In 2014, Rose Gowen, MD, faced a dilemma. Su Clinica, the federally qualified health center (FQHC) in Brownsville where she works as an obstetrician-gynecologist, had just received funding to do loop electrosurgical excision procedures (LEEP), a treatment that prevents cervical cancer. However, she wasn’t trained to do LEEP, and no formal courses provided the credential she needed.
“I was kind of between a rock and a hard place,” she said. “I wanted to do this. I knew I could do it because it’s not a difficult procedure. But I had no one to mentor me.”
At almost the same time, some doctors from The University of Texas MD Anderson Cancer Center in Houston happened to be visiting Su Clinica, and Dr. Gowen mentioned her problem. That conversation led MD Anderson to begin offering Project ECHO (Extension for Community Healthcare Outcomes), a teleconsulting and telementoring partnership between university-based specialists and physicians in rural and medically underserved areas. Through Project ECHO, Dr. Gowen could get the training she needed in a few months.
“That relationship started as an accident,” she said. “But everything just fell into place.”
Project ECHO now reaches a growing number of physicians across Texas and throughout the world. The program began at the University of New Mexico in 2003 because Sanjeev Arora, MD, a liver disease doctor in Albuquerque, was frustrated that only two clinics treated more than 30,000 hepatitis C patients statewide.
Dr. Arora launched a series of weekly teleconferences that allowed local physicians in New Mexico to present cases, discuss problems, and gradually become specialists in hepatitis C. Today, hundreds of physicians across New Mexico can treat the illness. A 2011 study published in the New England Journal of Medicine found that patients treated by Project ECHO-trained doctors received care equal to that provided by university-based specialists.
That success has caused Project ECHO to grow both geographically and among medical specialties. The program has more than 220 training centers like MD Anderson that educate physicians and health care professionals in 31 countries, with a focus on more than 100 diseases. In Texas, the other hubs are at Baylor St. Luke’s Medical Center in Houston, The University of Texas at Austin Dell Medical School, the TMF Health Quality Institute in Austin, and UT Health in San Antonio.
Project ECHO is a low-cost, efficient way to address the chronic shortage of physicians — specialists in particular — throughout Texas and the United States, says Norman L. Sussman, MD, a transplant hepatologist who heads up Project ECHO at Baylor St. Luke’s. But the teleconferences among physicians, midlevel practitioners, and other health care professionals are not simply educational, he says. They build a stronger, broader medical community across the state.
“We meet every week and discuss complex problems and manage their patients,” Dr. Sussman said. “It’s just like meeting your friends every week, except that we’re trying to solve some medical problems.”
Hubs and spokes
Project ECHO addresses those problems using a “hub and spoke” structure designed to disseminate information. The hubs are the training centers — medical schools and academic hospitals with lots of specialists. The spokes are the physicians and other medical personnel in rural and other underserved areas.
For Paul Bunnell, MD, a hospitalist at Memorial Medical Center in Port Lavaca, Project ECHO gets going every Monday at 3:30 pm. He and other Texas physicians teleconference to discuss hepatitis C patient cases with Dr. Sussman and Saira Khaderi, MD, the program’s associate medical director.
Dr. Bunnell’s county-run clinic uses Project ECHO primarily to treat hepatitis C patients who otherwise would have to travel more than two hours to Houston or San Antonio to see a physician. Before each teleconference begins, physicians or others looking to get help with a specific patient fill out a form detailing the patient’s medical history. The meeting itself is a kind of virtual grand rounds. The presenter discusses the patient with whomever is logged into the conference.
Naturally, the specialists weigh in on different treatment options, but so do the other health care professionals.
“It’s a back-and-forth bantering that helps everyone,” Dr. Bunnell said. “You have midlevels and family doctors and general internists, then you have Dr. Sussman and Dr. Khaderi there directing things.”
Dr. Bunnell says his clinic has treated more than 40 patients this way since 2014. But Project ECHO not only disseminates information about specialty care, it also builds physician networks that can be life-saving for patients. Dr. Bunnell says two of his hepatitis C patients have required liver transplants. Thanks to Project ECHO, they were already well-known by the transplant specialists at Baylor St. Luke’s.
“There are a number of hoops to jump through as far as pre-transplant testing and evaluation,” Dr. Bunnell said. “If they had to start from page number one to get transplant-ready, some of those patients [would] deteriorate, and there wouldn’t be enough time.”
New medications have made treating hepatitis C more routine, says Jose Luna, MD, a family physician who is chief executive officer at Centro San Vicente, an FQHC in El Paso. However, without his involvement in the Baylor St. Luke’s Project ECHO program, he could not prescribe those drugs because only hepatologists are permitted to do so.
