Report on the ECHO Institute
Survey of Launched Hubs 2017
Jessica L. Jones, MA, ABD
Research Scientist III
ECHO Institute
University of New Mexico Health Sciences Center
July 16, 2018
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Executive Summary
Project ECHO is a movement to demonopolize knowledge around the world, especially in the realm of
healthcare where access to specialty medicine is often difficult to come by. In August 2017, the ECHO
Institute surveyed all active (i.e. “launched”) hubs – institutions hosting ECHO telementoring programs
on various topics – in the United States outside of the Veterans Health and Defense Health agencies to
understand more about their ECHO work.
Findings
The survey was distributed to 70 launched hubs in the United States, with a goal of one survey
completed per hub. Responses from 48 hubs were received for a 69% response rate. Survey questions
were a combination of closed- and open-ended response options. Using descriptive statistics and
emergent themes identification, the following were found:
ECHO hubs host a diverse array of teleECHO programs, and many are planning to launch more
programs, increasingly in fields beyond healthcare (e.g. public health, education).
ECHO hubs rely on a range of various experts to run their teleECHO programs, and most hubs
employ a small administrative staff.
Most ECHO hubs provide continuing education credits to participants.
Most ECHO hubs evaluate their programs; a smaller proportion are researching the ECHO
model, the focus is largely on participation and how self-reported provider satisfaction,
knowledge, confidence, and behavior are impacted by teleECHO program participation.
ECHO hubs largely fund themselves with a combination of internal and external sources.
Internal support most often comes in the form of administrative staff, technical assistance, and
providing continuing education credit. The most common external sources of funding include
the federal government, state governments, and non-profit organizations.
Networking, using data and evaluation to show impact, and targeting local needs with
teleECHO programs were common strategies for obtaining funds. Launching ECHO hubs was
the most difficult resource challenge identified by hubs, and identifying sustainable sources of
funding was a common concern expressed by respondents.
Limitations
Limitations include the representativeness of the sample of hubs, and inability to capture all variation.
Representativeness: Not all launched hubs in the United States were surveyed; international
hubs were not surveyed; and only successfully launched hubs are included in the report. The
number of domestic hubs has also doubled since project completion.
Variation: Only one survey was completed per hub, so findings cannot address variation in
teleECHO programs within and across hubs.
Conclusion
The survey was a relative success. Results provide a picture of the “typical” launched hub in the United
States, and in several ways this report speaks to priority areas of the ECHO Act of 2016. Future work is
required to understand members of the ECHO movement that were not captured in this survey.
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ACKNOWLEDGMENTS
This report would not have been possible without the generous participation of our replicating partners
across the United States. I am grateful to each of you.
I want to thank all of my colleagues at the ECHO Institute for their support, especially the Account
Services Team for their work to encourage participation during survey distribution as well as those that
provided feedback on drafts of this report. Your efforts are sincerely appreciated.
CORRESPONDENCE
Please direct questions about this report to:
Jessica L. Jones, MA, ABD
Research Scientist III, ECHO Institute
University of New Mexico Health Sciences Center
1 University of New Mexico
Albuquerque, NM 87131
For more information on Project ECHO visit echo.unm.edu
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Table of Contents
Overview of Project ECHO ............................................................................................................................ 2
The ECHO Act ................................................................................................................................................ 3
The Survey of Launched Hubs 2017 .............................................................................................................. 3
TeleECHO Programs ...................................................................................................................................... 4
Content of TeleECHO Programs ................................................................................................................ 4
Structure of TeleECHO Programs .............................................................................................................. 7
The People Behind the Movement: Project ECHO Hub Teams .................................................................... 7
Subject Matter Experts ............................................................................................................................. 8
Administrative Staffers ............................................................................................................................. 9
Continuing Education: Prevalence in the MetaECHO Community ............................................................... 9
Types of Continuing Education ................................................................................................................. 9
Number of Continuing Education Credits ............................................................................................... 10
Measuring ECHO Impact: Evaluation and Research at ECHO Hubs ............................................................ 11
Funding ECHO ............................................................................................................................................. 13
Operations Funding: Financing TeleECHO Programs .............................................................................. 13
Research Funding .................................................................................................................................... 15
Funding Challenges and Opportunities ................................................................................................... 16
Discussion.................................................................................................................................................... 18
The Typical ECHO Hub ............................................................................................................................. 18
Conclusion ................................................................................................................................................... 19
Appendix A. Overview of ECHO Institute .................................................................................................... 21
Appendix B. Instrument for the Survey of Launched Hubs 2017 ............................................................... 22
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Overview of Project ECHO
Project ECHO® (Extension for Community Healthcare Outcomes) is a movement to demonopolize
knowledge and disseminate best practice care to underserved people all over the world. It is a low-cost,
high-impact telehealth intervention,i with the ambitious goal of touching 1 billion lives by 2025. The
ECHO model brings together primary care providers with interdisciplinary specialist teams to engage in
case-based learning, mentoring, and sharing of best practices in teleECHO programs. These communities
of practice are facilitated by regular videoconference-enabled sessions and guided by an all teach, all
learn philosophy to encourage collaboration.
Project ECHO employs a “hub-and-spoke” model, as depicted in Figure 1. “Hubs” are institutions (often
academic medical centers) that host teleECHO programs. These programs typically focus on chronic,
common, and complex medical conditions, though broader health and non-medically focused programs
are increasingly common. Programs are facilitated by a multidisciplinary team of subject matter experts.
