Letters to the Editor

Retail clinic guidelines

Retail based health clinics have expanded nationally (over 2,000) with plans to open hundreds more over the next several years. These clinics (Minuteclinic, RediClinic, Solantic, Take Care Health, etc.) evidently fill a need and provide another entry into the medical system.

But rapid expansion of these clinics raises concerns about the quality and efficiency of care. Regulation of these two parameters needs to keep pace, and state and national regulatory agencies need to play a proactive role in ensuring the health of the general public.

I propose a set of fundamental requirements (based on principles adopted by the American College of Physicians), all of which must be met to provide high quality, continuous, cost efficient care:

• The venue must meet strict standards for a health care facility, as set by a regulatory agency, for room size, disposal of medical waste, private and confidential areas of care, infection control, state of the art equipment, etc.
• The providers must be capable of delivering care with a well-defined scope of knowledge and skill set appropriate for the setting.
• Strict evidence-based guidelines and protocols should be followed. Access to health information if needed by other health care providers should be available at the point of care. If a patient's condition worsens, a plan should be in place for further evaluation and treatment by an appropriate health care provider/facility.
• Documentation should be in electronic form with interoperable capabilities, to allow for the transfer of clinical information to the patient's primary care physician/medical home.
• Prescriptions should be in electronic form and sent to the patient's choice of pharmacy.
• Each clinic should have a referral base of medical homes for follow-up.
• The supervising physician's name should be clearly posted in patient areas, with clear directions on filing complaints with the facility and/or health regulatory agency.
• Retail clinics should have the ability to refer patients to other facilities for health problems outside the scope of their practice.
• Advise patients that retail health clinics are not to be used for continuing, long-term or preventive care.
• A Quality Assurance program should be in place to monitor for adherence to clinical guidelines/protocols, adverse events, lack of follow up care, patient complaints and care delivery that is out of scope of practice, as well as evaluate clinical outcomes, cost savings and patient satisfaction.

I would suggest that physician offices take the following measures:

• Expand their hours and offer payment structures, convenience and quality of care similar to retail health clinics.
• Create a medical home and an alliance with retail clinics for patients with no primary care physician.
• Accommodate these new patients as well as their established patients for follow-up and continuing care in a timely manner.

If the goal is to provide integrated, coordinated, high quality, cost efficient healthcare to our citizens, the above system can fulfill these requirements.

N.S. Damle, FACP
Governor, Rhode Island Chapter
Wakefield, R.I.

EMRs questioned

Recently, the Department of Health and Human Services announced that they are looking for 1,200 practices to show that by using EMR care of patients is improved. They state that only practices with certified EMRs will be included in participation of this program, and those without EMRs and those with noncertified EMRs will be left out of this program. Why is the ACP supporting certification through the new CCHIT process, when throughout the Internet it seems that they will not have interoperability criteria for at least another two years, that there is no proof that using these expensive EMRs actually improve care, and that possibly Congress has now a bill that may turn over certification from CCHIT to NIST? The ACP has let its members down miserably as a lot of ACP members will thus not be able to participate.

If this is to be a true study demonstrating how important CCHIT certification is, those in charge should use a scientific method and include these very currently excluded practices as a “control group” to which to compare not only if CCHIT certified EMRs are better at providing care, but to what degree as a lot will depend on the final outcome. Anything less will be a sham. Only by having a control group will future practices like mine be convinced that what we are being told about CCHIT certified EMRs is true and that the investment is a worthwhile endeavor not only for our patients, but for our very survival.

The ACP is supposed to represent internists and thus should place our interests first, above misplaced efforts by the insurance companies and others who take physicians for a ride, all of who stand to benefit the most with the least amount of risk. Support of the expensive CCHIT certification process blindly at a minimum gives an impression that ACP does not care about its members, but also gives an impression that its very leaders are incompetent in dealing with such matters. While this 1200 practice pilot project is a start, once you let selective participation cancer trample ACP members, in years to come it will metastasize, but by then it will be too late. I am of the opinion that ACP then will sure regret its today's position of supporting CCHIT.

I strongly urge ACP to reconsider its position on supporting this unproven CCHIT certified EMR push. Not only will you will further lose membership but general medicine and our patients in will suffer when older physicians begin to retire early in lieu of this massive intervention and income loss, further worsening the primary care shortage.

B.P. Rajesh, ACP Member
St. Johns, Mich.

Editor's Note: The College supports the efforts of the CCHIT in identifying EHRs that meet baseline functional, interoperable and security criteria. There will always be tension between innovation and standardization within the ambulatory EHR industry; however, without certification, there is no clear way to assure that an EHR's solution is one that will endure over time. Many vendors, in an attempt to reach the market quickly, develop proprietary methods, terminologies and functions that do not necessarily adhere to industry standards. CCHIT certification provides a way to identify for our members EHR systems that not only meet specific test criteria, but do so in accordance with vetted standards. CCHIT certification is one step in facilitating EHR adoption among our community.

Governor honored

In the hard world of overwork and under-appreciation in the practice of medicine, there are still bright spots.

Two times in the past month, I have been caught up in the desperate drama of a regional trauma and critical care unit with families facing sudden and overwhelming losses. Waiting with these fine people as their loved ones struggled, too young and productive to die, I saw the incalculable good of a magnificent physician: competent, hardworking and totally professional. His facility is worn and understaffed but his associates clearly reflect his standards, dedication and determination to provide excellent care. As a somewhat jaded, over-the-hill physician who has seen most everything in the last 50 years, I recognized in him the rare, right stuff that makes true heroes.

It is reassuring in these difficult times to see the eternal value of a fine physician. And, to know that beyond his demanding clinical work, he is a leader in American medicine: Vincent Nicolais, FACP, is Governor of the Georgia Chapter of the American College of Physicians. We should all be thankful for internists like him.

Robert B. Copeland, MACP
La Grange, Ga.