Reflection | Morgan Mckinney

Day 1: March 13, 2019

Today was our first day in Washington D.C. Within the span of 24 hours we packed up a van, drove from Duke University to the nation’s capital, and attended four insightful meetings. I personally attended the meetings with Senator Burr’s health policy assistant, Rachael Soclof, Congressman Price’s senior legislative assistant, Nora Blalock, and attended the AHIP conference. Over the course these meetings, a common theme emerged regarding the barriers to the uptake of telehealth. Every day a new advancement in health technology is made and whole careers are spent innovating, but progress in the delivery of healthcare significantly lags behind health technology and innovation. While science advances at a quick pace, the lengthy process of policy implementation and regulation stands as a significant obstacle to the clinical implementation of scientific and technological advancements. For example, while telehealth is viewed as an opportunity to increase access to care, universalize knowledge, extend the existing provider base, and address social barriers, it also introduces patient privacy and security concerns, disrupts current business entities, and relies on access to broadband.

These concerns bring up important considerations for the Pocket Colposcope. Prior to these conversations, I did not realize that the United States had such a long way to go before we have universal broadband. This matters for the Pocket because without broadband access, those using the Pocket will have no way to send the images to a specialist for interpretation. This is especially problematic since areas that don’t have access to broadband are also likely ones that are medically underserved and would benefit the most from the Pocket. In the hopes of ensuring the Pocket’s longevity and efficiency, it will be important identify areas lacking broadband and track the progress of any attempts made to increase access.

Day 2: March 14, 2019

Today we met with Morgan Reed from Connected Health Initiative, two representatives from AHIP, nursing advocate, Winifred Carson-Smith, and CMS. In our second day of meetings, my biggest takeaway was the realization that a business-minded approach is hugely important in implementing a new device in the medical field. If physicians are not being paid to use a new device, then they simply won’t use it. And more importantly, physicians are held liable if they perform a procedure with a device that leads to inaccurate results or harms the patient, emphasizing the need for sufficient, readily available evidence supporting the safety of the device. Furthermore, we must not only have a safe device, we must also be able to accurately communicate the safety of the device to providers and patients as well as have clear and robust training guidelines to use the device.

From a business-minded perspective, one concern for the Pocket is that only a small fraction of telemedicine services are reimbursed for two reasons: 1) fraud and 2) concern that telemedicine adds an extra appointment or procedure that must be paid for rather than replacing them. Many insurance companies worry that a patient may have a procedure done, colposcopy for example, and will then need an additional appointment to get better results. While we already have evidence suggesting the Pocket produces images comparable to the traditional colposcope in the U.S. setting, it will be equally as important to compensate the providers who take the images as well as the ones who interpret them in order to promote use of the device. Furthermore, when a procedure is done, only one provider can be reimbursed. One way to deal with this in the case of the Pocket is for the provider who takes the image to claim the code for colposcopy and establish a business agreement to compensate the specialist who interprets the image. If providers were willing to negotiate this business agreement, then both providers would be compensated for their services without needing a new code.

Day 3: March 15, 2019

Today we met with a former FDA employee who currently works at the Duke-Margolis Center and the Prevent Cancer Foundation. We were invited to attend the annual Dialogue for Action which is conference on issues related to cancer screening and prevention to continue these important discussions. We were also guided to use colonoscopy as a case study for shifting the point of care as it deals with similar issues we are facing with the Pocket. With colonoscopy, primary care physicians and nurse practitioners can take images of the colon (similar to taking images of the cervix) and then send them to a specialist for interpretation. This process is extremely similar to what we envision for the Pocket and may be qualified to serve as a precedent case for task-shifting cancer screening.

After a couple of busy, but exciting days discussing barriers to accessible healthcare and technological innovation, today’s meetings brought our trip to D.C. full circle. In our discussions about accessible healthcare and preventative care, I was reminded why we go through all of the trouble to improve healthcare despite the many barriers discussed in previous days. We work so tirelessly to overcome these obstacles to eliminate health disparities. We are working toward a world where your background, location, or gender do not determine the quality of care you receive. After spending the year working on this project at Duke, it was empowering to finally bring all we had learned and accomplished to these meetings. We had a chance to share our research, but also had the opportunity to hear more about similar projects and issues establishing a deeper understanding of our work in the larger context of accessible health care.

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