By Matt Wood
Video conferencing has crossed the threshold from corporate boardroom to the household in the last few years. Anyone with a Skype account or an iPhone can host their own video chats. Now, a group at the University of Chicago Medicine is using video conferencing as a way to train primary care providers in clinics throughout the South Side of Chicago.
Daniel Johnson, MD, associate professor and chief of the Section of Academic Pediatrics, has taken a telemedicine system called Project ECHO and applied it to an urban environment. Project ECHO (Extension for Community Healthcare Outcomes) was a model originally developed at the University of New Mexico to train health care providers in rural clinics using video-conferencing equipment.
“Providers in urban areas, generally speaking, work their tails off, particularly if they’re working with an under-served or under-insured population,” Johnson said. “They quite simply don’t have the time to take advantage of some of the learning opportunities that are around them. So they end up being academically isolated, intellectually isolated and in some cases socially isolated. This system provides a forum for them.”
Johnson, along with colleagues at the University of Chicago and in the community, developed a pilot program for the ECHO system to train primary care providers on resistant hypertension management. They set up the video conferencing systems at six Federally Qualified Health Centers (FQHCs) affiliated with the South Side Healthcare Collaborative and conducted 12 sessions scheduled every other week over six months.
Each session began with a 20-minute lecture by George Bakris, MD, professor of medicine and director of the University of Chicago Medicine Hypertension Center, on topics such as how and when to take blood pressure, how to make sure patients take medications properly and how to treat hypertension in the elderly. Following the lecture, medical staff from the participating clinics presented cases of patients with resistant hypertension and discussed them with the group.
At the end of the 12 sessions, the providers who participated in the ECHO training sessions scored significantly better on a knowledge test about resistant hypertension than at the beginning of the project, and better than a control group that did not participate. They also said they were much more confident in their ability to treat resistant hypertension than before they started. The results of this study were published in The Journal of Clinical Hypertension.
Johnson says this method has a number of advantages over other remote training formats such as webinars or standard video presentations. “The video conferencing has the value over most other remote formats of making you feel like you’re almost in the room with other people,” he said. The cost to equip a site with video cameras, monitors and network equipment runs from $1,500 to 3,000. While this is a high initial investment for a small clinic, it’s more cost-effective than sending a physician to a training course and losing their services for a full day or more.
The format also mimics traditional case-based rounds in which most clinicians in academic medical institutions learn. “The subject matter expert isn’t the only person providing value to the activity because the other people in the room all have experience that is valuable to each other,” Johnson said. “So there is value in the shared experience that comes from people’s sitting around learning together.”
To be considered for the ECHO system, a health topic needs to meet certain criteria. First, it should be common enough to interest enough providers. Its treatment also should have high impact in that there are significant health consequences and increased costs for improper or delayed care. The condition should lend itself well to a protocol-driven model for diagnosis and treatment, with specific steps and procedures that can be taught, and the clinical results of treatment should be easily measurable. Johnson said that hypertension clearly fit these criteria.
“Twenty-five percent of the visits to the community health centers that we’re partnering with, the reason for the visit, is hypertension-related. Twenty-five percent of the referrals out are hypertension-related. Twenty-five percent of hospitalizations in this area are a consequence of hypertension,” he said. “So we meet the criteria in terms of common, high-impact and the ability to measure some type of economic impact. We should be able to reduce sub-specialty visits, ER visits and hospitalizations and produce an impact on the health care system.”
The providers approached by his team asked to start with hypertension for many of the same reasons. “You can measure the impact on the learner as well as the impact on their patients. So it was a very good place to start from that perspective,” Johnson said. “It was the area that our partners came to us and said, ‘If you can come up with a system where we could accomplish this training, we’d participate.’ ”
Following the success of this first project, Johnson and his colleagues have started ECHO programs for treating attention deficit hyperactivity disorder and managing care for breast cancer survivors. They are exploring programs in HIV, mental health, diabetes, geriatrics, pain management, school health, ethics, obesity and child abuse. They also have started thinking of ways to adapt the technology to set up breast cancer support group meetings where patients could participate in an online discussion at home from their own computers.
Johnson said the biggest advantage to this training model is that it lets urban community providers who might have been academically isolated previously by lack of resources and city congestion get together and learn from others on a regular basis, but sparing the commute time and travel expenses of traditional in-person classes. At the end of the sessions, they can go right back to work.
“On a given morning, we’ll have a site from Indiana, a site from 95th Street, a site from 55th Street, a site on the West Side,” he said. “You end up getting those people who are most motivated. You get to work with multiple locations, and by having small recurring sessions that are covering the topic, their ability to retain is greater.”
Masi, C., Hamlish, T., Davis, A., Bordenave, K., Brown, S., Perea, B., Aduana, G., Wolfe, M., Bakris, G., & Johnson, D. (2012). Using an Established Telehealth Model to Train Urban Primary Care Providers on Hypertension Management The Journal of Clinical Hypertension, 14 (1), 45-50 DOI: 10.1111/j.1751-7176.2011.00559.x