Spurred by Success of Remote Hepatitis C Care, Program Targets Remote Primary Care

In 2003, Sanjeev Arora, a liver doctor, came up with a creative solution to help hepatitis C patients in living rural New Mexico. Instead of asking patients to drive hundreds of miles to visit a big-city specialist, Arora would take advantage of new telemedicine technology to coach local primary care providers on how to treat hepatitis C just as skillfully as any highly trained gastroenterologist.

The program, dubbed Project ECHO (Extension for Community Healthcare Outcomes), was a resounding success. In fact, a 2011 New England Journal of Medicine paper showed that primary care providers trained as part of Project ECHO actually did a better job of curing their patients than specialists at the University of New Mexico in Albuquerque. Arora provided an update on the program and plans for its future at the Liver Meeting 2016, in Boston.

From its [[humble beginnings in New Mexico, Project ECHO has now been implemented in 19 countries and covers 45 complex medical conditions. Arora has big plans for Project ECHO's continued growth. By 2025, he wants ECHO to touch the lives of one billion people, which means he will have to bring the program to every single country in the world, he said, speaking on the sidelines of the conference.

It's an ambitious goal for a program that has already faced implementation challenges within the United States, but Arora is optimistic. Project ECHO works by connecting highly trained specialists with primary care doctors. Using remote teleconferencing technology, similar to Skype or FaceTime, specialists can help doctors treat patients locally. The goal is to avoid sending patients to a far-away specialist unless the case is especially complex.

It's a common-sense solution that uses technology to democratize medical knowledge. However, Project ECHO has faced implementation barriers United States because of the country's fee-for-service reimbursement system, which compensates physicians per appointment rather than on the quality of care received.

"As long as the U.S. health care system is predominately visit-based, or fee-for-service based, there is always going to be a little friction launching ECHO," Arora said. Luckily, "the vast majority of [U.S. doctors] are good people and not only interested in money, so they do it anyway."

The Affordable Care Act (ACA) has slowly but surely introduced value-based incentives to the U.S. health care market. Despite President-elect Donald Trump's vow to repeal ACA, Arora remains confident that Republicans and Democrats alike desire a continued shift toward a value-based reimbursement model.

"Perhaps the name 'Obamacare' will go away," Arora said, "but I believe some of the core principles are here to stay."

Outside of the United States, Project ECHO is expanding rapidly. Many countries provide universal health care for their citizens, so a huge incentive exists to democratize medical knowledge and do a better job of reaching rural patients, Arora explained.

Project ECHO is especially useful in low- and middle-income countries where Wi-Fi and satellite connectivity is often ubiquitous but medical infrastructure is sparse. With Project ECHO, Arora explained during his presentation, "the only technology a rural clinician needs is a webcam and internet access."

The program has undeniable appeal in Africa, Latin America and Asia, where rural clinicians struggle to treat complex medical conditions outside big cities and hospital networks. The telecommunications tools encompassed within Project ECHO can be tailored for diverse health care needs and have already successfully been implemented for HIV, dementia, rheumatology, addiction disorders and other complex conditions.

As Project ECHO expands to new countries, Arora is careful to consider which diseases are most challenging for public health workers and local governments.

"Because we want to get to a billion people, we really focus on the priorities of governments," Arora told TheBodyPRO.com. Based on input from stakeholders around the world, Arora and the Project ECHO team have developed several distinct initiatives to implement in the upcoming years. An HIV training program has already been implemented in five African countries, and Arora aims to expand into 10 additional African countries in the next three to four months. Ultimately, Arora hopes to expand to all 50 African countries currently receiving funding from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).

Another urgent global health challenge is tuberculosis, Arora said. In many places, such as India and Africa, tuberculosis (TB) is common but drug adherence is poor, he said. Clinicians face a growing challenge of multidrug resistant TB, so the Project ECHO program will turn to those treatment challenges next.

Ultimately, Project ECHO can be implemented for a wide variety of diseases, especially those that have the highest rates of morbidity and mortality in any given population, Arora noted.

"We think by treating patients close to home, in a culturally appropriate setting and with a doctor [they] trust, ... care can be better," Arora said during his presentation.