Ask questions before working at retail clinics

A for-profit health care organization employs certified registered nurse practitioners to treat common ailments in a clinic housed in a retail store and wishes to hire a physician to oversee the operation. How can the physician be sure the clinic will deliver quality care that meets professional standards?

Response

It appears that rapidly expanding retail-based medical clinics are here to stay. These clinics began in national pharmacy outlets, but their success has inspired large retail chains such as Wal-Mart to place them in stores. Their services appeal greatly to the segment of the patient population that values efficiency: They are available to patients when their primary care physician has no openings; appointments are not needed; waiting time is minimal; most insurance is accepted; and co-pays are not much different than for a routine visit to a primary care physician.

Retail clinics are proliferating because they offer a level of convenience that is not available at most primary care physician offices in the United States. They are open late at night during the week, and on Saturday and Sunday. Their niche is the provision of primary, nonemergent, acute care by licensed and certified registered nurse practitioners.

CRNPs treat a small number of common, self-limiting ailments, including cold viruses, the flu, sore throats, urinary tract infections and minor injuries, and offer vaccines and other routine preventive care. They do not treat complicated illnesses or offer EKGs, lab tests or x-rays. CRNPs do not give treatment advice over the phone or call in prescriptions. Other than treatment for UTIs, generally no care is provided "below the waist" -- neither routine ob-gyn care nor the evaluation and treatment of sexually transmitted diseases.

While experienced CRNPs staff the in-store clinics, physician oversight also is required, and many doctors find that the opportunity to serve in that capacity is worth exploring and potentially satisfying.

Operating out of select Walgreens drugstores in Pittsburgh, Take Care Health Systems is one of the larger store clinic operators. Each Take Care clinic is staffed by three to four CRNPs who provide coverage seven days a week, according to Sandra Ryan, chief nurse practitioner officer, and Donna White, assistant lead nurse practitioner. Take Care CRNPs rely on specific algorithms of care that the company developed to treat patients presenting with symptoms of the conditions listed above.

Importantly, CRNPs in Pennsylvania may practice independently. Physicians are not required to be on-site, supervise care directly or review treatment records in real time. They function instead as collaborators who oversee the clinic's operation and give real-time assistance and backup to the CRNP only when needed.

These physicians (most often board-certified family practitioners, since the clinics offer both adult and pediatric services) are essential to assure the quality of care and foster the spirit of a team-based approach in this new setting. They may supervise up to four CRNPs (in Pennsylvania, but this number can vary from state to state) by reviewing charts, being available for calls and providing help as needed.

Physician collaborators also serve as sources of continuing medical education for the nurse practitioners. The physician typically reviews about 10% of the charts for quality purposes, noting any individual or recurrent problems, and offers appropriate feedback and follow-up.

There are a number of ways for a physician to determine whether care at the clinic is appropriate, of high quality and professional. Before committing to be a physician supervisor:

• Visit one of the local clinics and observe its operation. Take note of the environment, staffing, adequacy of supplies and overall condition of the clinic space. See how it compares to a typical physician's office.
• Observe the nurse practitioner. With the permission of the patient, observe the exam and the treatment offered. Take the opportunity to speak with the nurse practitioner about his or her work experience at the clinic. Get a sense of whether this is someone you would want giving care.
• Ask to review a random selection of charts. Review documentation and treatment, and compare it to your own office experience. These charts should not contain patient names or other identifying information.
• Review the treatment algorithms the company uses. Make sure that they reflect current guidelines and are easily understood. The algorithms also should specify protocols for managing difficult situations and triaging challenging cases.

The above tasks are a necessary part of evaluating the quality of care the clinic can deliver. If you conclude that adequate controls are not in place for the provision of high-quality and professional care, I would suggest that you inform the managers of the health system so that they know what you find problematic or troublesome.

If you wish to explore involvement further, I encourage you to consider the following next steps:

• Meet with one of the current physician collaborators at the facility. Have a candid conversation about the responsibilities, the required oversight and, most importantly, the time commitment.
• Review the resumes of CRNPs you would be hired to oversee. You will want to see evidence of broad, general experience since CRNPs, to a significant degree, work independently. (Take Care CRNPs, for example, have four to seven years of experience on average, with an additional 10 to 15 years as a registered nurse.)
• Review the company's policies on quality control, auditing and chart review. Make sure you are satisfied there is a mechanism for managing clinical challenges and policies for handling problems with individual practitioners, should they arise.
• Review your state regulations on the scope of practice of CRNPs. Know exactly what CRNPs are allowed to do without your real-time approval in the retail-clinic setting. State laws may vary.

With a proper amount of physician collaboration, retail clinics can serve a need for patients who have acute, nonemergent, self-limiting illness and desire the added convenience of care without waiting for it or having to prearrange it.

This kind of care is not inherently unethical or unprofessional, and in fact, many primary care physicians already employ CRNPs in a similar capacity. Store clinics are doing it more conveniently by limiting the types of patients they see and staying open late at night and on weekends. Doctors can play an important role in assuring that retail-based clinics deliver services that meet or exceed high standards of professionalism and quality.

Scott Miller, MD, board certified internist; chair of the ethics committee, Allegheny General Hospital, Pittsburgh; medical editor of the monthly "Bulletin" of the Allegheny County Medical Society