Rapid Deployment of a Statewide COVID-19 ECHO Program for Frontline Clinicians: Early Results and Lessons Learned

Educational actions conducted during the pandemic with primary health care professionals: a scoping review

OBJECTIVES

to map the educational actions conducted with primary health care professionals during the COVID-19 pandemic.

METHODS

a scoping review conducted in August 2023, which covered databases such as CINAHL, Medline, LILACS, IBECS, BDENF, and Web of Science. In total, 32 publications were analyzed through content analysis.

RESULTS

the primary beneficiaries of the educational actions included 69% physicians, 56% nurses, 25% pharmacists, 13% social workers and dentists, 9% psychologists, community health agents, and laboratory professionals, and 6% nursing technicians, nutritionists, and physical educators. The predominant educational interventions were training sessions (mentioned in 19 publications), followed by Continuing Health Education (10 publications) and Continuing Education (three publications).

FINAL CONSIDERATIONS

the educational interventions demonstrated positive impacts on professional practice, particularly the Continuing Health Education actions, which were notable for stimulating critical problem-solving among professionals.

Response and innovations of advanced practice nurses during the COVID-19 pandemic: A scoping review

AIM

Identify and map international evidence regarding innovations led by or involving advanced practice nurses in response to COVID-19.

BACKGROUND

COVID-19 necessitated unprecedented innovation in the organization and delivery of healthcare. Although advanced practice nurses have played a pivotal role during the pandemic, evidence of their contributions to innovations has not been synthesized. Evidence is needed to inform policies, practices, and research about the optimal use of advanced practice nurses.

METHODS

A scoping review was conducted and reported using the PRISMA-ScR checklist. Electronic databases were searched for peer-reviewed articles published between January 2020 and December 2021. Papers were included that focused on innovations emerging in response to COVID-19 and involved advanced practice nurses.

RESULTS

Fifty-one articles were included. Four themes were identified including telehealth, supporting and transforming care, multifaceted approaches, and provider education. Half of the articles used brief and mostly noncomparative approaches to evaluate innovations.

CONCLUSION

This is the first synthesis of international evidence examining the contributions of advanced practice nurses during the pandemic. Advanced practice nurses provided leadership for the innovation needed to rapidly respond to healthcare needs resulting from COVID-19. Innovations challenged legislative restrictions on practice, enabled implementation of telehealth and new models of care, and promoted evidence-informed and patient-centered care.

IMPLICATIONS FOR PRACTICE

Advanced practice nurses led, designed, implemented, and evaluated innovations in response to COVID-19. They facilitated the use of telehealth, supported or transformed models of care, and enabled health providers through education, mentorship, and mental health support.

IMPLICATION FOR POLICY

Advanced practice nurses are a critical resource for innovation and health system improvement. Permanent removal of legislative and regulatory barriers to their full scope of practice is needed.

Positive impact of a telemedicine education program on practicing health care workers during the COVID-19 pandemic in Ontario, Canada: A mixed methods study of an Extension for Community Healthcare Outcomes (ECHO) program

INTRODUCTION

In addition to shifting and expanding clinical responsibilities, rapidly evolving information and guidelines during the COVID-19 pandemic has made it difficult for health care workers (HCW) to synthesise and translate COVID-19 information into practice. This study evaluated whether a COVID-19-specific telemedicine education program (ECHO COVID) would impact health care workers' self-efficacy and satisfaction in the management of patients with COVID-19.

METHODS

A prospective mixed methods parallel-design study was conducted among ECHO COVID participants using pre-post questionnaires and a focus group discussion. Questionnaire results were examined for changes in health care workers' self-efficacy and satisfaction. Focus group discussion data were analysed to explore health care workers' experience in ECHO COVID and the context of their practice during the COVID-19 pandemic.

RESULTS

239 health care workers registered in ECHO COVID and 114 (47.7%) completed questionnaires and attended at least one ECHO COVID session. Median self-efficacy scores increased from 5 (IQR 4-6) to 6 (IQR 6-6) (p < 0.0001), independent of profession, years in practice, age group, or practice environment. Participants were highly satisfied with ECHO COVID sessions with a median score of 4 (IQR 4-5). Focus group discussion data indicated that health care workers gained knowledge through ECHO COVID and revealed facilitators for ECHO COVID program success, including the transition to virtual care, the practicability of knowledge provided, and a 'perspective from the trenches.'

