Project ECHO brings faraway specialists close to home

NEW BRITAIN–The patient said she was committed to getting treatment for her hepatitis C, but she’d been missing appointments and doses of medication. Amanda Swan, the nurse practitioner caring for her at Community Health Center, Inc., sat in a conference room, preparing to get guidance on the case from 2,100 miles away.

“I’m really looking forward to hearing your feedback,” Swan told the audience, a room full of experts in Albuquerque, visible on a flat-screen television mounted on the wall, and several other clinicians tuned in via teleconference from various parts of New Mexico.

Nurse practitioner Amanda Swan (right) and nursing student Sarah Gilbert tune in to the hepatitis C clinic via teleconference

Swan laid out the case–the patient’s difficulty sticking to the regimen, her treatment and results so far, a gap in medication when her insurance lapsed–and asked questions.

From Albuquerque, Dr. Sanjeev Arora, a professor at the University of New Mexico Health Sciences Center and an expert in hepatitis C, asked questions about the patient and offered suggestions. So did his colleagues. Arora recommended that Swan let the patient know that the cure rate drops from 50 percent to 20 percent for patients who miss a month of medication, and said he tells his patients that taking medications is like paying for a car–if you make all your payments, you’ll get one, but if you miss a few, you don’t.

“This lady’s making a lot of payments here in terms of side effects, and she may not get her car,” Arora said. He complimented Swan’s work with a tough patient before moving on to the next case, from a primary care provider in New Mexico. Swan watched other cases for another hour, occasionally stopping to discuss the recommendations with her colleague, Dr. Marwan Haddad.

The consultation was part of the weekly hepatitis C clinic run by Project ECHO–Extension for Community Healthcare Outcomes–which provides guidance for primary care providers to handle care that would otherwise require a specialist.

The program was created to bring treatments to patients in rural New Mexico who have limited access to specialists. Connecticut hardly has the same geographic isolation, but many patients here face similar challenges accessing specialty care, even if they live in the same city as a hospital, or a short distance from private physicians.

“We are the wealthiest state in the country, and yet we have patients who have to wait for six months or more to see a certain specialist in some of our communities,” said Dr. Daren Anderson, vice president and chief quality officer at Community Health Center, Inc., which began participating in Project ECHO this summer.

Community health centers treat many patients who are uninsured or covered by Medicaid and often struggle to find specialists to see them. The UConn Health Center in Farmington takes all patients, but because capacity is limited, patients can wait months to get in. Even those with insurance and a specialist to treat them might have trouble getting there if they don’t have a car.

While much of medicine is becoming increasingly specialized, Project ECHO, which is largely grant-funded, is pushing in the opposite direction, helping to put more patient care in the hands of the generalists who practice primary care. It now operates clinics for more than a dozen medical conditions.

Dr. Michael Krinsky, president of the Connecticut State Medical Society and a neurologist, said telemedicine–in which health care is provided at a distance, using technology–has a role to play in medicine, particularly in rural areas or in fields where there aren’t enough providers. But he questioned why, if there are grants available to fund Project ECHO, the money couldn’t be used to augment the fees local physicians would be paid to see Medicaid patients or those without insurance, improving access.

“My thoughts about medicine in general are, especially regarding access to care, that good medicine is really like good politics–it’s all local,” he said.

But Anderson said Project ECHO benefits patients by allowing them to get specialized care from those who know them best–their primary care providers. He said the model could significantly change how patients with limited access get care, reducing potentially unnecessary visits to specialists and eliminating geographic barriers. He’s now discussing a similar model to treat patients with chronic pain with a center in Arizona.

“If no one in Connecticut can see our patients, well, we’ll go to Oregon, or wherever we can find a group that’s willing to work with us,” he said.

A force multiplier

Nearly a decade ago, Arora was becoming frustrated that barely 5 percent of the people in New Mexico with hepatitis C were getting treated. Many state prisoners had it too, but none were being treated.

Hepatitis C can be cured, but it requires intensive treatment, including frequent medical appointments. Patients have traditionally been seen by gastroenterologists, like Arora. But many patients in remote areas of New Mexico did not live near specialists. There was an eight month wait to see Arora.

He began to think about ways to multiply his expertise so more doctors in the state could provide the same level of care for patients with hepatitis C as he could. “We thought if we could bring the right knowledge to the right place at the right time, then we could reduce a lot of human suffering,” he said.

The result, Project ECHO, was based on the use of four things: Technology, best practices, tracking outcomes, and the sort of case-based learning that doctors get during their residency–managing patients with the help of mentors and professors, becoming more independent as they learn more.

For the clinics, primary care providers connect with Arora and his colleagues and other primary care providers through video conferencing equipment, or webcams. The specialists don’t see the patients. Instead, the primary care providers describe their cases, and the specialists, who have access to the patients’ records, offer treatment plans and guidance.

The Project ECHO experts in Albuquerque. Dr. Sanjeev Arora is at the head of the table.

In June, the New England Journal of Medicine published a study of the program by Arora and his colleagues. They compared patients treated by primary care clinicians participating in Project ECHO to those treated at the University of New Mexico’s hepatitis C clinic. Among Project ECHO patients, 58.2 percent had viruses that had been suppressed to undetectable levels, compared with 57.5 percent among the patients treated at the academic medical center.

“What we found was that people were essentially doing better [in Project ECHO] because they were getting treatment closer to their home, they were getting treatment by their doctor whom they knew and could trust, they didn’t have to travel so they didn’t miss appointments, and they were [receiving] very culturally appropriate care because it was provided in their communities,” Arora said.

Access barriers, rural and urban

Community Health Center, Inc., which has sites across the state, has worked to provide its patients with access to medical, dental and behavioral health care, nutrition support and case management. It’s considered a patient centered medical home and uses electronic medical records, two standards that primary care providers are increasingly being urged to adopt.

But when a patient needs a specialist, there’s only so much the health centers can do. Anderson called it “the one place that we really banged our heads against the wall.”

“We’re not in rural New Mexico, but we have the same access issues,” Anderson said.

Officials had been trying to figure out how to get their patients to specialists when they read the New England Journal article about Project ECHO, which Anderson said turns the model on its head: Instead of sending patients to specialists, it has specialists come to primary care providers and give them advice.

Only about 1,500 of CHC’s 130,000 patients have hepatitis C, but officials chose to start with Project ECHO’s hepatitis C program because it’s the original clinic, with the most experience. Anderson expects that CHC will use the model for other conditions too.

“The potential is almost unlimited,” he said.

While specialty consultations for some conditions require a visit–such as a swollen knee that an orthopedist would need to see to weigh in on–Anderson said others, including hepatitis C, tend to be tracked more by test results, making it possible for specialists to consult based on patient records, without seeing the patient. A model like Project ECHO could make care more convenient for patients and save the health care system money by reducing the use of specialty care, he said.

Krinsky said that in some cases, referrals to specialists could be addressed by having the specialist review a chart, rather than see the patient. “The trouble with that is that our payers have decided that that’s not a valuable experience. They’ll only pay for the proper face to face time,” he said.

One thing that hasn’t yet been worked out is how to pay for Project ECHO and models like it. CHC’s participation in Project ECHO is grant-funded. Arora said there have been negotiations with payers figure out a model for the primary care providers to be paid for the time they spend presenting cases and participating in the clinics.

“They have never paid for doctors talking to each other before,” he said. “But I think that they’re warming up slowly to the idea.”