Association of Community Cancer Centers ECHO Implementation Profile

Several factors were instrumental in bringing the ECHO Model to ACCC. Sanjeev Aurora, MD, founder and director of project ECHO, and associates from the University of New Mexico visited the ACCC office in Rockville, Maryland in 2016 to explore the concept of ECHOs with the ACCC executive director of development and education teams. This introduction to ECHO led Amanda Kamar, chief operating officer, to attend ECHO immersion training in New Mexico in 2017 and early conversations about implementing an ECHO program at ACCC. Schrag, who played a significant role in the implementation of the IO ECHO, worked for a hospital association where the University of New Mexico was a member and became familiar with Project ECHO through this relationship. Both Schrag and Latha Shivakumar, PhD, director of clinical affairs, gained exposure to the ECHO Model by joining other cancer focused ECHOs offered by the ECHO Institute and partner organizations. The most significant exposure to ECHO was in 2019 when ACCC was invited to support ACS in recruiting spoke sites for three of ACS’ ECHO programs. This was ACCC’s first formal involvement with an ECHO program. Additionally, in 2019, during a session of the ACCC’s Immuno-Oncology Institute Telemedicine Roundtable, a member of the ECHO Institute presented, initiating discussions among ACCC’s IO Institute Executive Committee to start the Immuno-Oncology ECHO. Together, these factors contributed to the adoption of the IO ECHO in 2021.

Several factors were instrumental in bringing the ECHO Model to ACCC. Sanjeev Aurora, MD, founder and director of project ECHO, and associates from the University of New Mexico visited the ACCC office in Rockville, Maryland in 2016 to explore the concept of ECHOs with the ACCC executive director of development and education teams. This introduction to ECHO led Amanda Kamar, chief operating officer, to attend ECHO immersion training in New Mexico in 2017 and early conversations about implementing an ECHO program at ACCC. Schrag, who played a significant role in the implementation of the IO ECHO, worked for a hospital association where the University of New Mexico was a member and became familiar with Project ECHO through this relationship. Both Schrag and Latha Shivakumar, PhD, director of clinical affairs, gained exposure to the ECHO Model by joining other cancer focused ECHOs offered by the ECHO Institute and partner organizations. The most significant exposure to ECHO was in 2019 when ACCC was invited to support ACS in recruiting spoke sites for three of ACS’ ECHO programs. This was ACCC’s first formal involvement with an ECHO program. Additionally, in 2019, during a session of the ACCC’s Immuno-Oncology Institute Telemedicine Roundtable, a member of the ECHO Institute presented, initiating discussions among ACCC’s IO Institute Executive Committee to start the Immuno-Oncology ECHO. Together, these factors contributed to the adoption of the IO ECHO in 2021.

As of October 2021, the IO ECHO was the only ECHO program operated by ACCC. The program consisted of a six-session curriculum offered to four spoke sites across the United States. Each ECHO session was an hour in duration and included an introduction, a didactic presentation, and a case discussion. The target audience was community cancer sites that had a basic understanding of immuno-oncology but were seeking to make practice improvements related to the use of immunotherapies.

ACCC’s IO ECHO was part of the Immuno-Oncology Institute that sits within the Provider Education department, and logistics and programming were led by program managers. Organizationally, two of ACCC’s staff members in the Clinical Affairs department were responsible for program development. They adapted the program for the intended audience members and pursued external funding. ACCC’s leadership had a limited but positive awareness of the IO ECHO.

An advantage of the IO ECHO being a part of ACCC was the alignment of the program and hub’s mission to disseminate specialized knowledge to community cancer centers, which were often under-resourced compared to academic medical centers or large integrated health networks. Additionally, ACCC had, through its Immuno-Oncology Institute and partnerships with cancer centers (e.g., VCU Massey Cancer Center), access to faculty who served as subject matter experts. These relationships were significant in developing the educational content for of the IO ECHO.

ACCC was managed by C Management, Inc. (CMI) an Association Management Company and all ACCC employees were CMI staff. The majority of ACCC’s educational programs, such as the IO ECHO, were primarily funded by biopharmaceutical companies. The IO ECHO did not receive dedicated funding. Rather, the Immuno-Oncology Institute received funding, some of which was used to support the ECHO program. A total of $23,000 was allocated for direct expenses to support the IO ECHO in 2021. These funds were used for honorariums for faculty and subject matter experts, as well as incentives for spoke sites that participated in the ECHO program. This figure did not include the ECHO staff members’ salaries which were paid by CMI.

The ECHO Model seeks to build a learning community where “all teach, all learn.” This is done by leveraging technology, by sharing best practices, through case-based learning, and using data. We asked respondents to tell us what “all teach, all learn” (ATAL) meant to them. Schrag described ATAL as leveling the playing field where facilitators and participants have equal expertise and where everyone can learn from each other. Shivakumar added that ATAL enables peer-to-peer learning among the lower resourced cancer centers as strategies used by one program could be used by other programs.

