Management of patients with hepatitis C (HCV) remains a considerable clinical challenge for nonspecialists, particularly in rural and underserved areas where access to expertise is often limited. Those challenges led HCV specialist Sanjeev Arora, MD, to develop Project ECHO (Extension for Community Healthcare Outcomes), a network of digital “hubs” where specialists can share knowledge with front-line clinicians with multi-user video conferencing apps and other technologies. Dr. Arora, a distinguished Professor of Medicine in the Department of Internal Medicine at University of New Mexico Health Sciences Center, recently met with Patient Care to discuss how Project ECHO has grown from humble beginnings to include not only 30 HCV-specific hubs, but also hundreds of others to address more than 70 other medical conditions in the US and around the world.
What clinical dilemma led to the creation of Project ECHO? "I’m a gastroenterologist, and was running this HCV clinic at the university, and there was an 8-month wait to see me. Some people were driving 250 miles, each way, making 12 to 18 trips. I was working all-out, and yet maybe 5% of the 28 000 patients had been treated. People started coming to see me with liver cancer, liver failure, dying."
"We need to treat them earlier; but, how? I thought that if I could figure out a way to get everyone on treatment, even in rural areas or prisons, then others would have a model that can be applied across the world. And now, Project ECHO is in 31 countries, and we use it for more than 70 different conditions. There are more than 30 hospitals doing HCV ECHO clinics, and at least 20 of those are in the US."
"How has the availability of DAAs changed the role of Project ECHO? "With the new medicines for HCV, treatment became easier, but the problem became lack of access due to expense of the drugs, so poor people had very poor access for a few years. Today, there is much broader access to medications, and we are able to treat thousands and thousands of patients."
What specific HCV-related challenges does Project ECHO address now? Treatment algorithms are very clear now, but many doctors in rural areas do not have the knowledge to diagnose cirrhosis appropriately. They may not have the testing modalities to evaluate the severity of liver disease. They don’t know how to modify treatment, how to help patients with treatment failure, or how to deal with adherence issues...It’s not that the subject matter is so complex that they cannot master it—it’s the breadth of the area they have to cover."
Is Project ECHO a technology platform, educational model--or both? "Project ECHO is not a technology play alone—it is a model to transform health care delivery by democratizing knowledge and mentoring providers. We call it an 'all teach, all learn' framework, however, technology is the enabler...Today, we have a partnership with Zoom—they believe in our social mission, and so, we have a worldwide license for using the Zoom video conferencing platform for the next seven and a half years.
Bottom line: does Project ECHO improve the care of HCV patients? What have you learned? "There are now many published studies that explain ECHO and describe its results in many different diseases. One of our HCV studies, published in 2011 in the New England Journal of Medicine, showed how the cure rate for HCV patients treated by primary care providers at ECHO sites was the same as the cure rate at our university clinic."
What’s next? Do you have a long-range plan for addressing HCV and other diseases? "Our long-term goal is to touch the lives of 1 billion individuals by 2025. To reach a billion people, we’ll need about 2700 hubs, and we’re growing at about 50% per year ... as a hepatologist and HCV specialist, elimination of the disease is very close to my heart."