Joanna G. Katzman

Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in specialty care†

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team‐based interdisciplinary development. Using state‐of‐the‐art telehealth technology, best practice protocols, and case‐based learning, ECHO trains and supports primary care providers to develop knowledge and self‐efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment‐induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self‐efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self‐efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence. (HEPATOLOGY 2010)

Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care

Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need because of various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity, chronic pain, substance use disorders, rheumatoid arthritis, cardiovascular conditions, and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have collaborated on more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.

Innovative Telementoring for Pain Management: Project ECHO Pain

Introduction: Project ECHO Pain, the innovative telementoring program for health professionals, was developed in 2009 at the University Of New Mexico Health Sciences Center to fill considerable gaps in pain management expertise. Substantive continuing education for clinicians who practice in rural and underserved communities convenes weekly by means of telehealth technology. Case‐based learning, demonstrations, and didactics are incorporated into the interprofessional program that helps to improve pain management in the primary care setting. Method: Three different approaches were used to evaluate the program over a 3‐year period: (1) evaluation of all weekly continuing medical education surveys; (2) aggregation of annual clinic data; and (3) assessment of practice change in clinicians who joined Project ECHO Pain for at least 1 year. Results: Between January 2010 and December 2012, 136 Project ECHO Pain clinics were held, with 3835 total instances of participation, representing 763 unique individuals from 191 different sites. Sixty percent self‐identified as advanced practice or other nonphysician health professional. Statistically significant improvements in participant self‐reported knowledge, skills, and practice were demonstrated. Focus group analyses of 9 subjects detailed specific practice improvements. Discussion: Project ECHO Pain is a successful continuing professional development program. The telementoring model closes the large knowledge gap in pain education seen in primary care and other settings. Expertise is delivered by implementing effective, evidence‐based, and work‐based education for diverse health professionals. Project ECHO Pain serves as a model for interprofessional collaborative practice.

Demonopolizing Medical Knowledge

In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHOs medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.

Expanding Health Care Access Through Education: Dissemination and Implementation of the ECHO Model

Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based model that provides high-quality medical education for common and complex diseases through telementoring and comanagement of patients with primary care clinicians. In a one to many knowledge network, the ECHO model helps to bridge the gap between primary care clinicians and specialists by enhancing the knowledge, skills, confidence, and practice of primary care clinicians in their local communities. As a result, patients in rural and urban underserved areas are able to receive best practice care without long waits or having to travel long distances. The ECHO model has been replicated in 43 university hubs in the United States and five other countries. A new replication tool was developed by the Project ECHO Pain team and U.S. Army Medical Command to ensure a high-fidelity replication of the model. The adoption of the tool led to successful replication of ECHO in the Army Pain initiative. This replication tool has the potential to improve the fidelity of ECHO replication efforts around the world.

Rules and Values: A Coordinated Regulatory and Educational Approach to the Public Health Crises of Chronic Pain and Addiction

Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexicos 2012-2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.

Project ECHO (Project Extension for Community Healthcare Outcomes): A National and Global Model for Continuing Professional Development.

Chronic disease management requires ongoing consultation between community providers and experts from medical specialties that are often limited in underserved rural and urban areas inNewMexico, patients from rural areas often wait many months for an appointment and travel up to 250 miles for an office visit. The Extension for Community Healthcare Outcomes (ECHO) model was developed at the University of New Mexico Health Sciences Center (UNMHSC) as a platform for teaching community providers to deliver best-practicemedical services to underserved populations with chronic complex conditions. Project ECHO has expanded from its initial focus on hepatitis C (2003) to teleECHO clinics that address numerous complex health problems. The objective of this report is to describe how as a best-practice model for continuing professional development, Project ECHO has grown statewide, nationally, and globally.

Evaluation of American Indian Health Service Training in Pain Management and Opioid Substance Use Disorder.

We examined the benefits of a collaboration between the Indian Health Service and an academic medical center to address the high rates of unintentional drug overdose in American Indians/Alaska Natives. In January 2015, the Indian Health Service became the first federal agency to mandate training in pain and opioid substance use disorder for all prescribing clinicians. More than 1300 Indian Health Service clinicians were trained in 7 possible 5-hour courses specific to pain and addiction. We noted positive changes in pre- and postcourse knowledge, self-efficacy, and attitudes as well as thematic responses showing the trainings to be comprehensive, interactive, and convenient.

Making Connections: Using TeleHealth to Improve the Diagnosis and Treatment of Complex Regional Pain Syndrome, an Underrecognized Neuroinflammatory Disorder

Complex Regional Pain Syndrome (CRPS) is a common and complex, but often underrecognized neuroinflammatory disorder. This syndrome can cause significant intractable pain, worsening motor changes, negative sensory symptoms as well as autonomic, vasomotor and trophic changes. Primary care providers and specialists are frequently challenged with patients who present with unusual symptoms and are unsure of the differential diagnosis and best practices treatment options for CRPS. The Project ECHO Pain Team leverages tele-health technologies to connect clinician specialists and primary care providers in order to increase awareness and create knowledge networks regarding improvement in clinical care for patients with CRPS.

Scope and Nature of Pain- and Analgesia-Related Content of the United States Medical Licensing Examination (USMLE)

Abstract Background “The ongoing opioid crisis lies at the intersection of two substantial public health challenges—reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications” [1]. Improved pain education for health care providers is an essential component of the multidimensional response to both still-unmet challenges [2,3]. Despite the importance of licensing examinations in assuring competency in health care providers, there has been no prior appraisal of pain and related content within the United States Medical Licensing Examination (USMLE). Methods An expert panel developed a novel methodology for characterizing USMLE questions based on pain core competencies and topical and public health relevance. Results Under secure conditions, raters used this methodology to score 1,506 questions, with 28.7% (432) identified as including the word “pain.” Of these, 232 questions (15.4% of the 1,506 USMLE questions reviewed) were assessed as being fully or partially related to pain, rather than just mentioning pain but not testing knowledge of its mechanisms and their implications for treatment. The large majority of questions related to pain (88%) focused on assessment rather than safe and effective pain management, or the context of pain. Conclusions This emphasis on assessment misses other important aspects of safe and effective pain management, including those specific to opioid safety. Our findings inform ways to improve the long-term education of our medical and other graduates, thereby improving the health care of the populations they serve.