Kerry Whittemore: In this episode of M.ED: Medical Education for the Practicing Clinician, I will be speaking with Dr. Terry Box. Dr. Box is a hepatologist, which is a liver specialist at University of Utah Health. He is also a Texan, as you can tell by his amazing accent. He received his undergraduate degree at UT Austin, followed by his medical degree at UT Southwestern. He then moved to Utah to complete his residency training in internal medicine, followed by a fellowship in gastroenterology. He then completed further training in clinical transplant hepatology. Dr. Box's expertise is in diagnosing and treating diseases of the liver. He has specific expertise in hepatitis B and C, hepatocellular carcinoma, and liver transplantation. He is also one of only two liver specialists in the world who have received their own liver transplant. He's going to be talking to us about his work with Project ECHO, which is a technology-based free learning collaborative between primary care and specialty providers, which he started at University of Utah Health 10 years ago. Please take a listen as we learn more about this worthwhile project that could benefit many of our listeners, as well as Dr. Box's personal experience as a liver transplant recipient. Let's get right to it.

Tell us about Project ECHO and how you got involved?

Terry Box: Project ECHO is an acronym for Extension for Community Healthcare Outcome. Project ECHO is the brainchild of a colleague of mine, a hepatologist in Albuquerque, at the University of New Mexico, who like the rest of us in hepatology in the early 2000s, were literally seeing almost nothing but patients with hepatitis C. Epidemic proportion, maybe 150,000 new cases a year at that time.

KW: Wow, I had no idea it was so much.

0:02:02.8 TB: We're having an epidemic now and it's 55,000 new cases a year. And so you can imagine what it was like, and it was dominating the lives of gastroenterologists and hepatologists. Moreover, in a state like New Mexico, Utah, Nevada, Wyoming, the West, a lot of people don't live close to their healthcare provider, particularly, if they need specialty care.

KW: Right.

TB: Dr. Arora's clinic was overrun with hepatitis C, couldn't see anything else, and it was evident to him that these patients were driving 250 miles each way to see him, spend 30 minutes with him to be seen, assessed, and started on Interferon and Ribavirin in those days, pretty toxic and barely effective. And if the primary providers in their home communities had enough resources and backup, so to speak, from specialists, they could do this themselves. So he came up with the idea of using exactly this type of platform, interactive video conferencing, to connect providers in rural and underserved frontier New Mexico with Albuquerque who would present cases to him and he would give them advice. They would treat the patients, they would have the same, if not better, outcome as he had in his clinic treating a very complex but common disease, hepatitis C. The medications of which, as I said, were very toxic and on a good day, 50% effective.

KW: Okay, did they end up with patients seeing the specialists at all or was all the care coordinated through their primary care?

TB: Nope, all the care was coordinated by the primary provider in the home community, or in the case of the prison, by PAs who were working in the prison. So this concept was very unique and disruptive, and it took a while for the impact of it to be recognized, but by 2009, a colleague of ours in Seattle, who was treating a lot of hep C and HIV in his infectious diseases clinic, replicated what Dr. Arora had done. Soon thereafter, a fellow in Chicago did, and then I replicated it in 2011 at the University of Utah, and since then, we've probably had ECHOs in about 18, 19 different disciplines, and are currently running ECHOs in six different disciplines, including the original hep C ECHO.

How many places across the country have a similar project?

TB: For the longest period of time, I was one of four, five, or six sites, and now there are over 180 in the United States, and approaching 300 worldwide. This has become a worldwide movement.

KW: Wow.

TB: As you can imagine, in resource-confined healthcare environments, this method of utilizing telemetry work exceedingly well, and particularly in centralized healthcare delivery countries. So in certain countries, this is practically the way that many infectious diseases are treated, HIV, tuberculosis in those countries where it's still a problem, as well as HCV, HBV, etcetera.

KW: Are those places that have one central electronic medical record system or not even necessarily have an EMR?

TB: Yeah, most of them do have a single universally accessible healthcare delivery system. And for what it's worth, those countries are the ones that are leading the way, quite frankly, in eliminating hepatitis C because everybody's on board with screening and treating.

