“AAP Criticizes Retail-Based Clinics — Again.”

I noticed the headlines rolling in about the AAP updated policy statement regarding retail based clinics.  The one above particularly caught my eye.  Something about the tacking on of “again” caught my attention.  It came across to me like we (pediatricians) were perceived to be saying something that was unnecessary, maybe even that we were just complaining.

Throughout the day, I monitored my Twitter feed and read some articles discussing the issue.  Fortunately, I didn’t see a whole lot to confirm my (perhaps defensive) concern that we would be perceived as whining about the emergence of urgent and retail clinics.

But, the guideline and the response from the retail clinics got me thinking.  Currently we seem to be doing okay in the public perception but how much longer does that hold up?  Are our statements going to forever be met with an understanding or is there eventually going to be backlash about our perceived inflexibility.

There are many things that parents want in medical care for their children but I believe this debate boils down to 2 main issues: quality and convenience.

Quality

Pediatricians claim, in the policy, that retail based clinics create a decrease in quality of care for the following reasons:

• fragmentation of care
• provision of episodic care to children with special health care needs and chronic disease
• lack of access to and maintenance of a complete, accessible, central health record that contains all pertinent patient information
• the use of tests for the purposes of diagnosis without proper follow-up
• possible public health issues that could occur when patients with contagious diseases are in a commercial, retail environment with little or no isolation (eg, fevers, rashes, mumps, measles, strep throat, etc.)

I do believe these are concerns that do need to be addressed by the urgent care and retail people.  I have written about many of these previously: My Questions for Urgent Care Clinics.

The AAP policy statement goes on to make recommendations for principles with retail clinics (my thoughts italicized):

• Supporting the medical home model: Retail- based clinics (RBCs) should support the medical home model by referring the patient back to the pediatrician or other primary care physician for all future care.  (Is this realistic?  They might even say that they will but will we eventually tell our patients that they should have just used the retail clinic for this complaint because it was simple?  This won’t happen and I don’t know why we’d expect them to refer back to us either.)
• Communication: The AAP recommends that RBCs promptly communicate with the patient’s pediatrician or other primary care physician within 24 hours of the visit.   (This seems logical and important.)
• Using evidence-based medicine: The AAP recommends that all those providing care to children follow all AAP clinical guidelines as well as those guidelines developed by other medical organizations that have the support and endorsement of the AAP.  (Again, a reasonable and critical expectation.)
• Contagious diseases: By providing medical care to individuals in a retail-based setting, RBCs must take the necessary precautions to prevent the spread of contagious diseases.  (While many pediatricians do this, it is not universal and we need to do a better job of providing well and sick waiting rooms.)

Many of these concerns are addressed in the quote from the article:

The Convenient Care Association, a Philadelphia-based retail clinic association, took exception to the AAP’s claims about its members’ work.

“Retail clinics work closely with local physicians and pediatricians. They all use electronic health records (EHR) and actively encourage the sharing of visit records with a patient’s family physicians and pediatricians in order to facilitate continuity of care,” Tine Hansen-Turton, JD, the association’s executive director, said in a statement. “Additionally, the industry is very focused on quality care, and EHRs are also used in clinics to monitor evidence-based practice performance.”

Whether or not you agree with the assessment, they do provide an answer to many of the concerns that the AAP has raised.

Convenience

The second major issue I see arising as a result of the conversation is about convenience.

Let’s imagine that the retail clinics drafted a policy statement that addressed their concerns regarding care at pediatrician’s offices.  Some of their concerns might go something like this:

• lack of same day illness appointments creates unnecessary overnight suffering for parents and children
• small waiting rooms create difficult environments for parents managing active kids
• minor complaints should be seen by mid-level providers and escalated as necessary to the physician
• parents’ schedules are malleable and need the flexibility of walk-in appointments
• parents need the ability to have their children seen outside of their typical working hours to avoid lost income

These are some of the benefits of convenience that a retail clinic provides that many of us currently do not or we meet it in some trivial way that does not provide a real solution for families.

Don’t get me wrong, we have come a long way.  Improving the patient/parent experience has always been a focus of pediatrics and will continue to be for years to come.  But, there is some reason that our patients are using these clinics (and why we have to issue statements about them) and I would guess that for the most part it’s a convenience issue.

So, we’re still missing the boat (and an opportunity) somewhere.

The race is on

The way I see it, the race is on.  One of two things are going to happen.

1. Retail clinics are going to figure out solution to our perception of their decreased quality of care and the public will know about it.  Consider this quote from Tine Hansen-Turton, JD: “Retail clinics work closely with local physicians and pediatricians. They all use electronic health records (EHR) and actively encourage the sharing of visit records with a patient’s family physicians and pediatricians in order to facilitate continuity of care.”  It tells me that they are already far along in their thinking and ready to make strides to improve their quality of care.  They can’t afford to stop trying because it means their future success or failure.
2. Pediatric offices are going to figure out a way to meet the demand for patient convenience that is currently being met by the retail based and urgent care clinics.  We need to make ourselves agile enough to meet the demands of convenience as they arise in the future.  We can’t afford to stop trying because it means our future success or failure.

Which is it going to be?  Are we going to whine or win?

Justin Smith is a pediatrician who blogs at DoctorJSmith.  He can be reached on Twitter @TheDocSmitty.