key: cord-0706620-gt6vd54r
authors: Alschuler, Kevin N.; von Geldern, Gloria; Ball, Darren; Costello, Kathleen; Skeen, Mark; Chahin, Salim; Wundes, Annette
title: Rapid transfer of knowledge for multiple sclerosis clinical care during COVID-19: ECHO MS
date: 2020-10-23
journal: Mult Scler Relat Disord
DOI: 10.1016/j.msard.2020.102600
sha: 0bb5de1a6cb56ec1d24cf67448bfa99a258c1579
doc_id: 706620
cord_uid: gt6vd54r

Background: Healthcare providers caring for people with multiple sclerosis (MS) have had significant concerns about the intersection of MS and COVID-19. As a result, there has been an urgency to understand and share information about how to best provide MS clinical care during COVID-19. The Project ECHO model is well-suited for this challenge, as it provides a uniquely efficient and effective approach to sharing information in real-time using real cases. We report on the translation of the Project ECHO model for the rapid sharing of knowledge among MS clinical providers during COVID-19. Methods: The ECHO MS COVID-19 Response Clinic was a videoconference-based education and case consultation program offered to providers in the U.S. who care for individuals with MS. The Response Clinic was offered as four sessions, each delivered by three regional hubs. Data were collected on participation and the self-reported impact of the program. Results: A total of 132 unique providers participated in the Response Clinic, which consisted of 11 didactic modules and 43 case consultations. Participant providers overwhelmingly indicated that the program improved their knowledge, attitude, and skills for providing healthcare for people with MS during the COVID-19 pandemic. Discussion: The Project ECHO model was successfully adapted to serve the needs of the MS community during COVID-19, suggesting the program could be continued or could be expanded to other disease areas for a similar purpose. More research is needed to objectively measure the impact of the program on patient outcomes.

In recent months, significant concerns have surfaced about the intersection of multiple sclerosis (MS) and the COVID-19 pandemic. 1- 3 These include concerns that individuals on immunosuppressive disease-modifying therapies (DMT) may be at higher risk for poor COVID-19 outcomes 1-3 and questions such as whether people living with MS are at greater risk of poor outcomes due to their higher rates of comorbidities, limited mobility, and/or higher likelihood of living in care facilities relative to the general population. [4] [5] [6] In response to these concerns, a significant amount of rapid innovation has occurred to leverage technology to use remote or digital health modalities to optimize patient care in order to limit COVID-19 exposure risks and unfavorable health outcomes. [7] [8] [9] Just as there has been real-time adjustment to clinical care for COVID- 19 , there has been a parallel effort to understand and share information among providers about how to best provide care for individuals living with MS during COVID-19. As that information quickly evolves, there is a need to share it efficiently and effectively, recognizing the myriad barriers to data sharing, including the urgency of time; the limited ability to share information at conferences, seminars, or workshops as in-person events are limited due to COVID-19 concerns; and the importance of delivering information in a way that is relevant and useful to the audience. Moreover, in the absence of clear, empirically-supported guidelines, there is the need to not only transfer information, but truly have providers share and discuss information to provide peer-to-peer support and practical help with medical decisions on the cases they see in their clinical practices.

Project ECHO (Extension for Community Health Outcomes) is well-suited to overcome these barriers. Project ECHO is designed for the "movement of knowledge…not people", leveraging videoconference technology to reach medical providers nationally or internationally to spread information via didactic modules and engagement in case consultations. In contrast to conferences and seminars, Project ECHO emphasizes a casebased learning model, as well as bidirectional shared learning between and among the participating experts and learners. The goal of Project ECHO is to learn through real-life cases, using Project ECHO sessions to make both patient-and practice-level improvements in the care provided by program participants. Project ECHO was initially established to improve the quality of care for infectious diseases that had large disparities in outcomes between specialty and non-specialty settings (e.g., Hepatitis C, HIV [10] [11] [12] [13] ). Empirical investigations of the Project ECHO model indicate a powerful effect on reducing disparities in quality of care, 14 sparking a rapid growth in the use of the model to 69 topics areas across over 1600 programs at the time of this writing. 15 This includes one prior translation of the Project ECHO model for management of patients with MS, which resulted in participants self-reporting improvement in perceived knowledge, expertise, and provider behavior. 16, 17 A related demonstration project also showed the model could be used to aid an international audience in improving their knowledge of DMTs for MS that were newly approved in their country but had been utilized for a number of years in the U.S. 18 Project ECHO has been previously recommended as a model for facilitating the rapid sharing of knowledge during global health crises (e.g., Zika crisis 19 ) and has preliminary evidence for utility with the MS healthcare community. Thus, the National MS Society Project ECHO is built on a hub and spoke model, with the presenting site(s) serving as "hubs" and participants as "spokes". The NMSS worked in partnership with three hub sites distributed across the U.S. -Duke University ("East"), Washington University in St. Louis ("Central"), and University of Washington ("Pacific") -to rapidly deploy the ECHO MS COVID-19 Response Clinic. Sessions were planned to run every other week as 60-90 minute sessions. Each session was scheduled to be delivered by each hub site on different days and times, providing participants the opportunity to choose a session that best suited their availability. The NMSS and three hubs collaboratively developed 15-20 minute didactic modules to be delivered at each session, covering topics such as DMT guidelines, telemedicine, employment resources, and updates from MS COVID-19 databases (see Table   1 for session-by-session detail). The remainder of each session was spent on case consultations and/or clinical practice questions which were collected from participating providers when they registered for each session. Thus, the content of the case consultations and clinical practice questions were designed to vary by site so as to be relevant to the unique subset of participants in each session.