KW: Right, interesting. Is there some overarching Project ECHO committee that gives approval to these different organizations or is it just kind of happened on its own?

KW: Well, there is a process in Albuquerque, and Dr. Arora has been so successful in lining up funding for this very innovative process that he now runs the ECHO Institute. So, there is a week-long process now where you go to Albuquerque or nowadays do it virtually, but you get what's called immersion, you learn about the history of, the implementation of and sort of get introduced to those aspects of Project ECHO, and create the success and what you must do to bring up an ECHO and keep it running.

Within the University of Utah or the state of Utah, what are the options of Project ECHO now? What fields are there?

TB: We have Adult Behavioral Health. We have sort of a General Pediatrics ECHO, which goes through different modules of different areas of need for community pediatricians or community providers, basically, seeing kids, a burn ECHO that does burn and soft tissue. Now they don't do it frequently, but they have huge, almost international turnout for their burn and soft tissue ECHOs. Pregnancy care, HCV. I do something with one of my GI colleagues in what we call GI liver care. 

KW: There's been a few on COVID.

TB: Yes, we had a limited series. Shortly after the pandemic was declared where we did an every other week presentation to community providers throughout the Mountain West, we would have 200, 250 people attend just to get introduced to the latest trends in COVID. And now quite frankly, we're wrapping up a 16-week series with about 60 to 80 nursing homes in the area doing specific issues as far as keeping COVID out of your nursing home.

KW: I saw when I was on the ECHO website about a nursing home project where the nursing home can get $6000. Is that the same thing or is that different?

TB: Yeah, that's it, for their time and their time is precious. We try to get one of the nursing home leaders, and the head nurse, and a couple of the staff to come and hear about all of these techniques that are useful in containing COVID once you have it in your building or hopefully keeping it out.

Where does the funding come from at the University of Utah level, is it from the university itself or some outside force?

TB: The University of Utah has been very insightful, in my opinion, from the beginning, I made a presentation back in early 2011. I went to Albuquerque in 2010 to look at it. I was sold on it immediately. I took another trip back with a couple of administrators. When we came back, I made a presentation to the department chairs and then the VP of Health Sciences, Dr. Lorris Betz, and by the end of my little short presentation, Dr. Betz was sold and he looked around the room and said we're gonna support you for two years, and then it's up to you to make it work." So, we had that support for a couple of years, and it was so successful that the hospital's program for outreach and network development has sort of taken us under their wing and we are part of their budget.

KW: Okay, so now you're going on 10 years?

TB: We are in our 10th year. We will celebrate our 10th anniversary in October this year and I've been able, finally, after trying for years to get on the agenda, I found I was able to make a plea to the State Legislature this last session and I had a pretty high ranking as far as the possibility of getting funding, didn't quite make it, but I think we'll get it next year. So hopefully, we can sustain ourselves. There is no method to bill for provider-to-provider consultation. And that's basically what we're doing. There is no patient interaction. We are interacting with the providers.

KW: That's what I was wondering. A lot of things come down to money, and it's nice that the university was supporting this because cause part of me thinks, "Well, they're gonna have less patients that come to the U because they're all gonna stay in their rural areas and they're gonna have less revenue." But I guess they didn't. You had so much Hep C patients that it was fine, like just have less waiting time.

How does Project Echo expands the workforce?

TB: Yeah. And now Hep C is so much easier to take care of but if you're not seeing your clinic full of Hep C, you're actually seeing in liver disease, you're seeing very complex liver disease that probably generates more income for the institution, quite frankly. You've sort of cleaned up your referral base in a way. But we never did pitch this as a money maker. We pitched this is as the right thing to do because what we're doing is using education. This is an educational platform. We're providing sort of filtered knowledge, I mean each of our half a dozen different disciplines, we have high-risk obstetricians taking cases, we have adult behavioral health, people taking behavioral health cases. They filtered all the knowledge that they're getting overwhelmed with, giving it back to the primary care in these case-based learning episodes.