Participants at partner sites, called “spokes”, whether individuals or teams, connect to the hub virtually
for teleECHO program sessions. This structure is replicated around the world and the movement
continues to grow, with over 200 hubs and tens of thousands of spokes.ii
Figure 1. The ECHO model utilizes a “Hub-and-Spoke” architecture. Hubs are sites that host teleECHO programs. Spoke participants programs connect virtually to teleECHO program sessions on a regular basis, where they receive didactics and engage in case-based learning of best practices.
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The ECHO Act
The United States Congress passed The ECHO Act in December 2016.iii The Act orders the Secretary of
the Department of Health and Human Services to examine the impact of the ECHO model (and other
technology-enabled collaborative learning and capacity building models) on areas that are a priority for
public health. It focuses on several areas pertinent to Project ECHO. First, the Act aims to assess the
impact of ECHO in specific domains of medicine: mental and substance use disorders, chronic diseases
and conditions, prenatal and maternal health, pediatric care, pain management, and palliative care.
Second, it aims to assess the impact of ECHO on healthcare workforce shortages and retention, and
third, the implementation of public health programs and disease surveillance. Finally, it aims to assess
the impact of ECHO on access to health care services for rural and underserved areas or populations.
These assessments are intended to identify barriers to adoption (i.e. “replication”) of the model.
The 2017 Survey of Launched Hubs speaks to several aspects of the ECHO Act, including the variety of
topics for which the ECHO model is utilized; constellations of the funding sources for hubs; and barriers
and facilitators to the adoption and continuation of ECHO hubs. To this end, we attempt to reference
the Act when relevant to the results of the survey.
The Survey of Launched Hubs 2017
The Survey of Launched Hubs captures a variety of information about the MetaECHO Community –
individuals and organizations using the ECHO model to help demonopolize expert knowledge – in the
United States. The survey asks questions about hub program operations, including the number and type
of programs in operation and development; expert facilitators and administrative staffers; continuing
education; evaluation and research; and funding sources. In this section, we discuss the methodology
underlying the survey. Then, we discuss the results of the survey in subsequent sections; this report
mirrors the general structure of the survey instrument (See: Appendix B).
The survey was administered July 31 – September 1, 2017 using REDCap electronic data capture tools
hosted at the University of New Mexico Health Sciences Center (UNM HSC).iv The study population was
all domestic, launched ECHO hubs – those in the United States that have signed partnership documents
and are actively engaged in hosting teleECHO programs. We excluded two groups: (1) hubs that were
not trained by ECHO Institute, because they could not respond to our customer service questions, and
(2) hubs in the Veterans Administration (VA) or Defense Health Agency (DHA) systems due to data
governance concerns.
The remaining 70 hubs received invitations to participate in the survey, and reminders each Monday
thereafter until a survey was completed for the hub or the end of the administration period was
reached. Primary contacts in the partner database at the ECHO Institute and other relevant personnel
received invitations. We requested that each hub group complete one survey capturing all ECHO work at
the hub –the choice of who completed the survey was left to hub teams. The ECHO hub at UNM HSC
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was excluded from the survey because it is the oldest and largest hub, and as such would be an outlier
for estimates throughout the report (see: Appendix A for more information).
The survey achieved a response rate of 69%, with 48 of the 70 hubs contacted completing a full survey.v
The sample of responding hubs is largely representative of the study population based upon available
information.vi Responding hubs represent 28 states, located across all 10 U.S. Department of Health and
Human Services regions, and range from some of earliest adopters of ECHO to hubs that began
operating during survey administration.
TeleECHO Programs
TeleECHO programs are diverse interventions, varying primarily in terms of content and structure. In this
section, we discuss the content areas of ECHO programs, in terms of currently operating programs and
future trends. We also describe the organization of programs by briefly examining the number of
teleECHO programs, how often these programs meet, whether programs use cohorts, and to what
extent hubs use the iECHO system to track programmatic data.
Content of TeleECHO Programs
When it comes to content, many of the teleECHO programs are multidimensional in terms of the topics,
population in focus, and setting of care. We address these in turn. First, respondents were asked to
report the title and topics of all operating teleECHO programs at their hub as well as any programs they
have in development. In total, 163 operating programs were reported by respondents. Table 1
summarizes the distribution of operating programs per hub. Most hubs host a single program, and the
number reported ranged from 1-16 programs with a median of two programs. Most hubs (n=31) also
report having at least one program in development, with a total of 62 programs in development listed.
This captures the potential for growth in teleECHO programs in the near future, and reflects the
continuing utility of the ECHO model for those implementing it.
TeleECHO Programs Hubs
One program 23 (48%)
Two programs 9 (19%)
Three programs 5 (10%)
Five-ten programs 7 (15%)
More than 10 programs 4 (8%)
Total 48 (100%)
Table 1. Counts with percentages of hubs hosting different numbers of teleECHO programs. Most hubs host only one program (n=23).
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Figure 2. Distribution of teleECHO programs over content areas. Stacked bars indicate the number of active programs (dark bars) and programs in development (light bars). Programs may fall in multiple content buckets.
Figure 2 provides a breakdown of topical categories identified as priority areas by the ECHO Act. ECHO
Institute research staff, in consultation with subject matter experts, developed a classification scheme
based on program titles and topics. Due to their multidimensional nature, teleECHO programs may fall
into more than one content bucket. For example, an ECHO focused on pediatric psychiatry may fall into
both Mental Health and Pediatric Care categories.
Chronic Diseases and Conditions is the most popular category for teleECHO programs in Figure 2.
Popular topics in this area include hepatitis C, HIV, autism, cancer and chronic pain. The broader foci of
programs in this group include endocrinology, cardiology and rheumatology. This area also has the
highest potential for program development, with the most programs or topics reported as in
development for this category (see: light teal bars in Figure 2).
