Title: 2017 GPARTS Dr Catherine Hanna
Funder: Health and Social Care Research and Development Division (HSC R&D) of Public Health Agency, Northern Ireland

Abstract: BACKGROUND. Project ECHO (Extension for Community Healthcare Outcomes) (Project ECHO, 2017) is a new technology platform supporting community healthcare education. The model (originally developed in New Mexico in 2003 by Dr Sanjeev Arora) was originally designed to support and train primary healthcare providers in rural and underserved areas so that they can better manage patients with complex health needs, and to improve access to what is considered to be specialised (usually synonymous with secondary) care. ECHO does this by creating an opportunity for healthcare professionals from various backgrounds to participate in a community of learners in conjunction with specialist mentors. As such, it has particular relevance to primary healthcare in bridging the primary-secondary care interface, and thus allowing new communities of practice to develop. Using webcams and video-conferencing technology, ECHO enables healthcare professionals to link-in from ‘spokes’ to a central ‘hub’ for case-based discussions. This overcomes the problems of geographical dispersion. The ECHO session starts with a short 15-minute didactic presentation on a topic relevant to the clinical area of that particular ECHO session. Following this didactic presentation, participants present and discuss the background history, clinical presentation, examination findings, investigation and management of actual clinical cases they have encountered. The model has proved highly successful and has been continually expanding since its formation, with it now being used in 23 countries for over 65 conditions (ECHO, 2018). At a time when there is increasing focus on healthcare reform and with local development of GP federations and integrated care partnerships, ECHO may help within these processes, through dissemination of knowledge in an effective, safe and efficient manner. Given that the ECHO model is still a relatively new approach to support learning, published research about it remains limited. Publications on ECHO to date have been largely quantitative, centred on clinical outcomes and with less focus on qualitative outcome measures. However, evidence is growing that the use of this innovative approach to learning has significant potential. A systematic review of the impact of Project ECHO on patient and provider outcomes identified 39 studies across 17 distinct disease groups (Zhou et al, 2016). For example, participation in Project ECHO led to changes in primary care provider behaviour, improvements in primary care providers’ knowledge and confidence and improvements in patient outcomes for people affected by dementia, diabetes and hepatitis C (Project ECHO NI, 2016). Of the qualitative evidence base available, it largely centres on participants’ experiences of using ECHO. Review of the literature reveals little in the way of explanation in respect of an exploration of the specific models of learning or a robust theoretical framework that could provide an explication of the ECHO platform. ECHO brings together a community of learners who are at the same-time situated in their place of work, and who use technology to support a social learning space (Socolovsky et al, 2013). Socolovsky et al therefore suggest that the success of Project ECHO for community-based learning can be explained by Situated Learning and Community of Practice theories (Lave and Wenger, 1991) and by Social Cognitive Theory (Bandura, 2001). The participants in ECHO are situated within the community-based context for which they are seeking to acquire knowledge, insights and skills and they come together to learn as a community albeit aided by a technology-enhanced remote access. Lave and Wenger’s work, with which many medical educators will already be familiar, explains that a Community of Practice (CoP) is a group of people undertaking shared activities and interests. The CoP normally has a domain, a community and a practice, and practitioners who develop a shared repertoire of resources. The CoP is seen as a conduit to promote innovation, develop social capital and to facilitate the spread of tacit knowledge within a group. The community develops its practice through the finding, sharing, and transferring of knowledge. It may be that all or none of these theories are a useful theoretical lens through which the learning taking place within the ECHO model may be explained. So a question which arises is: “What can be understood about the process of learning that occurs within a community using the ECHO Model?” My research aims to delve more deeply into how this interesting new model works at a fundamental level, by exploring the learning environment created within, and social context of the ECHO model. I plan to do this by using an ethnographic approach to collect observational data which will then be analysed using Activity Systems Analysis as a theoretical framework. This will be triangulated by data from Semi-Structured Interviews which will be analysed using Template Analysis as a framework. The greater depth of understanding of ECHO which I hope to afford through this research could help with planning and development of future ECHO networks within N.I. and further afield. The ECHO platform is a mode of delivering high levels of care within communities, through open communications and interactions between individuals from different care providers. RESEARCH PURPOSE. Research aim. The aim of this study is to explicate the learning environment created within, and social context of the ECHO model. Research objectives. To ascertain and afford greater understanding of the learning process occurring within Project ECHO. To use Activity Theory to explicate the learning environment created within ECHO. To gain a deeper understanding of ECHO as a learning environment. It is hoped that this could aid development of future networks both within Northern Ireland and further afield. METHODS AND METHODOLOGY. Context and setting of study. The setting for this study will be two or more ECHO networks within NI. ECHO N.I. is collaborating with the project and will help gain access to mutually agreed ECHO networks for the purposes of the study. Study subjects. General Practitioners, Secondary Care Specialists and the wider health care multidisciplinary team. Administrative and technical staff involved in the running of ECHO networks. It may be that GP trainees could be involved as they are part of the GP team but they will not be the focus of the study. Method. Mixed Methods Study. Study design. Direct observation using an ethnographic approach. Semi-structured interviews. Study sample. All participants of the ECHO networks observed will be eligible to participate in the study.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE