Children’s Healthcare of Atlanta ECHO
Implementation Profile

“Although it is my primary role to be a mentor, and a teacher,
I have learned that I get as much in return from the people that I’m teaching.”

Children’s Healthcare of Atlanta and two of its programs—Child Abuse Pediatric (CAP) Fellowship ECHO and Pediatric Obesity & Endocrinology ECHO—were part of a study, led by Diffusion Associates and funded by the Robert Wood Johnson Foundation. The purpose of this study was to document and share how ECHO is adopted, implemented and sustained across ECHO hubs and programs in the United States and Canada. This study was separate from, but endorsed by, the ECHO Institute.

Aires Morrison, CHOA learning coordinator for ECHO, was a 2021 implementation fellow, along with 14 other fellows, and worked alongside Diffusion Associates on this study. This profile is based on Interviews conducted in August and September 2021 by Nagesh Rao, PhD, professor at Ohio University, and Janelle Schrag, assistant director of Research Programs, Association of Community Cancer Center, and an implementation fellow in 2021.

We begin this profile by sharing unique implementation insights from the Project ECHO work at the Children’s Healthcare of Atlanta (CHOA).

ECHO Implementation Insights

Align ECHO Hub/Programs with Existing Education Activities

A defining factor of the CHOA ECHO work was the transition of the hub from the Telemedicine Department to the Learning & Development Department. Aligning ECHO with the other CME activities proved strategic as it fit with staff responsibilities and expertise, and consolidated resources. This transition made it possible for ECHO work to rapidly scale up with support from a single coordinator position.

Identify Passionate Champions

The CAP Fellowship and Pediatric Obesity & Endocrinology ECHO programs were both led by dedicated subject matter experts who spearheaded the program curriculum. These leaders valued the programs and had a strong desire for them to succeed. Positioning this “ownership” of the ECHOs with strong champions contributed to the programs’ longevity and strategic planning around next steps.

Evaluate and Adapt as Needed

Continuous improvement was apparent across CHOA’s ECHOs. All programs relied on evaluation surveys, participant feedback, and engagement trends as they progressed and moved through cycles. CHOA thought strategically about the value of the programs to their respective audiences. The CAP Fellowship and Pediatric Obesity & Endocrinology ECHO programs were at critical points of adaptation— e.g., introducing case presentations and deciding whether to conclude the program, respectively—which were examples of the hub culture to evaluate and adapt.

ECHO Model Adoption

The Telemedicine Department at CHOA launched the first ECHO program in 2016. At that time, the department was well positioned to support an ECHO program. As the number and scope of ECHO programs grew, resources in the Telemedicine Department became stretched and the ECHO Model and content was found to be a better fit for the Physician Education Team within the Learning and Development Department. In 2019, the ECHO hub was officially relocated to the Learning and Development Department, at which time Ashely Euler, manager, Physician Education and Medical Libraries, and Morrison assumed administrative oversight and coordination, respectively, for ECHO work at CHOA.

Both Euler and Morrison participated in immersion training with the ECHO Institute in 2019. Since then, their engagement with the ECHO Institute was limited to an exception for the CAP Fellowship ECHO. Euler and Morrison drew on their experience in continuing medical education (CME) and assessing and addressing clinical education gaps to implement ECHO work.

The CHOA ECHO hub was primarily supported through operational budget line items (e.g., FTE for coordinator position), though it did rely on initial grant funding from the AT&T Foundation and other small private foundations. Notably, the financial structure of support from the operational budget was inherited by the Learning and Development Department after being established by the Telemedicine Department. This included some protected hours for the physician champion on the Pediatric Obesity & Endocrinology ECHO program.

CAP Fellowship ECHO Program

The CAP Fellowship ECHO program was initiated in 2016 following success with another ECHO program, the Child Abuse and Neglect ECHO program, and from an interest to curate more resources so fellows could learn and share how to address child abuse and neglect challenges. Verena Brown, MD, child abuse pediatrician, in collaboration with Stephen Messner, MD, led the ECHO fellowship program. At the start of the program, Messner completed the immersion training with the ECHO Institute and since this ECHO “was so different because it didn’t follow the case presentation and was primarily didactic driven,” Messner sought permission from Sanjeev Arora, MD, director and founder of Project ECHO, to deviate from the traditional ECHO Model. Messner said Arora gave his approval for the program to move forward without case presentations because Arora saw the educational component as being valuable.”

The CAP Fellowship ECHO program transitioned from the Telemedicine Department to the Learning and Development Department and benefited from that transition with better resources and infrastructure; growing and expanding into a department became a better fit for the scope and scale of CHOA’s ECHO program portfolio. The funding for the program came from CHOA as primarily operational line items, but there were no dedicated FTE hours for Brown or Messner (only Morrison).

Pediatric Obesity & Endocrinology ECHO Program

This program was initiated by Sobenna George, MD, pediatric endocrinologist, when she joined CHOA in 2018. At that time, the CHOA hub was transitioning from the Telemedicine Department to the Learning and Development Department, which coincided with Morrison joining CHOA to coordinate all ECHO programs. George explained that “. . . the topic of obesity came about because we get a lot of referrals from community pediatricians about obesity and endocrine co-morbidities, so we thought that that would be a good wide-reaching place to start” an ECHO program. George attended immersion training with the ECHO Institute in 2018 and the first ECHO series was offered in 2020.

George served as the physician champion for this ECHO program, leading the curriculum development, and had protected hours to dedicate to the program. The funding structure for this program was the same as for the CHOA hub—primarily operational line items—which included George’s hours.

For both programs, adopted required waiting until the CHOA hub had resources to support them. Both programs had physician champions who initiated the program and continued to spearhead curriculum development. Both were supported by Morrison in the coordinator role. The programs also differ in their origin. The CAP Fellowship ECHO program, given its unique format without case presentations, was subject to a formal process of approval by the ECHO Institute, which was not required for the Pediatric Obesity & Endocrinology ECHO.

ECHO Model Implementation

The ECHO Model seeks to build a learning community where “all teach, all learn.”  This was 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” meant to them. Respondents tended to define it as a community where everyone has something to give and that teachers or expert had something to learn. Brown noted, “Although it is my primary role to be a mentor, and a teacher, I have learned that I get as much in return from the people that I’m teaching.”

In the CAP Fellowship ECHO, respondents talked about ECHO as a place where providers could build a community of support for what was “difficult work.” The Pediatric Obesity & Endocrinology ECHO provided a “reality check” between experts and community providers where “community physicians give feedback to the [expert] physicians so that they can restructure and reframe how they present information . . . without just throwing all the information at them and expecting them to be able to do it. I think it has been really interesting to watch. I don’t think the people here were expecting that.”  

Both programs used continuous improvement and feedback from spoke participants to assess program needs and participant interest when designing and revising curricula. Brown explained, “We’re listening to feedback of, ‘We need more of this,’ or, ‘I’d like to have a lecture on that.’ So, we’re reaching out, and actively saying, ‘Look at the curriculum again,’ Because we send it out in advance. ‘Tell me where the gaps are, and tell me what we need, and I will find you a speaker. If I know what you want, then we can talk about it.’”

Addressing disparities was a focus for both the CAP Fellowship and Pediatric Obesity & Endocrinology ECHOs addressed by including program topics related to culture and social determinants of health. For the Pediatric Obesity program, George stressed, “Obesity and these co-morbidities tend to be more prevalent in minority patient populations. . .  If we have someone who comes from a Spanish speaking country or culture, what kinds of foods or resources do you have in those situations? If you have a family who is very busy, they don’t have access to a local gym or what have you, how do you encourage them to exercise and do different routines in their homes?”  For CAP, Brown noted, “We do have lectures on cultural things that sometimes get confused for child abuse, like the practice of cupping [using suction cups] they’re not abusive, but if you don’t know what you’re looking at, people think that they could be.”

In addition, a diversity and inclusion panel formed under the CAP Fellowship ECHO to better address this critical aspect of the program curriculum. A prompting moment for the creation of that panel was a note from a physician that didactic presentation slides needed to be more inclusive of all communities to break from stereotypes about who was more likely to be affected by child abuse.

These programs had unique ways of interpreting the principle of mastering complexity typically associated with case-based learning. The CAP Fellowship ECHO did not include case presentations as part of regular sessions (i.e., didactic only), but during separate quarterly sessions, case presentations were used as the fellows found them more useful than a journal club. The Pediatric Obesity & Endocrinology ECHO sessions included case presentations in the agenda, but difficulties with recruiting cases led to many sessions with didactic presentations only. Despite pre-determining the case presentation assignments, and requiring cases to be presented to receive CME credits, this continued to be an ongoing challenge for this program.

