Lessons from MinuteClinic
After entering the clinic a thought occurred to me: why do we need doctors? Then a second thought: why do we need nurses?
Ah, but I’m getting ahead of myself.
About a decade before the Obama administration started touting electronic medical records and evidence-based protocols there was MinuteClinic. The entity came into existence primarily to cater to patients paying out of pocket.
There was no need for a law requiring price transparency. In every market where the dominant buyers are patients spending their own money, prices are always transparent. MinuteClinic posts its prices on a computer screen and on readily available pamphlets. Clearly, the organization is competing on price. Entities that compete for patients based on price usually compete on quality as well. One study found that MinuteClinic nurses following computerized protocols follow best practice medicine more consistently than conventional primary care physicians. They also do a pretty good job of knowing what kind of medical problems they are competent to handle and which problems need referral to a physician.
Wherever you find price competition you usually also find that providers are respectful of your time. As the name “MinuteClinic” implies, this is an organization that knows you value your time as well as your pocketbook. I couldn’t help but wonder if the entire health care system might be this user friendly, if only the third-party payers weren’t around.
One more minute
You’re gonna fall in it.
For the first 15 minutes of my 20 minute visit, the nurse barely looked at me. She was sitting in front of a computer screen typing in my answers to her questions, as she went through the required decision tree. I didn’t mind. Mine was a minor problem and I did not want to pay for more sophisticated service.
Then the nurse turned to some hands-on stuff. First she took my blood pressure. [Is this required by some law? Even my dental hygienist takes my blood pressure.] Then there was a quick look in my ears nose and throat (I was there for an eye problem). Finally, there was some listening to my chest cavity with a stethoscope.
Here is something that was especially impressive. The nurse was able to call up on her computer screen every prescription CVS pharmacy had filled for me — nationwide. MinuteClinic already has the beginnings of a medical home, in addition to electronic medical records and electronic prescribing. (Again, all this is without any prodding from government agencies.) In some places, walk-in clinics are sharing their records with hospitals, and I suspect doctors would be included as well, were it not for the silly restrictions imposed by the Stark amendments.
Now back to my original musings. Clearly lot of primary care can be delivered without doctors. But how much do we really need the nurse? If a nurse can type in my answers to questions and follow a decision tree, why can’t I do that myself? If the nurse’s advice is largely read off a computer screen, why can’t I read the advice myself?
What about the hands-on activities? Patients can already take their own blood pressure. In fact you can do it yourself inside the CVS pharmacy. If the health care system were not so dominated by third-party payer bureaucracies, I suspect my iPhone would already have a stethoscope app. If my iPhone can easily identify a piece of music playing in a local bar, how hard would it be to create an app that interprets stethoscope sounds? As for the ENT observations, couldn’t an app do that as well?
Finally, there is the matter of the prescription my nurse e-mailed to the pharmacy. If she is just following a protocol, why do we need the nurse? Why can’t I do it myself? Or more precisely, why can’t I authorize the computer to mail in the prescription the same way the nurse does?
Here’s my prediction: Within five years we’ll all have MinuteClinic decision trees on our personal laptop computers.
It’d be like a hypochondriac’s dream come true. I’m sure that the expertise is there, but nurses get paid to follow standard operating procedures. The objectivity is probably an important part as well, but hey, look at how well WebMD is doing.
WebMD, Online MinuteClinic, etc. are certainly all welcome innovations and beneficial to the consumer. There are plenty of things out there that intelligent people can self-diagnose themselves on. Many people, of course, probably can’t figure it out even with the help of WebMD, etc.
Whether or not one should go to the real doctor probably just depends on what kind ailment we are talking about.
I for one, welcome the arrive of online-diagnosis services.
I hope to see your prediction come true.
Wait a minute. Who do I sue if I have a bad outcome following a self diagnosis?
David: you sue your self. What fun!
This is an interesting concept. Nurse call centers that provide services for the VA Health System use decision-support algorithms. These are available to everybody online. Many nurse practitioners and physicians even use these. Numerous websites exist (such as WebMD) that allow patients to peruse symptoms. I suspect these decision-support systems will become increasingly complex and become increasingly available to patients without requiring the services of a doctor. Of course, these will never replace the need for a doctor. But it might allow patients to present to the office better informed about their conditions. In the coming years systems might also develop to routinely test bodily fluids for subtle clue to health status. I once read an article on the power of massaspectrometrie to diagnose diseases and conditions.
This will happen as you say. But in medical diagnosis context is everything. A wrong diagnosis is worse than none, and more expensive. Most presenting symptoms are partially or entirely colored by psychological traits unique to the patient, who usually has no clue about that aspect. Getting data is the easy part; interpreting it in the light of all the concomitant psychological and physical variables is the hard and necessary part that can’t be accomplished by automation. A decade ago we lauded the “biopsychosocial model” of medical care as the ultimate goal. With automation (and with many less-trained practitioners) we’re throwing that ideal away.
