Thank you, Andrew and Nancy and Lisa, for this great opportunity, honored to be here. I'm going to talk today about this issue of what is the role of ECHO, what is the role of telemedicine, integrative care models, in the next 15 minutes. I have a disclosure that I'm the director of the ECHO Institute and I've developed the ECHO model, so it's hard to be totally unbiased about it. So why do we need these new models? You heard the whole story, but the real issue is that only 19% of the estimated 71 million people have been diagnosed. And I can say this for certain, working in 38 different countries, that if a primary care clinician does not have a linkage to treatment, he or she will not diagnose the disease. Because the only thing it will do for him is create headaches with patient calls, etc. So screening has to be linked with some kind of linkage to care if one has to diagnose all the patients. And of course, we can see that it will save millions of lives if we do that. We had the same problem in New Mexico. We had diagnosed 28,000 patients and there was a tremendous lack of access to treatment. Less than 5% had been treated. This was around 2003. And I developed this model to bring access to care. It's based on four key ideas. First is amplification using technology to leverage specialty expertise. The second idea was to share best practices. And what we did is we set up 21 new centers of excellence for treating hepatitis C, five in the prison, 16 in rural clinics, gave them our protocol, the AASLD guideline, and not a single one of them was willing to give interferon ribavirin in the prison or clinic. So I asked myself, how did I become an expert? I was not born a hepatitis C expert. And when I did my fellowship in Boston, I would see a patient present to my professor, see another one present to my professor. I did this for two years and they started calling me a gastroenterologist. I said, aha, I'm going to use this model to create new hepatitis Cologists in New Mexico. We call that case-based learning or iterative guided practice in which all teach, all learn. So it's not a model of just specialists teaching primary care, but they are teaching each other. And then we use a web-based database to monitor outcomes. So what do we do? We train these physicians and physician assistants and nurse practitioners, give them web-based software and start conducting these tele-echo clinics called knowledge networks. In the big box is a liver specialist, a psychiatrist and a pharmacist, and 21 sites join and one by one present patients to each other and to the experts. And basically what we found was in a year, they became expert because they had presented about 10, 15, 20 patients, but learned on 300 of them. And now they could independently treat hepatitis C without the help of experts. And a typical echo clinic is two hours where we give one hour and 45 minutes of case discussions and a 15 minute lecture. And what we found is the expertise that they develop is through a process called a learning loop that they learn from the advice of experts. They learn from the lectures, the 15 minute lectures, they learn from each other, but mostly they learn by doing under guided practice, much like if you wanted to teach your daughter to drive a car, that's what you would do. You wouldn't just give her lectures. So of course, telemedicine has been around for a very long time. And so what is the difference? The top is echo and the bottom is telemedicine. In telemedicine, there is one expert helping a patient or helping one nurse practitioner. This could happen on the phone. This could happen virtual consultation. It could happen in many different ways, but it is traditionally a one to one interaction. Whereas in echo, there is a team of experts of different specialties, training whole teams who then help and go and treat hundreds and then thousands of patients. The idea is different. In telemedicine, it's like you're trying to give people fish, whereas in echo, you're trying to teach them to fish. The first series of studies we did in echo was to show that we could build self efficacy to give interferon ribavirin. If you look at question three, the ability to treat hepatitis C and manage side effects in 12 months goes from two out of seven to 5.2 out of seven, where seven is I'm an expert who can teach others. When you now become a local consultant within your clinic, it goes from 2.4 to 5.6. So what we found, every town that we put one echo expert in, all the patients in that community started ultimately going to them for treatment. And the weight in my clinic fell from eight months to two weeks, overall competence 2.8 to 5.5. We wanted to know why would a primary care doctor want to become a specialist in hepatitis C? So we did this kind of studies and showed that these doctors, nurse practitioners, and PAs felt that achieving competence in caring for patients was beneficial to them. They were not coming on the network just to help their patients, but they felt that it produces joy of work for them to participate in a community of learning. Finally, we did a study which was published in the New England Journal of Medicine in 2011, where we were able to show with interferon and ribavirin, these rural doctors, these prison doctors could get the same cure rates as university specialists. Another innovation by our team done by Dr. Carla Thornton from our team was we were treating in the prisons. We were getting very high cure rates, but they were infecting each other. So she developed this ECHO-based peer education program where she trained 500 prisoners with a 10-hour curriculum to become peer educators who would then participate in ECHO clinics. We connected all the prisons, and they in turn trained 10,000 prisoners on how not to get hepatitis C and take care of the liver, et cetera. This is the graduation ceremony. This is Albuquerque where ECHO started our hepatitis C network. We then expanded ECHO, and ECHO currently is occurring for 70 different disease areas, and we have 400 sites in New Mexico. This is the Veterans Administration ECHO network where nine university hubs are connected to 600 clinics for 39 different disease areas. We set a goal that we wanted to help a billion people. So we started teaching other universities to do ECHO, and there are 203 academic hubs in the United States. Most major universities have launched ECHO projects, and in the world, 38 countries have adopted the model as shown here. Getting back to hepatitis C, there are currently 51 HCV ECHO hubs in the world in countries as diverse as Australia, India, Pakistan, Georgia, Egypt, South Africa, Brazil, Argentina, United States, and Canada. And in the US, there are now 33 hub locations, and many of the people who run those ECHO projects happen to be sitting in this room today. As I mentioned now, ECHO is for 70 different disease