title: Mixed-Methods Study of Uptake of the Extension for Community Health Outcomes (ECHO) Telemedicine Model for Rural Veterans With HIV.
abstract: Extension for Community Health Outcomes (ECHO) is a provider-level telemedicine model successfully applied to hepatitis C care, but little is known about its application to Human Immunodeficiency Virus (HIV) care. We performed a mixed-methods evaluation of 3 HIV ECHO programs in the Veterans Health Administration, focusing on uptake by primary care clinics and veterans.
  
  
  
  Administrative data were used to assess program uptake, including adoption (ie, proportion of primary care clinics participating) and reach (ie, proportion of eligible veterans participating). Veterans were considered eligible if they had an HIV diagnosis and lived nearer to a primary care clinic than to the HIV specialty clinic. We interviewed 31 HIV specialists, primary care providers (PCPs), and administrators engaged in HIV ECHO, and we analyzed interview transcripts to identify factors that influenced program adoption and reach.
  
  
  
  Nine (43%) of 21 primary care clinics adopted HIV ECHO (range 33%-67% across sites). Program reach was limited, with 47 (6.1%) of 776 eligible veterans participating. Reach was similar among rural and urban veterans (5.3% vs 6.3%). In interviews, limited adoption and reach were attributed partly to: (1) a sense of "HIV exceptionalism" that complicated shifting ownership of care from HIV specialists to PCPs, and (2) low HIV prevalence and long treatment cycles that prevented rapid learning loops for PCPs.
  
  
  
  There was limited uptake of HIV ECHO telemedicine programs in settings where veterans historically traveled to distant specialty clinics. Other telemedicine models should be considered for HIV care.
authors.affiliation: VA Office of Rural Health (ORH), Veterans Rural Health Resource Center - Iowa City, Iowa City VA Medical Center, Iowa City, Iowa.|Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, Iowa.
authors.forename: Jane
authors.initials: J
authors.lastname: Moeckli
authors.affiliation: VA Office of Rural Health (ORH), Veterans Rural Health Resource Center - Iowa City, Iowa City VA Medical Center, Iowa City, Iowa.|Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, Iowa.
authors.forename: Kenda R
authors.initials: KR
authors.lastname: Stewart
authors.affiliation: VA Portland Health Care System, Portland, Oregon.
authors.forename: Sarah
authors.initials: S
authors.lastname: Ono
authors.affiliation: VA Office of Rural Health (ORH), Veterans Rural Health Resource Center - Iowa City, Iowa City VA Medical Center, Iowa City, Iowa.|Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, Iowa.
authors.forename: Bruce
authors.initials: B
authors.lastname: Alexander
authors.affiliation: VA Office of Rural Health (ORH), Veterans Rural Health Resource Center - Iowa City, Iowa City VA Medical Center, Iowa City, Iowa.
authors.forename: Tyler
authors.initials: T
authors.lastname: Goss
authors.affiliation: VA Portland Health Care System, Portland, Oregon.|HIV, Hepatitis, and Public Health Pathogens Programs, Office of Patient Care Services, Veterans Health Administration, Washington, District of Columbia.|Division of Infectious Diseases, Oregon Health and Sciences University, Portland, Oregon.
authors.forename: Marissa
authors.initials: M
authors.lastname: Maier
authors.affiliation: Department of Medicine, University of California, San Francisco, California.|Medical Service, San Francisco VA Medical Center, San Francisco, California.
authors.forename: Phyllis C
authors.initials: PC
authors.lastname: Tien
authors.affiliation: VA Office of Rural Health (ORH), Veterans Rural Health Resource Center - Iowa City, Iowa City VA Medical Center, Iowa City, Iowa.
authors.forename: M Bryant
authors.initials: MB
authors.lastname: Howren
authors.affiliation: VA Office of Rural Health (ORH), Veterans Rural Health Resource Center - Iowa City, Iowa City VA Medical Center, Iowa City, Iowa.|Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical Center, Iowa City, Iowa.|Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Ohl
mesh_terms: D003153:Community Health Services / Q000379:methods; D015658:HIV Infections / Q000523:psychology / Q000628:therapy*; D006282:Health Personnel / Q000523:psychology; D006297:Health Services Accessibility / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D020407:Internet; D011320:Primary Health Care / Q000379:methods / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012424:Rural Population / Q000706:statistics & numerical data; D017216:Telemedicine / Q000706:statistics & numerical data*; D014728:Veterans / Q000523:psychology / Q000706:statistics & numerical data
keywords: access to care; program evaluation; qualitative research; technology; veterans