TB: You present a case to your mentor, your mentor gives you feedback, you take that feedback and you treat that patient, but you also treat the next six that you see just like that. So we're really just expanding the workforce, so to speak, as to who can take care of these specialty level healthcare needs.

KW: And obviously it provides the best care for the patient, which is the best outcome.

TB: You get specialty level care at home. You don't lose a day travelling, you don't have to figure out what you're gonna do with your kids, you save the money. Theoretically, when you look at it from the perspective of what does it do for the system in general, this is an extraordinarily high value program.

KW: Right. And it also means the patient's being treated by their primary doctor that hopefully they trust and know and they're not gonna no-show as much as there are not less barriers.

TB: Well, you've been reading the book. That's exactly what Dr. Arora says.

KW: Well, through the root stuff, we talk about a lot about access to care. So I was looking on the website and for example, behavioral health, it looks like there's a weekly behavioral health talk on Thursdays from 12:00 to 1:00. How much of that... Because it looks like they all had kind of subjects, a broad topic, so how much of that is the psychiatrist going through that topic versus addressing a case that a primary care doctor... I don't know, do they email in? How does it get to the specialist?

TB: So we have an electronic format to submit cases. It's like taking a survey. You put in data that's requested, there are a few drop-down boxes, and then if you have specific lab data for instance, in my Hep C cases or my liver care cases, I have about a five page survey that patients... Not patients, but providers fill out and submit. And we'll run anywhere from 8 to 20 Hep C cases a week. Now for most of our ECHOs, there's about half of the time is a didactic on a specified topic and the rest of it would be a case or two discussion 'cause as you can imagine, a behavioral health care case takes more than five minutes to discuss. If you give me a Hep C case, we can get through that in a very efficient way anywhere from five to 10 minutes depending on the complexities. So in behavioral health, there's a lot more didactic than case presentation, but in reality, case presentation is the way we all learn in medicine, right?

KW: Right.

TB: I mean from the day you started doing clinical work, you wind up in some fashion and presented a case to your mentor, whether that was your resident or one of your fellow interns or your attending. This is the way we learn in medicine and this is the way we produce lifelong learning for our community providers who join our project's ECHO.

How are cases addressed?

KW: So do you try and have the cases be kind of a mixture of many cases that are presented so you can get the most common problems addressed or are they usually a specific case that gets addressed?

TB: No. Actually, we encourage people to bring any case at any time. If it happens to match up to the topic covered, hallelujah, but the reality is we want the providers to know that we're there to help them whenever they need help. And just 'cause we only meet with them on video conference weekly or every other week, they have all of our cellphones, they can approach us any time they need a little extra backup. And then of course if we hear a case that really needs referral, then we say, "Dr. X, this case is very complex. You need to send this to your favorite pediatrician," or whatever and we make sure the patient is in the proper environment to be treated. But the reality is 95% of what we get presented is easily treated in the ECHO environment.

KW: And is every specialty that's covered, So behavioral health, Hep C, pregnancy for example, are they all treated the same way or does each discipline do its own thing?

TB: Oh, every mentor will have her or his way of doing things and so that's... I mean we have sort of a standardized approach to extracting the cases, but every case in a way is unique. And depending on the provider, if it's a particularly complex case, you might get two or three opinions. In fact, what happens in these well-established ECHO sessions is that it's an all-teach, all-learn environment at that point. We have some of our Hep C providers who joined us since the beginning. They don't need to join, but they live in a rural remote area, this is their collegial environment.

KW: That makes sense.

TB: They get together with their virtual community and then they start making comments during the discussion, that is actually very instructive for everybody. So when a case gets really complex, there's frequently an interactive discussion, it's not just a one-way flow of information from the mentor.

Where do people come from to join Project Echo?

KW: And where do your people come from, that join ECHO. Is it just Utah? I'm guessing not.

TB: You're correct. When we were just isolated as the fourth ECHO in the world, we had people literally coming from Northern and Southern California. Now, it's just our continuous states, but we still have a reach just like the University of Utah has a reach, as far as from where do patients come, Wyoming, Idaho, Montana, eastern Nevada, actually, that southwest corner of Colorado. So our ECHO programs are very diverse as far as the states from which people come.

