Fixes looks at solutions to social problems and why they work.

Ten years ago Dr. Sanjeev Arora, a hepatologist at the University of New Mexico in Albuquerque, realized that he would need to change the way he practiced medicine if he was going to prevent his patients from dying.

Under the Affordable Care Act, 32 million Americans are expected to gain coverage. How will they be cared for?

Today, the solution he developed could transform health care.

Arora had been specializing since 1990 on the treatment of chronic hepatitis C, a disease that affects 3 million Americans (and 170 million people around the world). Most Americans don’t know they’re infected, which is one reason why it remains the leading cause of cirrhosis and liver cancer, resulting in 15,000 deaths each year in the United States, and 350,000 deaths globally.

In 1990, when drugs started emerging to treat the disease, the cure rate was just 6 percent. By 2003, however, the cure rate had climbed to 45 percent for some patients, and 70 percent for others (depending on their genotypes). “It had become a curable disease,” Arora recalled. (New medications have further improved the efficacy, safety and ease of treatment for hepatitis C, but high costs remain a barrier.)

The few specialists in New Mexico who treated it were in urban centers, and most patients went without treatment. Those who sought help had to wait six to eight months to get an appointment in a clinic. Many could not afford to drive hundreds of miles to Albuquerque, let alone make an average of 12 to 18 trips to complete a course of treatment.

The result: less than 5 percent of the estimated 34,000 chronic hepatitis C patients in New Mexico had been treated. It was estimated that 2,400 inmates in New Mexico’s prisons were infected with the hepatitis C virus (HCV). As of 2003, not one had received treatment for it.

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“The people who weren’t very sick yet couldn’t get into the clinics,” Arora said. “And the people who got in already had liver cancer or their liver was failing and it was too late to treat. So it was very frustrating. The thought came to me: If only I could expand my capacity in some way, and reflect my expertise on a much larger number of patients, lives could be saved.”

Could a system be built to “demonopolize” health care knowledge? To move it out of the heads of specialists into networks of primary care providers in remote places so they could manage complex illnesses in their local settings? And could rural clinicians provide care that was on a par with specialists?

Arora set out traveling around New Mexico, recruiting local providers one by one, explaining how hepatitis C was killing their patients, that there were effective treatments for it, but they were complicated to manage. He made an offer. If they volunteered to spend two hours a week with him, he and other specialists would work with them in close collaboration until they could manage their own cases.

People came on board and Project ECHO came to life. In Albuquerque, Arora pulled together a team of specialists and they developed a model that combined video conferencing technology to facilitate weekly case-based training (similar to the teaching approach in medical schools) with collaborative care and careful patient tracking. With funding from the Robert Wood Johnson Foundation, Project ECHO spread across the state.

In 2011, the New England Journal of Medicine published a study that compared the cure rates of patients treated at the University of New Mexico’s HCV clinic with those treated by primary care clinicians in 21 remote ECHO sites, including federal and state run health centers and five prisons. The study reported that the primary care clinicians achieved slightly better cure rates and their patients had fewer serious adverse events. The research suggested that, when treated in local settings, patients adhered better to treatments; and primary care doctors more familiar with patients’ medical histories and personal situations could better coordinate care and anticipate problems.

This is an example of what the Harvard Business School professor Clayton Christensen has called a “disruptive innovation” — an innovation that enables a large number of people who previously lacked resources or skills to do or get something important, often by themselves. What it’s doing is moving complex expertise to the front lines of the health care system, observed Nancy Barrand, a senior adviser at the Robert Wood Johnson Foundation, which has worked closely with Project ECHO.

Donald Berwick, the former administrator of the Centers for Medicare and Medicaid Services, who is currently running for governor of Massachusetts, observed that Project ECHO’s model represents a fundamental design shift — “from moving the patient to moving the knowledge” — that is needed to build a health care system capable of meeting today’s soaring demands for care. “They’ve shown that with proper support the primary care workforce, including nurses, not just doctors, can function to very high levels of precision with highly complex care,” Berwick said.

Others agree. Over the past five years, Project ECHO (short for Extension for Community Healthcare Outcomes) has spread well beyond its initial focus. It now supports ECHO hubs anchored out of 31 universities assisting providers in more than a thousand clinics who focus on 26 specialties including rheumatology (video), H.I.V., addiction, women’s health, hypertension, dementia, breast cancer, childhood obesity, diabetes and chronic pain. (Beyond the United States, the model is being used in India, Uruguay, the Irish Republic and Northern Ireland.)

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In 2012, the Center for Disease Control and Prevention sponsored a replication of ECHO in Utah and Arizona, using the model to work with 90 primary care providers, 96 percent of whom had never treated a single patient with HCV. “Within a year the proportion of patients treated in ECHO was twice the proportion treated in urban areas,” said John W. Ward, who directs the Division of Viral Hepatitis at the C.D.C. “It turned non-treaters into super-treaters.”

ECHO has also helped the Veteran’s Administration set up 11 hubs connected to 300 clinics around the country. It’s working with the U.S. Department of Defense to improve the way the Army manages chronic pain globally (video), and it recently formed a partnership with the Military Health System to set up ECHO projects within the Navy and Airforce.

Through a partnership with the Center for Medicare and Medicaid Innovation, ECHO is also helping doctors, nurse practitioners, case managers and community health workers to prevent hospitalizations among patients with multiple chronic diseases in New Mexico and Washington state.

Recently, I joined a hepatitis C video conference led by Project ECHO’s associate director, Karla Thornton, a specialist in infectious diseases, to see how it works. On my screen were a dozen live feeds: a team of specialists from the University of New Mexico and clinicians from places around the state like Las Cruces and Gallup and the Santa Fe Indian Hospital. They worked through cases briskly, in a collegial manner, with lots of feedback.

