ECHO on the front lines of COVID-19

Karen Edison, MD, senior medical director for the Missouri Telehealth Network & Show-Me ECHO, discusses the use of the Extension for Community Healthcare Outcomes (ECHO) Project during the COVID-19 pandemic.

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DW Weekly: Just for some background, what is the ECHO project?

Dr. Edison: Traditionally, the ECHO project entails a weekly didactic conference video with 10 to 20 primary care physicians located in rural and underserved areas, about a medical topic, such as dermatologic conditions, to improve patient access to care. We have been doing ECHO in a major way here in Missouri for about five years. We have 25 different topics including dermatology — it’s one of our longest-standing ECHO programs. We do the dermatology ECHO a couple times a month on Fridays.

DW Weekly: You have adapted the ECHO Project and have held several COVID-19 ECHO standups recently. Tell us how you came up with this idea.

Dr. Edison: I was just watching the news and seeing what was happening and seeing the disease spread in our country. I called Randall Williams, MD, director of the Missouri Department of Health and Senior Services on a Tuesday night and had a meeting with him on Wednesday morning. I asked him to serve as the lead health official in the state for a standup ECHO on COVID-19. A week and a half later, we had our first one. We have had four COVID-19 ECHOs since then. We’ve done all of this in partnership with the Missouri Department of Health and Senior Services and the Missouri Hospital Association.

DW Weekly: Who is the audience for these video conferences and what has participation looked like?

Dr. Edison: We see everyone at the COVID-19 ECHOs: primary care doctors, emergency physicians, advanced practice nurses, clinic case managers, etc. We even see school nurses. For the last three COVID-19 ECHOs, we’ve had over 300 participants on each call.

DW Weekly: What topics are you discussing and what is the format of these COVID-19 stand ups?

Dr. Edison: The way ECHOs work is that you do a short didactic, you ask questions, then a case presentation, and then you answer participant questions. We manage the questions by putting them on the chat function in Zoom. We have an expert hub team that consists of several infectious disease physicians from the University of Missouri, a couple from Washington University, one from Kansas City, a federally qualified health center, a pediatric infectious disease and critical care specialist, and an infectious disease physician in the University of Missouri’s department of critical care. We also have Dr. Lea Brandt, the director for the University of Missouri School of Medicine Center for Health Ethics.

The first day we did an introduction. We then did didactics on testing, didactics on PPE, and we had one on alternative testing scenarios. We have had cases presented all the way from testing to managing critically ill patients. I also invited my husband who is the retired director of the Center for Health Ethics, and he gave a talk together with Dr. Brandt on scarce resource triaging and the plan we have in place if we do get a surge and are overwhelmed with patients. They discussed how to go about transparently setting up a protocol for patients. We covered topics like ample communication of the protocol, and other issues like making sure there’s no bias and discrimination during triage and making sure there’s a process everyone agrees to.

DW Weekly: How did you get the word out about these COVID-19 ECHOs?

Dr. Edison: Because we have 25 ongoing ECHOs, we first sent out information about the COVID-19 ECHOs to all our ECHO participants. We also sent out information via our various medical partnerships and relationships throughout the state, so it was easy to get the word out in a hurry. We announced the first COVID-19 ECHO on a Friday at 4:00 p.m. and by Monday we had 90 people registered. It does speak to the need for high-quality information. There’s some misinformation out there that we can help clear up.

DW Weekly: You are also conducting telemedicine standup ECHOs as well. Tell us about those.

Dr. Edison: We also created two telehealth ECHOs a week (Tuesdays and Wednesdays). These are done in partnership with the Heartland Telehealth Resource Center that we are a part of with Kansas and Oklahoma.

For the last few weeks, we’ve done a regular telehealth ECHO on Tuesday and then a behavioral and mental health standup on Wednesday afternoons. These ECHOs support people who are being asked by their systems and patients to use telehealth to deliver health services. They need support on everything from the legal and regulatory framework, to changes in reimbursement that we’ve seen. I’ve seen about 20 years of regulatory and policy change around telehealth in the last few weeks.

I also gave an ECHO didactic on telehealth etiquette. I covered basically how to provide services via telehealth in a high-quality way that protects privacy and engenders the trust of patients. We discuss things like where you hold your gaze so it looks like you’re looking them in the eyes, and to make sure that you’re not saying things that you think they can’t hear but that they can hear. We’re discussing things like what you wear and being mindful of background noise — just all of those things that I have learned from having done teledermatology for 26 years.

DW Weekly: What else are you doing to ensure that patients can be seen by their physicians via telemedicine throughout the state?

Dr. Edison: We also partnered with the Missouri Research and Education Network (MOREnet) — which is a university-based organization that provides broadband access to K-12 schools and libraries. MOREnet had 1,500 Zoom licenses that they didn’t need. They buy them in bulk. The Missouri Telehealth Network was able to partner with MOREnet and get out Zoom licenses to primary care physicians in rural and underserved areas so they could take care of their patients in their homes. These are secure Zoom networks. The nice thing about them is that when the physician sends the email with the Zoom information to the patient, it includes a randomly created URL for one-time use so it’s quite secure. Also, the technology is very intuitive and easy for patients to use. Patients go to their email and click on the link, and they’re right there with their physician. We sent them out to federally qualified health centers, rural health centers, and critical hospitals that don’t typically have good access to things like a fully functioning patient portal.

DW Weekly: What type of feedback and/or anecdotes have you received from participants about the efficacy of the project?

Dr. Edison: We do surveys at the end of every ECHO and have received great feedback. People are very appreciative and grateful for this resource. We do these ECHOs for just an hour, but people have lots of questions. We give those questions to our expert hub team and all those questions get answered every week.

DW Weekly: What type of impact do you expect these initiatives will make on patient access and physician collaboration down the road?

Dr. Edison: I think patients appreciate being able to get the care they need from their physician in their own homes at their own convenience. I think in the future, health care will look different and our waiting rooms won’t be stuffed with patients waiting to see us. In health care we try to be as patient-centered as possible, and I can’t think of anything that better represents patient-centered care than taking care of patients where they are.

From the health care perspective, before this pandemic, most of the people in health care did not use telehealth. In this pandemic, most health care workers are being asked and even pushed to use telehealth. In doing so, no matter what the specialty is, people will find how telehealth can be applied to their patient population. In the future, I expect physicians to be more open to using telehealth.

The AAD has been a leader in the field of telehealth due to dermatology’s natural proclivity to using the technology. Dermatologists around the country are being asked to serve as resources for others. I think it can be a proud moment for dermatology as leaders in health care by showing other people the way in terms of how to use technology to deliver high-quality care at a distance.

Karen Edison, MD, is senior medical director for the Missouri Telehealth Network & Show-Me ECHO.

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Are you on the front lines managing COVID-19 patients? Share your story with DWW. Email dweditor@aad.org.