Project ECHO is revolutionizing the way healthcare professionals interact and share knowledge and information. But what is ECHO? As a pharmacy student, I had never heard of the term before, except for phantom copy-cat that mimics you in canons and caverns. This ECHO, or Extension for Community Healthcare Outcomes, has its roots in Albuquerque at the University of New Mexico (UNM). It was initially created in 2003 by a liver specialist named Sanjeev Arora, M.D., for the purpose of expanding the availability of hepatitis C treatment.1 Thanks to the ECHO project, specialized medical knowledge is made more easily available to underserved rural areas that have limited medical resources. Specialists in their respective fields serve as mentors and colleagues as they share their knowledge and experiences with other health care professionals. Video conferencing provides a secure link to primary care clinics within UNM’s School of Medicine. This helps keep rural clinicians current with advances in chronic disease treatment and provides continuing medical education (CME) credit.
As of December 2014, Project ECHO connected more than 20 partner clinics within the state of New Mexico alone, including prisons, public health departments, Indian Health Service sites, community health centers, and rural primary health practices sites around New Mexico. Currently, ECHO is expanding to cover a wide variety of conditions and chronic diseases including mental health, substance abuse, gestational diabetes, and rheumatologic diseases.2 The project has spread to 22 states and five countries outside the United States. 1
The Show-Me ECHO program kicked off in Missouri in 2014 with an initial focus on chronic pain management followed by a program focused on autism treatment. In the month of July 2015, Missouri became the first state to receive state funding for the implementation of Project ECHO with support from legislator and Governor Jay Nixon. The funding, totaling $1.5 million, will allow the establishment of four new ECHO focus areas: endocrinology, dermatology, hepatitis C, and childhood asthma.3 It will additionally help fund the ongoing, original ECHO programs of autism and chronic pain. The Show-Me ECHO program’s goal is “To use videoconferencing technology to provide education, training, and engagement opportunities to primary care providers concerning specific disease states or conditions that are chronic, costly, common, and complex to improve patient access and health outcomes as well as reduce overall cost for care of patients.”4 The program focuses on disease states that are “common but complex, chronic and costly.”5
On August 12th, 2015 I attended the Missouri Telehealth Network’s Show-Me EHCO Expert Panel Kick Off at the University of Missouri in Columbia. The conference covered the past year in regards to the ECHO program. The obstacles that were overcome to get the project off the ground and the success the chronic pain ECHO has seen thus far were discussed. The Chronic Pain ECHO began on November 6th, 2014. Today there are 2,024 people participating in the clinic, according to Richard Lillard, PsyD. The program boasts an integrative approach that depends on active participation for success.
The new chronic management disease ECHO groups that will be piloted this year in Missouri met with the expert panels and discussed their goals and anticipated start up dates and clinic times. In particular, the ECHO Autism program started in March of 2015. Dr. Sohl, an Autism ECHO facilitator, reports that their expert panel not only contains expert healthcare professionals but also a parent with an autistic child so that the panel can have a unique perspective on treatment and how it affects the family and patient outside of the office. She also states that of the children who are examined, less than half of this population are actually diagnosed with autism. The sheer volume of patients that the clinic has to sort through sets them back months and takes time away from the families and children who truly need counseling and guidance for their autism. If primary care physicians could be educated on how to properly identify and diagnose this disease, then physicians like Dr. Sohl, would have more time to focus on those who need her special set of skills and knowledge.
On August 13th, 2015, I attended the Show-Me Chronic Pain ECHO training at the Missouri Primary Care Association (MPCA). Dr. Karl Haake presented concerning the state of chronic pain in Missouri and the challenges primary care physicians face. During this presentation, the fact that Missouri is the only state without a drug monitoring program was highlighted. Patients from surrounding states prey upon Missouri for their opioid prescription drugs and the lack of drug monitoring lets opioid abuse run rampant. Missouri has the 7th highest drug abuse rate in the United States. The distinction was made between the treatment of chronic pain and the treatment of addiction. When approaching chronic pain treatment, it is important that both the physician and patient know that “no one can be 100% pain-free.” Reducing pain to a tolerable level where patients can perform certain daily functions is a more realistic goal.