The Pediatric Obesity & Endocrinology ECHO program had an eight-month curriculum, a closed cohort, and subject matter experts (SMEs) were recruited exclusively from the CHOA network. In contrast, the CAP Fellowship ECHO program had a two-year curriculum, an open cohort, and drew SMEs from around the country.

Factors Influencing Implementation

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 was implemented at the CHOA hub and the CAP Fellowship and Pediatric Obesity & Endocrinology ECHO programs.


Physician leaders in both programs developed curriculum and ensured they were of high quality. They further championed this work in the organization and played a key role in refining and sustaining the two programs.


The CHOA ECHO hub and programs were funded through the organization’s operational budget, though some initial funding was from a grant from AT&T. Around 50 percent of the ECHO budget goes toward Morrison’s salary with the remaining 50 percent used for ECHO operational costs. Of the ECHO physician leaders, only George had protected time to run the programs.

Organizational Characteristics

The transition of ECHO from the Telemedicine Department to the Learning & Development Department, had implications for the growth of the ECHO programs and resource allocation. Specifically, features of the CHOA Learning & Development Department influenced ECHO hub activities. For example, the department was accredited by the Medical Association of Georgia, which played an important role in offering continuing education credits for ECHO programs. Euler commented, “That really does mesh well with us developing new ECHOs and making sure that they are making an impact and that they have outcomes that are patient care driven and not just knowledge based.” Additionally, the department had a physician oversight committee that approved all new ECHOs.

Organizational Staffing 

The staffing structure across the CHOA ECHO hub and programs influenced CHOA’s ECHO activities. At the time of the interview, Morrison was the only coordinator for CHOA’s eight ECHO programs. As for individual ECHO programs, any dedicated physician time was essentially voluntary. Euler noted, “It just is part of our employment model expectation that if it’s a project that either [clinical staff] applied for or a project that’s associated with their area, that they work within their confines to be a part of it.” The one exception across CHOA’s ECHO portfolio was the protected hours for George on the Pediatric Obesity & Endocrinology ECHO program.

ECHO Vision and Sustainability

When asked about the vision for the hub in the next several years, respondents said that they would like to see an increase in funding. Euler would like the program to be more collaborative with shared responsibility between the hub team and the physicians. Additional staff and coordinators were also desired so they were less “in the weeds.” Growth in programs and staff came with challenges. More programs required more legal support to maintain compliance (e.g., CME accreditation). Growth also required “advocacy. It takes time and energy to make sure our leaders understand what it is we’re doing, the benefits of what we’re doing, and why it’s important not only to our providers, but also our patient population.”

The CAP Fellowship ECHO would like to improve what’s been working well to date, continue to serve the community of CAP fellows, and be an example for other ECHO programs. Brown felt a key step in achieving that vision was growing the number of program stakeholders, including SMEs and participants. She recognized that not having a formal home for the program recordings and materials had been a barrier, and she would like to see that change as the program grows. The desire for protected staff hours or another FTE was also noted.

The Pediatric Obesity & Endocrinology ECHO was uncertain about continuing the program. George’s vision was to have more participants engaged and to grow the geographic reach of the program. However, she was uncertain about the reality of this vision given the current challenges regarding participants time, bandwidth, and engagement in the program.


Verena Brown, MD
Child Abuse Pediatrician
Medical Lead, CAP Fellowship ECHO
Children’s Healthcare of Atlanta

Ashley Euler
Manager, Physician Education and Medical Libraries
Children’s Healthcare of Atlanta

Sobenna George, MD
Pediatric Endocrinologist
Medical Lead, Pediatric Obesity & Endocrinology ECHO
Children’s Healthcare of Atlanta

Stephen Messner, MD
Child Abuse Pediatrician
Medical Lead, CAP Fellowship ECHO
Children’s Healthcare of Atlanta

Aires Morrison
Learning Coordinator
Children’s Healthcare of Atlanta

Suggested Citation

Schrag, J., Morrison, A., & Rao, N. (2022). The Children’s Healthcare of Atlanta ECHO implementation profile. Diffusion Associates.