Could this new model end rural specialist wait lists?

US gastroenterologist Dr Sanjeev Arora had a big problem on his hands in 2003.
 
Desperate patients were driving hundreds of kilometres across New Mexico to see him. Their chronic hepatitis C was leading to liver cancers, liver failure, cirrhosis, or death.
 
But his waiting list was huge – eight months, at least.
 
Of the 28,000 people in the US state with the virus, fewer than 5% were being actively treated.
 
The problem was that in a state considerably larger than Victoria there were only two clinics equipped to treat the condition.
 
‘There was no way, no capacity to treat them all. And many [patients] were poor and couldn’t travel,’ Dr Arora told newsGP.
 
‘This is a big problem around the world. There are six billion people who don’t have access to the right knowledge at the right time at the right place, meaning they can’t get the right healthcare. 
 
‘The problem we are trying to solve is how you get specialist knowledge to where patients actually live.
 
‘We tried to solve for this by moving knowledge instead of patients.’
 
Dr Arora began testing his idea. He gathered a team of specialists with expert knowledge in hepatitis C management. He then found 21 primary care physicians outside of major cities who were eager to acquire new skills and to set up their clinics as centres of hepatitis C treatment excellence.  
 
Once a week, the primary care physicians would dial into a teleconference – and set about gaining new knowledge.
 
‘Doctors would present patients to each other and to us, the expert team. Over a year, they became experts, they didn’t need us any more. It was a learning loop – they learned from our advice and learned by doing,’ Dr Arora said.
 
The results were striking. The wait for treatment plunged from eight months to two weeks.
 
‘This is teaching people how to fish. It’s about force multiplication. It’s a movement to demonopolise knowledge,’ Dr Arora said.
 
The solution Dr Arora and his team settled on would become known as the ECHO Model, standing for Extension for Community Healthcare Outcomes.
 
The model is now in 38 countries around the world, including Australia.
 
Dr Arora will give a plenary speech at the RACGP’s upcoming GP19 conference on how wider uptake of his model could benefit Australia. 
 
Under ECHO, GPs and primary care physicians in rural or underserved areas gain access to a panel of city-based specialists through teleconferencing.
 
Over the course of a year, GPs gain skills and experience in managing common issues cropping up in their communities, which might otherwise force their patients to have long wait times and expensive trips to see a specialist.
 
Dr Arora – who is Distinguished Professor of Medicine at the University of New Mexico – has big plans for the ECHO Model. He estimates 10 million people have received care by ECHO-trained primary care doctors, with close to 700 networks and more than 100,000 doctors being mentored around the world.
 
‘There’s a lot of traction,’ he said. ‘It’s spreading like wildfire.’
 
Dr Arora believes Australia is ideally placed to benefit.
 
‘Australia is best suited for ECHO, of all developed nations of the world. It has internet access, it has all the experts in cities like Brisbane, Sydney and Melbourne, and it has a public health system which wants to help everyone,’ he said.
 
‘But there is no way you can help people in the outback with specialist services because all of the specialists are in big cities.
 
‘I know you make a massive effort to transport people to specialists after waiting for a year. It’s hard to see specialists, especially because knowledge is increasing so quickly and demand is very high. So if you move the knowledge to GPs who actually live in those communities, it can transform healthcare.
 
‘I don’t mean improve, I meant transform.’
 
Dr Arora believes the model requires reimagining the role of a city-based specialist.
 
‘If you have a specialist in Melbourne, instead of being a person who sees patients [directly], they also take on the responsibility of mentoring a group of primary care doctors,’ he said.
 
Asked about the at-times fractious relationship between GPs and other specialist doctors, Dr Arora said it is time to move past the notion of protecting specialised knowledge.
 
‘We need to think of all of us working for the welfare of our patients,’ he said. ‘There is really no way in the world for people to get the right care without this kind of collaboration.
 
‘GPs and other specialists are equally smart. But the specialist has all their knowledge in a small field, while the generalist is spread across a large area. They can do heart attacks, mental health, delivering a baby. It is difficult to get deep into one area.
 
‘To treat complex health problems, we need depth as well as breadth; and that’s why a collaborative approach is required, because there just aren’t enough specialists for rural and underserved areas.’
 
Dr Arora will use his plenary speech to outline how the ECHO model could benefit a small group of GPs serving a large rural area.
 
‘Let’s say you have six GPs in a community, where many patients have a difficult time accessing specialists,’ he said. ‘One might decide they want to become an expert in diabetes through ECHO, another might do the mental health ECHO, and another the rheumatology ECHO.
 
‘That means they can take care of the vast majority of specialist needs on their own, creating self-sustaining networks by first referring to each other. This is working in the US.
 
‘So at GP19 I’m going to sell the vision of how we should test this model at a wide scale to demonstrate it actually improves access to care, improves quality of care, treats disease at an earlier stage and reduces costs dramatically.’
 
Dr Arora’s speech will be followed by Dr Dana Newcomb, the medical director of integrated care at the Children’s Health Queensland Hospital and Health Service. Dr Newcomb, who has a background in general practice, will talk about her direct experience using the ECHO model to train GPs and other healthcare providers in managing chronic and complex paediatric conditions.

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