KW: If there is some doctor in say Arkansas listening to this who's interested, could he come to Utah, is he or she, or would there be a closer one that they would be referred to? How does that work?

TB: In the early days, we would have people... Literally, we had a person from Tennessee come. And even though after a few years, there were places between here and Tennessee, because he knew us, he just kept coming. So you're absolutely correct. If you have access to the internet, it doesn't matter where you are.

How many providers join Project Echo in a year? 

TB: We will have to our ECHO roughly... The Covid year doesn't count, 'cause we had so many more people than usual, we had 250 unique providers signing on for our Covid limited series. During a typical year, we'll have maybe 300 to 400 unique providers joining our ECHOs during the...

KW: Different specialties.

TB: Yeah, across the entire spectrum. I may have 100 or so people join my Hep C ECHO, but the Hep C historically, has been our busiest as far as cases, but it's not our best attended. Our best attended ECHOs right now are our adult behavioral health, and pediatrics.

KW: Impressive, I'm totally not surprised about the adult behavioral health. As just a primary care doctor, behavioral health is really challenging, especially... I'll try this anti-depressant and then that one and one more, and then I'm stuck.

TB: That's the whole point. What we want to do is, be able to efficiently create an environment where these rural providers can get to the root of the problem and treat them appropriately, as long as possible before they really have to call for help. The reality is, I think we just need to work harder in a way, on creating a more efficient way to deal with these complex cases. We're always evolving, trying to improve our product.

KW: And I think that also reflects the fact that there's such a limited amount of behavioral health specialists out there. It's just so hard for me as a pediatrician, to find a child psychiatrist is really challenging for my patients. I'm sure it's the same in the adult world, there's just not many psychiatrists in the rural parts of the state or elsewhere.

TB: No, there simply are not. It's really an urban... It's an urban phenomenon, as to where the trained psychiatrists land, and particularly in pediatrics. So having access to pediatric behavioral health and just pick your disease state. We had one year committed in pediatrics, to autism. And it was hugely successful, but you gotta move on, you gotta treat the entire spectrum. And this year, we're doing different modules, so it's been different. But just taking an entire discipline like peds and figuring out how to attack it, has been challenging, but it's been fun.

KW: Yeah, and looking also on the website, it looks like some of the talks are uploaded and you can watch the video and some aren't. How does that happen?

TB: Yeah, we can do this asynchronously. We do not record the case presentations. Now, we do our best to de-identify every case presented. It's a HIPAA-compliant environment, but just to keep it as safe as possible, we don't record the case presentations, but we record all the didactics for asynchronous learning.

KW: Okay and those are all available online.

TB: They're all available, you just go to our website and go into the discipline and find the videos and start watching. I will say that, because we do use case-based learning and appropriate CME criteria for our didactics, participants get Category 1 Continuing Education units, whether they're PAs, MDs, nurses. So this is a way for people in remote areas, to get CME, and we have been fortunate enough to have such a good relationship with the CME office, that they give us a big break on what it costs, and so we just assume those costs in our budget and we don't charge for our case-based CME learning in Project ECHO.

How do I recieve free CME from participating in Project ECHO?

KW: So they can listen to this podcast and get free CME and then go to Project ECHO and participate and get more free CME.

TB: That's right. Just keep it coming.

KW: And just obviously, you can Google this, but I'll just put it out there. The website is no www, it's just physicians.utah.edu/ECHO. So again, that's physicians.utah.edu/ECHO. And in terms of the finances, obviously, on the part of the rural doc, they're not getting paid to do this either, taking time out from when they could be seeing patients. That's just part of how it is, I guess?

TB: That's right. Time is money, and that's what they're giving up, is their time, but they do not have to pay for any of this. But you don't get everybody, because everybody can't afford that time if they just can't work it into their schedule or Thursdays at noon just doesn't work. And so we understand that we reach a limited office, but we could, with proper funding, expand things more. But we have 2.5 coordinators who handle all of our ECHOs right now, and they're stretched very thin, so we're just dying to resume an opioid ECHO, which we had to give up because we lost the faculty. Now we have the faculty back, but we don't have the coordinators, blah blah, blah. It is unfortunate that we are dependent on funding, but just like everybody else, you gotta pay the people who work for you. Yeah.