Participating spoke sites were recruited by the National MS Society's healthcare access team via personal contact and email advertisements sent to the NMSS's large networks of MS specialists and community providers who care for individuals with MS. In contrast to prior MS Project ECHOs that focused on improving care provided by generalist neurologists or primary care providers who care for people with MS, the goal here was to rapidly share information among all providers who care for people living with MS. As such, recruitment 

Participation data were examined via the Project Echo iECHO platform. Basic descriptive data were tabulated for session participation by site and in total, including attendance, topics covered, and case presentations. Participant self-report data were downloaded from the SurveyMonkey platform and were examined for completeness or other obvious errors.

Means were calculated for self-reported impact on knowledge, attitudes, and clinical skill, as well as the perceived impact on changes in clinical practice.

The ECHO MS COVID-19 Response Clinic was delivered over 4 rounds, with each round offering similar sessions delivered by each hub (e.g., Round 1 was run three times, once by As anticipated, the ECHO MS COVID-19 Response Clinic was feasible and well-received.

Recruitment was carried out over a short period of time but leveraged the National MS Society's healthcare access team's network of connections and the significant demand for this information to yield 67 participants for the first round of sessions with less than 2 weeks of recruitment. Participation remained good throughout the program, but did steadily decrease in parallel to the decrease in novel information emerging about COVID-19

after the first few months.

Participants overwhelmingly indicated that the program improved their knowledge, attitude and skills related to providing healthcare for people with MS during the COVID-19

pandemic. This is consistent with the variety of peer-reviewed publications that have reported on program evaluation data from Project ECHOs. 10-13, 16, 17 With that said, participants indicated a greater benefit in knowledge, attitude, and skills relative to the likelihood that it would change their clinical practice. While we initially viewed this as an While we report on the ECHO MS COVID-19 Response Clinic with great enthusiasm, we also recognize the limits of the supporting data. First, there is undoubtedly a selection bias, as is the case with any program were participants have voluntarily signed up for the experience.

Spoke participants were providers who were interested and motivated to participate in the ECHO MS COVID-19 Response Clinic, increasing the likelihood that they would rate the program beneficial and impactful. Moreover, only 51% of participants responded to the survey, which may further bias the results. Second, this was not a rigorous trial, there was no comparison condition, and data were primarily self-report. Analysis was limited to data available from program evaluations. This educational program was purposefully open to any health care providers engaged in MS care; no data were collected on the quantity or nature of the patients cared for in participant providers' practices, although we can anecdotally report that the vast majority of participants were heavily engaged in MS clinical care. In general, the literature on Project ECHOs is disproportionately comprised of this type of program evaluation data, with a small subset of data collected on objective outcomes. Future research on the Project ECHO model should move towards this higher standard of research, including research that identifies the impact of the Project ECHO model on patient outcomes.

In summary, we found the Project ECHO model to be a suitable model for the transfer of knowledge among MS specialist providers during the COVID-19 pandemic. The model successfully attended to the urgent need for information sharing, rapidly transferring knowledge to MS providers across the U.S. The ease of participation, coupled with a format that emphasizes discussion and application to real cases was engaging and was met with positive feedback from participants. This is now the third iteration of an MS-focused application of the model, with prior efforts focused on non-MS specialist providers 16, 17 and an international audience. 18 All have achieved similarly positive self-reported and qualitative results, suggesting further development of the model in the MS community may be worthwhile. However, as with the Project ECHO movement at large, there remains a

The COVID-19 pandemic and the use of MS disease-modifying therapies

Rethinking high-risk groups in COVID-19. Multiple Sclerosis and Related Disorders

Multiple sclerosis and the risk of infection: considerations in the threat of the novel coronavirus, COVID-19/SARS-CoV-2

Emerging effects of comorbidities on multiple sclerosis

Cumulative impact of comorbidity on quality of life in MS

e-Health and multiple sclerosis: an update

Digital triage for people with multiple sclerosis in the age of COVID-19 pandemic

Assessing disability and relapses in multiple sclerosis on tele-neurology

Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico

Expanding access to hepatitis C virus treatment-Extension for Community Healthcare Outcomes (ECHO) project: Disruptive innovation in specialty care

Demonopolizing medical knowledge

Building capacity to reduce disparities in diabetes: training community health workers using an integrated distance learning model

Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers

Project Extension for Community Healthcare Outcomes (ECHO) in Multiple Sclerosis: Increasing Clinician Capacity

Impact of Multiple Sclerosis Project ECHO (Extension for Community Healthcare Outcomes) on Provider Confidence and Clinical Practice

Accelerating international MS care through videoconference-based education and case consultation

Building Physician Networks as Part of the Zika Response

The prevalence of MS in the United States: A population-based estimate using health claims data

ECHO MS is a provider education and case consultation program run by the National