National Nurses United

CE:8 page 2/8/08 2:25 PM Page 26 REPORTING, REFERRAL SERVICES, FOLLOW-UP, AND RECORD KEEPING physician offices and medical clinics have an important community surveillance role; they must report to the public health departments any reportable disease, such as AIDS, measles, mumps, tuberculosis, etc. Physicians in these settings have contracts with insurance companies, Medi-Cal, and Medicare and are required to adhere to standards of practice (a Medi-Cal-approved physician must adhere to the county's health plan) and oversight (proof of physician license/malpractice coverage/ business license/CV/TB testing, attestation of no impairment, no investigation by licensing board, and no past or present liability claims). Patients who are cared for in these settings have recourse and can file complaints with government agency regulators (federal, state, or county). Referrals to ensure continuity of care and follow-up by multidisciplinary teams (social workers, physical therapists, and nutrition specialists) are very much part of physician office and medical clinic practices. Many of these patients have primary care physicians and can be further referred to specialists. These practice settings are required to keep accurate, concise, and timely documentation and record keeping. They are part of a network and are a critical source for tracking deterioration of patient condition, ER visits, or tracking the patient in case of an outbreak of a communicable disease. PROBLEM STATEMENT – RETAIL CLINICS in con trast with the safeguards, standards, and guidelines imposed on physician offices and medical clinics, retail clinics are unregulated, unlicensed entities not answerable to regulatory agencies and not held accountable for the public's health, welfare, and safety. Since they are cash payment ventures they are not subject to any federal, state, or county regulatory authority. They have supreme flexibility and can act in any arbitrary, capricious, and whimsical manner they see fit. They have unfettered authority to set their own standards of practice. There is no infection control infrastructure. They are exempt from complying with numerous critical public protection measures, such as infection prevention and control standards, reporting of communicable diseases to prevent epidemics or pandemics, keeping concise and accurate records including record keeping for referral, follow-up, patient tracking for transmission prevention purposes, prescreening for contagious diseases prior to retail visit, triage/assessment to rule out whether the ailment falls within the "Menu of Services." Retail clinic practices discourage the establishment of a continuous therapeutic relationship between the healthcare practitioner and the patient. It is yet another "throughput" scheme – you're sick. we're quick, come get your express care. There is a great likelihood of a conflict of interest. The emphasis is on writing prescriptions. It is unclear whether the MD/NP/PA is allowed to make recommendations that do not include writing prescriptions. Furthermore, compensation and financial incentives tend to be tied to promoting the merchandise, in these cases – drugs. In addition, there is also a very disconcerting revenue-generating scheme in place where retail clinic patients now have an enticing opportunity to purchase not only the drugs and medical devices prescribed but also purchase any of the merchandise conveniently located in the waiting aisle near the kiosk, or any item in the store. To 26 REGISTERED NURSE facilitate such an opportunity Wal-Mart now proposes the marketing of a Wal-Mart card where individuals without a checking account (the overwhelming majority of their customers are low wage) can deposit their paychecks on the card for easy shopping at Wal-Mart. A word of caution: In addition to professional liability for malpractice suits against MDs/NPs/PAs there is currently a major concern about whether or not these practitioners remain liable to third parties who have been injured as a result of exposure to the practitioner's contagious patient, regardless of the practitioner's effort to minimize the risk. Until the laws regarding third party liability are clarified by the California Legislature, Congress, or the courts, this issue remains burdened with uncertainty. This is another response to rapid changes in the healthcare market and payment methods and even government health, welfare, and safety regulation policies by redesigning and repackaging healthcare delivery. The industry through redesign has created the problem and caused this phenomenon of lack of access to primary and acute care, which caused overcrowding of the ER. Now it pretends to be a victim of its own redesign. This is not the time to add to the long list of licensure exemptions. This retail clinic entity must be stopped. In addition, these clinics will cause further fragmentation of the delivery of healthcare in an industry that is already on life support. This is totally incompatible with CNA/NNOC principles of a singlepayer system and single excellent standard of care. Conclusion: Healthcare provided in retail clinics poses a major threat to the health, welfare, and safety of the store's retail and healthcare shoppers, including the public in general in cases of epidemic and pandemic outbreaks. I Hedy Dumpel, RN, JD is National Chief Director of Nursing Practice and Patient Advocacy for CNA/NNOC. Resources I American Academy of Pediatrics, Infection Control in Physicians' Offices. Pediatrics, Vol. 105 No.6, June 2000. I The College of Physicians and Surgeons of Ontario, Canada. Infection Control in the Physician's Office. 2004 edition. I The Centers for Disease Control, Infectious Disease Information, http://www cdc.gov/ncidod/diseases/ index.htm, July 12, 2007. I New York State Department of Health. Health Advisory: Prevention and Control of Community-Associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA). (Letter from NYSDOH Bureau of Communicable Disease Control, Regional Epidemiology Program to Hospitals, Nursing Homes, Health Care Providers and Local Health Departments, October 18, 2007). http://www.health.state.ny.us/diseases/ communicable/staphylococcus_aureus/methicillin _resistant/community_associated/health_advisory _2007-10-18.htm W W W. C A L N U R S E S . O R G JANUARY | FEBRUARY 2008

• Cover