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Welcome to ECHO at UHN

Thank you for your interest in Project ECHO at UHN.

This registration form is for ECHO Managing COVID-19 in Primary Care.
 
We’d like to learn a little bit more about you, your interest in Project ECHO, and your practice. By completing this form, you consent for your information to be used to better inform and tailor our program to suit your needs.

Please allocate approximately 10 minutes to complete this form.

If you have any questions or troubles with our registration process, please contact us at echo.ontario@uhn.ca

Important Information before you get started

ECHO will connect you with an inter-professional specialist team and other primary care providers from across Ontario by videoconference. Each weekly session includes case-based discussions and a short didactic.

There is no charge to attend but we ask that you actively engage in the peer learning community by sharing case presentations and ideas with the group.

Participants are asked to:
  • Attend ECHO sessions (There are 12 curriculum topics. Please join as often as possible.)
  • Present at least 1 case (All cases are de-identified.)
  • Complete 2 questionnaires (Pre-Impact questionnaire will be sent to you before you start and Impact questionnaire is sent after attending 8-10 sessions.)
ECHO at UHN is fully funded by the Ministry of Health 

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* 1. I have reviewed the important information above

ECHO uses ZOOM, a free videoconference platform. You may download it from www.zoom.us. You will need internet access, speakers, microphone (and a camera) OR a SMART telephone

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* 2. First and Last Name

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* 3. Primary Email Address (this will be the email we send program information and materials to)

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* 4. Phone Number

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* 5. What is your profession?

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* 6. What is your age group

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* 7. What is your gender identity?

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* 8. What is the name of your primary place of practice (organization name, clinic name, hospital, etc.)?

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* 9. Practice Address

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* 10. What type of practice is your primary place of practice?
Check all that apply.

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* 11. What LHIN are you a part of? 

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* 12. What type of environment do you practice in? (Select all that apply. If more than one, please elaborate under "Other")

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* 13. How many years have you been in practice?

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* 14. Approximately how many patients do you have in your practice right now?

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* 15. How many patients with COVID-19 are you managing in your practice right now?

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* 16. How did you hear about ECHO Managing COVID-19 in Primary Care?

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* 17. When are you available to start? (Program starts Tuesday April 13th)

Date
Data Use Notice:

I understand that the following data will be collected for reporting purposes:

1. In order to meet Ministry of Health (MOH) funding deliverables, ECHO UHN collects participant data for quarterly and annual reports that are submitted directly to the MOH. Any public dissemination outside of the MOH is anonymized. If ECHO UHN shares any documents for use outside of MOH reporting, participant name will be removed but the name of the organization will be included. Those working independently will be identified as “Solo Practitioner”. Any quotes that may be shared outside of MOH reporting will be identified as “[Profession], [ECHO Name]”.

2. In order to support quality improvement and quality assurance, the ECHO Ontario Superhub collects participation data for each ECHO program in Ontario, including ECHO UHN. This data allows ECHO Ontario to measure, analyze, and report on the model’s reach within Ontario. Your data will be used in reports for quality improvement and quality assurance purposes. If shared for use outside of Superhub reporting, participant name will be removed but the name of the organization will be included.

3. In order to support the growth of the ECHO model, the Project ECHO Institute at the University of New Mexico, USA collects attendance for each ECHO program globally, including ECHO UHN. This data allows the Project ECHO Institute to measure, analyze, and report on the reach and impact of the program internationally. Your participation data, including name, organization name, organization address and ECHO session attendance, will be shared. Aggregated data (at a program level) will be used in reports, for quality assurance/improvement activities, and for decision-making related to new initiatives. If you would like to opt-out of this, please contact a member of our team.
Participant Collaboration: Please note that there are certain conditions which must be agreed to in order to participate in this program. Please indicate if you agree with the following statements (all must be agreed to):

The statement of collaboration may be downloaded by clicking here

Patient Relationship Disclaimer: ECHO case presentations do not create or establish provider-patient client relationship between any ECHO Hub Clinician and a patient whose case is presented.

Commitment to Collaboration: Recommendations from the Hub do not in any way replace my own diligence and professional expertise with respect to my patients or clients. University Health Network and its officers, directors, employees, subcontractors and agents accept no responsibility or liability for any treatment decisions I make as a result of my participation, or association with ECHO UHN. I agree to be solely responsible for the treatment of my patients and understand that all clinical decisions rest with me regardless of recommendations provided by the expert hub team and other ECHO participants.

De-identified Information Notice and Confidentiality: Personal identifying information is not to be shared during ECHO sessions. If this does occur, I'll follow my own organization's policies and procedures to address the privacy breach.

Participation Notice: I and/or my organization (Spoke) will participate in as many sessions as possible during the curriculum to maximize my learning experience. I understand that case discussions are part of every session and that I, or a member of my team, will be expected to present at least 1 (one) de-identified patient case.

Recording, Photographs and Guests: The ECHO team records sessions for educational purposes and occasionally takes photos for promotional purposes. I give permission for my photos to be used unless explicitly requested in writing

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* 18. Statement of Collaboration and Data Sharing
Agreement of Participants

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* 19. Case Presentations are an integral part of ECHO sessions. There is no limit to the number of cases you can present, however we ask that all participants present at least 1 case.
  • All cases are de-identified
  • There is no patient doctor relationship established between the ECHO specialist team and your patient.
  • Case presentations are mostly pre-scheduled, however you can reach out whenever you have case questions to schedule a more ‘spontaneous case’.
  • Although most participants discuss their own patient cases, others present cases on behalf of their team. All cases relevant to the specific program topic.
Please indicate an answer below and our administrative team will contact you with more information

What happens next?
You will receive an email shortly with the following:
  • Confirmation of your registration 
  • The Pre-ECHO questionnaire
  • Case Presentation Form
  • You will receive the weekly ECHO e-agenda on the day prior to your start date
  • The e-agenda has the link to join ECHO session
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