Each case presented a different challenge. Hepatitis C treatments can be toxic, so they have to be closely managed. In one case, a 55-year-old man had grown severely depressed, a common side effect of treatment with the drug interferon. Should treatment be continued? Lab reports appeared on screen. There were discussions of viral loads, hemoglobin levels, the ALT test, which reveals liver damage. Best to stop treatment for now.

Another patient, a 58-year-old Native American woman with cirrhosis, had, after multiple requests by her doctors, gotten insurance coverage for the new drug, Sovaldi. Her viral load was now undetectable, but platelets and ANCs (a measure of a type of white blood cell) were worrisome. Could she come in weekly or even twice weekly to the clinic to watch for infection? Was she a transplant candidate?

Related More From Fixes Read previous contributions to this series.

Each case presented an opportunity to connect state of the art care to front-line treatment, something the health care system does not do well. (In 2001, the Institute of Medicine reported that it took an average of 17 years for new evidence to be incorporated into health care practice.)

The variety of cases was interesting and useful for teaching. “In a period of two hours I could see three patients in my clinic,” said Thornton. “In that teleconference, we heard about 18 patients. For me, it’s so much more gratifying than just doing it one on one.”

“You learn so much by listening to other people’s cases,” said Laura Bush, a family nurse practitioner, at First Choice Community Healthcare, in Valencia County, 30 miles south of Albuquerque. “When I hear someone else’s presentation, I’ll think, ‘Oh, I need to ask about that. Or why did they do that? Maybe something’s changed.’ Or something gets questioned by Dr. Arora or Dr. Thornton and they explain, ‘We’re doing this because of this study. Or this treatment would be more efficacious for this genotype.’ Hearing the same information with different cases, you start to develop pattern recognition.”

One of the big forces driving up health care costs is the demand for high priced specialty care — and the cost of providing it. But how do you brings costs down, and standardize quality, when demand is outstripping supply? That’s a problem many clinicians are facing — particularly those in the military — with regard to complex pain management.

When Col. Kevin Galloway, Chief of Staff of the U.S. Army Pain Management Task Force, heard about Project ECHO, his first reaction was: “We’re already doing this. We’re the military. Of course we’re leveraging technology.”

Galloway had been using telemedicine since his days as a lieutenant in Yugoslavia in the 1990s. But that was a linear application of technology, he said. While a specialist sitting in Landstuhl Regional Medical Center was seeing patients by video, he wasn’t seeing patients in his clinic. “So it was not really working on the capacity issue,” he said. By contrast, Arora characterizes ECHO as a “force multiplier.”

“What we didn’t know was that the ECHO model [had] repurposed it in a way that was building capacity in the remote locations,” Galloway added. “It was teaching a man to fish rather than giving him a fish. It allowed us a way to grow and manage the transformation all across army medicine pain care.”

It’s no accident that ECHO emerged in Albuquerque, rather than, say, Boston. One of the principles of disruptive innovations is that they often emerge where there is nothing else to compete with. “It probably couldn’t have been successful if it hadn’t started in poor areas with patients that nobody else was serving,” said Barrand.

The Army has had to work to encourage its pain specialists to rethink their fundamental roles, to see themselves as mentors and collaborators on a level playing field with primary caregivers, said Galloway. “It’s not good enough to have smart people sitting in specialty care if they hold that knowledge to themselves.”

This approach runs up against the stratifications of the American health system, where specialists now stand to earn two to four times as much money as primary care doctors on average — one reason only 25 percent of new physicians are going into primary care. At the same time, physicians and nurses are suffering from high levels of burnout and depression.

In this context, one of the potential attractions of Project ECHO is the satisfaction it offers through collaboration. “I’ve developed relationships with many primary care providers,” said Thornton. “They call me all the time. We have this sort of community of practice that’s very enjoyable to be a part of.”

Those relationships can be particularly enriching to clinicians in rural settings. Lore Pease, Chief Executive Officer of El Centro Family Health in Española, which covers an area of 22,000 square miles in northern New Mexico, says Project ECHO has helped her to retain providers, a major challenge in rural areas. “We’ve had providers who’ve told us, ‘I won’t stay long,’ but they do,” she said. “Because we can offer a specialty for them to learn and expand their knowledge and expertise. It’s a whole new adventure and a whole new challenge.”

A big barrier Project ECHO faces as it continues to spread is the way we pay for health care — the fee-for-service model, which currently provides little monetary incentive for clinicians to exchange knowledge this way, even if in the long term society stands to save oodles of money by strengthening primary care.

Currently, primary care clinicians volunteer their time to participate in video clinics, and they typically earn less by seeing complex patients, because they get paid per visit and these visits take more time. Specialists get paid primarily through grants. Project ECHO received major support from the Robert Wood Johnson Foundation to expand the model in New Mexico and Washington state, and later to spread nationally. The project has also received funding from the GE and Helmsley Foundations, as well as federal and state government sources. But for ECHO to become a national model governments and insurance companies will need to advance a standardized reimbursement approach to support its work.

It’s hard to imagine that these changes won’t gain more traction. Under the Affordable Care Act, 32 million Americans are expected to gain coverage and many will be coming from underserved rural and urban areas, and will have chronic illnesses. How will they be cared for? “At some point in the future I can’t imagine a primary care clinician not connected to an ECHO clinic,” says Barrand. “It wouldn’t make sense.”

“ECHO is allowing clinicians to reconnect with the reasons for being a doctor,” adds Arora. “It’s about working to enhance your knowledge, to develop yourself as a professional, and to deliver the highest quality care for the right reasons. And it’s about building a community to solve a major problem in society.”

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David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.