Enthusiasm can be a double-edged sword, as Christopher Langston notes in his recent critique of Project ECHO. He describes the model’s success as a case of enthusiasm overtaking evidence.
It’s true that the spread of ECHO has outpaced the publication of the research exploring it.
The enthusiasm of specialists and primary care providers engaged in this model of collaborative practice and mentorship has spurred tremendous momentum for ECHO all over the world. In fewer than 14 years, Project ECHO, which I developed with my colleagues at the University of New Mexico Health Sciences Center as a way to help people with hepatitis C get treatment, has spread to address more than 50 complex medical conditions. More than 100 academic organizations lead ECHO projects in 30-plus states and 21 countries, connecting with thousands of community clinics. And more than 200 other ECHO projects are in the pipeline.
Meanwhile, 46 published peer-reviewed papers from 18 academic centers in five countries describe a range of benefits and positive impacts from ECHO. But more research is needed to continue to build our understanding of the model and its impacts and ensure its continual improvement.
At the ECHO Institute, we are committed to a full and rigorous exploration of the ECHO model, which is why outcome monitoring is a critical pillar in our work. It’s the only way we will achieve our goal of improving the lives of underserved populations around the world.
The body of work included in the research review referenced by Mr. Langston demonstrates positive effects of ECHO on provider knowledge, self-efficacy, and professional satisfaction across multiple conditions. The period covered by that review ended more than a year ago. Since then, several important studies have been published. These include a study from Beth Israel Deaconess in Boston showing that its ECHO-AGE program significantly reduced the use of physical restraints and antipsychotic medications among nursing home residents. Another study, on ECHO’s substance abuse treatment program, won recognition from the journal Substance Abuse as the best paper of 2016.
A forthcoming research paper, undertaken as part of a grant award from the Center for Medicare and Medicaid Innovation, will demonstrate improved access and reduced costs, hospital admissions, and emergency room visits from a project focused on care for the most complex Medicaid patients. The manuscript is in preparation.
Additional research is underway, in diabetes, autism, and opioid addiction treatment. Several ECHO partners and state government agencies are conducting cost analyses of their ECHO programs including looking at return on investment.
Finally, we are excited that the recently enacted ECHO Act, which directs the Department of Health and Human Services to examine the model’s impact across a range of conditions, will add to our collective understanding.
What ECHO Is… And Is Not
It is critical here to clarify what ECHO is — and what it isn’t. ECHO is not a continuing medical education program that relies on seminars and lectures. Nor is it a quality improvement program. At its core, Project ECHO is a model for sharing knowledge to expand the capacity of the existing health care workforce so that many more people are able to get high-quality care for their conditions, in or near the communities where they live.
Four characteristics distinguish ECHO from other models: the commitment of primary care providers to become experts in an area of community need; their active involvement in presenting patient cases from their own practices; the development of a community of practice and learning; and the establishment of meaningful, ongoing connections with specialists who serve as mentors for primary care providers.
ECHO is about true partnership. We often describe ECHO as a coalition of the willing — of specialists who want to extend their knowledge and expertise for the social good and of primary care providers who want to do more for patients who would otherwise have great difficulty getting the care they need. By entering into this partnership of knowledge-sharing and collaborative practice, they build up the health care delivery infrastructure of underserved communities.
Enabled by ECHO, these primary care providers not only take care of their own patients with complex health problems (who otherwise would have been referred out to specialty care), but also become local experts and receive referrals from colleagues across their region. The result is force multiplication, an exponential expansion in capacity to deliver best-practice specialty care.
Without question, ECHO needs to be evaluated further, across numerous dimensions. We invite readers of Health Affairs to share their ideas and suggestions.
We also invite not only Mr. Langston but all readers who wish to learn more about Project ECHO firsthand to visit us in Albuquerque or connect with a local ECHO project. At the ECHO Institute, we set aside time every month for visitors. Not only is this an opportunity for us to share the ECHO model in an in-depth, immersive way, but it is also an opportunity for us to learn from you, as experts in the field, and gain your assistance in evaluating and improving ECHO.