publication date: May. 31, 2019
Conversation with The Cancer Letter
Project ECHO brings specialized knowledge to rural providers
Chief operating officer, Project ECHO
Program planning manager, ECHO Cancer Initiative
Project ECHO, a service that provides physicians in rural areas with access to multidisciplinary expertise, will soon announce partnerships with four cancer centers—Dana-Farber Cancer Institute, Mayo Clinic Cancer Center, University of New Mexico Comprehensive Cancer Center, and Yale Cancer Center.
Founded in 2003 by Sanjeev Arora, a hepatologist based out of Albuquerque, NM, Project ECHO is based at the University of New Mexico School of Medicine. The oncology arm of the project, the ECHO Cancer Initiative, reaches physicians in 10 countries through 45 hubs.
The project’s name stands for Extension for Community Healthcare Outcomes, connects rural providers to specialist teams at academic medical centers. It has long-standing collaborations with four NCI-designated cancer centers: MD Anderson Cancer Center, The University of Chicago Medicine Comprehensive Cancer Center, Vanderbilt-Ingram Cancer Center, and the University of Colorado Cancer Center.
“Because cancer is a very complex disease, and often a combination of diseases, it is essential that Cancer ECHO hub teams are also multidisciplinary,” said Lucca Cirolia, program planning manager at ECHO Cancer Initiative, to The Cancer Letter. “For example, if you’re a physician assistant who is dealing with a survivorship plan adherence issue, you can use ECHO to discuss the case with a social worker, a nutritionist, a pharmacist, and a psychiatrist, as well as an oncologist, about the side effects your patient is experiencing.”
Using teleconferencing systems, physicians are able to call specialists and discuss diagnoses and treatment options for their patients.
ECHO collaborations have a “hub-and-spoke” design, with multidisciplinary expert teams at the hubs and community-based providers in underserved communities at the spokes, said Oliver Bogler, ECHO’s chief operating officer.
“[They] use case-based presentations to share best practices, and do group problem-solving,” Bogler said to The Cancer Letter. “Short didactics are usually also part of an ECHO session, and over time, through what we call tele-mentoring, the spoke providers become knowledgeable and empowered. They feel confident to start treating patients they had not previously treated.”
The original ECHO hub in New Mexico was focused on hepatitis C. Over the years, the model has expanded to other areas of medicine, including oncology.
In 2003, there were approximately 28,000 cases of hepatitis C in New Mexico—the fifth largest state in the U.S.—but only two treatment facilities where patients could access care, Bogler said.
“At the time, hep C was treatable with a fairly complex regimen of chemo that caused notable side effects,” Bogler said to The Cancer Letter. “It was not an easy treatment to manage—a 75% cure rate, and so was certainly effective enough for him to want to bring it to people.”
In 2011, a study published in the New England Journal of Medicine describes Project ECHO’s impact on underserved communities.
“The results of this study show that the ECHO model is an effective way to treat HCV infection in underserved communities,” the authors concluded. “Implementation of this model would allow other states and nations to treat a greater number of patients infected with HCV than they are currently able to treat.”
ECHO is a department of the School of Medicine at the Health Science Center of the University of New Mexico. Operationally, ECHO consists of two components:
The first part runs over 30 ECHO programs with and for UNM faculty for the benefit of the people of New Mexico and beyond. For this, ECHO receives funding from the State of New Mexico.
The second aspect is focused on replicating the ECHO model with partners both in the U.S. and around the world. This is entirely “soft-funded” by grants from foundations and government.
Some of these funders include:
General Electric Foundation;
Robert Wood Johnson Foundation;
Bristol-Myers Squibb Foundation;
Department of Defense—Defense Health Agency;
Health Resources and Services Administration;
Centers for Disease Control and Prevention;
“For replication in cancer, we rely on the grant from Bristol-Myers Squibb Foundation which is $10 million over five years and started in 2017,” Bogler said. “Because of the generous support of our funders, we are able to offer our training and support to our hub partners at no charge, and so there is neither a training fee nor any kind of annual fee to be an ECHO partner or to use the ECHO model.”