areas. At any particular point of time, there are 72,000 clinicians being mentored around the world by ECHO networks. There have been about 1,300 ECHO networks set up, and our partners around the world and some from us have published 182 times in peer-reviewed publications demonstrating the effectiveness of ECHO. For hepatitis C, Argentina, they mentored 25 providers in 14 widely distributed provinces and showed that the SVR rate, they replicated our NEJM paper with DAAs and showed that 94% of their university patients and 96.4% of their ECHO patients got cured. This is the VA ECHO network for hepatitis C showing that they compared 6,400 patients of ECHO doctors versus 32,000 of non-ECHO doctors showing there was better access. And if the doctor participated in ECHO, there was a 21% times greater likelihood of getting treatment. This is an interesting paper reported by them for cirrhosis of the liver. Many of them had hepatitis C showing there was a 46% reduction in mortality. They did propensity score matching if the patient was presented in ECHO published in Hepatology in 2018. So let me switch to telemedicine. So in telemedicine, as traditionally, we think of it four separate ways, doctor to patient telemedicine, teleconsultation, teleeducation, and telemonitoring. The first three have been used in ECHO. There are so many studies showing effectiveness of telemedicine, but they're usually small studies. I think that the primary reason this modality, first of all, the modality has shown very high degree of effectiveness. Score rates are the same as specialists. The primary reason it hasn't really exploded in the world, despite the fact that telemedicine is widely available all over the world, is there's a shortage of specialists in the world. So when you take a specialist and put him on a camera with one patient or one doctor, they see less patients in the city. So the total number of patients doesn't go up as much as we would like. And so specialists, in general, have been reluctant to provide telemedicine services. Now there are two principal advantages that I see. So for example, since there are so many studies, I'll just cover two to show you some lessons that can be learned. This is Victoria, Australia. What they did is they created a nurse-led model in 14 prisons. And they used telemedicine support for these nurses and were able to show over a 13-month period that they could get a 96% cure rate. Intention to treat SVR-12 was 72%, largely because of loss to follow-up when people get released from prison. But demonstrating that telemedicine is as good as specialty care. Another important key lesson from telemedicine studies, all of them, is illustrated by this paper from Canada. Here what they did, they compared the characteristics of 157 patients they treated with telemedicine versus 1,130. Now this is direct telemedicine care. But what they showed was that the people who got telemedicine treatment were marginalized populations of one kind or another. So 7% indigenous versus 2.2% in the university. His history of injection drug use, 70% versus 54%. And cure rates were extraordinary in both groups. The key lesson from this part of telemedicine studies is that if you want to reach marginalized populations, it's going to be much easier to reach them where they live rather than make them travel to the university. And this is going to be a core key lesson that we'll have to learn in the integrated care models where we integrate for substance use care. And is that it's going to be impossible to take someone who's actively using drugs and move him to your university clinic for treatment. That's not going to happen. He or she is not going to show up there. So telemedicine can be an effective way to take care there. So one of the biggest challenges, of course, for us is this issue of people who inject drugs. Now what we know is that 40% of them globally have hepatitis C. And they are not only at a greater risk of infection, reinfection, disease progression, mortality, et cetera. And in order to get treatment to them, we need to integrate care of substance use with hepatitis C. The traditional model of making the diagnosis and then referring the patient just doesn't work. There is a massive amount of evidence for that. And this is a review of 44 studies that if you co-locate and do this issue of point of care testing and then treat them right then and then, you're going to get good success. And the other advantage in this setting is often these treatment sites have behavioral health expertise, which is very, very useful for these patients. Another really important model developed by Dr. Dheeman in Punjab, what they did is they did a multi-component intervention. And Punjab has 700,000 patients in India with hepatitis C. And their major university, which is PGI Chandigarh, created three university and 22 district hospitals. First they did a workshop with a predefined curriculum and a simplified algorithm. Second, they set up echo clinics every other week to supervise them. And another innovation they had is what we did with echo in the US with cell phones, phone calls. They created a WhatsApp group of these PCPs and enrolled 51,000 patients, SVR rates per protocol was 92.7%, intention to treat 72% ITT, modified ITT. This was published in Journal of Hepatology. This is their poster here, updated data. This is the echo clinic out of PGI Chandigarh. This is Dr. Dheeman on the top left. Another very important paper that they are actually going to present Dr. Dheeman tomorrow is that for PWID, 2700 patients, exactly the same model, that multi-component model, 92.4% per protocol, intention to treat 51.1%. They found exactly what every other study is finding, that you cannot easily get these people to come back for follow-up. A question that I'm often asked, I'll just take two minutes, that why do you need some models like this when you've got DAAs? The principal reason is that primary care doctors still have difficulty in correctly interpreting hepatitis serology, especially in accurately making the diagnosis of cirrhosis, screening for HCC, managing complications, and assessing need for liver transplant. And the virus doesn't walk into our clinic, it's patients that walk into our clinics. And so therefore, we need to be able to evaluate them effectively. So the conclusion that I wanted to bring to you is that if you're going to screen and diagnose all the patients, we have to build linkage to treatment, otherwise these screening programs will not work. And new care models that integrate technology to bring access to care to patients in their local communities will be highly effective in overcoming the barriers to care. And many studies have shown they're as effective as specialist-delivered care. Thank you for your attention.

Dr. Sanjeev Arora

ECHO

telemedicine

hepatitis C treatment

primary care clinicians