As a future pharmacist, this presentation made me excited to learn more about chronic pain and ways that I can help decrease the amount of opioid abuse within our state while also providing alternative solutions to patients. I also learned more about alternative treatment options for this disease. Listening to specialists speak about their own experiences gave me more insight into chronic pain than four years of school ever could. Dr. Haake described how his opioid pain clinic worked to control chronic pain without opioid use even if it meant making the difficult decision of sending the patient through withdrawal. Each patient is diagnosed on an individual basis and treatment is continually modified to ensure that the patient is being adherent and that the dose is appropriate, which may include decreasing to lower dosages instead of adding newer analgesics to mask the underlying problem.
I was further intrigued by the myriad of healthcare professionals that made up the Chronic Pain ECHO Clinic, along with the new ECHO clinics emerging this year. Pharmacists, physicians, behavioral health providers, and administrative personnel all come together to ensure the program’s success. Active participation between the expert panel and the primary care providers is crucial within ECHO. ECHO enables the sharing of knowledge between specialists and primary care providers allowing patients to stay within their local communities, thereby increasing the number of patients that will receive treatment and improving overall access to care. With such common and costly disease states, providing specialty knowledge to outlying areas creates ease of access to knowledge while also ensuring quality care.
The disease states that ECHO focuses on are complex in their treatment guidelines. Treating pain, psychological and behavioral diseases requires a different approach than when treating a patient with hypertension or chronic cardiovascular disease. The disease states currently covered by the ECHO program are monitored using more subjective measures than those conditions that may have more objective measures such as heart failure. A patient cannot be weighed and measured to determine the progression of chronic pain. The diagnosis and treatment is based upon the patient’s description and treatment is determined at the physician’s discretion. By communicating with a diverse panel of qualified professionals, providers are able to collaborate with specialists and make more informed decisions for their patients.
I believe it is imperative that pharmacists participate in programs such as the ECHO project. Pharmacists provide a unique outlook on patient care and can provide insight on medication administration, compatibility, and adherence that other primary care professionals may fall short on. The field of pharmacy is transforming and is focusing on patient centered care. It only makes sense that pharmacists become familiar with all aspects of patient care and share their knowledge to help decrease adverse drug reactions, prevent hospital readmissions, and ensure patients receive the best possible care. The ECHO program creates an opportunity for primary care providers to interact and learn from one another in a way that is normally not possible in their respective settings.
If you have any questions about the Show-Me Echo project or want to get involved, you can contact Rachel Mutrux, the senior program director at the Missouri Telehealth Network, at email@example.com or by calling her at 573-884-7958.
UMKC School of Pharmacy in Columbia
Pharm.D. Candidate 2016
- UNM School of Medicine. Project ECHO. Accessed August 14th, 2015. http://echo.unm.edu/
- Health IT. PROJECT ECHO: Bringing Specialty Care to Rural New Mexico. Accessed August 18th, 2015 at https://healthit.ahrq.gov/ahrq-funded-projects/transforming-healthcare-quality-through-health-it/project-echo-bringing
- Heartland Telehealth Resource Center. Missouri telehealth project lands state funding. Accessed August 19th, 2015 at http://heartlandtrc.org/missouri-telehealth-project-lands-state-funding/
- Missouri Telehealth Network. Show Me ECHO. Accessed August 18th, 2015. http://c.ymcdn.com/sites/www.maops.org/resource/resmgr/Show-Me_ECHO/ECHO.faq.flyer.pdf
- Edison K, MD. University of Missouri Health Systems. State Funding Gives Providers Access to Telehealth Training for Chronic Diseases. Accessed August 19th, 2015 at http://www.muhealth.org/news/releases/state-funding-gives-providers-access-to-telehealth-training/