ECHO has now become integrated into several international governments’ systems, including Ontario’s Ministry of Health. In 2016, President Barack Obama signed the ECHO Act, which directed the Department of Health and Human Services to not only study ECHO, but also report their findings to Congress.
“The assistant secretary for planning and evaluation at HHS worked with the RAND Corporation and others to produce the report, which recognizes the significant momentum for the adoption of ECHO and noted the need to expand the evidence base,” Bogler said. “We agree, especially as the portfolio of ECHO programs diversifies. Now, there’s discussion around opportunities to fund more research on ECHO.”
Across the board, Project ECHO has 300 hubs for more than 100 diseases and conditions in 35 countries. The project now has more than 650 programs.
“ECHO is not a consult service that you access occasionally; it is a long-term learning community that increases capacity and improves care, over time,” Bogler said. “Improved learning of the entire ECHO program community is the larger goal, and the advice for a given patient is one key component of how that is done. Eventually, the spoke providers can reach a point where they don’t need advice to manage their patients for the condition in question.”
Bogler and Cirolia spoke to Claire Dietz, a reporter with The Cancer Letter.
What are the origins of Project ECHO?
The program was developed by Dr. Sanjeev Arora here at the University of New Mexico. He’s a gastroenterologist, and he started Project ECHO about 15 years ago. He came to New Mexico from Boston, where he had trained, and he was interested in treating hepatitis C. He noted that there were 28,000 people thought to have hepatitis C in the state [in 2003], but that there were only two places where they could get care.
At the time, hep C was treatable with a fairly complex regimen of chemo that caused notable side effects. It was not an easy treatment to manage—a 75% cure rate, and so was certainly effective enough for him to want to bring it to people.
Dr. Arora initially sent the treatment guidelines to rural providers. However, New Mexico is the fifth largest state geographically, with only about 2.09 million people, and the majority of the state is medically underserved. A third of the people in the state are supported by Medicaid. So, it is a difficult environment in which to provide complex care. And unfortunately, when he shared the guidelines, providers did not take on the care of hep C. It was too complex and they didn’t feel empowered.
So, Dr. Arora created the first ECHO community. ECHO communities are by their nature relatively small. They’re highly social, they have a hub-and-spoke architecture with a multidisciplinary expert team at the hub, and spokes with community-based providers, typically from underserved areas, whether rural or urban.
They meet synchronously, supported by real-time teleconferencing on the Zoom platform, use case-based presentations to share best practices, and do group problem-solving. Short didactics are usually also part of an ECHO session, and over time, through what we call tele-mentoring, the spoke providers become knowledgeable and empowered. They feel confident to start treating patients they had not previously treated.
That’s what happened in the original hepatitis C community, and ultimately the capacity for care for this disease increased about fivefold in New Mexico.
And Dr. Arora’s wait time went from eight months to two weeks. He was able to see the patients that really needed him, and much sooner than he might otherwise have been able to. Before ECHO, patients would often present with advanced stage disease, partly because they had been so delayed in getting to him, because it was hard for them to travel, take off time from work, and for other reasons that are social determinants of health. After ECHO, that certainly changed.
So, that is the story of the original ECHO community, which is still going strong today. It still meets once a week on Wednesdays for 90 minutes. But Dr. Arora quickly understood from this work that other people and other use cases might be a good fit for ECHO. When he published his experience in 2011 in a New England Journal paper, it brought attention to the model and initiated the formation of partnerships and ECHO’s rapid expansion to where we are today.
So, kind of like grand rounds with specialty care providers?
Yes, grand rounds in the traditional sense of presenting the medical problems and treatments of an individual patient for discussion, and not grand rounds in the sense of a lecture.
