A telementoring pioneer brings expertise to 'front lines of health care'

The COVID-19 pandemic forced people online to consult their doctors, fast-tracking the growth of telemedicine as lockdowns prevented patients from leaving their homes. It also brought telementoring — specialists using technology to guide less experienced care providers from afar — to “the front lines of health care." Such mentoring is particularly valuable in rural or remote areas, where patients need care that may be unavailable closer to home. Project ECHO, a pioneer in the telementoring field, has seen exponential growth since the pandemic, notably in low- and middle-income countries. The New Mexico-based nonprofit organization brings teams of experts from specialized care sites together with local providers in weekly video sessions to discuss real, anonymized cases and share ways to address a specific health problem. “Telemedicine overcomes a geographic divide, but it does not solve the capacity problem,” says Sanjeev Arora, founder and director of Project ECHO, the acronym for Extension of Community Health Outcomes. Project ECHO helps specialists expand their capacity by sharing knowledge with less experienced providers. It’s an entirely different model than massive online open courses, which 90% of those enrolled do not complete. The guided practice offered by Project ECHO, which is inspired by the way clinicians learn from medical rounds during their residencies, ensures that learning results in implementation. “We are democratizing the ability to solve problems,” said Arora, who has spent 20 years refining Project ECHO’s approach to sharing knowledge. A growing body of evidence shows how effective the ECHO model is in helping professionals learn and share best practices, while also improving quality of care for patients. As the worst of the pandemic winds down, Project ECHO has turned its attention back to a broader range of global health priorities, including noncommunicable diseases like cancer and heart disease. The organization also plans to apply the lessons learned around what makes virtual capacity building effective to other sectors beyond health, like education. Sharing knowledge Arora’s brainchild began in 2003 to enable more clinicians across New Mexico to treat Hepatitis C, a viral infection that causes liver inflammation. Arora, a gastroenterologist, ran the state’s only dedicated Hepatitis C clinic with a waitlist that ran to eight months. People were dying from a curable disease as they awaited treatment, he said. Arora needed to somehow expand his capacity. “We could not save their lives because the right knowledge did not exist in the right place at the right time,” he said. Scores of clinicians from across the state met weekly on video, where Arora shared treatment protocols and they discussed cases. The online calls were a massive success. Clinicians became experts in Hepatitis C, wait times fell to two weeks, and tens of thousands of patients received treatment closer to home. Arora realized he could scale the initiative nationally — and even globally. Since then, Project ECHO has expanded its model worldwide to help care providers treat a range of global health challenges. Now, 871 groups offer training using the ECHO model, reaching learners in 193 countries. Its technology and methodology is used for 70 diseases and conditions, including COVID-19, maternal and child health, and tuberculosis. The ECHO model Project ECHO has a “hub and spoke” model. It connects specialists at regional and national medical centers, or hubs, with providers in underserved communities, known as spokes. Instead of moving patients to receive specialized care, Project ECHO “moves complex medical expertise to the front lines of health care,” Arora said. Project ECHO describes this approach as “all teach, all learn.” Local health care providers apply knowledge in their communities, while also learning from each other and sharing knowledge with specialists as new best practices emerge. Though most of Project ECHO’s work is in health, Arora and his colleagues are exploring how the model could work in other fields, including education. ECHO India, for example, is getting teachers, administrators, and other school support staff onto the ECHO platform. India, where Arora grew up, was Project ECHO’s first location for expansion outside the United States. “Our theory is that if we build the capacity of the teachers, then in their lifetime, they can possibly influence — given the size of India — hundreds and thousands of students,” said Dr. Kumud Rai, chairman of ECHO India, its own nonprofit entity. Responding to COVID-19, and strengthening health care systems Project ECHO has drawn attention from a number of major donors, including the Robert Wood Johnson Foundation and MacKenzie Scott. In 2020, it was a semifinalist for the MacArthur Foundation’s $100 million grant competition. And while it didn’t win the big prize, Project ECHO aims to raise the money with a major boost of support from Co-Impact, an effort that brings donors together to support systems change. And when COVID-19 struck that same year, Project ECHO pivoted to train health professionals in pandemic response, with support from the Audacious Project, a philanthropic collaborative housed at TED. Project ECHO deployed its entire global network to meet the COVID-19 challenge, Arora said. It launched programs with the World Health Organization and health ministries, including Kenya, Côte d’Ivoire, and Namibia that allowed best practices and emerging learnings to be shared between experts and health practitioners working in the world’s most vulnerable communities. The goal is for governments, NGOs, and other organizations to build on those COVID-19 response programs and move into other health areas with their own funding or outside support. Côte d'Ivoire is building on its work with Project ECHO on COVID-19 response with telementoring sessions focused on HIV. Africa has become a focus for Project ECHO, partly due to its partnership with WHO’s Regional Office for Africa, or WHO AFRO, on its digital learning system. “Digital learning is critical to preparing for and responding to health emergencies. It promotes better coordination, communication, and rapid dissemination of knowledge across distances, saving time and money,” said Dr. Salam Gueye, regional emergency director at WHO AFRO, one of WHO’s six regional offices. “Digital learning also promotes collaborative problem solving among people who are geographically displaced.” Since March last year, WHO AFRO has worked to integrate the ECHO model to support health care workers’ education across its 47 member states. The partnership is focused on preparing for future pandemics, outbreaks, and other health emergencies. Project ECHO wants to expand the collaboration with WHO AFRO beyond emergency preparedness and response to help strengthen health care more broadly on the continent. Connecting learning and performance But telementoring alone can’t ensure quality health care in rural and remote areas, experts caution. Other health systems interventions are necessary to ensure that learning improves outcomes, said Somesh Kumar, senior director of new initiatives and innovations at Jhpiego, a nonprofit affiliated with Johns Hopkins University focused on improving the health of women and families. “Learning cannot be disassociated with performance,” he said. “Telementoring must be deployed as part of a suite of interventions tackling the multidimensional needs of health system performance.” Jhpiego has worked with Project ECHO and other partners on virtual mentoring, and has also developed its own telementoring and digital learning platforms, Kumar explained. Challenges facing the growing field of telementoring include internet connectivity, content that is accessible and relevant to the local context, and ownership by local clinical learning communities. “Unless you have that, then these learning interventions become episodic,” Kumar said. Project ECHO sees an opportunity to help governments as they rethink ways to provide healthcare to their constituents, Arora said. “We believe we have an unprecedented window of opportunity,” he said at Devex’s Prescription for Progress event last year. “The ECHO model can become the new operating system for health systems strengthening so we can address the massive health needs of the world and prepare for future pandemics.”