DISCUSSION

This study demonstrated that a telemedicine education program aimed to support health care workers in managing patients with COVID-19 had a positive impact on health care workers' self-efficacy and satisfaction. This impact was specifically mediated by the ECHO COVID program.

Patients' Willingness to Accept Social Needs Navigation After In-Person versus Remote Screening

BACKGROUND

Social needs screening and referral interventions are increasingly common in health care settings. Although remote screening offers a potentially more practical alternative to traditional in-person screening, there is concern that screening patients remotely could adversely affect patient engagement, including interest in accepting social needs navigation.

METHODS

We conducted a cross-sectional study using a multivariable logistic regression analysis and data from the Accountable Health Communities (AHC) model in Oregon. Participants were Medicare and Medicaid beneficiaries in the AHC model from October 2018 through December 2020. The outcome variable was patients' willingness to accept social needs navigation assistance. We included an interaction term (total number of social needs + screening mode) to test whether in-person versus remote screening was an effect modifier.

RESULTS

The study included participants who screened positive for ≥1 social need(s); 43% were screened in person and 57% remotely. Overall, 71% of participants were willing to accept help with social needs. Neither screening mode nor interaction term were significantly associated with willingness to accept navigation assistance.

CONCLUSIONS

Among patients presenting with similar numbers of social needs, results indicate that type of screening mode may not adversely affect patients' willingness to accept health care-based navigation for social needs.

The administrative burden on physicians and technicians for organizing international telemedicine conferences: utility of a shared program management system in an international telemedicine network

Background

The use of international telemedicine conferences for doctor-to-doctor education has increased following the coronavirus disease 2019 pandemic to ensure health and safety. Previous studies have shown that administrative tasks are an obstacle to promoting international telemedicine conferences but have not identified the type of system needed to alleviate this burden.

Objective

The Asia-Pacific Advanced Network Medical Working Group (APAN-MWG) is an international telemedicine network that includes 1171 medical institutions and 3653 members as of July 21, 2021. The APAN-MWG has supported international telemedicine conferences since 2005 and implemented a program management system in 2014. The present study explores the conference organizers' tasks and evaluates the APAN-MWG management system through a survey of organizers.

Methods

We developed a system called med-hok for managing conference programs, international medical institutions, and their members. We investigated all event programs using the med-hok system from June 3, 2015 to July 21, 2021. The target samples included 64 conference programs in 12 series hosted by 13 program organizers. The effectiveness of the system was evaluated using a four-point Likert scale (very good, good, poor, and very poor). The User Experience Questionnaire (UEQ) was used to assess user experience.

Results

The survey response rate of the program organizers, who hosted 11 different program series in 7 Asian countries, was 92% (12/13). The administrative tasks for managing the programs were primarily handled by physicians (67%, 8/12), followed by technicians (17%, 2/12). The average program scope encompassed 7 countries, 10 institutions, and 44 members. The largest program comprised 194 members from 49 institutions in 25 countries and was managed by two physicians and one technician. Most program organizers (8/12, 67%) indicated that verifying member information was the most burdensome aspect of organizing teleconferences. Over 90% of respondents positively evaluated med-hok in the following areas: "Confirmation of institution information," "Confirmation of member information," "Confirmation of technical information," "Maintaining the latest status of the program," "Announcing and publicizing the event," and "Formatting and correcting misspellings." They rated user experience positively for all aspects (attractiveness: 1.22; practical quality: 1.42; and hedonic quality: 1.24).

Conclusions

Many tasks of organizing casual international telemedicine conferences are handled by physicians and technicians with no operating funds or staff, unlike those in large academic conferences. The proposed system was found to help program organizers manage participants and communicate information effectively. These findings suggest that international telemedicine networks should implement an administrative support system to conduct program operations efficiently.

