Spreading a new model to treat complex chronic diseases in rural and underserved areas by connecting urban healthcare specialists with rural providers through communication technology.
Dr. Sanjeev Arora is using communication technologies to dramatically reduce disparities in care in the United States for patients with common chronic diseases who do not have direct access to healthcare specialists.
In 2003, nearly 30,000 New Mexicans were infected with Hepatitis C, yet only 5 percent were able to access treatment which is available almost exclusively through specialists at the University of New Mexico (UNM) in Albuquerque. The plight of these underserved patients inspired Sanjeev Arora, one of the top Hep C specialists in the country to develop a plan to deliver state of the art treatment to these communities through Project ECHO (Extension for Community Healthcare Outcomes).
Project ECHO creates a one-to-many “knowledge network” of specialists and up to 40 rural providers, who meet by videoconference to co-manage specific patients and share two-way teachings in which the ECHO staff works with remote clinics to coordinate and educate. Sanjeev calls this aspect of ECHO the “workforce multiplier.” Through the “knowledge networks” of the clinics, specialists co-manage patients and teach rural medical professionals to be mini-specialists, to whom patients from that area are increasingly referred, This eventually saturates the state with the ability to treat Hep C and also helps deconstruct stereotypes and prejudices that often have existed between specialists and providers.
By pushing the ability to treat chronic, complex diseases down the work chain, ECHO is not only bringing specialized treatment to thousands of patients who would have otherwise gone untreated, but it is also keeping remote providers where they are most needed. Retention rates for rural medical professionals in New Mexico are notoriously low, and Sanjeev’s work is changing this by empowering isolated providers with stimulating, practical, cost-effective continuing education.
Sanjeev has expanded ECHO beyond Hep C to ten other diseases and conditions, including HIV/AIDS, pediatric obesity, asthma and high-risk pregnancy. As public health experts, doctors and health professionals in the US and abroad beat a path to his door, he is envisioning ECHO’s “knowledge networks” being used outside of medicine to meet needs anywhere in the world where knowledge is transmitted from a specialist to more general practitioners, including in the fields of education, engineering, and agriculture.
Patients who live in rural, underserved areas and prisons lack access to specialty care to manage chronic and complex diseases, such as Hep C. Community-based primary care physicians, especially in Federally Qualified Health Centers, are not trained to deliver treatment to Hep C patients, more than 50 percent of whom are uninsured and rely on these Centers for care. In the case of Hep C, treatment consists of a highly customized weekly chemotherapy regimen with serious side effects lasting up to a year, with at least six months of follow-up. Without treatment, six thousand New Mexicans would develop cirrhosis and many hundreds would develop liver cancer.
With the rapid advancement of science and the exponential growth of medical knowledge American medicine has become increasingly specialized. Many cannot afford these specialists’ services or even get to them physically. Adding insult to injury, there is also a shortage of primary care physicians, fewer medical school students are going into primary care, and fewer still are willing to serve in places like rural New Mexico. Those who do are isolated, have few opportunities for meaningful professional development, and cannot effectively treat many of the patients with chronic, complex diseases they see in their practice. While traditional telemedicine has helped in a few isolated cases, it is fraught with reimbursement problems and is not scalable.
Prior to ECHO, these problems—meeting the needs of underserved Hep C patients, as well as of rural doctors—were hardly addressed in New Mexico. Specialty clinics at UNM typically treat the majority of patients with chronic and complex conditions, which ensures excellent care, but creates hardships for rural patients, including great distances to travel, waits as long as ten months for appointments and expenses of a clinic visit. As for the rural healthcare providers, continuing education is offered by many organizations, but participating in the co-management of patients through ECHO is a more effective learning process and is more satisfying and practical for those working in underserved communities.
Sanjeev’s overall strategy is to create a new way of delivering specialized medical care, replacing monopolies of knowledge that pull treatment away from the underserved with knowledge networks that send it back out. Within New Mexico, Sanjeev’s goal is to saturate the state with enough rural and prison clinics whose staff can treat the eleven chronic, complex diseases/conditions that ECHO now addresses so that no patient has to travel long distances to be seen.
ECHO began with one Hepatitis C clinic and today, after less than five years, it has 21 Hepatitis C clinics in its fold. In the weekly teleclinics Sanjeev holds through ECHO, community providers learn to treat chronic, common, complex conditions through three main routes:
- Longitudinal co-management of patients with specialists;
- Communication with other primary providers on the network via shared case-management decision-making;
- Presentations from specialists or experts on relevant topics.