John, Can you expand on the decision to use MinuteClinic instead of teledoc, which is even lower priced than MinuteClinic?
In my thirty years of medical practice I have seen many cases of errors in self-diagnosis. Of course, there is some selection bias (they did not come see me unless their treatment had failed) but well designed studies have confirmed that there is a high rate of misdiagnosis. One such study, http://www.ncbi.nlm.nih.gov/pubmed/20010039 showed only about 50 to 70% of the patients got the right diagnosis on identitying common vaginal infections even when using simple lab tests designed to be used by patients along with a written protocol. The goal was 95% accuracy. Medical diagnosis techniques have changed markedly from when I finished my training forty years ago but we still are not yet to the level of “Dr. Leonard ‘Bones’ McCoy.”
Let’s follow your flawless analysis to its logical conclusion: the self diagnosing patient will consult eprognosis to find out whether it’s cost effective to society to keep on living and will also use your or Peter Orzag’s app to see if the country can afford to have him or her stay alive. You devise the formulae about whether the new F-35 engine is more valuable to this greatcountry than keeping some marginal grandma alive.
All we need are politicians and economists to program our medical decisions. And maybe a New York Times editorial page editor and a national TV network summer intern with a good Ivy League pedigree.
I sure hope that case of the flu doesn’t turn out to be heart failure. But if it does, c’est la vie.
I’ve experienced a variant of “Minute clinics” in Canada. Great concept and service.
I practiced when third party intrusion did not exist for my profession and I still believe that is the primary reason why health care delivery is so poorly delivered (and received) today. Any time a third party enters the picture for the purpose of paying for services, the first two parties lose (give away) their responsibility. The patient “takes whatever he/she can get,” and the physician “gives service and tests based on what is the known formula for reimbursement,” with the result that neither the patient nor the physician share the responsibility found in a two person “contract.” Self diagnosis might be ok up to a point, but clearly a professional is educated for a purpose – to make sense out of the information discovered in a history and physical examination BUT get the third party out of the picture. Doctor’s fees would become reasonable as would the costs of tests and procedures if the payment came out of the patient’s pocket – as it should! To me, government funded catastrophic care with individual tax free HSAs are the best answer.
Minute Clinics will expand.
But they will never be a medical home. There is much more to a medical home than a computer screen and a decision tree.
I have many patients come to my office with a diagnosis in mind. They are right about half the time, but their treatment is wrong most of the time. So Minute clinic decision trees will not replace doctors.
Primary care will morph anyway. It needs to in order to survive.
I foresee concierge-lite practices with prepaid plans for between 40-120/month.
No third party intrusion into routine, wellness and preventive care.
Dr. Winterstein, makes very good sense. For the average cold, sore throat or that ake all over feeling then a well trained nurce practitioner is what should be your 1st stop. But then her/his insight would then direct the patient to the appropiate Doctor if more help is needed or the patient wants a 2nd oppinion. Health Insurance should be the patients choice with the ability to choose any health insurance company in the US, currently not possible in Calif. with the Gov. mandated monopoly set up for 3-4 third party insurers? I should be able to deceide for my self what I want covered. I do not need maturnity or heart desease coverage but do have lots of cancer in my family so I want cancer covered. I am very athletic so I want physical theropy and Chiropractic covered etc. Let me design it and have the insurer tell me what it will cost and then I will shop and compare with the other US wide insurance companies. Please do not think that the incredably complicated issue of health care can be regulated to a computor print out with out the experiance of a trained professional. Plus get ride of frivalus law suites that cause an OBGYN in the Bay Area to carry $200k of premium insurance just to cover the possible law suites.
I totally agree with Dr. Mittler. John, with all due respect, you have completely “lost it” on this one! You are either very lucky or you haven’t had to deal with a serious illness or injury. I am an experienced healthcare and hospital administrator with above average intelligence (unless you talk to my wife!), yet I misdiagnose myself often. God help the average citizen when they don’t have a true Medical Home physician who cares for them. Especially when they go to a hospital whose interest is to keep them in the bed and train their resident staff at the patient’s and society’s expense, regardless of need or necessity. My prediction is exactly the opposite; Minute Clinics will be put out of business by their own incompetence when truly sick patients begin to rely on their misdiagnoses to their own detriment…
I just discovered there are home saliva, urine and blood spot tests that can be ordered online, self-administered and sent back to the lab for analysis. Very cool. It’s been quite some time since I consulted a doctor about my health, I mostly research whatever issue I’m dealing with and treat it myself. So far it’s been quite effective. I still say it boils down to this: We are ultimately responsible for our own wellbeing and that includes our health. I long ago abandoned the belief that I could abuse my health as much as I wanted because I could always go to a doctor if I got sick. Good self care is critical. But as I age I deal with issues associated with it and I love the idea of the MinuteClinic concept.