The Computerworld Honors Program
Honoring those who use Information Technology to benefit society
LOCATION:
Albuquerque, NM, United States

YEAR:
2008

STATUS:
Laureate

CATEGORY:
Healthcare

NOMINATING COMPANY:
Infosys

ORGANIZATION:
University of New Mexico Health Sciences Center

PROJECT NAME:
Project ECHO - Project Extension for Community Healthcare Outcomes



Introductory Overview
Project ECHO (Extension for Community Healthcare Outcomes) is an innovative, collaborative partnership of an academic medical center with a network of rural health clinics, Public Health Service, and the Department of Corrections for the delivery of health care and clinical education in the management of complex, common and chronic diseases in underserved areas, using hepatitis C (HCV) as a model.
The key component of the ECHO model is a disruptive innovation called a Knowledge Network. In a one-to-many knowledge network, the expertise of a single specialist shared with several primary healthcare providers, each of whom sees numerous patients. The flow of information in a Knowledge Network is NOT unidirectional; the specialist and community-based primary care providers gain invaluable feedback and case-based experience through weekly consultations.
Telemedicine and internet connections enable specialists in the program to co-manage patients with complex diseases using best practce protocols, case-based knowledge networks and learning loops. Learning loops are case-based educational experiences in which community providers learn through three main routes: (1) longitudinal co-management of patients with specialists, (2) other primary care providers on the network via shared case-management decision making and, (3) short didactic presentations on relevant topics, such as vaccination for hepatitis A and B and diagnosis of depression. These learning loops create deep domain knowledge about the area in question—here HCV—among rural providers, enabling them to provide the highest quality treatment for their patients Systematic monitoring of treatment outcomes is an integral aspect of the project. We believe this methodology will be generalizable to other complex and chronic conditions in a wide variety of underserved areas to improve disease outcomes. The primary beneficiaries of this innovation are patients in underserved areas.

The U.S. Dept of Health and Human Services’ Healthy People 2010 program has identified the elimination of health disparities as a national health goal. Rural, uninsured, and underserved populations represent three of the most significant sectors of inequality in the provision of health care in the U.S. system. Additionally, many patients in rural and underserved areas with chronic complex diseases such as HCV, substance use and mental health disorders face difficulties in accessing the specialty treatment they need. The ECHO model addresses this problem by giving physicians who specialize in treating complex and chronic conditions like HCV access to technology, enabling them to share knowledge about best practice protocols using a case-based learning approach to co-manage patients with primary caregivers in rural communities and prisons in New Mexico. Conservative estimates suggest that approximately 34,000 New Mexicans, including 2500 prisoners are infected with HCV, and the state leads the nation in deaths from chronic liver disease and cirrhosis. Prior to the launch of project ECHO, less than 1600 rural residents and no prisoners had received treatment for chronic liver disease. Since its inception in June 2004, Project ECHO has established 21 HCV treatment centers in rural New Mexico and at prisons around the state, resulting in an addition 3500 patients receiving disease management services during this time who were otherwise unlikely to have received any treatment at all. Empowering primary caregivers at rural clinics has several long term effects. Rural physicians gain expertise, earn required continuing education credits, and are encouraged to remain in remote communities by having one of their highest priority needs answered: an opportunity to continue learning and to interact with professional colleagues. Project web site address is http://echo.unm.edu/