Community Case Study: The Role of Live-Interactive Learning Network in Addressing Community Wide Information Needs Through Show-Me COVID-19 ECHO

After the COVID-19 pandemic reached Missouri, the Show-Me ECHO (Extension for Community Healthcare Outcomes) project initiated COVID-19 ECHO virtual knowledge-sharing networking sessions. These live-interactive weekly sessions inform participants about up-to-date evidence-based recommendations and guidelines through expert didactic lectures followed by real-life case discussions. We conducted a qualitative analysis of pre-session surveys and questions asked during sessions to learn about information needs of community members during first months of public health emergency. This was a pilot project using qualitative analysis of registration questions regarding anticipated COVID-19 community information needs, and participants' questions asked during sessions collected from March 23 until May 4, 2020. We also analyzed participants' satisfaction surveys collected in December 2020. A total of 761 unique participants attended COVID-19 ECHO during the study period. Survey was completed by 692 respondents. Participants asked 315 questions resulting in 797 identified community information needs. Five thematic categories were recognized: patient care, information seeking, minimizing exposure, financial themes, and general comments. Most attendees rated content quality, logistics, and technical operations as good or excellent on a five-point Likert scale. The COVID-19 ECHO model was responsive to the needs of participants by sharing and discussing up-to-date recommendations and guidelines regarding COVID-19. Sessions were well-attended, and the didactic presenters were invited to deliver same or similar presentations at Boone County Medical Society (BCMS) weekly seminars, suggesting the value of the project to healthcare providers and other community members caring for or working with the most vulnerable populations.

Stakeholder perceptions of the use of a rapidly deployed modified ECHO to train and prepare healthcare providers for COVID-19

Background:

Innovative approaches to deliver timely information to rural healthcare providers are necessary with the COVID-19 pandemic. Project Extension for Community Healthcare Outcomes (ECHO) is a telementoring program designed to provide practitioners in rural communities with opportunities to engage in specialty training. We examined participant perceptions of a rapidly deployed, single continuing education session to improve healthcare provider preparedness for COVID-19 in Idaho.

Methods:

A modified Project ECHO session was developed to inform providers about emergency preparedness, treatment, testing, and resources for COVID-19. A post-session survey examined session impact and barriers on clinical practice.

Results:

Respondents believed the modified ECHO session increased COVID-19 knowledge and would improve their clinical practice and preparedness. Respondents were satisfied with the session and identified content, interdisciplinary collaboration, and format as beneficial; perceived barriers for utilizing session information included a lack of relevance of content and clinical applicability, and time constraints.

Conclusions:

A rapidly deployed modified Project ECHO session was perceived as an effective mechanism to foster collaboration and relay information to promote best practices at the start of the COVID-19 pandemic. An established Project ECHO network may be useful to rapidly exchange knowledge and information during a health emergency.

Remote learning developments in postgraduate medical education in response to the COVID-19 pandemic - A BEME systematic review: BEME Guide No. 71

BACKGROUND

Prior reviews investigated medical education developments in response to COVID-19, identifying the pivot to remote learning as a key area for future investigation. This review synthesized online learning developments aimed at replacing previously face-to-face 'classroom' activities for postgraduate learners.

METHODS

Four online databases (CINAHL, Embase, PsychINFO, and PubMed) and MedEdPublish were searched through 21 December 2020. Two authors independently screened titles, abstracts and full texts, performed data extraction, and assessed risk of bias. The PICRAT technology integration framework was applied to examine how teachers integrated and learners engaged with technology. A descriptive synthesis and outcomes were reported. A thematic analysis explored limitations and lessons learned.

RESULTS

Fifty-one publications were included. Fifteen collaborations were featured, including international partnerships and national networks of program directors. Thirty-nine developments described pivots of existing educational offerings online and twelve described new developments. Most interventions included synchronous activities (n Fif5). Virtual engagement was promoted through chat, virtual whiteboards, polling, and breakouts. Teacher's use of technology largely replaced traditional practice. Student engagement was largely interactive. Underpinning theories were uncommon. Quality assessments revealed moderate to high risk of bias in study reporting and methodology. Forty-five developments assessed reaction; twenty-five attitudes, knowledge or skills; and two behavior. Outcomes were markedly positive. Eighteen publications reported social media or other outcomes, including reach, engagement, and participation. Limitations included loss of social interactions, lack of hands-on experiences, challenges with technology and issues with study design. Lessons learned highlighted the flexibility of online learning, as well as practical advice to optimize the online environment.