Mental Health is the second most popular category for teleECHO programs in Figure 2, and this category
has the second-highest development potential based on the count of programs in development. Among
the most common topics in this group are general behavioral health, integration of behavioral
healthcare in various practice settings, and substance use disorders (SUD), often paired with medication
assisted treatment (MAT). Pediatric behavioral health, psychiatry, and autism are also frequently listed.
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Pain management and SUD teleECHO programs overlap in part. Most SUD programs focus on opioids
and MAT. Figure 2 reveals that SUD teleECHO programs are likely to expand by roughly 50% in the near
future, based on the number of programs reported in development. This increase is likely due to
increased attention on the opioid epidemic in the US and the decision of many states to adopt ECHO as
a component of their 21st Century Cures Act funding to counter the crisis.vii
Some teleECHO programs focus on distinct demographic groups. Age and gender groups were the most
common sub-populations. Pediatric care is popular, with 18 programs currently operating and roughly as
many in development (see: Figure 2); so, ECHO work in pediatrics may double in the near future. Many
of these teleECHO programs are in the areas of Chronic Diseases and Conditions or Mental Health, and
special topics in this area include pediatric hypertension and child abuse and neglect. Geriatric
populations are also the focus of 13 teleECHO programs, some of which focus on care homes. With
respect to gender, Figure 2 reveals that teleECHO programs focused on Prenatal and Maternal Health
are relatively rare, with six programs operating and one in development across both areas. Women’s
health programs are even rarer, with only two focusing on topics not directly associated with pregnancy
(e.g. cervical cancer prevention).
Finally, teleECHO programs can focus on specific care settings. For example, the ECHO model was
developed to increase access to specialty care, but teleECHO programs focused on primary care are
growing in popularity. Twelve hub respondents report programs in this area, often focused on
integrating behavioral or mental healthcare. While they were not among the most common, hospitals,
family or community homes and care homes were mentioned as the care setting focus for several
teleECHO programs. Just a few programs target an audience of community health workers (CHWs)
outside of these care settings.
Going Beyond Healthcare
Increasingly, teleECHO programs are expanding to areas beyond healthcare to broader topics in health
and beyond. These enterprising hubs demonstrate the versatility and strength of the ECHO model.
Common non-medical programs provided by respondents focus on Education and Public Health.
Innovations in the area of Education include programs focused on incorporating assistive technologies
and improving behavior supports in the classroom. For public health, notable teleECHO programs focus
on public service, community engagement and other initiatives developing youth capacity for designing
community health solutions. Also, quality improvement (QI) focused programs are growing in number as
QI elements are integrated into existing programs focused on medical topics or standalone QI teleECHO
programs develop. Examples of teleECHO programs (active and in development) in this area include
patient flow, care transitions, and antimicrobial stewardship teleECHO programs.
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Structure of TeleECHO Programs
The ECHO model embeds case-based and distance learning, but there are still a variety of ways to
structure teleECHO programs. We asked respondents to estimate the number of sessions held in an
average month for all active teleECHO programs at their hub. Most teleECHO programs meet at least
once a month, with the largest proportion of hubs reporting five or fewer sessions per month (54%)
across all programs.
A second organizational facet we were curious about is the use of cohorts, or groups of learners moving
through a program with pre-set start and end dates. A larger proportion than expected report
employing cohorts at their hub, 20 of 46 responding hubs (43%). The ECHO model is geared toward
developing communities of practice as well as expanding specialty knowledge. More evidence is needed
to understand the benefits (and costs) of cohorts versus ongoing teleECHO programs, but for now, we
simply seek to know the prevalence of cohorts.
iECHO System Use Hubs are given access to proprietary programmatic
data-tracking software developed by the ECHO
Institute, called iECHO. The software is intended to
give teleECHO programs a system for tracking
participant attendance at teleECHO sessions,
didactics, and a case presentations, among other
details. We first asked hubs if all, some, or none of
their teleECHO programs utilized iECHO – roughly
60% (n=29) of hubs reported that all of their
programs use iECHO, 19% (n=9) reported that some
of their programs do, and 21% (n=10) reported that
none of their programs use the software. For those
programs that do not use iECHO, hubs most often
reported a lack of staff or time to use the system for
tracking data.
The People Behind the Movement: Project ECHO Hub Teams
Respondents were asked to provide an estimate of the number of subject matter experts (hereafter
“experts”) and administrative staff (hereafter “staffers”) engaged in running teleECHO programs at the
hub. Experts are medical or other professionals providing specialized knowledge to participants at
spokes, whether facilitating discussion/Q&A or providing didactic presentations. Staffers are defined as
individuals occupied with supporting the day-to-day operations of
Figure 3. Pie chart depicting the proportion of ECHO hubs with all, some, or no programs using the iECHO data system.
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the ECHO hub, including teleECHO program coordinators,
program managers, administrative assistants, and
information technology support staff.
Subject Matter Experts
Table 2 shows the distribution of the number of experts
across hubs. Most hubs have 10 or fewer experts engaged
in their ECHO work. The correlation between the count of
programs at a hub and the number of experts reveals a
strong, positive association between the two (rs=0.63);viii
so in general, as the number of programs at a hub
increases, the number of experts at the hub increases.