“With the assistance of Project ECHO, when we present a case, [the pharmacy] will accept the recommendation from the hepatologist, even though it is at a distance.”
Of the five Texas institutions that participate in Project ECHO, MD Anderson offers the most programs (14) and is a “superhub,” meaning it is certified to train new hubs. (See “Project ECHO in Texas,” page 46.) MD Anderson launched its first program in 2014, says director Ellen Baker, MD.
MD Anderson, which is famous for its cancer care, has invested in Project ECHO in part because “ECHO is a part of a larger strategy in the cancer world, even more so than in the hepatitis world,” Dr. Baker said. “The whole intent of ECHO is to build capacity where you might not have it. [It creates] a foundation for providers in the areas to be able to treat these [cancer] patients independently eventually, and to provide quality and safe care in their own communities.”
So far, Project ECHO has become known among physicians, midlevel practitioners, and other health care professionals mostly thanks to word of mouth, Dr. Baker says. Specialty interest can vary. MD Anderson’s cervical cancer teleconferences usually draw 20 to 25 participants each week. Dermatology sessions can include up to 80 participants. She believes 25 is closer to the ideal size for sparking the collegial conversation Project ECHO tries to foster.
“It’s not a webinar,” she said. “What you want with ECHO is a horizontal, level playing field where everybody can get into the discussion. The information doesn’t just flow out of MD Anderson. We learn a lot during these sessions. For example, how to treat patients when your resources are somewhat limited. And providers also learn from each other.”
These discussions reverberate throughout the state’s health care system. Since 2014, Baylor St. Luke’s has helped between 400 and 500 physicians and other health care professionals deal with hepatitis C, Dr. Sussman says, and each of them can affect hundreds of patients in a short time.
For instance, Centro San Vicente in El Paso, where Dr. Luna works, tested more than 7,000 people for hepatitis C in 2017, uncovering 263 cases of the disease.
“And for the majority of the ones we treated, they’ve had great success in that they’ve had no detectible virus,” he said.
Before Project ECHO, Dr. Luna’s low-income patients had no reasonable options for hepatitis C treatment. That was a serious barrier because El Paso has four times the prevalence of the disease as the rest of the country, he says.
“If [low-income patients] were lucky and they got an appointment at the county hospital, the wait might have been over two years,” he said.
With Project ECHO, these same patients can be diagnosed and cured within eight to 24 weeks. This reduces a financial burden on Medicaid and other public health care programs by keeping low-income people out of hospitals and off liver transplant lists. More importantly, it gives patients better quality of life.
“Their whole lives have changed,” Dr. Luna said. “And the most important thing is that treating them will hopefully eliminate their chance of getting [liver] cancer.”
The teleconferences are free and require minimal technological know-how. Perhaps the biggest drawback for physicians is finding the time for them, Dr. Luna says. Busy doctors already have a hard time just seeing patients at clinics like his. Adding an extra duty can be a challenge. Some Project ECHO programs try to create an incentive by offering continuing medical education credit to physicians and others who participate.
Funding can also be a challenge. Most hubs tackle the issue with a mix of internal and external resources. The Cancer Prevention and Research Institute of Texas (CPRIT) has been a major funder for some hubs, like MD Anderson. CPRIT also has provided a $1.3 million grant that will soon allow Centro San Vicente to become a hub for hepatitis C training, Dr. Luna says.
He’s eager to spread the message about Project ECHO because he believes it is the answer to the lack of specialty care in medically underserved areas. With more hubs, more physicians can help more patients.
“It’s not only helpful, but life-saving,” he said. “Only your lack of imagination can withhold the benefits.”
Project ECHO in Texas
In Texas, five institutions serve as hubs, or training centers, for Project ECHO. Here is a look at some of the programs they offer to mentor physicians in specialties unavailable in shortage areas:
Baylor St. Luke’s Medical Center, Houston
• Hepatitis C
• Advanced liver disease, hepatitis B
• HIV, infectious diseases
• Transplant co-management
TMF Health Quality Institute/The University of Texas at Austin Dell Medical School, Austin
• Depression, alcohol abuse
UT Health, San Antonio
• Hepatitis C
• Infectious diseases
The University of Texas MD Anderson Cancer Center, Houston
Texas and United States
• Cervical cancer
• Cancer survivorship
• Head and neck, breast, cervical cancer
Tobacco education, cessation
• Palliative care (Africa)
• Radiation oncology (Zambia)
• Cancer pharmacy (Tanzania and Zambia)
• Gynecological cancers (Latin America)
Tex Med. 2019;115(2):44-46
February 2019 Texas Medicine Contents
Texas Medicine Main Page