The Importance of Technology
How did the technology you used contribute to this project and why was it important?
In project ECHO the University of New Mexico and its partners are connected with a robust information technology infrastructure. Through the purchase and installation of two Network Video Teleconferencing Bridge MCU units, ECHO has the capacity to link with video to 40 sites at one time. A Polycom MGC 50 Bridge was purchased specifically for ECHO and is dedicated to the project. The New Mexico Department of Corrections demonstrated its commitment to this collaboration by purchasing a second bridge to link its nine facilities across the state. Video-conferencing facilities include high quality video and audio for clinical telemedicine consultations with the capability to encrypt traffic thus minimizing the risk of unauthorized access to protected health information. These tools allow providers to interact as if they were holding a case conference in a single room, rather than in multiple locations around the state.
Electronic Health Record and Data Management System:
Providers require access to patient-specific information in order to conduct case consultation and track patient progress. This data is also the basis for evaluation of clinical outcomes. At Project ECHO’s inception community-based providers transmitted patient-specific information to specialists via the Care Manager data management system. Data was entered and stored locally on a laptop, transmitted via a secure Virtual Private Network (VPN), and maintained in a centralized HIPAA-compliant SQL database server. This central data warehousing has been used to support both current clinical needs and future research data-mining activities. With Project ECHO’s rapid expansion, Care Manager quickly proved an inadequate application as it presented numerous, insurmountable barriers ranging from site-based maintenance and VPN problems to critical data feed and reporting inadequacies. To address these barriers, Project ECHO turned to an outside vendor, Infosys Technologies, Inc., (http://www.infosys.com/) to develop a new web-based clinical management system. A key requirement for the new system included the ability to create “anytime, anywhere” access to data for even the most remote locations across the State. Thus, it was imperative the new application be web enabled and also enhanced further to support new and increasingly complex functional requirements of the Project. Additionally, the application must possess the means to adapt to future expansion to other disease conditions. After preliminary analysis, Infosys proposed the development of a web-based application that would be flexible enough to support both current and future needs.
DISEASE MANAGEMENT TOOL (DMT)
Project ECHO’s HIPAA-compliant, web-based disease management tool (DMT) has been designed and the underlying architecture has been developed by our technology partner, Infosys Technologies, and is based on a 3-tier architecture design that incorporates Microsoft technologies, such as .Net 2.0, SQL Server and SSRS, and allows for the effective management and collection of patient data across multiple provider organizations. Readily replicated, the disease management tool is implemented easily with little expense to Project ECHO ambulatory sites. Project ECHO’s Disease Management Model focuses on improving health outcomes in the treatment of complex and chronic diseases using best practice protocols. Combining this web-based application with interactive telecommunication technologies, Project ECHO can leverage scarce healthcare resources in rural and underserved communities. Built-in reporting features of this clinical management tool allow health practitioners to easily identify abnormalities and negative trends in a timely manner, improving patient safety and efficacy. Built-in clinical presentation tools enable a seamless collaboration between the patient’s care team and UNM-HSC specialists while simultaneously enhancing the knowledge networks and learning loops embedded in the model. This DMT allows for the standardized collection of data; b) improve practice efficiency; c) generate practice profiles and QI reports

Benefits
Has your project helped those it was designed to help?   Yes

Has your project fundamentally changed how tasks are performed?   Yes

What new advantage or opportunity does your project provide to people?
Project ECHO currently partners with the UNM HSC Department of Internal Medicine, nine prisons in the NM Department of Corrections (DOC), Indian Health Service (IHS) hospitals, the NM State Health Department (DOH), and Federally Qualified Health Centers in locations across the State as listed below.

1) DOC: Santa Fe, Los Lunas, Las Cruces, Roswell, Grants, Santa Rosa and Hobbs
IHS Shiprock, Santa Fe
2) Federally Qualified Health Centers: Albuquerque, Farmington, Las Vegas, Las Cruces, Truth or Consequences, Silver City, Portales, Espanola, Gallup, Hobbs, Lovington, and Carlsbad
DOH Las Cruces

The primary beneficiaries are the patients. Patients in remote rural and prisons areas have, access to expertise of university based medical specialists without having to travel long distances. Prior to the launch of Project ECHO in June 2004, less than 1,600 rural residents and no prisoners had received treatment for chronic liver disease. Since its inception, Project ECHO has conducted 205 HCV "knowledge network" clinics and provided 2,316 consultations for HCV patients. 21 HCV centers of excellence have been established around New Mexico and thousands of high risk patients have been screened for the disease and eligible patients have received a 6-12 month treatment regimen with interferon and ribavirn under the remote supervision of UNM specialists. 71% of rural patients and 74% of prisoners treated were minorities. Without intervention, these patients are likely to have suffered cancer or cirrhosis and might have required liver transplants.
Outcome studies have demonstrated that the care provided in rural areas and prisons is as safe and effective as that provided in a university-based clinic. Additionally, providers have reported significant improvements in both provider self-efficacy and professional satisfaction.

Results from Provider Surveys: The project’s impact on provider knowledge and self-efficacy in treating complex health conditions is assessed through intensive written surveys administered at baseline and repeated every six months. The following findings are from six-month questionnaires completed by 24 community providers in September 2006. These providers had been in practice for a mean of 15 years. Only one provider reported an ability to manage and treat HCV patients prior to ECHO participation. Almost all providers have reported moderate or major improvements in their knowledge and self-efficacy about a variety of treatment issues.

Degree of Reported Improvements in Provider Knowledge:

HCV management and treatment 96%(major) 0% (moderate)
Symptoms of HCV patients in treatment 79% (major) 13%(moderate)
Competence in caring for HCV patients 92% (major) 17% (moderate)
Access to expertise in behavioral/mental health 84%(major) 8% (moderate)
Access to expertise in pharmacology 67% (major) 21%(moderate)
Collegial discussions with peers 71% (major) 17% (moderate)

Perceived Benefits to Rural Providers (n=24)

Enhanced knowledge about management and treatment of Hepatitis C patients 4%(moderate) 96%(major)
Being well informed about symptoms of Hepatitis C patients in treatment 13%(moderate)79% (major)
Achieving competence in caring for Hepatitis C patients 8%(moderate) 92%(major)
Self-efficacy: Belief in my ability to treat Hepatitis C patients 17%(moderate)71% (major)