Respondents were asked to indicate whether individuals
with each type of professional training serve as experts at
their hub; if they marked “Other”, they were provided a
space to list the other types of experts engaged in their
ECHO work. Table 2 reveals the most common types of
experts participating in ECHO. Many teleECHO programs
are focused on medical care. Accordingly, almost all hubs
(97%) have physicians serving as experts, and the majority
have nurse practitioners. The second most common
group represented among hub experts are mental health
professionals (79%). Ten hubs (21%) also listed
psychiatrists, psychologists and/or behavioral health
specialists as “Other” experts engaged in their ECHO
work. This is no surprise given the popularity of
mental/behavioral health-focused teleECHO programs,
and it speaks to the benefits many hubs see from including these experts on their multidisciplinary
program teams. Pharmacists (n=20) and social workers (n=16) are also prominent in the “Other” types
of experts listed by hub respondents. Given their increasing role in healthcare, CHWs were surprisingly
uncommon, with only 15% of hubs reporting them among their experts.
Table 2 also includes a breakdown of how hubs compensate their experts. Hubs most often rely upon
experts to volunteer their time (60%) or are able to cover experts’ time for their ECHO work (52%).
Interestingly, a relatively large share of hubs (25%) provide continuing education credit to their experts
as compensation for their time. The section below focuses on the provision of continuing education (CE)
credit to spoke participants, so we were surprised to see this mechanism employed to reward experts.
Hubs by Number of Experts (n=48)
1-5 experts 15 (31%)
6-10 experts 14 (29%)
11-20 experts 11 (23%)
21-30 experts 2 (4%)
31-40 experts 3 (6%)
41+ experts 3 (6%)
Hubs by Expert Training (n=48)
Physician 47 (97%)
Mental Health Professional 38 (79%)
Other 30 (63%) Nurse Practitioner 28 (58%)
Nurse 20 (42%)
Physician Assistant 10 (21%)
Community Health Worker 7 (15%)
Hubs by Expert Compensation (n=48)
Volunteered time 29 (60%) Time coverage 25 (52%) Cont. Ed. Credit 12 (25%) Part-time employment 9 (19%) Service credits 7 (15%) Full-time employment 5 (10%) Job sharing 3 (6%)
Table 2. Number (and percentage) of hubs with a number range of experts, and with each type of training and compensation. Hubs may have experts with none, some, or all of the featured training and compensation types.
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Administrative Staffers
Table 3 shows the distribution of the number of staffers
across hubs. Most have 1-5 staffers supporting their ECHO
work. Accordingly, the correlation between the number of
programs hosted at a hub and the number of staffers is
weaker (rs=0.43) but in the expected direction, indicating
that the number of staffers at the hub increases with the
number of teleECHO programs hosted by a hub. At the
same time, a large majority of programs have only 1-5
staffers, including 17 hubs running more than one teleECHO
program. So while it is likely that hubs would prefer to hire
more staff if given the financial opportunity, it is possible to
scale ECHO work at a hub with a relatively small group of
staffers.
Respondents were asked whether they have “an
administrative staffer dedicated to meeting technology
needs or troubleshooting during TeleECHO sessions.”
Approximately 74% of hubs (n=46) reported having such a
staff person. Additionally, of the 46 responding hubs, most provide full time employment (56%), part
time employment (26%), or partial time coverage (33%) to their staffers.
Continuing Education: Prevalence in the MetaECHO Community
We suspected that providing continuing education credit for participation would be a common feature
of operating hubs, given the distance education components of the ECHO model. In the survey, we
asked respondents whether their hub “provide[s] any type of continuing education (CE) credits to any of
[their] spoke participants”, and if so, whether the hub is “an accredited provider of CE credit.” According
to expectation, 83% of hubs (n=40) report providing some type of CE credit, and of these, 75% (n=30)
report that they are accredited.
Types of Continuing Education
Hubs that provide CE credit were asked to indicate which types, and approximately 68% (n=27) of these
hubs provide more than one type of credit. Table 4 displays the number of hubs providing each type of
CE credit. Accreditation Council for Continuing Medical Education (ACCME) and standard CE Unit/Credit
(CEU/CEC) are the most common types, provided by 80% (n=32) and 60% (n=24) of responding hubs
respectively.
Hubs by Number of Staffers (n=48)
None 2 (4%)
1-5 staffers 38 (79%)
6-10 staffers 5 (10%)
11-20 staffers 3 (6%)
Hubs by Staffer Compensation (n=46)
Full-time employment 26 (57%)
Time coverage 15 (33%)
Part-time employment 12 (26%)
Volunteered time 8 (17%)
Job sharing 4 (9%)
Service credits 2 (4%)
Table 3. Number (and percentage) of hubs with a number range of staffers and with each type of compensation for staffers. Hubs may have staffers with none, some, or all of the featured training and compensation types.
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CE Credit Type Hubs
Accreditation Council for Cont. Medical Ed. (ACCME) 32 (80%)
Cont. Ed. Unit/ Credit (CEU/CEC) 24 (60%)
Cont. Nursing Ed. (CNE) 14 (35%)
Cont. Pharmacy Ed. (CPE) 4 (12%)
Maintenance of Certification (MOC) 5 (13%)
Other 8 (20%) Table 4. Number (and percent, n=40) of hubs providing each type of continuing education credit. Hubs may provide more than one type of credit; thus, percentages are independent and not cumulative.
Respondents were also prompted to list any “other” types of CE credit they provide that were not
specified. These credit types include:
American Academy of Family Physicians (AAFP) CME
American Osteopathic Association (AOA) CME
American Medical Directors Association (AMDA) Certified Medical Director (CMD) credit
Community health worker (CHW) credits
Emergency medical services (EMS) certification credit
Other types, including credits for counseling, psychology, and social work.
The variety of CE credits provided by hubs speaks to both the multidisciplinary nature of many teleECHO
programs and the diversity of participants from spoke sites around the country. The common, chronic,
and complex conditions upon which most teleECHO programs focus require patient care and support
from an increasingly diverse range of professionals, all of whom can benefit from participation in ECHO.
