers at district hospitals will take part in weekly teleECHO clinics by joining a videoconference Knowledge Network (see attached image for visual representation of a Knowledge Network). As part of Phase 1, there will be separate 2-hour diabetes and hypertension clinics each week. The community providers will be encouraged to take turns presenting their cases by sharing de-identified patient medical histories, lab reports, and treatment plans. Specialists at the AMC, chosen by Project ECHO, will provide case-specific advice and didactic training.

Working together, the community providers and specialists will manage patient care by following evidence-based protocols. Community providers will ultimately be accountable for patient care, with specialists serving as mentors.

This case-based approach creates a "learning loop," in which community providers “learn by doing" in a guided practice model. They will also learn through brief lectures (via video) on clinical issues.  In this way, care teams at the community clinics learn to work together to manage chronic conditions. Primary care providers gain competence in identifying and treating high-risk patients while nurses become adept in patient education and support. 

In addition, the ECHO model will be used to train community health workers (CHWs), using specialty curricula in diabetes and other conditions. There is evidence that CHWs can play key roles in helping patients manage chronic conditions, make recommended behavioral changes, and adhere to treatment plans. This project will train paraprofessionals to assist patients in managing diabetes, hypertension and other chronic conditions.

The Academic Medical Center (AMC) will appoint a specialist physician leader along with nursing and administrative support.  The specialist physician leader will recruit about 20 peripheral sites to participate in this project. Community clinics will partner with the AMC to address diabetes and hypertension. Community clinic participants will include a lead clinician as well as nurses and CHWs or medical assistants who help manage patient care in small towns. Project ECHO-Gujarat will appoint a local coordinator in India for day-to-day project management. 

India, like most developing nations, lacks a fully developed infrastructure, often limiting broadband connectivity between rural and urban areas. However, many towns and district hospitals have access to broadband connectivity. Clinics located in district hospitals will be chosen for the project based on availability of reliable broadband connectivity. Project ECHO will provide the webcams and software necessary for community clinics that have broadband Internet access for conducting videoconferences.

The program could establish collaboration with other organizations if necessary.

Future Dissemination

Project ECHO will develop systems, tools, and resources to assist in the replication of the ECHO model (diabetes, hypertension, and/or cardiac risk factors) in India by creating and documenting a successful implementation in one state.  As part of this process, the project will determine the resources, support, expert leadership team, partners, and sustainability plans required to bring ECHO to other areas.  It will also demonstrate that this paradigm is a robust and effective way of delivering best practice care with varying patient and provider populations.

Key Measures and Results:

To gauge the effectiveness of this care delivery model, leaders will track the following measures:

•      Participating community provider’s self-reported knowledge and skills in the management of chronic and complex conditions.  After participating in ECHO for 12 months, community providers (physicians, physician assistants, nurse practitioners and CHWs) will complete surveys evaluating the program. On all measures, we expect our providers to report greater knowledge and confidence in treating patients with chronic and complex conditions after participation.  Notably, their self-reported ability to serve as local consultants will improve significantly.  Leaders will use the results to improve the program.

•      Evaluation of provider knowledge and self-efficacy will be based on past and ongoing evaluation of the ECHO clinics in the United States, which will reduce the task of addressing issues and developing questionnaires and tools. We will measure the number of patients treated, the efficacy of treatment in small towns, compare the results to published literature and thus assess our success in deploying information technology for enhancing healthcare delivery in India.

Success of the program will demonstrate the effectiveness of project ECHO as an innovative paradigm for providing best practice care for complex diseases in India.

Discussion:

This project is not a traditional telehealth or telemedicine model that links a doctor and a patient using technology; but it builds altogether new and permanent capacities by developing specialist expertise where it did not previously exist.  It’s not one-to-one; it’s a one-to-many knowledge network that fosters rapid-cycle learning in real time.  These knowledge flows are constantly being renewed to bring best new medical information and experience to primary care providers and best treatment to patients who would otherwise lack access to high-level care for their chronic illnesses.  The model also improves healthcare in remote locations in several ways. It ensures continuing education and boosts satisfaction and retention rates in areas where it is often hardest to retain providers with expertise.

Project ECHO will demonstrate that healthcare delivered by primary care providers in rural areas can be as safe and effective as that provided by specialists in larger health centers. The goal of the project is for community providers to gain enough knowledge about care of common chronic and complex diseases and to become self-sufficient. We know that providers will need less and less support over time and will eventually start using the teleECHO clinics for help with only the most complex cases. In addition, the knowledge network clinics and lectures inform them of the latest methods of treating diseases.

The project will demonstrate that technology and cross-disciplinary collaboration can be used to leverage scarce healthcare resources. Some telehealth projects link specialists with remotely located patients.  Our project, by contrast, uses technology to build knowledge and skills among remotely located providers.

In addition to technology, Project ECHO relies on cross-disciplinary collaboration for chronic disease management. Collaboration among specialty and primary care providers is an inexpensive way to increase the capacity to provide complex chronic care in medically underserved communities. To get the primary care physician to participate, ECHO-Gujarat will use existing community clinicians and give them the expertise and confidence to be able to treat these diseases. This has the potential to result in a major expansion in capacity to deliver healthcare in rural areas. Such networks also can help alleviate the sense of professional isolation experienced by many rural providers and help them keep up to date with evolving treatment modalities.

Research has shown that communication between primary care providers and specialists is often poor. Primary care providers may not receive feedback about patients they have referred, and specialists may not know the history of patients who have been sent to them for treatment. Project ECHO focuses on care coordination, with primary and specialty care providers working together to care for patients using tools such as videoconferences and shared medical records. It will reduce duplication and variation in treatment and promote evidence-based, reliable care in rural areas, where patients do not have much choice in selecting their primary or specialty providers.

We believe that this healthcare delivery model is uniquely suited to our semi-urban areas in India and could potentially work in poor urban areas or any other communities where there are shortages of healthcare providers. Successful demonstration of the project will allow us to expand the model to address other health care priorities in India and increase the number of participating clinics.

Conclusions:

Reducing barriers and improving access to specialist care represents an important component of health care. Limited access to specialty care leads to worsened health outcomes.  

ECHO is an innovative idea that can lead to breakthroughs in the future of Indian healthcare delivery. Ultimately, instead of just treating a few hundred patients a month in each clinic, a cadre of health professionals trained in care of complex diseases such as diabetes and hypertension can deliver specialty care to thousands of patients across India.  This “force multiplier effect” holds dramatic promise for transforming health care delivery nationally.   

Nick Shroff MD, FACS                                     

Chair, AAPI Charitable Foundation 2012-2014