ECHO distinguishes itself from other forms of distance education. It’s not a webinar, it’s not an online course, it’s not videos. ECHO is highly interactive. We believe that adult learning occurs best when focused on a real-world problem.
In medical ECHO, like in residency training, you look at a case, you present it to an experienced team of colleagues, they give you feedback, and everyone discusses. We talk about “All teach, and all learn” because it’s very dynamic. ECHO breaks down learning hierarchies that typically exist in traditional education settings. We don’t want “the professor and the student.” We want people to interact as peers.
So, the community providers will meet with the hub experts and say, “My patient is presenting symptoms of what I think is probably hepatitis C, what do you recommend? What would be the best course of treatment?”
Correct. Unlike in telemedicine, where the remote provider cares for the patient at a distance, in ECHO the provider does not change. ECHO is not a consult service that you access occasionally, it is a long-term learning community that increases capacity and improves care, over time.
Improved learning of the entire ECHO program community is the larger goal, and the advice for a given patient is one key component of how that is done. Eventually, the spoke providers can reach a point where they don’t need advice to manage their patients for the condition in question.
For example, in hepatitis C, we currently have over 35 active programs, rather than one big program. We don’t want massive programs, but rather we want to achieve scale by replicating programs. ECHO programs are best when they are local, highly interactive, and social. If there are 300 spokes, then your turn to present a case will only come rarely and interaction will be difficult.
The cases are presented in an abstracted and de-identified form. The patient themselves never appear in the ECHO. Each ECHO community determines best disease-specific information that they feel they need to share in order to discuss the patient.
Is that to stay compliant with HIPAA protections?
Yes, we do not share PHI—protected health information. We intentionally do not have PHI in our systems because of that. It’s to protect people’s privacy.
With rural cancer care, how have you seen ECHO improving access?
In cancer, ECHO is seeing a lot of growing interest, some great partnerships are forming. However, for an ECHO community to work, the value proposition to the spoke participant has to be very clear.
So far, we’ve seen the most success in ECHOs focused on areas like palliative care. Similarly, there are programs in survivorship where specialist oncologists are collaborating with community providers to manage patients after their active-phase of treatment.
There are also great programs in tobacco prevention and cervical cancer prevention. We also have new ECHOs focused on increasing clinical trial access for underserved populations and managing the rapidly increased use of molecular genetic testing.
What makes ECHO so innovative is that the multidisciplinary nature of the hub team. In the original hepatitis C community, spokes were not just calling in to talk with Dr. Arora as the one hepatitis C expert. They called in to present their patient’s case, receive advice from the network at large, and learn from the multidisciplinary team comprised of gastroenterologists, social workers, nurses, pharmacists, and psychiatrists.
Because cancer is a very complex disease and often a combination of diseases, it is essential that Cancer ECHO hub teams are also multidisciplinary. For example, if you’re a physician assistant who is dealing with a survivorship plan adherence issue, you can use ECHO to discuss the case with a social worker, a nutritionist, a pharmacist, and a psychiatrist, as well as an oncologist, about the side effects your patient is experiencing.
I also want to emphasize the benefit of what we call the ‘learning loop.’ ECHO is really innovative because it’s not just the spokes that are learning from the experts, but the experts are also learning from the community providers. And that’s essential.
In New Mexico, we have a lot of cultural differences. It’s really important that we are aware that a tobacco cessation plan may be more difficult for one of the tribes to implement, since they have traditional rituals that include tobacco. And the experts should be culturally sensitive when they provide recommendations to the network. This is the learning loop: the providers learn best practice from the hub team, and the experts learn about local community issues related to best practice adherence from the spokes.
One interesting ECHO program is the American Academy of Pediatrics. They’re a super-hub, which means that they train other hubs in the ECHO methodology in addition to running their own ECHO programs. This network is running programs for HPV quality improvement. AAP has really taken ECHO to the next level, which means they not only have their spoke sites participate and learn as a community, but they become the experts and disseminate best practices to local providers across states like Arizona, New Jersey, and Oregon—a great example of force multiplication.