Perceived Benefits from the Project ECHO Hepatitis C Clinics (n=24)

Access to expertise in mental health resources in caring for HCV patients 8%(minor)92%(major)
Access to expertise in pharmacology 8%(minor)88%(major)
Enhanced skills in communication with HCV patients and their families 25%(minor)75%(major)
Collegial discussions with peers about HCV patients 13%(minor)88%(major)




If possible, include an example of how the project has benefited a specific individual, enterprise or organization. Please include personal quotes from individuals who have directly benefited from your work.
Here is an excerpt of a letter from Leslie Hayes, MD a primary physician in Espanola to governor Bill Richardson of New Mexico:

“I practice in Espanola, in a community health center. Most of my patients are poor, and many do not have health insurance. As you know, there is a large problem with IV drugs in the community, and we have a huge population with hepatitis C. Up until the ECHO project came along, all I could offer most of them was some general health advice and vaccinations against hepatitis A and B.

I see someone die from the long-term effects of hepatitis C every 3-4 months. Since there is treatment available for the disease, it was very frustrating to me not to be able to offer it to my patients. However, treatment was simply out of reach for most of my patients.

Being able to offer the treatment program here locally has been wonderful. Currently, we have 10 patients on treatment, with an 11th who just completed treatment, having successfully cleared the virus. We have a half dozen more who are about ready to start, and dozens more who have been evaluated and are making changes to their lives so that they can be treated as well.


Many of my patients have quit drinking or using drugs just so that they can be treated for hepatitis C. As you know, substance abuse is a huge problem in northern New Mexico. It can be extremely difficult to get substance users to stop their habits. I have been astounded what a powerful motivator being treated for hepatitis C has been for our patients. The ECHO project gives patients two strong incentives to give up their alcohol or drug use: 1) It gives them hope. Many of these people have had no hope for anything getting better. When they realize they can actually be cured of a deadly disease, it turns things around. 2) It gives them someone (a health-care provider) who cares for them.

The benefits of the ECHO project are not only for the patients, though. I have also gotten several things from it personally. One of the problems with rural practice is a sense of stagnation. It is hard to learn new things and keep up. With the ECHO project, I have been able to learn a huge amount about a disease that I see every day. I feel a sense of pride that I am actually at the forefront of knowledge about hepatitis C. When I first met Dr. Arora, my comment on the program at the time was that in medical school, it is all learning and no actual work, and being an actual practitioner is all work and no learning. I don’t think either is the proper balance for physicians, who are, by our very nature, people who want to work and learn both. ECHO has been an enjoyable way for me to extend my learning”.


Dr. Alfredo Vigil, the Secretary of Health for the State of New Mexico writes:

"We are extremely proud of the close relationship we have developed with Dr. Sanjeev Arora and the numerous people at the School of Medicine who created and developed Project ECHO. They took great pains to include numerous organizations around the state including our own, in the development of a patient care model that is relevant and effective in our “real world” environment. Additionally, there have been major benefits as far as creating a high level of professional satisfaction amongst our health professionals which has translated to improved employee retention.”


Originality
Is it the first, the only, the best or the most effective application of its kind?   All of the above

What are the exceptional aspects of your project?
Common diseases such as HCV, cardiovascular disease, and mental health disorders account for the majority of morbidity and morality in the United States. Improving outcomes for these diseases can thus have a disproportionately great impact on quality and quantity of life in this country.

These common conditions are also complicated to manage, and effective treatment usually requires a combination of education, lifestyle modification, and medication regimens beyond the training, time, resources, or experience of most primary care providers. Often multidisciplinary teams with expertise in specific areas are necessary to competently treat these conditions. The treatment of these diseases is rapidly evolving with new research constantly dictating changes in disease management, making it nearly impossible for a primary care provider to keep up with the latest developments in one, much less a multitude of, chronic health problems.

These diseases have high societal impact, including loss of productivity at work early disability and retirement, absenteeism, and excessive use of health care resources, including hospitalizations and pharmaceutical costs. Seventy-five percent of the United States annual medical expenditures of $1 trillion can be attributed to chronic diseases. Failing to treat these conditions early and adequately results in increased morbidity and mortality, as these conditions are the leading causes of death in the world. Through the use of state-of-the-art technology and best practices for the management of such diseases, substantially improved outcomes in quality of life, cost-effectiveness of care, and survival. We chose HCV as the exemplar in Project ECHO because it exhibits the six characteristics we have identified that make a disease amenable to treatment utilizing knowledge networks:
1. The disease is common.
2. The disease has complex management.
3. Treatment for the disease is evolving.
4. The disease has high societal impact.
5. There are serious outcomes of failing to treat the disease.
6. Improved outcomes can be obtained with disease management.