Throughout the week, ECHO staff also trains and shares information with the remote clinic staff. An ECHO nurse educator may clarify by phone issues that were addressed in the teleclinic, or may provide clinical support and mentoring, safety monitoring, or data collection help for outcomes measures. The ECHO education coordinator may also follow up on the teaching presented in clinics, help providers network, register continuing education credits, and arrange outreach activities.
Sanjeev’s strategy also includes showing that ECHO patients are not only benefiting by receiving treatment, but that they have as good or better outcomes than if they were seen by a specialist in person. The “better” care comes, in part, from having multiple specialists in most ECHO clinics (e.g. Hep C has a hepatologist, psychiatrist, psychologist, and pharmacist), which would be impossible in an in-person consultation in a rural area. Sanjeev and his team use software to track this by collecting data in both the teleclinic and a small in-person clinic population that Sanjeev sees once a week.
Through ECHO, Sanjeev also seeks to significantly enhance the experience of remote healthcare providers in order to keep them where they are most needed: in underserved communities. ECHO offers them a hands-on, fulfilling way to earn the continuing education credits they need, and breaks their isolation by engaging them in a statewide force of medical professionals. ECHO convenes an annual conference where providers learn from ECHO specialists while also having a chance to network among themselves. Many providers eventually treat the diseases without ECHO clinics, though they usually stay in the network for professional growth, or occasionally rejoin to present a particularly difficult case or to seek assistance from the network The result is a greatly improved sense of professional growth and satisfaction that causes many to stay in their rural posts longer than anticipated, or even permanently.
Sanjeev seeks to empower healthcare providers not only to treat chronic, complex diseases, but to prevent them. To that end, ECHO has recently begun to train peer educators in prison in order to reduce Hep C infection rates, improve general health literacy among prisoners, and help some of them gain employment as community health workers upon release. The ECHO Addictions & Psychiatry clinic is also working with the county jails and Albuquerque Healthcare for the Homeless to train healthcare providers to administer bupenorphine to heroin addicts in detention, and to arrange a warm hand-off for them to a community provider upon discharge, in order to reduce recidivism by treating opiate dependence while in detention, and to ensure continuity of care upon discharge.
ECHO is currently moving into the first of two state expansions in Washington state, and once it has effectively replicated its process, Sanjeev plans to spread his program internationally. ECHO has chosen to collaborate with the Government of India National Aids Control Organization to use enhance care for HIV/AIDS patients in small towns in India.
As a child, Sanjeev followed his father – a leader in the Government of India and the World Health Organization’s effort to eradicate small pox in India – and his mother who was an OB/GYN to underserved populations on their rounds, and from that young age he knew that he would grow up to use medicine to help those in need. After getting his medical degree in India, and completing his training in the United States, Sanjeev spent several years teaching before setting his sights on the prevention of GI cancers through more and better scoping procedures. After a few years, he focused his attention on Hepatitis C, and further specialized in hepatology to treat patients suffering from the disease.
However, this still was not enough for Sanjeev, who knew that despite working long hours, he was only able to see a small number of patients, many of whom were already in advanced stages of liver cancer. In addition, thousands more in rural areas and all of those in New Mexico’s prisons were receiving no treatment at all. Eager to find a way to pass his knowledge on to as many people as possible so that underserved patients would have better access to care, Sanjeev created Project ECHO and changed his life for the better.
Everyone who knows Sanjeev says that he is not a typical doctor, let alone specialist. He is humble and driven, not by ego but by a deep desire to help the underserved and to do something constructive in the broken United States healthcare system. He is also gifted with an extremely collaborative spirit, continually engaging others about his model, relating to people on all levels, from legislators down to drug-addicted patients.
As a leader, Sanjeev is admired by his team, who see him as a mentor, a motivator and an inspiration, always encouraging innovation and initiative at all levels of the staff. Most importantly, however, Sanjeev brings a very human element to all of ECHO. During the weekly clinics, he is a teacher as well as a clinician and though specialists often come to him out of respect for his medical credentials and ECHO’s track record, they are quickly drawn to his deep belief in the importance and the power of what ECHO is doing.
Sanjeev is married to a physician, and their two daughters are currently attending Stanford University and Dartmouth Medical School with the intention of pursuing careers in public service.