PROJECT ECHO:

Building a Virtual Community of Practice to

Improve Chronic Disease Outcomes

Brian R. Wood, MD

University of Washington, Seattle, WAMountain West AIDS Education & Training Center

April 4, 2019

What is Project ECHO?

Extension for Community Health Outcomes

Key Points About ECHO

• Providers log in from any desktop, laptop, mobile

device, or phone with at least 3G

• Same providers and specialist panel join each week;

NOT a one-time consultation service & NOT a webinar

• Creates a technology-mediated learning collaborative

and longitudinal peer-support network

Does ECHO Work?

Study Sites

Intervention (ECHO)

16 Community-based clinics

5 Dept. of Corrections sites

Control

Univ. of New Mexico HCV Clinic

Primary Endpoint

Sustained virologic

response (SVR) at 6

months

Arora S, Thornton K, et al. NEJM. 2011;364:2199-207.

Outcomes and Conclusions

Subgroups SVR, ECHO

N=261

SVR,UNMH

N=146

P Value

Genotype 1 50% 46% 0.57

Genotype 2/3 70% 71% 0.83

Patients from minority

ethnic groups

68% 49% <0.01

Cost-effectiveness: average ICER/QALY $8,3002

1. Arora S, Thornton K, et al. NEJM. 2011;364:2199-207.2. Wong JB et al. AASLD 2013, Washington DC, Abstract 245.

• Uses technology to leverage scarce resources

• Creates a virtual peer-to-peer network

• Promotes sharing best practices

• Employs case-based learning

• Establishes mentoring relationships

• Fosters local care champions

Why Does ECHO Work?

Arora S, et al. Acad Med. 2007 Feb;82(2): 154-60.

Mechanics of Weekly ECHO Sessions

Mini-Didactics

• Focused clinical topic

• First 15 minutes of session

• Recorded & publicly available

Case consultations

• Remainder of session

• 3-5 cases in 1 hour

• Goal: each site contributes at least one case per month

UW HIV ECHO To Date

- Intensive weekly training sessions

>220 sessions, >7,500 CE hours

- Longitudinal mentoring and training

Mean 27 providers/session

- Peer-based HIV knowledge network

53 core clinicians, 30% CHC/FQHC

- Just-in-time clinical consultations

>700 total (mean 3.21/session)

Washington

Oregon

Idaho

Montana

Utah

South Dakota

Alaska

Capacity Building

*Yellow dots = locations where an ECHO site trainee moved and continued to participate

Comprehensive Clinical Advice

Immediate Feedback & Teachable Moments

Do you routinely offer

zoster vaccine to

individuals with HIV?

A. Yes

B. No

Yes No

50% 50%

Participant Characteristic Proportion

Professional training/discipline

Physician 55.4%

Pharmacist 13.6%

Advanced nurse practitioner 10.3%

Physician assistant 9.3%

Nurse 5.1%

Social worker 4.6%

Years experience treating HIV (median) 5.0

HIV+ patient panel size (median) 19.0

Practice location

Rural 38.0%

Urban or suburban 62.0%

Provider-Level Data: UW HIV ECHO

Wood BR et al. Open Forum Infect Dis. Summer 2016;3(3):doi:10.1093/ofid/ofw123.

Self-Assessment Items Pre/Post Mean Paired

Diff

P Value

Counsel to reduce HIV transmission 7.18/8.98 1.80 <0.001

Perform initial HIV-related history/physical 7.38/8.33 0.96 0.001

Screen for viral hepatitis 7.62/8.56 0.93 0.002

Screen for substance abuse 7.24/8.07 0.82 0.004

Screen for mental health issues 6.56/7.82 1.27 <0.001

Select an initial ART regimen 5.42/7.78 2.36 <0.001

Manage common ARV side effects 6.00/7.27 1.27 <0.001

Assess for drug-drug interactions 6.04/7.04 1.00 0.004

Manage opportunistic infections 5.76/6.93 1.18 <0.001

Identify malignancies in persons with HIV 5.91/6.51 0.60 0.023

Care for women of childbearing age with HIV 5.38/6.62 1.24 0.006

Be a resource to other providers in the region 5.44/6.53 1.09 0.003

Wood BR et al. Open Forum Infect Dis. Summer 2016;3(3):doi:10.1093/ofid/ofw123.

