1. Sanjeev Arora M.D., FACG Professor of Medicine Executive Vice Chairman
Department of Medicine
Director of Project ECHO
University of New Mexico School of Medicine

2. MISSION MISSION The mission of Project ECHO is to
develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.
Supported by Agency for Health Research and Quality HIT grant 1 UC1 HS , and MRISP, R24HS and the New Mexico Legislature

3. Hepatitis C: A Global Health Problem
170 Million Carriers Worldwide, 3-4 MM new cases/year
EAST
MEDITERRANEAN
20M
WEST
EUROPE
9 M
FAR EAST ASIA
60 M
U.S.A.
4 M
SOUTH EAST ASIA
30 M
AFRICA
32 M
WHO estimates that 170 million persons or 3 % of the world’s population are infected with hepatitis C and 3 to 4 million persons are newly infected each year. The prevalence of HCV in some countries in Africa, the Eastern Mediterranean, South East Asia and Western Pacific is high compared to some countries in Europe and North America.
According to the National Health and Nutrition Examination Survey of 1988 to 1994, the NHANES survey, and other population-based surveys, nearly 2% of Americans test positive for the hepatitis C antibody. This prevalence corresponds to an estimated 4 million Americans infected with HCV.
SOUTH
AMERICA
10 M
AUSTRALIA
0.2 M
Source: WHO 1999

4. HEPATITIS C IN NEW MEXICO HEPATITIS C IN NEW MEXICO
Estimated number is greater than 28,000
Less than 5% had been treated
Without treatment 8,000 patients will develop cirrhosis between with several thousand deaths
2300 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated
Highest rate of chronic liver disease/cirrhosis deaths in the nation

5. Rural New Mexico RURAL NEW MEXICO 121,356 sq miles
Underserved Area for Healthcare Services
121,356 sq miles
1.83 million people
42.1% Hispanic
9.5% Native American
17.7% poverty rate compared to 11.7% nationally
>22% lack health insurance
32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUA’s)
14 counties designated as Health Professional Shortage Areas (HPSA’s)

6. 20% practice in rural or frontier areas
HEALTH CARE IN NEW MEXICO
HEALTHCARE IN
NEW MEXICO
20% practice in rural or frontier areas
New Mexico Physician Survey 2001

7. GOALS
GOALS
Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes
Develop a model to treat complex diseases in rural locations and developing countries

8. PARTNERS
PROJECT ECHO
University of New Mexico School of Medicine Dept of Medicine, Telemedicine and CME
NM Department of Corrections
NM State Health Department
Indian Health Service
Community Providers with interest in Hepatitis C and Primary Care Association

9. METHOD
METHOD
Use Technology (telemedicine and internet) to leverage scarce healthcare resources
Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices”
Case based learning: Co-management of patients with UNMHSC specialists
Centralized database HIPAA compliant to monitor outcomes

10. STEPS
STEPS
Train providers, nurses, pharmacists, educators in Hepatitis C
Install protocols and software on site
Conduct telemedicine clinics – “Knowledge Network”
Initiate co-management – “Learning loops”
Collect data and monitor outcomes centrally
Assess cost and effectiveness of programs

11. COMMUNITY PARTNERS BENEFITS TO RURAL PROVIDERS
No cost CME’s and Nursing CEU’s
Professional interaction with colleagues with similar
interest
– Less isolation with improved recruitment and retention
A mix of work and learning
Obtain HCV certification
Access to specialty consultation with GI, hepatology,
psychiatry, infectious diseases, addiction specialist,
pharmacist, patient educator

14. Comprehensive Electronic Medical Record
Solution Functional Capabilities
Comprehensive Electronic Medical Record
Comprehensive Patient Demographics
Patient Care Management Workflow (ECHO Clinics)
Health History, Physical Examination, Review of Systems
Dynamic Forms
Allergies
Vitals
Patient Presentation and Case study
Labs
User and Site Management
Medications
Reporting & Search
Diagnosis (Medical Conditions)
Patient Health Surveys
Surgical Procedures
Imaging
Patient Registration 14

15. DISEASE SELECTION DISEASE SELECTION Common diseases
Management is complex
Evolving treatments and medicines
High societal impact (health and economic)
Serious outcomes of untreated disease
Improved outcomes with disease management

16. BUILDING BRIDGES HEALTHCARE IN NEW MEXICO BUILDING BRIDGES
PARETTO’S PRINCIPLE
State Health Dept
Community Health Centers
Private Practice
UNM HSC
Hepatitis C
Asthma and COPD
Substance Use and Mental Health Disorders

17. KNOWLEDGE IMPORTANT - NOT TITLE
FORCE MULTIPLIER
HEALTHCARE IN NEW MEXICO
Use Existing Community Providers
Primary Care
Nurse Practitioners
Physician Assistants
Specialists
Hepatitis C
Asthma and COPD
Substance Use and Mental Health Disorders

18. COMMUNITY HEALTH EXTENSION AGENT COMMUNITY HEALTH EXTENSION AGENT
CHEA

19. KNOWLEDGE IMPORTANT - NOT TITLE
FORCE MULTIPLIER
HEALTHCARE IN NEW MEXICO
Chronic Disease Management is a Team Sport
Community Health Worker
Medical Assistant
Primary Care
Nurse
Hepatitis C
Asthma and COPD
Substance Use and Mental Health Disorders

