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An Evaluation of Hepatitis C Virus Telehealth Services Serving Tribal Communities: Patterns of Usage, Evolving Needs, and Barriers

Stephens, David RN; Leston, Jessica MPH; Terrault, Norah A. MD, MPH; Gailloux, Keri; Mera, Jorge MD; Essex, Whitney MSN, BSN, FNP-BC; Reilley, Brigg MPH

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Journal of Public Health Management and Practice: September/October 2019 - Volume 25 - Issue - p S97-S100
doi: 10.1097/PHH.0000000000001061


American Indians and Alaska Natives (AI/ANs) have the highest hepatitis C virus (HCV)–related mortality rate (10.75/100 000) of any race/ethnicity, more than double the national rate (4.45/100 000).1 Treatment for HCV is highly effective and greatly reduces risk of death from hepatocellular cancer, cirrhosis, or liver failure.2 The foremost medical provider for AI/AN communities is the Indian Health Service, a federal agency that serves an estimated 2.2 million tribally enrolled patients in 36 states. The Indian Health Service, Tribal, and Urban (I/T/U) health care facilities are a predominantly rural health care network and, as such, can face barriers to HCV services such as having few specialists, as well as elevated vacancy rates and turnover for providers.3–5

Telehealth models have proven effective in treating HCV in primary care settings.6,7 Extension for Community Healthcare Outcomes (ECHO) programs provide telehealth support to multiple health care facilities to increase clinical capacity through case-based learning. Rather than the telemedicine model of a specialist consulting with a single provider on a single patient, ECHO sessions consult on multiple patients with multiple providers in a Health Insurance Portability and Accountability Act of 1996 compliant manner, thereby increasing medical skills and knowledge on a much broader scale. The US Department of Veterans Affairs (VA) has documented that TeleECHO services for HCV have been a cornerstone of the VA response and has increased rates of antiviral treatment with excellent clinical outcomes.8,9

The Regional HCV ECHO clinic is under the Northwest Tribal Epidemiology Center. It was created in response to a stated need from tribal leaders to address the burden of HCV in tribal communities to meet the needs of tribes without access to a local infectious disease program. In collaboration with California- and Oklahoma-based peers, the regional HCV TeleECHOs seek to improve health care delivery systems and serve tribal communities in the Pacific Northwest (Washington and Oregon), California, and Cherokee Nation in Northeast Oklahoma. Clinicians can attend an in-person training via the Northwest Tribal Epidemiology Center, University of California at San Francisco (UCSF), or Cherokee Nation Health Services (CNHS) that provides HCV clinical training as well as familiarity with ECHO platform and the specialist team. Subsequently, participants are invited to monthly TeleECHO sessions and encouraged to submit case presentations. This study sought to discern patterns of ECHO usage and its impact on the provision of HCV care in participating I/T/U facilities.


The study was conducted in partnership with the Northwest Portland Area Indian Health Board (NPAIHB), UCSF, and CNHS. These entities have replicated HCV ECHOs that serve tribal populations in collaboration with The University of New Mexico (see Supplemental Digital Content, available at The hour-long TeleECHO sessions provide an opportunity to present cases, receive recommendations from the specialist team, and share HCV service challenges and solutions with peers. The community is connected via video technology (Zoom, San Jose, California), an e-mail listserv (Constant Contact, Waltham, Massachusetts), and short messaging service. These platforms are used to discuss a variety of topics important to clinicians serving AI/AN communities, including HCV clinical updates and best practice treatment guidelines. Through these platforms, the TeleECHO services had an existing relationship with participants and well-established lines of communication that could be used for survey-based research.

Eligible participants included I/T/U clinicians participating in any of the HCV ECHOs operated by NPAIHB, UCSF, or CNHS. The NPAIHB serves 43 tribes in Washington, Oregon, and Idaho, UCSF has had participation from 25 tribal clinics in California, and CNHS has a hospital and 8 clinics. In addition to these 3 regions, I/T/U facilities from other states may sometimes attend on the basis of availability and convenience.