Provider-Level Data: UW HIV ECHO

Self-Assessment Items Pre/Post

Mean

Paired

Diff

P

Value

Degree of professional isolation 2.69/2.27 -0.42 0.012

Feel part of an HIV community of practice 3.78/4.16 0.38 0.016

Feel connected to academic faculty 3.56/4.11 0.56 <0.001

Overall knowledge regarding HIV care 2.89/3.22 0.33 0.004

Wood BR et al. Open Forum Infect Dis. Summer 2016;3(3):doi:10.1093/ofid/ofw123.

Provider-Level Data: UW HIV ECHO

PrEPHepatitis B coinfection

LTBI or MTB diagnosis or treatmentSyphilis and other STI's

Non-AIDS complications of HIV infectionDrug-drug interactions

HIV treatment monitoringManagement during pregnancy

OI primary prophylaxisOther

Antiretroviral side effectsStarting or restarting ART

Low-level viremiaSubstance abuse

Adherence/engagement in careOI diagnosis and treatment

Hepatitis C coinfectionMental health

Acute symptomatology/lab abnormalitiesART regimen change

0 50 100 150 200Number of times clinical consultation sought

Wood BR et al. Open Forum Infect Dis. Summer 2016;3(3):doi:10.1093/ofid/ofw123.

Consultation Topics

Provider Responses Regarding PMTCT

• 100%: presenting a case during an ECHO session

influenced patient care “significantly”

• 76%: observing a case influenced management of a

patient in their practice “significantly” or “somewhat”

• 34%: helped a local colleague manage a pregnant

patient with HIV based on knowledge learned in ECHO

• 37%: without ECHO, would refer to another provider

(distance range 30 miles to 589 miles by plane)

Ness T et al. AIDS Educ Prev. 2017 Dec;29(6):516-526.

Provider Responses Regarding PrEP

• >90% of respondents reported that ECHO improved their

knowledge “extremely” or “moderately” well regarding

PrEP candidacy, lab monitoring, and adherence

- Exception = insurance and financial resources (<80%)

• 93.3% reported that ECHO helped stay up-to-date on

national PrEP guidelines “extremely” or “moderately” well

• 91.1% reported that ECHO increased their likelihood to

prescribe PrEP

Wood BR et al. Sexual Health. https://doi.org/10.1071/SH18062

Provider Responses Regarding PrEP

• 86.7% stated that, as a result of knowledge gained from

ECHO, they had served as a resource for other medical

providers in their region for PrEP

• 40% reported that without ECHO they would refer

patients to another provider for PrEP

• “My comfort with prescribing and troubleshooting

challenges has demystified PrEP prescribing and has

made me much more comfortable in providing it and

building the knowledge of others around me who don’t

access ECHO.”

Wood BR et al. Sexual Health. https://doi.org/10.1071/SH18062

Project ECHO Programs at UW

• HIV

• Hepatitis C

• Tuberculosis

• Antimicrobial Stewardship

• Heart Failure

• Geriatrics

• Psychiatry & Addictions

• Mental Health Counseling

ECHO Replication in the US

Map courtesy of William Szaroletta

ECHO Hubs Worldwide

Map courtesy of William Szaroletta

Benefits of ECHO To Health Systems

• Standardize care quality and safety

• Improve access & reduce disparities

• Strengthen workforce training

• Reduce burnout and turnover

• Encourage cost-effective care

• Strengthen academic-community partnerships

Slide adapted from Dr. Sanjeev Arora

Challenges to Project ECHO

• Funding

• Provider time & competing priorities

• Perspective shift for participants

• Administrative buy-in

• Variety of training backgrounds & experience levels

• Outcomes research

Overcoming the Challenges

• Get administrative buy-in

• Set clear expectations

• Visit sites when possible

• Treat longstanding participants as experts

• Encourage interaction and

relationships

• Plan for evaluation and sustainability early

• Track outcomes as much as

possible

• Cultural & professional/ disciplinary humility

• Ensure HIPAA

compliance/medicolegal safety

The Future

• Expansion to new regions and domains

• Incorporate training into medical education

• Partner ECHO with telemedicine

• Telehealth advocacy & legislation

Source: https://www.govtrack.us/congress/bills/114/s2873

The ECHO Act

Our goal is to touch the lives of 1 billion people by 2025…

“…and ensure that the world’s most vulnerable benefit from the world’s best collective knowledge.”

Resources:MacArthur Foundation 100 & Change: https://www.youtube.com/watch?v=CVAcx0QFzPUTED Talk: http://tedxtalks.ted.com/video/Changing-the-World-Fast-Dr-Sanj