Project ECHO: The Specialist Will See You Now
Authors: Saira Khaderi, Norman Sussman, Fasiha Kanwal
Journal: Hepatology (2018)

SEE ARTICLE ON PAGE 2317 The American Telemedicine Association defines telemedicine as the "remote delivery of health care services and clinical information using telecommunications technology." The first article on telemedicine was published in 1962, but widespread use would have to wait for broad availability of interconnected computers around 30 years later. Even in the 1990s, teleconferencing required two dedicated phone lines and expensive equipment that was not readily available. Now, teleconferencing has become an everyday occurrence with people communicating by video from any computer or hand‐held device with a connection to the Internet. Telemedicine can work in many different ways. A psychiatrist holding a counseling session directly with his or her patient on video is an example of the "direct‐to‐patient" model. Project ECHO (Extension for Community Healthcare Outcomes) is an example of "telementoring" in which specialists transfer their knowledge and experience directly to community providers without direct contact with the patient. The ECHO model was developed to improve access to specialist care for underserved populations with complex health problems. It originated in New Mexico, a state where lack of access to specialists meant patients in rural areas either went untreated or had to wait several months and travel up to 250 miles for an appointment at the University of New Mexico (UNM). Using state‐of‐the‐art multipoint telehealth video technology, Dr. Arora developed a system in which community providers presented hepatitis C cases and were coached on management by specialists at UNM. Remarkably, rates of sustained virological response were identical in patients treated at UNM and those treated by primary care providers at 21 ECHO sites.1Project ECHO has since proven effective in a number of other medical specialties, including drug addiction2and dermatology.3 In 2011, the Veterans Health Administration adopted the ECHO program to innovate specialty care delivery and renamed it SCAN‐ECHO (Specialty Care Access Network‐Extension for Community Healthcare Outcomes). The VA Ann Arbor was one of the first to implement SCAN‐ECHO for chronic liver disease. Having already shown that in‐person specialist consultation visits were associated with improved survival in patients with liver disease,4 Su et al. set out to extend those findings by examining whether a virtual specialty consultation had a similar benefit on survival. Their findings are published in this month's Hepatology.5 The original cohort included 67,314 regional patients with liver disease in the VA from June 1, 2011 to March 31, 2015. Eligible patients with a VA SCAN‐ECHO visit (513 patients) were compared to 62,234 patients with no visit. SCAN‐ECHO patients were more likely to live in an area characterized as "rural" or "highly rural" and to have a well‐characterized liver disease, such as hepatitis C, hepatitis B, or cirrhosis. Matched patients who had a consultation with the SCAN‐ECHO program were 46% less likely to die during the follow‐up period (hazard ratio, 0.54; 95% confidence interval, 0.36‐0.81; P = 0.003) compared to those with no visits. The reduced risk of death in SCAN‐ECHO patients included those with and without advanced fibrosis. Importantly, patients with SCAN‐ECHO visits had similar survival when compared to patients with traditional in‐person visits. The researchers concluded that SCAN‐ECHO is an effective method to improve access to care for rural and underserved patients with liver disease. These data are important because they show a strong beneficial effect of a SCAN‐ECHO consultation on the outcome most valued by patients and their physicians (i.e., survival). However, the explanations underlying this finding are less clear. For example, and as discussed by the researchers, improvements in the processes of care for patients with cirrhosis might have played a role. Patients in the SCAN‐ECHO group were more likely to undergo surveillance for esophageal varices and HCC. However, fewer than 17% of patients in the SCAN‐ECHO group had cirrhosis. Thus, differences in cirrhosis related care, per se, are unlikely to fully explain the difference between the observed and expected survival. It is possible that the beneficial effect of SCAN‐ECHO was driven primarily by (successful) treatment of patients with hepatitis C virus (HCV) infection. More than 40% of patients in SCAN‐ECHO had hepatitis C; some, if not most of whom, likely received antiviral treatment for hepatitis C. This issue does not undermine the internal validity of the study findings, but these data may not be fully generalizable to the newer cohorts of chronic liver disease patients in the VA, most of whom will be patients with treated HCV and hepatitis B virus or those with nonalcoholic fatty liver disease. Last, and as noted by the researchers, it is not possible to establish conclusively a causal relationship between SCAN‐ECHO delivered specialty care and decreasing mortality in patients with liver disease from this study. Unmeasured confounding, at both the patient and primary care physician levels, may have influenced the results. It is even possible that primary care physicians who use SCAN‐ECHO are generally more diligent or skilled in patient management. Notwithstanding these caveats, the study by Su et al. has significant implications. These results are consistent with the few available data in other areas of medicine showing that care by specialists can provide the best chance at improving the process and/or outcomes of care.4 The finding of similar outcomes between a traditional face‐to‐face and telemedicine visit with specialists is particularly relevant as the U.S. health care delivery system evolves into value‐based models that rely primarily on generalists as part of patient‐centered medical homes and accountable care organizations. Telemedicine programs in general, and ECHO‐based programs in particular, may integrate both primary and specialist care and benefit everyone involved in the process. Patients who are uninsured, underinsured, or in lower socioeconomic strata often have limited access to specialty care. Driving to an academic medical center for a specialist appointment may not be financially feasible for many reasons (cost of gas, child care, time off of work, and visit co‐pay), and wait time to see a specialist may be several weeks to months. With ECHO, patients can stay with their local health care providers who provide culturally appropriate and accessible care. Local providers also benefit. In 2010, Arora et al. published results from an annual survey taken by community providers involved in ECHO.7 The survey data showed a significant improvement in provider knowledge, self‐efficacy, and professional satisfaction through participation in ECHO. Providers acknowledged the acquisition of clinically relevant information that assisted them in caring for patients with specific diseases, including some who were not actually presented in an ECHO clinic. Clinicians expressed confidence in the support they received from specialists and their own ability to identify and address patient safety issues. Specialists also benefit by being able to devote their time to patients with more‐advanced disease. If community providers manage low‐acuity problems, specialists have more time to spend with patients that really require the attention of an academic medical center. Despite initial concerns about the quality of care, telemedicine has found its way into mainstream medicine. Su et al.'s article in this edition of Hepatology shows how videoconferencing and telemedicine have the power to revolutionize medicine by delivering state‐of‐the‐art care to patients in medically underserved areas. With all this promise, telemedicine has grown into a multibillion dollar business. In 2017, Congress unanimously passed the ECHO Act that mandates the Department of Health and Human Services to study Project ECHO's impact on patient care and clinician development. Congress' overwhelming support of the ECHO Act may be the tipping point for telehealth—bringing health care delivery in rural settings and provider shortage issues into the national spotlight. The questions that remain include finding time and funding to run these programs. The VA is a closed, fully integrated health care system—very different than the fee‐for‐service environment in which most providers currently practice. The majority of ECHO programs in the nonclosed system are supported by grants, an unreliable source of funding. We hope the findings of the ECHO Act will convince payers that telemedicine is an excellent, cost‐effective method to provide care to their clients. Potential conflict of interest Dr. Kanwal received grants from Gilead. Dr. Sussman spoke and consulted at AbbVie, Gilead, and Intercept, and received research grants from Allergan, Conatus, Cymabay, Enanta, Gilead, Genfit, Genkyotex, Intercept, Novartis, Pfizer, and Wilson Therapeutics.