We used an online survey development cloud-based software (Surveymonkey, San Mateo, California) and a text message service provider (Mobile Commons, Austin, Texas) to collect data. The survey instrument included basic demographic data on location (state) and clinical profession/role, general data on HCV services, and evaluation data on the use and satisfaction of key elements of TeleECHO (see Supplemental Digital Content, available at The survey was pilot tested with nonparticipating clinicians and comprised a set of closed-ended questions, with an option for open-ended comments as the final question. Participants were invited to provide feedback via e-mail (based on ECHO clinic invitation lists) or text message (to participants of a tribal HCV text messaging service). The anonymous survey took approximately 20 minutes to complete.

From January 10 to February 26, 2018, surveys were sent by e-mail to 234 individuals as well as text message to 103 individuals. A total of 3 attempts were made to reach respondents. As many policy or other nonclinical persons are on the HCV short messaging service, and professional profile is not linked to this platform, the survey instrument indicated only clinical professionals were eligible to respond.


Of the 337 e-mail and text message recipients, 44 (13%) completed the survey, although the inclusion of noneligible recipients in the denominator underestimates the true response rate. The 44 ECHO participants comprised 17 (39%) physicians, 13 (30%) nurse practitioners, 5 (11%) pharmacists, 4 (9%) registered nurses, 2 (4%) physician assistants, and 3 (7%) other clinical, nonspecified. The participants practiced in 9 different states, primarily California (13), Washington (11), Oregon (8), and Oklahoma (6).

A majority of respondents indicated that their facility began treating HCV subsequent to joining ECHO (61%). Other respondents indicated that their primary care facility treated HCV before joining ECHO (20%) or did not yet treat HCV (16%). Respondents varied in level of ECHO participation; 9 (21%) had attended 1 to 2 sessions, 19 (43%) had attended 3 to 10 sessions, and 16 (36%) had attended more than 10 sessions.

Respondents varied in the proportion of HCV patients under care who they presented on ECHO for treatment guidance. Nearly half (41%) stated that ECHO reviewed more than 75% of HCV patients. Slightly fewer clinicians (34%) had ECHO review less than 25% of HCV patients. Notably, among respondents in California who had attended more than 10 sessions, 7 of 8 clinicians used ECHO for less than 25% of patients.

In addition to clinical considerations, respondents rated the usefulness elements of TeleECHO sessions and suggested improvements. The majority of respondents rated all elements at the highest possible rating of “extremely useful,” led by presenting cases (81%), teaching session (75%), listening to case presentations (68%), and sharing general HCV program information (66%). Clinicians named possible improvements to TeleECHO sessions. From a set list of options, the main responses were clinical/treatment plans (25%), more complex cases (25%), and substance abuse disorders (16%). Of the 11 respondents requesting more complex case presentations, 73% had participated in more than 10 ECHO sessions.

Finally, respondents rated 4 potential barriers to HCV treatment as it pertained to their facility. The most highly cited barrier was time spent accessing/acquiring medications for HCV (eg, third-party payers requiring late-stage liver disease and/or extensive periods of documented sobriety), with 60% rating it as a moderate or extensive barrier, followed by getting HCV patients into care, cited by 50% of respondents (see the Table).

TABLE - Barriers to HCV Treatment, I/T/U Clinicians Participating in Extension for Community Healthcare Outcomes (N = 44)
Not a Barrier Minimal Moderate Extensive
Accessing drugs 0 18 (41%) 17 (39%) 9 (21%)
More frequent/regular access to specialists 12 (27%) 19 (43%) 12 (27%) 1 (2%)
Getting patients into care/follow-up 4 (9%) 18 (41%) 17 (39%) 5 (11%)
Limited clinical time for HCV services 9 (21%) 17 (39%) 13 (30%) 5 (11%)
Abbreviation: HCV, hepatitis C virus.


In this sample of primary care facilities, involvement in HCV ECHO preceded the provision of HCV services, suggesting that linkage to specialists is an essential element not only to improving quality of HCV treatment but also for the inception of local provision of HCV services in rural clinics. Clinicians who attended more than 10 TeleECHO sessions sought more complex case presentations, which is an ideal trajectory of telehealth participants as they gain more experience. Similarly, experienced ECHO participants, notably in California, sought specialist input for a smaller proportion of HCV patients, which can also be an indicator of increasing clinical capacity.

