Building Regional Expertise: Perspectives from Show-Me ECHO Participants

Abstract

This article highlights four primary care providers that practice in underserved areas in Missouri. Show-Me ECHO (Extension for Community Healthcare Outcomes) provides colleagues opportunities for consultation and Continuing Medical Education (CME) around particular conditions. Through their participation, these providers have 1) enhanced their comfort and skill in diagnosis and treatment, 2) become important regional resources for patients and other providers, and 3) improved access to specialty services in their community.

Introduction

This article highlights how participation in Show-Me ECHO (Extension for Community Healthcare Outcomes) enhanced comfort and skill in diagnosis and treatment for four primary care providers practicing in underserved areas in Missouri. It also explores how ECHO collaborations enhance access to specialty services and allow participants to become important regional resources for patients and other providers.

Providers of underserved populations can face isolation, excessive workloads and may lack access to consultation. The purpose of this article is to demonstrate how participation in Show-Me ECHO addresses these issues by providing colleagues, opportunities for consultation and Continuing Medical Education (CME).¹ ECHO participants demonstrate significant increases in their knowledge, improved attitudes, and confidence in clinical and nonclinical skills.² Further, they report increased self-efficacy which fosters behavioral change.^2–3

Background

Show-Me ECHO is a state-funded telehealth project created and operated by the Missouri Telehealth Network at the University of Missouri. Begun in 2014, Show-Me ECHO is modeled after the University of New Mexico’s Project ECHO which was originally created to educate providers about Hepatitis C. Key features of all ECHOs include: 1) a hub and spoke organization where multi-disciplinary content experts mentor participants through teleconferencing, 2) regular and recurring virtual meetings, 3) focused didactic presentations, and 4) case-based learning where participants select and present cases from their own practices.⁴ There are opportunities for practice in diagnosis and treatment and feedback among all participants as they consider complex cases.^1,5

Participation in a community of clinicians committed to providing the best care possible has given interviewees the opportunity to become important regional resources for their patients and other providers.

Although Show-Me ECHO draws participants from across the United States and internationally, it focuses on the needs of Missourians. Expert mentors are recruited from across the state with twenty-one counties represented on expert hub teams from inception to date. This geographic diversity enhances learning because these experts understand local resources, local contacts, and local realities for providing care in underserved areas. Show-Me ECHO participants come from 89 counties (Figure 1).

Figure 1.

Participation in ECHO from 2014–2019

Learning in ECHO

ECHO adheres to best practices in adult learning theory. Using informal discussions and guidance, ECHO offers the advantages of learning through authentic cases, focusing on the current needs of participants and building on participants’ current knowledge.⁶ ECHO situates learning within professional practice and connects to workplace learning thus enhancing the likelihood that newly acquired knowledge will change professional practice. ^5,7–8

Multidisciplinary teamwork is essential to the ECHO model.⁹ Show-Me ECHO connects primary care providers with each other, with specialists, and with regional resources. Diverse perspectives aid the ECHO teams in arriving at “wise action” better than any one individual participant.¹⁰ Discussions with, and mentoring from, content experts help equip primary care providers to give their patients the right care, in the right place, at the right time. Knowledge is no longer created top-down, but is made by the group, “by demonopolizing medical knowledge and creating collaborative practices between community-based clinicians and specialists, local primary care clinicians can become experts in a chronic condition and they can provide the best evidence-based treatments to many more patients.”^9(p32) This article highlights four health care providers experiences of learning within Show-Me ECHOs.

Interviews

ECHO hub leadership recommended the four providers that we interviewed. After a short introduction, excerpts from longer interviews provide insight into their considerable experience as members of the ECHO learning community.

Ning Haluck, MD, is a Pediatrician and Director of Pediatrics at Swope Health, which is a federally qualified health center in Kansas City, Missouri. She has been practicing medicine for four years. Dr. Haluck began participating in the Asthma ECHO when her boss suggested it.

“He showed me some information about Asthma Ready. I signed up mostly because my boss told me to, but as I did it and got to learn more about what ECHO was, as well as about asthma, I realized ‘Wow, this is amazing.’ I learned about asthma in training, but learning about it and then doing it is so different.

Having a community of experts who work with me is a great benefit of ECHO. I had been using (national asthma guidelines) through residency, but when I had problems, I didn’t really know what to do, (and) it took us a lot longer to access specialists. ECHO (gave me planned) access for one-hour per week. (When) I had a patient who was a little bit trickier, then I thought, ‘I can just bring it up in the next session’. And, they were just so helpful. There were no stupid questions. So, I can take very nitty gritty, practical questions and they just had a treasure trove of answers.

