Project ECHO Review and Research Agenda

Document Type

Working Paper

Publication Date



This study assesses the state of the evidence about Project ECHO (Extension for Community Healthcare Outcomes) and suggests directions for improving its performance in the field. As sometimes happens in the diffusion of a promising intervention, the state of the art—what practitioners are doing in the field—can outrun the state of the science—what researchers know with confidence about that intervention and its effects. Even with a number of publications in peer-reviewed journals, this is a fair characterization of the status of Project ECHO. In response to great need, its deployment has moved ahead at a rapid pace with little time to pause and assess. It is always possible to improve the knowledge base about an intervention: more precisely determining just which intervention components are responsible for observed effects, how those variables interact, and the reproducibility of effects. But sometimes an intervention achieves a degree of face validity through repeated evaluations such that further tests of internal validity are less pressing than are pragmatic studies to better understand an intervention’s performance under varied field conditions. That way, improvements can be rolled out as the intervention is adopted and implemented by more practitioner teams. In this paper we introduce Project ECHO, describe its core components as an intervention, and briefly recount its ascent as a way to bring specialty health care to underserved rural populations. We review the published peer-reviewed literature about implementations of ECHO for different health conditions, first concerning patient access and health outcomes, and second about provider outcomes. We summarize these findings at the end of Sections 2 and 3, and at the beginning of Section 4. In Section 4 we prioritize types of evaluations that could best add value to what ECHO leadership and implementation teams are learning about this intervention. The highest priority for needed research about ECHO reflects the reality of interest in this model as a means of strengthening the professional engagement of, and continuing medical education for, rural primary care providers. It is ECHO’s ability to affect the professional engagement and continuous learning of primary care providers that makes this model so promising for improving access to specialty care for disadvantaged patients. The research priorities that we list do not require a slowing of ECHO implementations. We describe approaches to evaluation that can come alongside the daily work of practitioners in the field so that additional patients can continue to benefit from this model.