AMA Principles to guide the establishment and operation of store-based health clinics and CareWorks' response.

Although the concept of store-based health clinics appears to be consistent with the market-based, pluralistic health care delivery systems supported by long-standing American Medical Association (AMA) policy, there are some areas of obvious concern with the operation of such clinics, particularly as they relate to patient awareness, physician oversight, and continuity of care.

The AMA believes that it would be best to help facilitate how store-based health clinics operate in the market, in order to ensure that optimal care is provided to patients. Therefore, the AMA recommends that the following eight principles should be advocated with respect to the establishment and operation of store-based health clinics:

1. Store-based health clinics must have a well-defined and limited scope of clinical services, consistent with state scope of practice laws. Clear definitions of the scope of clinical services offered at store-based health clinics will demonstrate the limitations of the services provided, and should increase the knowledge of patients who seek services at such clinics.
   CareWorks response: CareWorks clinics provide a pre-determined menu of quality health care and preventive services, including routine tests and treatment for common illnesses, in a non-emergency environment. Care is limited to a narrow scope of services that can be safely and reliably treated in an in-store clinic location. Certified registered nurse practitioners and physician assistants provide regularly updated patient education and care instructions verbally and through printed material available “just in time” through Geisinger’s electronic health record system, ensuring consistent quality, content and format across the CareWorks network.
    
2. Store-based health clinics must use standardized medical protocols derived from evidence-based practice guidelines to ensure patient safety and quality of care. It is important that the medical decision-making protocols used by health care practitioners in store-based health clinics are developed from evidence-based practice guidelines, preferably those developed by the medical profession.
   CareWorks response: The certified nurse practitioner or physician assistant is supported by a world-class electronic health record with physician-approved practice guidelines, ensuring the consistent provision of safe and reliable care.
    
3. Store-based health clinics must establish arrangements by which their health care practitioners have direct access to and supervision by physicians. Long-standing AMA policy encourages physicians to be available for consultation with physician assistants and nurse practitioners at all times, either in person or by phone or other means. When health care practitioners have direct access to physicians, the lines of communication are open to contact physicians daily with medical-related questions. In addition, consistent interactions between physicians and health care practitioners will help in coordinating the care of patients.
   CareWorks response: CareWorks agrees with this guideline. Clinical staff communicate with the medical director by phone, electronic health record and in team meetings.
    
4. Store-based health clinics must establish protocols for ensuring continuity of care with practicing physicians within the local community. Store-based health clinics should develop systems that appropriately coordinate care between store-based health clinics and physician offices in the local area. Continuity of care is necessary to ensure that patients are receiving optimal medical care for their conditions.
   CareWorks response: At CareWorks, we understand and respect the importance of our patients’ relationship with their personal physician. We will notify their physician and provide their physician with the results of testing or treatment soon after the patient visit to make sure that care is effectively coordinated. Their physician can also access Geisinger’s electronic health record’s automated communication capability.
    
5. Store-based health clinics must establish 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. In some instances, patients who visit store-based health clinics may have serious medical conditions. By establishing a physician referral system, patients with serious medical conditions can easily be referred to a physician's office or, if necessary, to an emergency facility.
   CareWorks response: We will encourage patients to see their physicians for follow-up care if necessary, or for chronic conditions, which CareWorks is not designed to treat. If patients do not have a personal physician, we will refer them to one if they wish.
    
6. Store-based health clinics must clearly inform patients in advance of the qualifications of the health care practitioners who are providing care, as well as the limitation in the types of illnesses that can be diagnosed and treated. Patients should know in advance what types of medical services are offered and understand that health care practitioners working in store-based health clinics might not be able to diagnose and treat certain conditions. It is important that patients are aware that store-based health clinics are not a substitute for visiting a physician, and occasional clinic visits should be complemented by regular care visits with a physician.
   CareWorks response: CareWorks agrees with this principle and has clearly defined the roles for the certified nurse practitioner and physician assistant. Those explanations are posted in the clinics and are articulated in marketing materials and customer communications. A menu board of offered services and fees is also posted in the clinics.
    
7. Store-based health clinics must establish appropriate sanitation and hygienic guidelines and facilities to ensure the safety of patients. It is critical that sanitation and hygienic guidelines established by store-based health clinics are similar to protocols used by physician practices. As previously noted, concerns have been raised in some regions of the country regarding the lack of such guidelines and facilities that may violate OSHA rules and regulations.
   CareWorks response: A toilet and sink is available for patient’s use in all CareWorks clinics, where patient safety and comfort are our primary concerns Procedures to ensure a sanitary clinic environment are strictly enforced.
    
8. Store-based health clinics should be encouraged to use electronic health records (EHRs) as a means of communicating patient information and facilitating continuity of care. EHRs may make the sharing of patient information and the referral process more efficient between store-based health clinics and physician offices.
   CareWorks response: All patient information is documented in Geisinger’s electronic health record, enabling the sharing of patient information among authorized health care professionals and ensuring coordination of care.