Additionally, the National Cancer Institute’s Center for Global Health has three programs focused on disseminating best practices in national cancer control planning in the Caribbean, Asia Pacific, and Africa. The national cancer control plans have a special focus on breast and cervical cancer, as well. ECHO facilitates learning across communities where samples and tests can be compromised by distance and temperature. This knowledge can then be shared with other regions facing similar challenges.
NCI’s Africa program met recently and discussed cancer registries and heard presentations from Rwanda, among other countries. Very interesting to see a dynamic community of practice working together.
But to come back to your question, Claire, I would say ECHO focuses on moving knowledge and oftentimes, knowledge can be the missing piece. But technology and medicines are also critical. For example, in surgery, ECHO can bridge the gap between in-person visits, where there is hands-on training in the OR with colleagues; in-between visits, ECHO can be used to keep the conversation going.
MD Anderson has an ECHO program with Mozambique and Brazil that initially focused on cervical, it now includes breast and head and neck cancers. Physicians from Houston and Brazil visit Maputo [capital of Mozambique] periodically for workshops and then meet in ECHO sessions in-between.
It sounds like the focus in the Cancer Initiative right now is on expansion and getting people to have access to cancer-specific ECHOs?
Yes, at the ECHO Institute at the University of New Mexico in Albuquerque, we’re just 110 people. ECHO is entirely a partnership model, and we help partners learn ECHO and then launch their own programs. The institute is grant funded, which allows us to provide training and participation in ECHO with no charge. Today we have 300 partners, or hubs—it’s growing weekly. Most have received formal ECHO training with us here in Albuquerque and some with our superhubs. MD Anderson is the superhub for oncology, and they are training many hubs in cancer.
[Across Project ECHO], these hubs are in 35 countries, running nearly 650 programs in about 70 different subject areas. Lucca and I focus on expanding the use of ECHO in cancer, thanks to a grant from the Bristol-Myers Squibb Foundation that supports our work in the United States and South Africa. We connect with potential partners, hold exploratory conversations, and if there’s interest, we bring them in for training. Then we provide technical assistance and mentorship as they launch their programs. The hubs become very quickly self-sufficient and then run programs to meet their missions.
We also catalyze communication across programs. Lucca runs a monthly call, the Cancer Collaborative, where anybody participating in a cancer-related ECHO is welcome to join and then discuss areas of common interest. We’re also moving toward building a stronger digital platform for the practice of ECHO and improved networking of ECHO participants.
Of the 70 NCI-designated cancer centers, we have eight either launched (The University of Chicago, University of Colorado, University of Texas MD Anderson Cancer Center and Vanderbilt-Ingram Cancer Center) or preparing to launch (Dana-Farber Cancer Institute, Mayo Clinic Cancer Center, University of New Mexico Comprehensive Cancer Center, and Yale Cancer Center). We welcome more conversations with community-based organizations and other groups focused on cancer, like patient advocacy groups.
We mentioned MD Anderson and NCI, and we also partner with the American Cancer Society, American Society of Clinical Oncology, and the American Society of Clinical Pathology. There are also quite a few that are in pre-launch, but we did just learn that ASCO has launched their first program. Theirs is an interesting use case, where they are taking on the training component of the Union of International Cancer Control’s City Cancer Challenge within four cities. Again, ECHO is being deployed alongside in-person training with the goal to more effectively treat and teach people best practice in cancer care delivery.
We have a dashboard that shows the current footprint in cancer. And you can see all the individual programs. What are the numbers today, Lucca?
We have a global interactive map that tracks all of our partners replicating the ECHO model, but this is specific just to cancer. [ECHO Cancer Initiative], has 45 hubs in 10 countries and each of the hubs has at least one active program, but many have more than that.