Number of Continuing Education Credits
We asked hubs to provide an estimate of the number of CE credits provided to participants in the last
year. The quantile distribution of credits is in Figure 4. Of the 40 hubs providing CE credit, only 21 (~53%)
responded to this question, and most of these hubs provide less than 100 credits per year. The average
number of credits provided by hubs in the last year is approximately 329 credits, with a median of 60
credits. Hubs providing more than 1,000 CE credits in the past year were rare (95% of responding hubs
provide 700 credits or less).
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It is interesting that the number of
credits provided is relatively low, given
the high proportion of hubs providing
credit and the large number of
participants across teleECHO
programs. This may be due to bias
from item non-response– only 53% of
hubs providing CE responded to this
question – but the granting of CE
credits depends in large part upon
factors outside of hubs’ control, including whether participants choose to collect their CE credits. More
investigation is needed to understand how continuing education-ECHO integration can be improved
from the hub side, including needs assessments to understand whether investing in CE credit is
reasonable given demand from spoke participants.
Measuring ECHO Impact: Evaluation and Research at ECHO Hubs
For this survey, we draw a distinction between evaluation and research as having different goals. We
define the goal of evaluation as “measur[ing] the value of a program with the goal of supplying
information to stakeholders…”, and the goal of research as “producing generalizable knowledge of a
phenomenon.” We want to know whether hubs engage in evaluation and/or research, and if so, the
details of these projects. We expect that more focus on evaluation than research given the relative ease
of conducting evaluations in terms of funding, methods, and scope.
While there are a variety of frameworks for characterizing both evaluation and research, we use
Moore’s Levels of Continuing Education Outcomes as a general structure,ix which starts with relatively
simple outcomes (participation in a program/demographics) and moves to increasingly complex
outcomes (community health). We modified the language and included other outcomes given the
potential impact of ECHO on both patients and providers, as seen in the list of Data Types in Table 5.
We expected evaluation and research by ECHO hubs to focus on lower levels (i.e. “spoke participant”
attitudes, knowledge, and behavior) relative to other categories in Table 5. This is due to the relative
ease of access to spoke participants versus patients, as well as the relative ease of measuring these
effects through primary data collection by survey, as opposed to accessing those secondary data
resources including electronic health records, insurance claims data, and other administrative data sets
needed to examine patient behavior and outcomes over time.
Figure 4. Quantile distribution of the number of CE credits provided by hubs in the last year (n=40). The average number of credits is given by a dashed line.
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Data Type Evaluation (n=38) Research (n=19)
Spoke participant demographics 30 (79%) 13 (68%)
Spoke participant satisfaction 35 (92%) 12 (63%)
Spoke participant knowledge 28 (74%) 12 (63%)
Spoke participant behavior 21 (55%) 12 (63%)
Patient behavior 2 (5%) 3 (16%)
Patient medical outcomes 9 (24%) 6 (32%)
Patient socio-economic outcomes 2 (5%) 1 (5%)
Community outcomes/health 4 (10%) 4 (21%)
Epidemiology/disease monitoring 1 (3%) 2 (11%)
Workforce recruitment/retention 3 (8%) 0 (0%)
Evaluation Of the 48 respondents, 38 (79%) report their hub has done some kind of program evaluation (see: Table
5). Branched questions asked these hubs to briefly describe their evaluation process and list the types of
data they are collecting. The most common evaluation methods reported were post-teleECHO session
surveys and pre-post program surveys. Post-teleECHO session surveys are distributed to participants
after a virtual telementoring session to evaluate that meeting, often including CE credit questions. Pre-
post program surveys are those designed to compare participant characteristics before and after
participating in Project ECHO. These surveys may be distributed to participants once before the program
and once after, or may be delivered in retrospective format where participants concurrently evaluate
themselves before and after participation at the end of a program. Hubs listed interest in capturing self-
reported changes in provider characteristics and behaviors with these surveys, including: knowledge,
satisfaction, and self-efficacy, comfort delivering specialty care, patient caseload, wait-times, and
evidence-based practices.
A number of hubs also report using qualitative methods to evaluate their programs. Respondents
mention peer-to-peer evaluations of teleECHO program facilitators, interviews with facilitators and
participants (both in focus groups and as individuals), and thematic analysis of recorded teleECHO
sessions and case topics. These methods can be critical for understanding hubs ECHO work, given the
complexity of the ECHO model as an intervention, and therefore the diversity of potential mechanisms
by which positive impacts are produced.
From Table 5, we see that our expectations about the content of evaluations are met. Spoke participant
satisfaction data is collected by 92% of hubs conducting evaluations, demographic data by 79% of hubs,
and knowledge data by 74% of hubs. These constitute those lower-level categories in Moore’s
Table 5. Number (and percentage) of hubs collecting each type of data for the purposes of evaluation or research. Percentages are independent calculations using the number of hubs that engage in evaluation (n=38) or research (n=19) as the denominator.
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Framework. Beyond these, quantitative claims data and quality metrics, as well as estimates of patient
travel time avoided by providers’ participation in ECHO were mentioned by just a few hubs. This is likely
due to the difficulty of accessing data and conducting such analyses.
Research Table 5 reveals that a smaller number of hubs are engaged in research on ECHO, only 19 of the 48
respondents (40%). As expected, changes in provider (i.e. “spoke participant”) characteristics and
behavior as a result of ECHO participation is more likely the focus of hubs’ research; over 60% of hubs
conducting research reported collecting data on spoke participant demographics, satisfaction,
knowledge, and behavior. For example, hubs are looking at self-reported changes in providers’
performance of appropriate screenings, referral patterns to sub-specialists, and prescribing behavior.
