ECHO India – A novel, sturdy tele-mentoring initiative

By Aarthi Kannan

India’s healthcare model strives to achieve health for all, while specialist physicians remain few and far in between. Tele-mentoring projects like ECHO India serve as lighthouses in training rural primary care physicians to provide specialty care to rural Indian patients, right where they are. “It is not in the stars to hold our destiny, but in ourselves” – William Shakespeare

“It is not in the stars to hold our destiny, but in ourselves” – William Shakespeare

Gone are the days when books in dusty library shelves were the bleak ray of hope that answered our unsolvable medical dilemmas. Telecommunication and internet have skyrocketed our healthcare system into this age. As medical evidence evolves hand-in-hand with technology, medical education for doctors has catapulted into an era of internet-based learning and workshops. A remarkable development is the field of tele-mentoring, where ECHO India serves as a north star. Project ECHO (Extension for Community Healthcare Outcomes) is the brainchild of Dr. Sanjeev Arora, a gastroenterologist from New Mexico, USA.

Colonel Kumud Rai, ECHO India chairman and vascular surgeon, shares his thoughts in an insightful interview. A graduate of Armed Forces Medical College Pune and current director of vascular surgery at Max hospital New Delhi, he served the Indian army for 27 years including his contribution in the Kargil war. He is deeply committed to the development of ECHO India.

1. Hepatitis-C, a chronic fatal infection if left untreated carrying a high risk of liver failure and death, has become curable in recent years through development of novel antiviral medications. Punjab became the first Indian state to provide free treatment to hepatitis-C patients in the state through ECHO India, treating an astonishing 55,000 hepatitis-C cases in a 30-month period. ECHO, a tele-mentoring project, is aspiring towards rural patients outreach. What is tele-mentoring and how does it differ from telemedicine?

Telemedicine delivers care from physician to patient through telecommunication. Tele-mentoring literally “mentors” primary care physicians (PCPs) in rural areas to cater to their patients’ specialty medical needs appropriately. Mass teaching models do not provide mentoring, two-way communication or follow-up discussions. In a tele-mentoring model like ECHO, small groups of PCPs meet with their mentor at regular intervals via Zoom® video conferencing (ECHO clinics), enabling medical education for PCPs through case-based learning. ECHO India values mutual respect and teamwork rather than hierarchy and follows an interactive all teach, all learn method where every team member learns and has follow-up discussions.

ECHO’s tele-mentoring model (picture adopted with permission from ECHO India website)

2. How was Project ECHO born?

New Mexico (USA) had a problem of hepatitis-C. Through Dr. Sanjeev Arora’s mentorship, PCPs in underserved areas of New Mexico formed the first ECHO clinics utilizing video conferencing technology to discuss cases and treat rural hepatitis-C. A trial published in the New England Journal of Medicine® showed that ECHO clinics successfully achieved hepatitis-C cure rates similar to those at the university hospital. ECHO then blossomed across the world to about 40 countries including India.

3. What is ECHO India's aim?

ECHO India aims to improve healthcare delivery to rural and underserved areas of India.

4. How does ECHO India achieve its goals?

ECHO India uses a hub and spoke model - A mentor in a centralized academic center acts as a hub, connecting with primary care providers/mentees (often MBBS doctors) who act as spokes, to deliver appropriate care to rural patients.

5. How do patients benefit from ECHO India?

Through ECHO, PCPs in rural areas are equipped to treat challenging cases, eliminating travel time and cost for rural patients, enabling them to obtain appropriate care where they are.

6. How has ECHO India changed the outcome of common health issues?

Bedaquiline is novel, effective drug used to combat multidrug resistant Tuberculosis (MDR-TB) in India. The National Institute of Tuberculosis and Respiratory disease and ECHO India together mentored district TB officers (DTOs) to address their hesitancy in prescribing Bedaquiline due to fear of adverse drug events. After mentoring on appropriate prescribing, Bedaquiline prescriptions from DTOs soared from a mere 600 to 6000 in the subsequent few months.

PGIMER Hospital was detecting and treating around 1500 patients of hepatitis-C in Punjab each year. After our joint effort in mentoring 23 local PCPs, the hepatitis-C detection and treatment numbers went up 30-fold over the subsequent 1.5 years

7. What are the primary challenges that ECHO India faces?

ECHO is purely volunteer-based — identifying motivated champions and mentors is challenging. Most mentors work in government hospitals and medical colleges, but there aren’t many from private hospitals. ECHO also requires mentees to have good internet connectivity.

8. What is in the pipeline for ECHO India?

Our upcoming project in collaboration with NICPR involving early detection of cancers of oral cavity, breast and cervix in India, especially since their early treatment significantly improves survival. Our new initiative which mentors ASHA workers at primary health centers (PHCs) in Gujarat, Haryana and Uttar Pradesh holds hope. Their knowledge will then be compared with their peers who don’t receive ECHO India mentoring.

 States with active ECHO projects (picture adopted with permission from ECHO India website)

Between 2017 and 2018, NIMHANS Institute and ECHO conducted a study on mental health practices in rural Chhattisgarh patients undergoing counseling, which trained rural mental health counselors in best practice management of common mental health conditions, resulting in a significant increase in learning and self-confidence amongst counselors, with a reduction in professionals’ isolation. This was a significant breakthrough in educating rural counselors for mental health.

ECHO India holds the power to narrow the existing care gap between physicians and patients in India by using technology to improve medical care for rural patients, encouraging best practice, fostering medical education and improving support amongst physicians in rural areas.

ECHO Mentors are highly motivated, eminent health care leaders who enroll in a 3-day immersion program with ECHO India, to obtain training on starting ECHO clinics. Placing one foot in front of another, ECHO is spearheading over 400 programs in India. For more information, visit www.echoindia.in