KW: And then if someone does participate, I'm guessing, on the website is where they could get the CME or how to contact the CME office?

TB: Actually, after every session, the coordinator mails out an email with the CME code number for the day, and you just enter that into a web-based calculator and you'll get your CME credit.

KW: Gotcha. One thing, and I don't actually know if we will keep this in the recording or not. So Kaila is the person who does my editing, this is just a heads up, but I don't know if we'll keep this. Did you know, at the University of Utah, we now have e-consults that you can do, through Epic and you get paid part of a RVU, and then the specialist gets part of an RVU for doing it?

TB: Yes, in fact, there is E-consultation in adult hepatology. And at one time, we had an ECHO that was devoted just to our community physician group, for their HCV cases because we could use our own EMR and we could actually talk about the patients in a less than unidentified way.

KW: Yeah, that was my partner actually, Dr. Solomon. He's right next to me, and so that's how...

TB: And so, now that E-consultation is available for university providers, we basically lost that business, but that's okay. A few of the community physicians still like to come 'cause they like the discussion, but for the most part, our University of Utah, Hep C business has gone the way of E-consultation, which that's great. There's plenty of business out there without having our own people do something that's, for them, less efficient than E-consultation.

KW: Right, and do you see that growing beyond the U, some... A real doc can get an e-consult and get some RVU for it, and then you could get some RVU for it, or is that just not possible outside of the University of Utah system?

TB: Well, you're gonna have to have either a universal agreement among payers, or you're gonna have to have very few payers, and you know where that argument is gonna go. So I think, if we had three or four payers in the country, yeah, that would be the ticket. We've seen what the use of technology can do, as far as create efficiencies in medical care. When we had to go to tele medicine overnight, so to speak, to deal with the pandemic, there was a little push back on both sides, I think, early on. Now, I've got providers, my colleagues would prefer to do nothing but telemedicine, except for those patients where you just have to see them, and I guarantee you, our patients who live in South Western Montana would much rather see us virtually than drive down here. And then of course, there is the realization that if you don't bring people in and see them, you may lose their lab business, their X-ray business, their pharmacy business and whatever.

KW: All these charges and all that...

TB: Yeah. So all of a sudden, these "facility fees" are missing, and I'm not gonna jump in with both feet into this political discussion. I would say, the exceptional patient experience is virtual care.

KW: So are you doing a lot of that?

TB: In hepatology, we ramped up about as quickly as anybody in our division, in our GI hepatology division, and it's still going pretty strong. It's obviously falling off now, but the person in our division who was most reluctant to do it, is now the biggest convert.

KW: And I guess, a lot of your care is based on history and lab numbers. So they're having not much of a physical, other than the size of...

TB: Yeah. If you just aim your phone at... I wanna see your eyes to see if you're jaundiced, I wanna see your skin to see if I see spider telangiectasia, let me look at your abdomen to see if you have Ascites Just think about the part of the physical examination that you do when you walk into a room and sit down. If you are observing, you've got half of your physical exam done before you've said a word.

You're one of two hepatologists in the world who've had a liver transplant. Is that still the case, or is there more than that, now?

TB: Still the case. Just two of us. Dr. Peter Ferenci is a hepatologist at the University Of Vienna in Austria. And he and I, as far as I know, are still the only two.

KW: Do you share a special bond with him then? Do you ever...

TB: Used to. I would see him once a year or maybe twice a year. I would go to a meeting in Europe or he would come here. So yeah. We didn't... Peter Ferenci is a very famous hepatologist, so I knew who he was before I was transplanted, and I was transplanted first and then he was transplanted a couple of years later. And then so, on meeting, I just introduced myself to Dr. Ferenci, "You and I share something common."

KW: Other than seeing a liver doctor? In what year were you transplanted in?

TB: 2002.

KW: Okay, so you're coming up almost on 20 years.

TB: Yes, my new liver is old enough to vote now.

