Sanjeev Arora M.D., FACG Professor of Medicine Executive Vice Chairman Department of Medicine University of New Mex

1. Sanjeev Arora M.D., FACG Professor of Medicine Executive Vice Chairman Department of Medicine University of New Mexico School of Medicine

2. MISSION MISSION The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. Supported by Agency for Health Research and Quality grant 1 UC1 HS015135-03 and New Mexico Legislature

3. Rural New Mexico RURAL NEW MEXICO • Underserved Area for Healthcare Services • 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUA’s) • 14 counties designated as Health Professional Shortage Areas (HPSA’s) • 121,356 sq miles • 1.83 million people • 42.1% Hispanic • 9.5% Native American • 17.7% poverty rate compared to 11.7% nationally • >22% lack health insurance

4. HEALTH CARE IN NEW MEXICO HEALTHCARE IN NEW MEXICO • 20% practice in rural or frontier areas New Mexico Physician Survey 2001

5. HEPATITIS C IN NEW MEXICO HEPATITIS C IN NEW MEXICO • Estimated number is greater than 32,000 • Less than 5% have been treated • Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths • 1978 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated • Highest rate of chronic liver disease/cirrhosis deaths in the nation

6. GOALS GOALS • Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes • Develop a model to treat complex diseases in rural locations and developing countries

7. PARTNERS PROJECT ECHO • University of New Mexico School of Medicine Dept of Medicine and Telemedicine • NM Department of Corrections • NM State Health Department • Indian Health Service • Community Providers with interest in Hepatitis C and Primary Care Association

8. METHOD METHOD • Use Technology (telemedicine and internet) to leverage scarce healthcare resources • Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices” • Case based learning: Co-management of patients with UNMHSC specialists • Centralized database HIPAA compliant to monitor outcomes

9. STEPS STEPS • Train providers, nurses, pharmacists, educators in Hepatitis C • Install protocols and software on site • Conduct telemedicine clinics – “Knowledge Network” • Initiate co-management – “Learning loops” • Collect data and monitor outcomes centrally • Assess cost and effectiveness of programs

10. BENEFITS TO RURAL PROVIDERS COMMUNITY PARTNERS • No cost CME’s and Nursing CEU’s • Professional interaction with colleagues with similar interest – Less isolation with improved recruitment and retention • A mix of work and learning • Obtain HCV certification • Access to specialty consultation with GI, hepatology, psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator

13. DISEASE SELECTION DISEASE SELECTION • Common diseases • Management is complex • Evolving treatments and medicines • High societal impact (health and economic) • Serious outcomes of untreated disease • Improved outcomes with disease management

14. BUILDING BRIDGES HEALTHCARE IN NEW MEXICO BUILDING BRIDGES PARETTO’S PRINCIPLE State Health Dept Community Health Centers Private Practice UNM HSC Hepatitis C HIV Hepatitis B

15. KNOWLEDGE IMPORTANT - NOT TITLE KNOWLEDGE IMPORTANT - NOT TITLE HEALTHCARE IN NEW MEXICO Use Existing Community Providers Primary Care Nurse Practitioners Specialists Pharmacists Hepatitis C HIV Hepatitis B

16. COMMUNITY HEALTH EXTENSION AGENT COMMUNITY HEALTH EXTENSION AGENT CHEA

17. ROLE OF KNOWLEDGE NETWORK A KNOWLEDGE NETWORK IS NEEDED Increasing Gap Medical Knowledge Learning Capacity Time “Expanding the Definition of Underserved Population”

18. KNOWLEDGE MODEL KNOWLEDGE MODEL Patient specific knowledge on demand Access to Case-Specific Information like Access to Electricity

19. PROJECT ECHO RURAL SITES 8/1/06 Rio Arriba Colfax San Juan Taos Union Los Alamos Mora Harding McKinley Sandoval Santa Fe San Miguel Quay Bernalillo Cibola Guadalupe Valencia Curry Torrance De Baca Roosevelt Socorro Catron Lincoln Chaves Sierra Lea Grant Otero Eddy Dona Ana Luna Federally Qualified Health Centers ( FQHC ) Hidalgo Department of Corrections Indian Health Service ( IHS ) Department of Health ( DOH ) Pending FQHC & IHS

20. How well has model worked? • 173 HCV Telehealth Clinics have been conducted • 3016 patients managed • CME’s/CE’s issued: • 2917 CME/CE hours issued to ECHO providers at • no-cost. • 205 hours of HCV Training conducted at rural sites • 6 Million Dollars of No Cost Drug Obtained • National Recognition as Model for Complex Disease Care

21. Robert Wood Johnson Changemaker Award KNOWLEDGE MODEL • Applications sought for Disruptive Innovations in Healthcare – New Models that would change healthcare nationally and globally • 307 Applications from 27 countries • 9 finalists selected by a panel of Judges • Project ECHO selected a winner by worldwide online voting

22. VISION FOR THE FUTURE VISION FOR THE FUTURE 28

23. Perceived Benefits to Providersscale: 1 = none or no skill at all 7= expert-can teach others

24. Perceived Benefits to Providersscale: 1 = none or no skill at all 7= expert-can teach others Cronbach’s alpha for the BEFORE ratings = 0.93 and Cronbach’s alpha for the TODAY ratings = 0.90 indicating a high degree of consistency in the ratings on the 9 items

25. Project ECHO Annual Meeting Survey September 23, 2006

26. Objectives-Disease Outcomes • To show that hepatitis C treatment delivered through Project ECHO is as safe and effective as care given at the University of New Mexico • To show that Project ECHO improves delivery of hepatitis C care to minority populations • To compare treatment outcomes for minority and non-Hispanic white subjects

27. Methods • Study design: • Prospective cohort study • Site effect adjusted for patient covariates • Study sites • Project ECHO • 14 community clinics • NM Department of Corrections • University of New Mexico Liver Clinic • Subjects: referred by their primary care providers

28. Interim Results * Of the preceding row

29. ECHO Sites Serve Minorities

30. Outcomes by Site * Excludes subjects stopping treatment for other reasons

31. Outcomes by Minority Status * Excludes subjects stopping treatment for other reasons

32. Factors Affecting Response

33. Factors Affecting SAE

34. Factors Affecting SAE

35. Disease Outcome Conclusions • Project ECHO provides hepatitis C treatment that is as safe as care delivered at UNM • Preliminary data suggests that Project ECHO delivers hepatitis C treatment that is just as effective • Project ECHO treats a larger proportion of minorities than UNM • The outcomes of treatment for minority and non-Hispanic white subjects are similar

36. Use of telemedicine, best practice protocols, co-management of patients with case based learning (the ECHO model) is a robust method to to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. Supported by Agency for Health Research and Quality grant 1 UC1 HS015135-03 and New Mexico Legislature