Compared to evaluation data in Table 5, relatively higher proportions of hubs are doing research on
more complex outcomes in Moore’s Framework, including patient behavior and outcomes. For example,
some hubs are looking into changes in patient utilization patterns and whether costs are decreased as a
results of ECHO participation. Interestingly, quality improvement (QI) projects were mentioned by
several hubs doing research. QI is a burgeoning area for Project ECHO, and is one space where provider
performance is monitored over time – often on measures that capture elements of patient outcomes as
well.
Funding ECHO
The ECHO Movement is not supported by a centralized funding source – hubs fund their ECHO work
through a variety of mechanisms, often on a program-by-program basis. With respect to funding, we
hoped to better understand three things from the survey: hubs’ sources of funding, the ease with which
they are able to obtain different types of funding, and the difficulties and successes hubs face with
respect to funding.
Operations Funding: Financing TeleECHO Programs
Figure 5 displays information from two sets of related questions on the survey. First, respondents were
asked to categorize the funding scheme for their hub as being: from internal sources only, external
sources only, or a combination of both internal and external sources. A total of 46 hubs responded to
this question. Eleven hubs (23%) report receiving only internal funding for their ECHO work – that is,
from within their home institution. External funding sources only were reported by 15 hubs (31%), while
20 hubs report a combination of both internal and external funding (42%).
Internal Funding
Hubs with any internal funding (whether in whole or in part) were provided an open-ended space to
describe how this takes place at their hub. Internal funding is most often dedicated to providing
administrative staff, technical assistance, or continuing education credit support for the ECHO hub. With
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Figure 5. Hubs were asked to report whether their funding comes from internal, external, or a combination of both sources (left); those reporting any external funding were then asked to identify sources (right). Hubs may have more than one funding source.
respect to administrative staff, one respondent says, “Our onsite A/V department provides some
support. Because our ask is only for 3 hours per month, they provide this free of charge. I am full-time
and fill several ECHO staff roles. Because we are a huge institution, we're able to write our program into
hub staff members' time…” One respondent states, “We operated our program with minimal
administrative support, all involved wore many hats and we utilized a volunteer for IT support…”, while
another says “[my organization] has provided the equipment and facilities to host the ECHO programs
and has funding the ECHO manager who moderates and provides technical assistance for all ECHOs.”
Internal funding may be the closest mechanism available to hubs, but these resources may not be
reliable. A respondent at a public institution notes, “While [we are] a hub… the state/institutional
funding are to support specific programs, not the hub infrastructure, per say.” Finally, some ECHOs also
received no-cost continuing education credits, as they were able to leverage the infrastructure in place
at their organization.
External Funding
Hubs with any external funding were asked to list the sources of this external funding in a subsequent
set of questions.x The bar graph in Figure 5 provides a breakdown of the sources reported by the 35
hubs receiving some external funding for their ECHO work. Federal funding sources are the most
common, followed by state government and non-profit sources tied for second most common. Private
payer and non-profit organizations, as well as individual donor sources were relatively uncommon and
each reported by fewer than five hubs (14%). No local government sources are reported by our
respondents; this is interesting, given the potential utility of the ECHO model for addressing knowledge
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gaps in response to localized crises, especially in urban areas. Included among the “Other” external
sources of funding noted by hubs were two novel means of funding ECHO: one antimicrobial
stewardship teleECHO program charges hospitals a monthly rate for participation, and another hub
within a payer organization charges client-businesses a fee for making ECHO available.
Research Funding
Additional questions asked about funding sources for research. Of the 19 hubs that report doing
research (see: Table 5), eight (42%) report receiving funding from the federal government for their
projects; the same number report receiving funding from other sources for their projects (three hubs
received both federal and other funds for research). The most common source of federal funding for
research was the Health Resources and Services Administration (HRSA), followed by the Centers for
Disease Control and Prevention (CDC) and the Centers for Medicaid and Medicare Services (CMS). Other
federal funders for research on ECHO include the Agency for Healthcare Research and Quality (AHRQ),
the Substance Abuse and Mental Health Services Administration (SAMHSA) and even the Department of
Justice (DOJ). For non-federal funders, state departments of health were most commonly mentioned,
Figure 6. Distribution of launched ECHO hub responses to four questions about ease of obtaining funding to research, operate, launch, and expand their ECHO work. Scales are five points, ranging from “Very Difficult” to “Very Easy.”
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followed by public/private foundations and grants from healthcare industry leaders (e.g. Pfizer, Novo
Nordisk).
Funding Challenges and Opportunities
Respondents were asked the extent to which they agree or disagree with four items: “Funding [to
launch our first teleECHO program…to launch subsequent teleECHO programs…to operate our ECHO
hub… for research on ECHO] is readily available.” For ease of interpretation, we translate the scales of
agreement into scales of difficulty in Figure 6, which contains the distributions of responses for each of
the four items. Two open-ended questions then encouraged respondents to share the central challenge
they face and thoughts on what has made them successful when it comes to securing funding.
Distributions across these four indicators in Figure 6 demonstrate the varied experiences of partners
with respect to funding. In the aggregate, obtaining funding to launch their first teleECHO program was
the most difficult activity for hubs, with about 55% of respondents reporting that this task was “difficult”
or “very difficult.” Finding funds to operate an ECHO hub has a bimodal distribution, with approximately
45% of respondents indicating this process was difficult and 43% indicating it was easy. Funds for
launching subsequent teleECHO programs and for doing research on ECHO are relatively easy to obtain
for our reporting hub partners. This latter finding is particularly intriguing, given the relatively low
number of hubs conducting research on their ECHO work (see: Table 5).
To gain a deeper understanding of the difficulties our partners have experienced, we look to their open
responses. One of the main themes of the issues they encountered was access to sustainable funding.