Respondents are very supportive of all 4 main elements of the TeleECHO sessions (presenting cases, teaching session, listening to case presentations, and sharing general HCV program information). However, challenges emerge as both new and experienced clinicians attend sessions; new participants must be made welcome in terms of teaching and case presentation complexity, which in turn may become redundant for experienced participants.

Barriers to providing HCV treatment remain. Accessing medications for HCV was cited as the foremost challenge due to administrative barriers to treatment by third-party payers such as requiring late-stage liver disease and extensive periods of documented sobriety. These conditions are not supported by national guidelines (American Association for the Study of Liver Diseases) and are cost containment measures enacted by public and private insurers to contain high drug costs.10 While not covered in this survey, addressing these nonclinical barriers (drug access, linkage to care, and similar) is often discussed peer to peer in ECHO case presentations, which are especially pertinent among clinicians working in a similar environment in terms of administrative/insurance requirements and distant referral options. These nonclinical barriers continue to shift with new clinical guidelines, insurer requirements, and presence of ancillary programs such as medication-assisted therapy for opioid use. Further research would be needed to determine whether TeleECHO sessions have had a measurable impact on navigating these barriers. Some nonclinical issues, such as linkage to care, will need resources outside the purview of TeleECHO, such as effective patient outreach to encourage HCV patients to seek care.

Implications for Policy & Practice

  • TeleECHO has been an important part of not only the provision of HCV curative services but also their inception.
  • Case presentations were deemed the most useful element of telehealth services and appear to increase facility-level capacity over time.
  • Notable barriers to HCV treatment are primarily nonclinical, such as medication acquisition and linkage of patients to care.
  • Increase of access to treatment using TeleECHO may reduce disparities in liver cancer and other HCV-related morbidity and mortality among AI/ANs.

The efficacy of HCV drugs, the successful example set by the VA, and the ability to use TeleECHO in conjunction with other strategies for successful treatment and prevention at the primary care level have been influential to policy. Key entities such as the National Congress of American Indians and Cherokee Nation have declared elimination of HCV as a public health goal.11,12

These data have limitations. Some health care facilities may have had multiple respondents, which may overrepresent certain responses. The response rate was low, although likely higher than the base calculation of 13%. These data do not include sustained virologic response data to monitor clinical outcomes. The proportion of HCV patients presented to TeleECHO sessions may be linked with state Medicaid requirements. Finally, the small sample size precludes statistical tests of significance.


1. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance: United States, 2015. Atlanta, GA: Centers for Disease Control and Prevention; 2017.
2. Van der Meer A, Veldt B, Feld J, et al. Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis. JAMA. 2012;308(24):2584–2593.
3. Kovich H. And how long will you be staying, doctor? N Engl J Med. 2017;376(14):1307–1309.
4. US Government Accountability Office. Agency faces ongoing challenges filling provider vacancies, GA 18-580. Published August 15, 2018. Accessed August 24, 2018.
5. Westergaard RP, Stockman LJ, Hyland HA, Guilfoyle SM, Fangman JJ, Vergeront JM. Provider workforce assessment in a rural hepatitis C epidemic: implications for scale-up of antiviral therapy. J Prim Care Community Health. 2015;6(3):215–217.
6. Arora S, Kalishman S, Thornton K, et al. Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52(3):1124–1133.
7. Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199–2207.
8. Beste L, Glorioso TJ, Ho PM, et al. Telemedicine specialty support promotes hepatitis C treatment by primary care providers in the Department of Veterans Affairs. Am J Med. 2017;130(4):432–438.
9. Belperio PS, Chartier M, Ross DB, Alaigh P, Shulkin D. Curing hepatitis C infection: best practices from the US Department of Veterans Affairs. Ann Intern Med. 2017;167(7):499–504.
10. Reilley B, Leston J. A tale of two epidemics—HCV treatment among Native Americans and Veterans. N Engl J Med. 2017;377(9):801–803.
11. National Congress of American Indians. Support for Hepatitis C Elimination, Resolution MKE-17-038. NCAI annual meeting 2017. Accessed January 2, 2019.
12. Cherokee Nation. Cherokee Nation Screens more than 40,000 patients for Hepatitis C. Published October 31 2017. Accessed January 2, 2019.

American Indian/Alaska Native; evaluation; hepatitis C; implementation; rural; telehealth

Supplemental Digital Content

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