A counterintuitive and powerful example of ATAL was demonstrated in an IO ECHO session discussing a rare patient case. For this case, the clinical experts did not know the answer to a question. In a culture where the clinician was expected to have answers to questions, the experts displayed vulnerability by stating that did not have an answer and acknowledged the need to do more research to find out the answer. This episode exemplified how ATAL reduced hierarchy and leveled the playing field.

Some hub team members provided feedback to Schrag that they felt they were not contributing to the ECHO sessions. Schrag explained that the ECHO Model highly values community engagement and this may require less engagement from the hub team. Although some hub team members were unhappy when their expertise was underutilized, most attended all six sessions.

The curriculum was developed based on an annual needs assessment survey sent to all the spokes and included topics suggested by the IO executive committee. Following the curriculum, the ECHO team reached out to topical faculty experts and invited them to be a part of the program team. The faculty were sent the session objectives and a template for their presentation. When needed, the ECHO team member walked faculty through the session and answered their questions.

Each session included a didactic component led by the expert and a case presentation from the participants. Each of the spoke sites were paid $2,500 to participate in the program with an understanding that each spoke site would present a case. Five of the six sessions had a case. In the last session, the program team produced a hypothetical case to discuss.

Studies of program implementation identify contextual factors that can shape how a program was implemented. These factors include leaders and champions, state and federal policies, funding, partnerships, and internal organizational structures and processes, monitoring for quality and fidelity, and staffing—including how people were trained and the characteristics of the people leading and supporting the program.

Not all of these factors play a role in how ECHO was implemented here or elsewhere. Below, we identify factors that emerged during interviews that appear to influence how ECHO is implemented at ACCC and the IO ECHO.

Innovation Characteristics – Specialized Content

The IO ECHO’s educational content was specialized. To participate, spoke sites were expected to have a basic understanding of immuno-oncology as a prerequisite. The content of this ECHO was often related to adverse clinical events in immuno-oncology but sometimes touched on broader issues such as shared decision making, patient education, patient’s financial situations and reimbursements, and survivorship. ACCC saw a need for this, especially in community cancer centers that were under-resourced and had limited access to specialists, but the specialized content contributed to challenges that ACCC faced in the recruitment of spoke sites and patient cases.

Organizational Staffing

The IO ECHO did not have dedicated staff members. It was operated by two staff from the Immuno-Oncology Institute paid by CMI, with faculty experts from other departments and leadership support within ACCC. This lean staffing model required limited project funding but also limited evaluation and content validity checkpoints.

Partnership and Networks

The partnerships and networks that ACCC established were essential to the implementation of the IO ECHO. The IO ECHO relied on partnerships and networks to identify and recruit faculty and subject matter experts to develop the educational content for its sessions. Little training or guidance was provided to these content experts. Many of experts were unfamiliar with the ECHO Model and had not attended immersion training, however the speakers were faculty known to be good educators and established ECHO protocols brought them up to speed.

When asked about the vision for ECHO work in the ACCC in the next several years, respondents said ACCC wanted to continue the IO ECHO and hoped to expand their offerings to include more oncology-related programs. They wanted to create a more comprehensive hub that included non-oncology specialists with expertise in managing immune-related adverse events (e.g., rheumatologists, cardiologists, ophthalmologists, endocrinologists) as many community cancer programs did not have access to these specialists and ECHO could provide these resources. Additionally, ACCC envisioned making their current and future ECHO programs Continuing Education (CE) certified and was looking into diversifying their funding to support this vision. They hoped to secure grants from a foundation to augment current funding from pharmaceutical companies.

While the IO ECHO was successful and held to fidelity to the ECHO Model with its current resources, additional funding would allow the program to provide more to its participants through CE certification, access to additional specialists, and greater geographical reach. With additional funding, the program would increase staff time dedicated to evaluation and content validity, and raise greater awareness of the hub and program through metrics demonstrating ECHO’s impact.

Recruiting cases was an ongoing challenge for the IO ECHO. ACCC wanted to create a repository of cases to use in sessions. They also hoped as ACCC gained more recognition as a hub that it would become easier to recruit spoke sites.

Janelle Schrag
Program Lead, Immuno-Oncology ECHO
Assistant Director, Research Programs
Association of Community Cancer Centers

Latha Shivakumar
Director of Clinical Education Development
Association of Community Cancer Centers

Jiwan, A., Schrag, J. & Rao, N. (2022). Association of Community Cancer Centers ECHO Implementation Profile. Diffusion Associates. https://www.diffusionassociates.com/echo.