“We were fortunate enough to get a small amount of seed funding from our medical school to get going,
but we are still in search of long-term sustainable funding” says one respondent, while another notes
the limitations placed on the hubs ECHO work by not having sustainable funds: “These are not billable
clinical encounters and funding for clinical capacity building is difficult to come by – and often soft-
dollars – which makes it especially difficult to develop appropriate administrative support positions
without sustainable funding.” One respondent attributed a lack of sustainable funding to the difficulty of
marketing their ECHO work, particularly because “We don't have team members that are expert in this
or have time.” Also, marketing the value of ECHO can be particularly difficult in the ‘fee-for-service’
context of American healthcare: “[the] value of Project ECHO [is] not represented by billable services in
an environment in which RVU's still dominate means of determining compensation.”
Related to the challenge of marketing ECHO is the most common issue noted by respondents – the
difficulties of relying upon grant funding. As one respondent says, “A lot of time goes into identifying
funding sources and grant writing.” This is exacerbated when grant cycles are particularly competitive.
“[Another] challenge is the current funding climate and generally feeling discouraged to apply for grants
that are competitive, time consuming, and announced with very short turn-around times,” notes one
respondent. Another highlights the need for strategic grant-writing: “Differing visions among founding
members have impacted collaborative efforts to secure further grant funding…Earlier, a good grant
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application was not funded because the request was large for this funder and it was a particularly
competitive cycle.”
At the same time, the experiences of hubs provide three general strategies for securing funding:
networking, data and evaluation, and targeting existing initiatives. Networking, both internally and
externally with key stakeholders, was mentioned frequently by respondents. One respondent says:
“Networking has played a vital role in growing our funding sources. As we began to gain
visibility within the state through networking events, conference presentations, and
collaborations with outside organizations and agencies, our ECHO program began to
receive more opportunities for funding.”
Other hubs found it helpful to work with their state’s Primary Care Association, their associated
university or hospital foundation, or to collaborate with other departments at their institution.
Relationship building with funders is key, including federal agencies, and some hubs were able to engage
existing funders in networking for more resources. Still others created a structure in which stakeholders
could be engaged:
“Central to our success has been building relationships with payers and other key
statewide stakeholders. We are in the process of creating a more robust infrastructure
for our ECHO programming in [our state] where little infrastructure was in place in the
past. In order to set this up, we engaged key statewide stakeholders in a steering
committee prior to the launch of the infrastructure.”
Data and evaluation results were critical for some hubs in acquiring financial support. One hub “track[s]
data for hospital administration to see financial benefit of relationships built by Project ECHO
teleClinics.” Another focuses on data collection for appeals to external stakeholders: “We will compile
data from [our] project to use in future presentations and appeals to funders.”
Finally, some hubs found success by targeting their ECHO work to existing, funded initiatives. Local
funding opportunities can be less competitive, and projects targeting specific needs are more likely to be
funded. One respondent notes, “In [our state], health department funding has been available for specific
projects that meet state priorities,” while another emphasizes “Targeting an urgent public health need,
and then requesting funds from a foundation focused on that need.” In any case, the “model's ability to
expand reach” is a noted selling point by hubs. One respondent summarizes this with a note of caution:
“Our initial program fundraising was successful as we pulled together many different
sources to meet a match grant we received from a health plan partner. Looking locally to
match larger corporate foundation or payer grants was a good strategy. Those local
funders, however, most generally support basic human needs programs and are not able
to provide long-term support.”
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Discussion
The goal of the Survey of Launched Hubs 2017 was to gain a high-level picture of the community of
ECHO hubs the United States outside of the DHA and VA systems. In part, this was done as a response to
the ECHO Act (2016), which calls for a broad understanding of the applications of the ECHO model as
well as barriers to and facilitators of its adoption (i.e. “replication”). The results of this survey speak to
the diversity of teleECHO programs hosted by hubs across the country, in terms of their number, topics,
and structure. Results with respect to funding in particular highlight some barriers to and facilitators of
ECHO replication.
It is important to note a several limitations of the survey results. First, the sample of hubs reflected in
our results, while generally representative of launched hubs in the United States, is not reflective of
hubs in the VA and DHA systems in US or hubs outside of the US. In future iterations of the survey, we
will work to reach out to these hubs. Second, results from this survey only provide information about
hubs that have successfully launched – understanding the barriers to and facilitators of ECHO for those
hubs that have not begun operating must be done through a separate survey project. Third, those
launched hubs that did not respond to the survey may operate in contexts that differ from those in our
sample. In future work, we hope to capture their feedback. Finally, because we chose to administer the
survey at the hub level, and not at the program level, we are unable to capture variation in teleECHO
programs across hubs beyond their titles and topics. In the future, we hope to reach out to individual
teleECHO programs to understand their specific operating contexts, which are likely to vary within and
across hubs.
The Typical ECHO Hub
Having examined our results across a variety of measures in the preceding report, we can now imagine
what the average ECHO hub in the United States (outside of the DHA and VA systems) looks like. The
hub will have one or two teleECHO programs running, likely focused on a chronic disease or condition,
and will not use cohorts to structure participation. It will have fewer than 10 experts facilitating
teleECHO programs, with five or fewer staffers (including a dedicated IT person) supporting operations
at the hub. Among these experts you are most likely to find physicians and mental health professionals
who have volunteered their time. The hub would provide continuing education credit, typically in the
form of CME, and will evaluate its teleECHO programs on a few metrics regarding spoke participant
satisfaction, knowledge, and changes in behavior as a result of ECHO participation. Finally, the hub is
likely to receive funding from both internal and external sources, the latter of which is most likely to
come from sources within the federal government.