KW: There you go, that's a good one. How has hepatology or liver transplant changed since your transplant, at almost 20 years ago? Do you feel like it's more of a whole person care? I feel like we put a lot more focus on social workers and community, they make sure your whole community is supportive of you. Do you think that's gotten better? Or...

TB: I do think that the total care team was good when I had it, don't get me wrong. It's always been multi-disciplinary, which is one of the beautiful things about transplant, 'cause you are covered, you have all those resources. But we just understand better, having done this so long, what it takes to be a more complete, supportive team. And so, for instance, now we have housing for families who were displaced for weeks or months, coming here for the transplant, and then things don't go well, and they can't get back to Idaho or Montana or Nevada for a long time. We didn't have that 20 years ago. These people were just sort of on their own, scratching the ground trying to find a place to stay. We now do living donor liver transplants, which we were not doing in 2002. So the field has evolved in that way, and the surgeons are... They do their job very well then, and they do it better now. But unfortunately, we have a whole lot more people waiting and people are getting very, very sick, and it's a different thing.

How many people die in the US every year, waiting for a liver transplant?

TB: I can give you the percentage of people, and I could sort of do the math to figure it out. We lose about 10% to 15% of our waitlist every year. They're withdrawn without being transplanted, which almost certainly means that very few of them get to healthy and come off. So about 15% on a bad year, will die, and we have about 18,000 people waiting. So 2400 people a year, die waiting.

KW: I'm guessing the number one cause is not Hepatitis C anymore, because of the treatment.

TB: You're very smart. You're absolutely correct. It used to be number one, now it's a distant third to both forms of fatty liver disease, non alcoholic and alcoholic fatty liver disease.

KW: I have, unfortunately, a good number of my adolescent patients that already have fatty liver, from obesity.

TB: Yeah, in fact, I think the primary Children's Hospital has already done a couple of NASH cerotic children, older kids, but we're thinking that the median age of our transplant recipients, which used to be in the mid-50s, is gonna drop, because of the childhood obesity. And if we don't get a handle on it, they're gonna be cerotic by the time they're 35 years old.

KW: Wow, that's amazing. Through Project ECHO, have you come across any patients that have ended up being transplanted and then you've used that provider that you met through ECHO, is the referring provider and help to provide care back to them and support?

TB: Yeah, that's been very rewarding. We've met providers from literally all over the west, and people who didn't even know about us before we got into their sphere, because of Project ECHO and HCV or some other disease, and particularly in the liver world, we've gotten several transplant referrals. We don't ask for referrals in Project ECHO, we teach. If we make a good impression, generally, they wanna send us patients, if they need it. And so we've heard about these patients, we've talked to the providers about how to manage them, and when they get really, really sick, we say, "Well, Dr. X, you need to send this patient to your favorite transplant center," and they'll say, "Well, when can you see them?"

KW: I'm guessing you see them pretty quickly if they need to be seen.

TB: We do the best we can. Unfortunately, there are a lot out there and you gotta prioritize them, those that are gonna be dying soon, if you don't see them soon, you have to see others, if they have a low score, they are gonna wait a little while. Unfortunately, it's just like everything else, a lot of work and not enough people.

You are the inaugural recipient of the Terry box MDA Lifetime Achievement Award. How did that feel, to receive an award with your name on it?

TB: You know what the Impostor Syndrome feels like. I'm proud of the work I've done. I don't know that I need an award named after me. I'm very honored, don't get me wrong, but there are a lot of very accomplished people around these parts, and I look up to a lot of people and feel that I'm in their shadow, and I appreciate my colleagues in the American Liver Foundation chapter in Utah, for designating me that and I look forward to...

KW: So, I see they didn't give you a choice, for the name, right?

TB: No, I wasn't given a choice.

KW: Awesome. Well, thanks so much for talking to us and hopefully, people learned about Project ECHO and can start participating if they're not already.

TB: Well, thank you very much. It's been a pleasure chatting with you. You do a wonderful job, and I look forward to taking a listen when it's all tidied up.

KW: Sounds great. Alright. Take care.