CONCLUSIONS

This review offers guidance to educators attempting to optimize learning in a post-pandemic world. Future developments would benefit from leveraging collaborations, considering technology integration frameworks, underpinning developments with theory, exploring additional outcomes, and designing and reporting developments in a manner that supports replication.

Clinicians' Core Needs in a Pandemic: Qualitative Findings From the Chat Box in a Statewide COVID-19 ECHO Program

PURPOSE

Research on primary care's role in a pandemic response has not adequately considered the day-to-day needs of clinicians in the midst of a crisis. We created an Oregon COVID-19 ECHO (Extension for Community Healthcare Outcomes) program, a telementoring education model for clinicians. The program was adapted for a large audience and encouraged interactivity among the hundreds of participants via the chat box. We assessed how chat box communications within the statewide program identified and ameliorated some of clinicians' needs during the pandemic.

METHODS

We conducted a qualitative analysis of chat box transcripts from 11 sessions.We coded transcripts using the editing method, whereby analysts generate categories predominantly from the data, but also from prior knowledge. We then explored the context of clinicians' needs in a pandemic, as conceptualized in Maslow's hierarchy of needs adapted for physicians: physiologic, safety, love and belonging, esteem, and self-actualization.

RESULTS

The mean number of chat box participants was 492 per session (range, 385 to 763). Participants asked 1,462 questions and made 819 comments throughout the program. We identified 3 key themes: seeking answers and trustworthy information, seeking practical resources, and seeking and providing affirmation and peer support. These themes mapped onto the Maslow's needs framework. We found that participants were able to create a virtual community in the chat box that supported many of their needs.

CONCLUSIONS

Using a novel data source, we found sharing the experience of practicing in a rapidly changing environment via comments and questions in an ECHO program both defined and supported participants' needs.

Use of Project ECHO Telementoring Model in Continuing Medical Education for Pediatricians in Vietnam: Preliminary Results

The ECHO (Extension for Community Health Outcomes) model has been introduced and implemented in several hospitals and health programs in Vietnam since 2015. In 2018, Vietnam National Children’s Hospital (VNCH) officially implemented the ECHO model to provide continuing medical education (CME) credits on pediatrics topics for medical staff in its satellite hospitals and health centers in the Northern region of Vietnam. This paper presents preliminary results of the ECHO program at VNCH. Methods included pre- and post-program assessments of pediatricians’ clinical knowledge, self-efficacy, and professional satisfaction. The analysis compared the differences between pre/post scores descriptively. Knowledge of participants increased by 22.5% points on average. More than 90% of Project ECHO-Pediatrics participants experienced increased confidence. Overall, there was an improvement in participants’ self-efficacy in the post-training compared to the pre-training (range 14.7%-22.6% difference from pre-training). All participants improved on their results in the clinical test immediately after the training and maintained it after 3 months. The study demonstrated the ability Project ECHO to improve healthcare worker knowledge and satisfaction.

Building Mental Health Capacity: Exploring the Role of Adaptive Expertise in the ECHO Virtual Learning Model

INTRODUCTION

With the proliferation of virtual learning programs during the COVID-19 pandemic, there is increased need to understand learner experiences and impact on developing expertise. Project Extension for Community Healthcare Outcomes (Project ECHO®) is an established hub-and-spoke tele-education model aimed at building capacity and expertise in primary care providers. Our qualitative study explored how learning experiences within an ECHO mental health care program supported provider learning and ability to solve complex clinical problems.

METHODS

We sampled ECHO sessions across a 34-week cycle and analyzed audio transcribed data. Two individuals coded participant interactions during 2-hour recorded sessions using an iterative, constant comparative methodology.

RESULTS

The authors identified four key mechanisms of learning in ECHO: (1) fostering participants' productive struggle with cases, (2) development of an integrated understanding, (3) collaborative reformulation of cases, and (4) generation of conceptual solutions based on a new understanding. Throughout the ECHO sessions, learning was observed to be multidirectional from both the hub-to-spoke and between spoke sites.

