House of Delegates issues guidelines for in-store clinics

Chicago -- With quick clinics opening in chain stores across America staffed by nurse practitioners and physician assistants, the AMA House of Delegates made clear during the Association's Annual Meeting that, while it's not against the facilities in principle, it believes they are no substitute for a long-term relationship with a doctor.

The house adopted a report June 13 establishing nine guidelines for the operation of in-store clinics. The action comes as pharmacy chains, shopping malls and retailers around the country, including Wal-Mart Stores Inc. and Walgreen Co., rapidly move to lease space to in-store health clinics to treat nonurgent minor conditions such as colds, ear infections and strep throats.

These clinics target the insured, uninsured and underinsured who value the convenience and flexibility of getting treatment on a walk-in basis instead of having to schedule an appointment to see their physician.

While the clinics say they complement and are not intended to replace physicians, delegates at the AMAAnnual Meeting expressed concern about the clinics' impact on quality care, leading the house to adopt the guidelines and direct the AMA to monitor the effects of the clinics on the health care marketplace, then report its findings back to the House.

"The guidelines that were passed are ones that we'd use when asked for [our] opinion of store-based clinics," board Trustee Rebecca J. Patchin, MD, an anesthesiologist and pain management specialist in Riverside, Calif., said at a press conference following the house's action. "What we're interested in is making sure that they are operated in a way that protects the public. That's what the guidelines are intended for and to provide some parameters to provide quality care."

Under the guidelines, store-based clinics must establish arrangements by which their health care practitioners have direct access to and supervision by MDs and DOs as consistent with state laws. They also should be encouraged to use electronic medical records as a means of communicating patient information and facilitating continuity of care. The clinics also must:

• Encourage patients to establish a relationship with a primary care physician to ensure continuity of care.
• Have a well-defined and limited scope of clinical services consistent with state scope-of-practice laws.
• Use standardized medical protocols derived from evidence-based practice guidelines to ensure patient safety and quality of care.
• Establish protocols for ensuring continuity of care with practicing physicians within a local community.
• Set up a referral system with physician practices or other facilities for appropriate treatment if the patient's conditions or symptoms are beyond the scope of services provided by the clinic.
• Clearly inform patients in advance of the qualifications of their health care practitioners as well as limitations in the types of illnesses that they can diagnose and treat.
• Establish appropriate sanitation and hygienic guidelines and facilities to ensure the safety of patients.

Generally, the companies operating the in-store clinics say the facilities are overseen by physicians, even if they're not in the office, and that they follow these guidelines already.

Several AMA delegates spoke in favor of the guidelines. However, some of them wanted the issue referred back to the Council on Medical Service because they wanted stronger standards addressing their concern that pharmacies leasing space to the clinics would pressure the latter to write prescriptions that would be filled on their premises.

Some also were concerned that the clinics would cherry-pick paying patients and not take care of Medicaid and nonpaying patients as doctors do.

Art Snow, MD, a Shawnee Mission, Kan., family physician and the Kansas state chair of the AMA's Organized Medical Staff Section Governing Council, worried that some seemingly minor symptoms could actually mask something much more serious that the clinics might miss.

"My real concern is that some [patients] are going to have problems ... and they are likely to walk out of the store and die if they are not treated on an emergent basis," Dr. Snow said.

But AMA Delegate Richard Wherry, MD, a family physician from Dahlonega, Ga., warned against a delay because the horse, so to speak, was already out of the barn.

"First of all, if we think we're going to stop these, we're wrong," Dr. Wherry said. "They are very well-capitalized, and they have an excellent business and medical leadership. My concern about referring this back is that this is a very fast moving target. ... We're asking the AMA to engage the clinics [now]."