Since participating in ECHO, I’ve started seeing myself more as a bridge in my community. Between my patients and the specialist information that they need because some of my patients either can’t make it to the specialty clinics or don’t want to because they’ve already established care with me and our clinic. So now even with other topics, not just asthma, I’ve found the courage and have the format to get information from a specialist in ways that I probably wouldn’t have before. It can be pretty intimidating as a primary care provider who knows a little bit about a lot of things, to be able to go out to a specialist, ask my questions and not let fear or anything else get in the way.

Now, I have access to (experts) and share that access with my patients and with kids in my community. I am a pediatrician, but I’m also a mom. Everything that I’m learning at work, I am using at home with my family and with my friends’ kids. So really, I’m learning that being a pediatrician is being an advocate and the best way to be an advocate is to have knowledge. And that knowledge currently is with the specialists. So, I’m just trying to disseminate it as best I can and ECHO is a great dissemination model. I was able to get my two nurse practitioners on board. And so now as a clinic, every kid with asthma, no matter who they see, even if asthma’s not the reason why they come to our clinic, gets to have their asthma taken care of. ECHO taught me how to do it in a systematic way and in a way that pushed me towards continued improvement.

What I really love is the community. Now when I sign on to a meeting, I just wave at everybody. It’s just all these people that I know are as dedicated as I am to providing excellent care for asthma. I’ve been able to make so many changes in the year I’ve been involved with ECHO without actually having to go anywhere other than work. It’s so convenient!”

Bill Wright, MD, is a family medicine physician located in Houston, Missouri. He has been practicing medicine since 1980. Dr. Wright participates in three ECHOs related to autism. He began participating as his practice was shifting.

“I gave up obstetrics and started working in an office practice doing mostly pediatrics and some family medicine. It wasn’t the same intensity that I had with obstetrics. I was kind of floundering around and one day I had this invitation from the Thompson Center about autism. I liked it the first week, so I attended the second session and it was really almost too much for me. (But) then I went back a third time, and I just fell in love with it. And so, I continued along (joining additional ECHOs), kind of getting immersed in the whole arts and science of autism.

I’d never seen anything like ECHO really. I haven’t done much stuff online before. It was good teaching and then you actually got to work, on a case basis at least, and hear kind of what happened. The greatest part about it is having been able to work with the hub teams. I’ve got some good friends on the hub team now and that makes it just that much more powerful.

It’s just a really good learning experience. A couple of the people that are involved nearby, I’ve gotten to know them and actually worked with a couple of them directly; and that’s been nice to be able to do that. But I think it’s a combination of learning: a little bit of didactic information, along with going through and studying the cases. It’s really helpful as far as learning goes.

I’ve always practiced medicine with the idea that I need to be able to teach patients about what’s going on with their health, whatever that may be. Whether it’s having a baby or it’s taking care of a child with pneumonia, or whatever it may be. I think that ECHO helped a lot both in the insight of what goes on with families that are dealing with this difficult diagnosis and their children. I think it’s been really helpful in allowing me to be hopefully a better clinician and a better teacher. I think it has.

My community benefits. This is a very rural area. And, because there are not any other providers nearby, that provide (autism services), I’m getting referrals from all over this area of the state really. So typically, I would say people are driving on average forty-five minutes to be seen here for the evaluation. One family I saw this morning drove for an hour and twenty minutes. Between Springfield and Columbia and somewhere down near the Cape, there are no behavior therapists available. I mean not certified behavior therapist. Hopefully soon we’ll have someone in this area. So, for a therapy that is supposed to be happening several times every week, you can’t travel a hundred miles every day to take your child to therapy, take him home and then turnaround go back. So that’s a little frustrating. I’ve got dreams of having something like that happen; still just dreams as far as I can figure out.

I would tell others that are interested that the hub people in all three ECHOs that I’ve been in have been encouraging. They’ve been stimulating. They’ve been knowledgeable. It’s been a pleasure to work with them. I think it’s a great opportunity to learn more and to get some feedback and on what you’re doing.”

Hope Misterovich, DO, is a family medicine physician located in Springfield, Missouri. She has been practicing medicine since 1998. Dr. Misterovich began participating in the Dermatology ECHO in 2016.

“I guess it was four years ago now, our health system was really struggling with access to dermatology in particular. They approached me about starting a primary care skin care clinic as a way to offset some of the referrals that were kind of overwhelming the current dermatologist with our system. As we investigated it, we wanted to have some sort of backup or access to a higher level of knowledge if needed. So, we started participating before we ever started the primary care skin care clinic.

I utilize ECHO for a number of different resources. One is just for the education piece at the beginning of each session, I think that’s valuable. They, at times, will make it simpler and at times make it more advanced. And I appreciate all levels that they explore when they present their didactic portion.

