Primary Care

A New Paradigm for Care: The Extension for Community Healthcare Outcomes (ECHO)

University of South Alabama

Dr Rutecki is professor of medicine at the University of South
Alabama College of Medicine in Mobile. He is also a member of the editorial board of CONSULTANT.

Experts agree that the present subspecialty model for the management of hepatitis C cannot be maintained.1 The sheer numbers of persons with hepatitis C, its increasing incidence, the large population with as-of-yet undiagnosed infection, and a limit to the number of gastroenterologists to see these patients equal a serious bottleneck. Presently, patients in underserved areas lack access to lifesaving care for this progressive disease. How about a remarkable solution to this problem that has been proven to work?


Subspecialists at the University of New Mexico decided to share their academic expertise related to hepatitis C with primary care physicians. As a result of the success with hepatitis C, they then expanded the model to a number of other diseases (diabetes, for example).2

The template is simple and successful. The subspecialists began a video interface with primary care physicians in underserved areas. They call the connection a “Community of Practice.” The subspecialist and his/her associates (colleagues, nurses, and physician extenders) discuss cases and share relevant information. The face-to-face time serves as a dynamic consult. Communication is clear and unfettered. Treatment for the disease can be discussed and side effects predicted. But it doesn’t end there. Follow-up can be presented at the next session.

The effort has been characterized as a “force multiplier.” When one patient is discussed, the primary care practitioner becomes a local expert on the disease in question and translates the expanded knowledge to more patients. Before anyone responds that he/she couldn’t manage interferon, ribavirin, and antivirals such as telaprevir, quality outcomes demonstrate that ECHO-trained primary care practitioners have outcomes equal to those of the academic subspecialists.

For those who do not reside in underserved areas (or locations far removed from academic support), the model was extended to urban sites as well. Outcomes were equivalent. Expertise has been built into primary care practices for diseases that were once considered the exclusive domain of subspecialists.


If ECHO becomes a new paradigm for additional locations and diseases, do you feel up to the challenge of becoming a combination primary care provider and subspecialist? It would be exciting to obtain continuing medical education in such a collegial and dynamic manner. Let me know your thoughts. 


1. Fried MW. Addressing the HCV referral and treatment bottleneck. Accessed July 11, 2012. 

2. The University of New Mexico School of Medicine Internal Medicine Project ECHOTM promotes care in underserved areas. Accessed July 11, 2012. 

Dr Rutecki reports that he has no relevant financial relationships to disclose.