20. ROLE OF KNOWLEDGE NETWORK
A KNOWLEDGE NETWORK IS NEEDED
Increasing Gap
Medical Knowledge
Learning Capacity
Time
“Expanding the Definition of Underserved Population”

21. How well has model worked?
305 HCV Telehealth Clinics have been conducted
3016 patients entered HCV disease management program
CME’s/CE’s issued:
3631 CME/CE hours issued to ECHO providers at
no-cost.
205 hours of HCV Training conducted at rural sites
National Recognition as Model for Complex Disease Care

22. Project ECHO Annual Meeting Survey
Mean Score
(Range 1-5)
Project ECHO has diminished my professional isolation
4.3
My participation in Project ECHO has enhanced my professional satisfaction
4.8
Collaboration among agencies in Project ECHO is a benefit to my clinic
4.9
Project ECHO has expanded access to HCV treatment for patients in our community
Access to in general to specialist expertise and consultation is a major area of need for you and your clinic
Access to HCV specialist expertise and consultation is a major area of need for you and your clinic

23. Project ECHO Providers HCV Knowledge Skills and Abilities (Self-Efficacy) scale: 1 = none or no skill at all 7= expert-can teach others
Community Providers
N=25
BEFORE Participation
MEAN (SD)
TODAY
Paired
Difference
(p-value)
Effect Size
for the Change
1. Ability to identify suitable candidates for treatment for HCV.
(1.2)
(0.8)
(1.2)
(<0.0001)
2.4
2. Ability to assess severity of liver disease in patients with Hepatitis C.
(1.2)
(0.9)
(1.1)
(< )
2.1
3. Ability to treat HCV patients and manage side effects.
(1.1)
(0.8)
2.6

24. Effect Size for the Change
Project ECHO Providers HCV Knowledge Skills and Abilities (Self-Efficacy)
Community Providers
N=25
BEFORE Participation
MEAN (SD)
TODAY
Paired
Difference
MEAN/SD
(p-value)
Effect Size for the Change
4. Ability to assess and manage psychiatric co-morbidities in patients with Hepatitis C.
(1.2)
(1.0)
(1.3)
(<0.0001)
1.9
5. Serve as local consultant within my clinic and in my area for HCV questions and issues.
(1.2)
(0.9)
(1.2)
2.8
6. Ability to educate and motivate HCV patients.
(1.1)
(0.6)
(1.1)
2.4

25. Effect Size for the Change
Project ECHO Providers HCV Knowledge Skills and Abilities (Self-Efficacy)
Community Providers
N=25
BEFORE Participation
MEAN (SD)
TODAY
Paired
Difference
MEAN/SD
(p-value)
Effect Size for the Change
7. Ability to assess and manage substance abuse co-morbidities in patients with Hepatitis C.
(1.1)
(1.1)
(1.1)
(<0.0001)
1.9

26. Effect Size for the Change
Project ECHO Providers HCV Knowledge Skills and Abilities (Self-Efficacy)
Community Providers
N=25
BEFORE Participation
MEAN (SD)
TODAY
Paired
Difference
MEAN/SD
(p-value)
Effect Size for the Change
Overall Competence
(average of 9 items )
2.8*
(0.9)
5.5* (0.6)
(0.9)
(<0.0001)
2.9
Effect size is the standard mean difference between paired post participation and pre-participation ratings. It is calculated by using the average paired difference between post participation and pre-participation ratings as the numerator and the standard deviation of the paired differences as the denominator. A classification of effect size offered by Cohen is: 0.2=small, 0.5=medium, and 0.8=large. [Cohen, Jacob.91988) Statistical Power Analysis for the Behavioral Sciences. 2nd edition. Lawrence Erlbaum Associates, Hillsdale, NJ.]
Cronbach’s alpha for the BEFORE ratings = 0.92 and Cronbach’s alpha for the TODAY ratings = 0.86 indicating a high degree of consistency in the ratings on the 9 items

27. KNOWLEDGE MODEL Ashoka and Robert Wood Johnson Changemaker Award
Applications sought for Disruptive Innovations in Healthcare – New Models that would change healthcare nationally and globally
307 Applications from 27 countries
9 finalists selected by a panel of Judges
Project ECHO selected one of three winners by worldwide online voting

28. VISION FOR THE FUTURE VISION FOR THE FUTURE Mon Tue Wed Thurs Fri
8-10 AM
Hepatitis C
Cardiac Risk Reduction Clinic
Asthma and COPD
Prevention of Teenage Suicide
Mental Health Disorders
10-12 AM
Rhuema-tology
Chronic Pain and Neurology
Substance Abuse
High Risk Pregnancy
Endocrine
2-4 PM
Gastro
Cardiology
Heart
Failure
Childhood
Obesity
Orthopedics 28

30. Potential Benefits of the ECHO Model DISEASE SELECTION
Quality and Safety
Access for Rural and Underserved Patients
Workforce Training and Force Multiplier
Improving Professional Satisfaction/ Retention
Cost Effective Care- Avoid Excessive Testing and Travel
Integration of Public Health

31. Use of telemedicine, best practice protocols, co-management of patients with case based learning (the ECHO model) is a robust method to to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes.
Supported by Agency for Health Research and Quality HIT grant 1 UC1 HS , and MRISP, R24HS and the New Mexico Legislature