I like it all. I like the camaraderie. I like the collegial atmosphere. I’ve even gotten to know some of the participants that are in outlying communities. We have met at conferences and have gotten to know the other people that are participating. I enjoy it tremendously.

My patients benefit because I am able to say, ‘I’m not sure what’s going on here, but I’m gonna reach for my backup and get their thoughts and their opinions, and see if we can help you’. I tell patients, ‘You know, we don’t know what’s going on. You’re not responding to the treatment that would typically help this condition. I’d like to present your case at the ECHO’. I describe it as a situation where we present their case in an anonymous format with no charge to them. They have the benefit of getting several dermatologist opinions, and then I call them with the recommendations. Patients love it. They’re thrilled that somebody has taken the time to listen to them and has taken their concerns seriously.

My community benefits as well. I’ve had other providers say, ‘I’m referring you this patient. They’re very complicated. You may want to present this patient to Derm ECHO’. So, they know that I’m kind of the point person, and look to me as a resource. They’re from the surrounding community, so they’re within the Springfield area, but they’re in outlying areas as well: Monett, Aurora, and Branson.

I try to talk about Derm ECHO every chance I can when I talk to other providers. I’m happy to talk about the great resource. ECHO is really easy to do and so much fun. And, you get CME. It’s a great opportunity to connect with other providers in the state and I’ve enjoyed every aspect of it.”

Karyn Dean, NP, is a nurse practitioner located in Kennett and Hayti, Missouri. She has been practicing for about thirteen years. Karyn has participated in both the Asthma and the Child Psych ECHO. She began participating to help bring specialized care to her area.

“The nearest pediatric specialist is anywhere between an hour to three hours away for patients. So, by doing the ECHOs and learning the information from the experts, it allowed me to better practice and keep the patient in the local area as much as possible.

ECHO helped me become more of an expert and a resource to my colleagues within the clinics I work at and to the community. Patients can receive high quality care without having to leave their communities as often and travel long distances. Also, helping me to improve my practice gave me more confidence.

My favorite part of ECHO is getting to network with my fellow nurse practitioner and physician colleagues in the state and even beyond because there were some from Africa and other places that were on the ECHOs. (Also) just to have access to those experts, those specialists to consult with and pick their brains.

My asthma patients benefit because I know the guidelines quite a bit better off the top of my head, so I can better diagnose them and manage them. I learned to use different tools in evaluating patients and have actually gotten some of the physical tools to use in the clinic, and that allows me to more objectively evaluate the patients.

The Child Psych ECHO gave me access and knowledge of different screening tools, and the pharmacist on that ECHO was very helpful. He helped a lot with giving me knowledge about the different main drugs used for different mental health illnesses. It did give me exposure to some of those common psychological therapies because I really had no knowledge of that. In fact, the Child Psych ECHO prompted me to go ahead and become a pediatric mental health specialist through my certifying board.

I see my role in the community after going through the ECHOs as more of a center of excellence. (Patients) can know that they’re getting the most current evaluation and management methods and that I now have contact people that I can turn to if I have questions in the future. Also, I’ve shared (information learned in ECHO) within the clinic (and) at the provider meetings (for the) five or six clinics within SEMO Health Network. I’m the only pediatric nurse practitioner and there’s not a pediatrician in either clinic that I work at, so I serve as a general pediatric expert, too. So, they oftentimes will pick my brain.

It’s an easy and very valuable way to get added education on disease processes and management and you get official CME credit. That’s always a plus. We need that for our licensure. And, it gives a way to network with your colleagues and other experts in the field without having to really leave your hometown or (even) home sometimes!”

Conclusions

Similar to other ECHO participants, our interviewees were motivated to participate in ECHO to learn more about medical conditions, to increase collaboration with specialists, a desire to save patients time, and to obtain CME.¹¹ As these four dedicated clinicians have shown, Show-Me ECHO helped them meet their personal goals and benefitted their patients and larger community.

All of our interviewees really appreciate the access to specialists. Specialists on the hub team are able to answer practical questions and to help participants build up their own condition-specific knowledge. Beyond relationships with hub team specialist, interviewees value the relationships they have developed with other ECHO participants. Building a community of clinicians committed to providing the best possible care has given our interviewees more confidence in their own practice and the confidence to interact with specialists outside of the ECHO format.

Local access to specialized medical care can be especially helpful for patients with transportation issues or other limitations. The larger community benefits as ECHO participants become local resources. All of our interviewees described taking information learned in ECHO back to their communities, and sharing their new knowledge with other healthcare providers.

If you would like to experience for yourself the benefits described by interviewees, please visit https://showmeecho.org/ for more information.