Across the 45 hubs, we have 70 programs. As Oliver mentioned, since 2003, when Dr. Arora started the first hepatitis C ECHO program, we have grown to about 35 hep C hubs globally. We’re very happy that within about five years of diving into the cancer space, we’ve been able to help partners launch 70 programs focused on cancer.
In five years?
Yes, we are relatively new to cancer. MD Anderson, of course, has been a great partner and has been replicating the model in cancer since early 2014, but we’re seeing an increased interest in the ECHO model for cancer care improvement.
We are seeing similar growth in other areas, including other infectious diseases, autism, mental health issues related to the opioid crisis, among others. There are some really interesting use cases outside medicine too, including a sheriff’s department using ECHO for telementoring de-escalation tactics.
We’re moving rapidly outside of medicine. Education and civics are fast growing areas. ECHO can be used in many areas and we’re excited about innovation from our partners. When you have scarce expertise, you have dynamic complexity, you have high social impact, then ECHO might be useful, and we’re always excited when people come to us with new ideas.
I don’t know how many cancer-related conversations Lucca and I are having, but there must be 20 or 30, at least, going on at the moment. Some of them with patient advocacy organizations and other kinds of programs. It’s really exciting, I have to say.
What does the new legislative support for ECHO entail?
Our ultimate goal is to have ECHO embedded in systems. We at the ECHO Institute are mostly catalysts, and whether that capability exists in five or 10 years is really not as important to us as if we’ve succeeded in getting ECHO into systems.
Internationally, that’s been very successful. For example, in the state of Ontario, the Ministry of Health has adopted ECHO. In Namibia, in the country of Georgia, in India, national and regional governments have engaged. In these partnerships, either state or country-level ministries of health are the first to adopt ECHO and implement ECHO programs, because that’s where it really shines, at the systems level.
In the United States, the health care system is organized a little differently, but we’ve also had some real success. In 2016, the ECHO Act was signed by President Barack Obama, and it directed the Department of Health and Human Services to study ECHO and report to Congress. They published their report in March of this year. The assistant secretary for planning and evaluation at HHS worked with the RAND Corporation and others to produce the report, which recognizes the significant momentum for the adoption of ECHO and noted the need to expand the evidence base. We agree, especially as the portfolio of ECHO programs diversifies. Now, there’s discussion around opportunities to fund more research on ECHO.
In the course of ASPE’s work, they uncovered that many parts of the federal government are supporting ECHO in different ways, including AHRQ, SAMHSA, CMS, IHS, and more recently the National Institutes of Health. For example, we are seeing an increased interest by Clinical and Translational Science Centers or members of NCI core grants to include support for ECHO.
In addition, New Mexico is operating under a Medicaid waiver to support ECHO programs, and Oregon and California are coordinating with their coordinated care and managed care organizations for this purpose.
Additionally, there was recent legislation in response to the opioid crisis where funding preference is given to health centers participating in ECHO programs, in recognition that the ECHO opioid programs are effective.
ECHO is also an educational methodology. You can deliver continuing education credits and certification credits through ECHO programs. Certification of programs is a service we offer at the institute, and we feel that such credits can be another incentive to participate in the ECHO community.
Did I miss anything?
We welcome conversations with community-based cancer providers and others in the cancer space, because ECHO is a great way to share scarce expertise. ECHO was born in an academic medical center, so we are well connected to the academic cancer community through our comprehensive cancer center here at the University of New Mexico.
Before I joined ECHO, I worked at MD Anderson for 13 years, and learned about the hyper-specialization that is going on in cancer and in medicine broadly. The top specialists are getting more and more knowledgeable, but they are also focusing their specialization.
This is why ECHO was created; we will never train enough specialists—particularly these extreme specialists—to meet the needs of the world. We have to find more innovative ways of getting that expertise to everyone who needs it. We want to make sure that if there’s a breakthrough at an MD Anderson or at a Sloan Kettering, that it doesn’t take 20 years to get to the front lines of our communities, particularly those who are underserved globally.