Project ECHO addresses the aforementioned six core characteristics of diseases amenable to treatment via knowledge networks through four major avenues. The first of these avenues is the use of telemedicine to maximize scarce specialty health care resources. The Institute of Medicine’s definition of telemedicine is one of the most widely accepted: “the use of electronic information and communication technologies to provide and support health care when distance separates the participants. What renders the use of telemedicine in Project ECHO innovative and relatively unique is that learning technology is geared toward ensuring providers are as well informed as possible, rather than telemedicine’s traditional focus exclusively on treating the patient . Thus, in contrast to forms of telemedicine that are direct treatment modalities, the use of information technologies in Project ECHO facilitates and supports the provision of care. It is this shift in the fulcrum of telemedicine that gives power and scope to the program’s learning loops and knowledge networks.

The second avenue to treating diseases through knowledge networks is the utilization of a disease management model combined with the employment of best practices. The third avenue is case-based learning with longitudinal co-management of patients by primary care providers and specialists from the University of New Mexico Health Sciences Center and the New Mexico State Health Department. The fourth is the coordination of Project ECHO through a centralized Health Insurance Portability and Accountability Act (HIPAA)-compliant database that allows outcomes to be monitored for continuous quality assurance and improvement.

The primary goal of Project ECHO is to demonstrate how a partnership of academic medicine, public health, corrections, and community health centers can foster the capacity of rural physician partners to provide safe and effective treatment for chronic complex diseases in any population.




Difficulty
What were the most important obstacles that had to be overcome in order for your work to be successful? Technical problems? Resources? Expertise? Organizational problems?
Establishing our teleconferencing network required both technical expertise and negotiation. On the technical side, we identified and installing telecommunication equipment at the Urban location compatible with those at each of the Rural Clinics.

By entering into a partnership agreement with Primary Care Association we were able to instantly expand our network and provide them with an opportunity to participate in the ECHO knowledge network.

Additionally, the project required:

• Changing mindset of rural practitioners and convincing them that they were capable of learning how to treat complex diseases.
• Rural sites often did not have significant expertise in information technology and substantial training was required. Using our old disease management tool (care manager) was an enormous challenge for providers and we experienced difficulties in retrieving the data for outcomes analysis.
• Multiple trips to rural sites were required to establish the processes for effective conduct of knowledge networks





Often the most innovative projects encounter the greatest resistance when they are originally proposed. If you had to fight for approval or funding, please provide a summary of the objections you faced and how you overcame them.
Obtaining funding for the project was a chanllenge in the first few years of the project. We had to compete nationally for federal funding and make our case to the New Mexico legislature. Project ECHO is funded by Agency for Healthcare Resarch and Quality grants: Project ECHO Extension for Community Healthcare Outcomes, grant number 5 UC1 HS015135 and Expansion of Rural Health Care Research Infrastructure through the ECHO Model, grant number 1 R18 HS16510, and the State of New Mexico Legislature.

Success
Has your project achieved or exceeded its goals?   Exceeded

Is it fully operational?   Yes

How do you see your project's innovation benefiting other applications, organizations, or global communities?
Our short term plan is to expand the ECHO model for care of other common, chronic, complex diseases in rural New Mexico and prisons. In April 2006 we initiated a program to increase access to chemical dependency treatment for underserved residents across the state of New Mexico. Because New Mexico leads the nation in the incidence of death from heroin overdose the initial focus for the substance use clinic has been on opiate dependence; over the next year we will expand to include alcohol and other substance use disorders. The ECHO substance use clinic has provided Buprenorphine training (8 hours of face-to-face training per provider) and federal certification at no cost to 70 physicians, more than doubling the number of providers in New Mexico who can prescribe Buprenorphine for opiate addiction. We plan to develop 10 additional Centers of Excellence throughout the state for the treatment of substance abuse and associated behavioral health disorders (similar to what is being accomplished for treatment of HCV).
Other ECHO clinics that have been started are HIV care, rheumatology consultation, autism, cardiac risk reduction, high risk pregnancy, childhood obesity, and prevention of teenage suicide. Clinics in planning stages are chronic pain management, occupational health disorders, general child psychiatry, and asthma. We have established a partnership with the government of India to use the ECHO model for expanding access to anti retroviral treatment for HIV in rural India

Any underserved community—whether remote rural areas, developing countries, or inner city neighborhoods in the US, could benefit from the ECHO model: Knowledge Networks mediated through communication technology. This model is an efficient means for co-managing complex chronic conditions .


How quickly has your targeted audience of users embraced your innovation? Or, how rapidly do you predict they will?
Convincing our first rural clinic partner required four or five site visits, including an overview of the program and many discussions. Once the first clinic signed on, however, it has spread rapidly to the other federally qualified community health centers. Now we get requests from rural clinics to be part of the Echo network. New ECHO clinics are being launched every two to three months.
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