Trends in the MetaECHO Community
The survey results also bring to light trends in the MetaECHO community, including the multidisciplinary
nature of teleECHO programs and strategies for sustainability. The multidisciplinary nature of the
movement is reflected in the range of topics covered in teleECHO programs, diverse professional
backgrounds of expert facilitators, and the types of continuing education credit provided by hubs. The
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focus of so many teleECHO programs on chronic, complex, and common conditions creates a need for
multidisciplinary perspectives, mirrored in the topics of teleECHO sessions and professional backgrounds
of experts. Behavioral/mental health integration is a common example provided by hubs. While this
survey otherwise focuses on ECHO hubs, the types of CE credit awarded by hubs provides a glimpse of
the array of participants that join teleECHO programs in hopes of providing better care for their
patients.
A large part of this survey focused on the funding of ECHO hubs; given that limited-term funding
mechanisms, including grants, are a very common source of funding, concerns about sustainability are
justified. At the same time, ECHO hubs have developed successful strategies for identifying and
acquiring funding for their ECHO work. These include leveraging available networks, using data and
evaluation to demonstrate the impact and value of their ECHO work, and targeting teleECHO programs
to local needs.
Conclusion
We consider the 2017 Survey of Launched Hubs a successful first attempt at better understanding
variation in ECHO hubs across the country that cannot be captured in our existing data systems. With a
response rate of 69%, we were able to capture information about teleECHO programs operating and in
development as of July 31 – September 1, 2017; the experts and administrative staff working at hubs;
the use of continuing education credit for teleECHO programs; hubs’ work to evaluate and research
ECHO; and how hubs have been able to fund their ECHO work. The survey results allowed us to speak to
areas that are a priorities in the ECHO Act of 2016 as well as create a picture of the “typical” launched
hub in the United States at the time. Since the conclusion of this survey, the number of hubs in the
United States has roughly doubled to 137 domestic hubs (as of June 29, 2018). Future work is required
to understand members of the ECHO movement that were not captured in this survey, including these
new hubs, launched hubs outside of the United States and teams that have received training but not yet
launched their ECHO programs. These partners will provide us with still more useful information about
the barriers to and facilitators of increased adoption of the ECHO model. Additionally, future work must
address the role of ECHO as a component of larger scale telehealth programs and training initiatives.
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i The Health Resources & Services Administration (HRSA) in the United States defines “telehealth” as the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. The ECHO model™ is not ‘traditional telemedicine’ where the specialist assumes care of the patient, but instead a telehealth intervention where the provider retains responsibility for managing the patient. iiii Estimates as of May 1, 2018. iii Expanding Capacity for Health Outcomes Act, Pub. Law 114-270,130 Stat. 1395. iv Paul A. Harris, Robert Taylor, Robert Thielke, Jonathon Payne, Nathaniel Gonzalez, Jose G. Conde, Research electronic data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support, J Biomed Inform. 2009 Apr;42(2):377-81. v Several hubs provided partial (n=5) responses. We do not report information on responses that were not completed (i.e. respondents hit “Submit”). Several hubs also provided multiple responses (n=4), but we worked with these partners to verify which completed response best reflects the hub as a whole, and we only report information from that entry. vi iECHO for Superhubs, the customer relations management software used by ECHO Institute, provides the age, location, and information on the number and topic of teleECHO programs the hub is running. vii Pub. Law 114-255, 130 Stat. 1033. Thirty states plan to fund teleECHO programs using Cures Act money to combat the opioid crisis. viii Spearman’s rank-order correlation coefficient (rs) is appropriate for measuring the association between continuous (count of teleECHO programs) and ordinal (# sessions per month) variables. It assumes a monotonic relationship between the variables, instead of the constant rate of change assumed by linear Pearson’s correlation. Correlation coefficients range from -1 to 1, with numbers closer to zero indicating weaker associations. ix Moore DE Jr, Green JS, Gallis HA. Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. J Contin Educ Health Prof. 2009;29(1):1-15. x We also asked respondents to estimate the percentage of their external funding that comes from these sources. However, we have reasons to doubt the reliability of these measures. The question wording did not clearly distinguish between external vs. all sources of funding when asking for a percentage breakdown. Also, many of our respondents note confusion in how to characterize federal “pass through” funding, often delivered through the state.
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Appendix A. Overview of ECHO Institute
The hub at University of New Mexico Health Sciences Center (UNM HSC), in Albuquerque, New Mexico
has been in operation since 2003. The hub at UNM HSC operates within the ECHO Institute, an
organization that plays a key role in the growth of the ECHO Movement; as such, it has a large staff,
many of whom dedicate some of their time to a facet of operating the hub but many of whom are also
focused on replication activities (i.e. “superhub” duties).
Because of its long history and role within the movement, ECHO Institute is an outlier. Therefore, it was
excluded from the hub survey process. In this section, we provide an overview of ECHO Institute’s
activities and characteristics in as of July 2017 for comparison.
As of July 31, 2017, ECHO Institute estimated* activities included:
30 active teleECHO programs focused on topics including Bone Health, Endocrinology, Chronic Pain, HIV, HCV, Integrated Addictions and Psychiatry, and Crisis Intervention Training.
Approximately 60 teleECHO program sessions per month
100+ staff, including hub experts and administrative staffers
More than 4,000 continuing education credits issued for the year: July 1, 2016 – July 1, 2017.
At least 15 IRB-approved projects to evaluate or research teleECHO program activities.
Funding from state and federal governmental as well as philanthropic sources.
* Rough estimates based upon available records.
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Appendix B. Instrument for the Survey of Launched Hubs 2017
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