DISCUSSION

Despite the widespread implementation of Project ECHO and other virtual learning models, a paucity of research has focused on mechanisms of virtual learning within these models. Our study demonstrated a bidirectional exchange of knowledge between hub specialist teams and primary care provider spokes that aligned with the development of adaptive expertise through specific learning experiences in Project ECHO. Moreover, the ECHO structure may further support the development of adaptive expertise to better prepare participants to address patients' complex mental health needs.

An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64

BACKGROUND

COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research.

METHODS

The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts.

RESULTS

One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning (n = 58), simulation (n = 24), assessment (n = 11), well-being (n = 8), telehealth (n = 5), clinical service reconfigurations (n = 4), interviews (n = 4), service provision (n = 2), faculty development (n = 2) and other (n = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement).

CONCLUSIONS

This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.

Remote Mentorship Using Video Conferencing as an Effective Tool to Strengthen Laboratory Quality Management in Clinical Laboratories: Lessons From Cambodia

This program to strengthen laboratory quality management systems in Cambodia demonstrated significant improvements in conformity to ISO 15189 standards in participating laboratories, correlating with laboratory participation time in video conference training activities led by quality improvement mentors over the program implementation period.

Background:

Providing professional development opportunities to staff working in clinical laboratories undergoing quality improvement programs can be challenged by limited funding, particularly in resource-limited countries such as Cambodia. Using innovative approaches such as video conferencing can connect mentors with practitioners regardless of location. This study describes and evaluates the methods, outputs, and outcomes of a quality improvement program implemented in 12 public hospital laboratories in Cambodia between January 2018 and April 2019. The program used mixed intervention methods including both in-person and remote-access training and mentorship.

Methods:

Training outputs were quantified from the activity reports of program trainers and mentors. Program outcomes were measured by pre- and postimplementation audits of laboratory quality management system conformity to international standards. Variations in improved outcomes were assessed in relation to the time spent by laboratory personnel in video conference training and mentoring activity. An additional cross-sectional comparison described the difference in final audit scores between participating and nonparticipating laboratories.

Results:

Laboratories significantly improved their audit scores over the project period, showing significant improvement in all sections of the ISO 15189 standard. Pre- and postaudit score differences and laboratory personnel participation time in remote mentoring activities showed a strong monotonic relationship. Average input per laboratory was 6,027±2,454 minutes of participation in video conference activities with mentors. Audit scores of participating laboratories were significantly higher than those of laboratories with no quality improvement program.

Conclusion:

Laboratories improved significantly in ISO 15189 conformity following structured laboratory quality management systems training supported by remote and on-site mentoring. The correlation of laboratory participation in video conference activities highlights the utility of remote video conferencing technology to strengthen laboratories in resource-limited settings and to build communities of practice to address quality improvement issues in health care. These findings are particularly relevant in light of the COVID-19 pandemic.

Innovative COVID-19 Programs to Rapidly Serve New Mexico : Project ECHO

Project ECHO (Extension for Community Healthcare Outcomes) at the University of New Mexico is a telementoring program that uses videoconferencing technology to connect health care providers in underserved communities with subject matter experts. In March 2020, Project ECHO created 10 coronavirus disease 2019 (COVID-19) telementoring programs to meet the public health needs of clinicians and teachers living in underserved rural and urban regions of New Mexico. The newly created COVID-19 programs include 7 weekly sessions (Community Health Worker [in English and Spanish], Critical Care, Education, First-Responder Resiliency, Infectious Disease Office Hours, and Multi-specialty) and 3 one-day special sessions. We calculated the total number of attendees, along with the range and standard deviation, per session by program. Certain programs (Critical Care, Infectious Disease Office Hours, Multi-specialty) recorded the profession of attendees when available. The Project ECHO research team collected COVID-19 infection data by county from March 11 through May 31, 2020. During that same period, 9765 health care and general education professionals participated in the COVID-19 programs, and participants from 31 of 35 (89%) counties in New Mexico attended the sessions. Our initial evaluation of these programs demonstrates that an interprofessional clinician group and teachers used the Project ECHO network to build a community of practice and social network while meeting their educational and professional needs. Because of Project ECHO's large reach, the results of the New Mexico COVID-19 response suggest that the rapid use of ECHO telementoring could be used for other urgent national public health problems.