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.

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.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

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  2. If you think for one minute that primary care docs, ED physicians, hospitalists, etc. do not follow computerized protocols…YOU ARE OH SO WRONG! These physicians and many others such as NPs and PA-Cs are highly educated individuals treating the sick; however, I have found no matter the letters behind the name, ALL of these professionals follow some type of evidenced based medicine using or “computerized protocol”..wait for it…UP TO DATE! Any computerized protocol the Minuteclinics are following is/are the most recent evidenced based medicine you have out there. It’s CVS…they make trillions each year due to providing health products and services nationwide, not by providing mediocre care in their minute clinics. Please don’t be ignorant to the evolving options we have in medicine and making this country a healthier place!!!

  3. One difference is that you cannot prescribe yourself medications that a Nurse Practitioner, Physician’s Assistant, or Physician can. There are Nurse Practitioners or Physician’s assistants that work for Minute Clinic. I am sorry that you thought that your experience was worthless. Self diagnosis could easily lead to self destruction. I have seen too many patients that have tried to self diagnose only to be wrong and find out the hard way (death).

  4. In the past few years, I have come across many doctors that have what I like to call a ” God Complex”. They think they know everything and think because they have a PHD that they are now psychic. A patient could spend hours telling this doctor what is wrong with their body, what has worked and what hasn’t, as far as medications and treatment plans, yet will be completely ignored. If this doctor thinks this patient fits a typical stereotype then they will not treat them appropriately. This just happened to me at a local Urgent Care, TWICE! Due to being stereotyped, and having two doctors give their personal opinion rather than diagnose based on facts, I am now permanently disfigured ( I had to have a Distal Amputation of my left index finger because I had a severe bone infection, osteomyelitis ). I was told by this Urgent Care that I only had a ” Simple Skin Infection ” and to go home. In my 30 years of being treated by Doctors in the USA, I have only had one that understood me. He just so happened to be a Physician Assistant. He understood my lifestyle as a military wife ( I am now a wife of an army veteran). Unfortunately I was told by the practice I could not return. It was the Head doctors choice, mind you, I never saw that doctor the entire time I went to that practice. Since then, I have not been able to find adequate care. I have had 4 surgeries just this year. I am scared that one of these times, these doctors who have a “God Complex” will indeed cost me my life. I have suffered enough and so has my family. I have gone as far as writting the president and will be calling the FDA and the DEA. I live an honest life, neither my family not I deserve any of this.

  5. And why do we need policy analysts? I would be willing to bet that if you employed 10 policy analysts to examine the same policy, the result would be 10 disparate analyses.

  6. As for midlevels like yourself, I never implied that there isn’t a role for you. There certainly is as a physician extender, which is what you are trained to do

    Well and succintly put……….

  7. MG, good point. It is nice to know that there is intelligent life on the internet.

  8. Good point Peter. When you health or even life is on the line, you are best served by someone think & with years of experience NOT a data entry clerk that the nurse practitioners have been turned into by the minuteclinics

  9. What a crack of…. That is there Minute Clinic gets majotiry of provit in Preventative medicine.If you don’t like the care your patients get in UC and EDs, then stay open 24 hrs. a day. Also, make sure you practicing evidence-based medicine as those MinuteClinic which are all JACHO accredited. How about your office?

  10. I have determined that I am now well qualified and sufficiently entitled as a “victim of social consequence’ to say that doctors and nurses and everyone else that says I have no value to practice medicine as a midlevel…can now just go “fuck themselves”. Oh?? Is that harsh? Non-professional?? The reality is that I do not give a shit as to your own personal agendas or values or prejudices based on fear. There. I am now being honest and totally entitled to voice exactly what some doctors think of US as professionals in the medical practitioner sphere of influence. Oh…if it makes any doctors on this thread feel better about themselves in terms of special entitlement…I DO plan on leaving medicine in the next year…but only because I have absolutely no confidence in ANY improvement in the environment of primary care and internal medicine in terms of satisfaction of practitioner expectations and happiness.. Of course, there will be PLENTY of doctors available in the next 20-30 years to take PROPER care of patients and not have to worry about the subjugation of the American population to that nasty core incompetency of those midlevels. If I have offended anyone by my language…oh well…deal with it.

  11. I would say as an NP that my practice is guided by protocols rather than mandated by them. I work for Minute Clinic and see plenty of people who walk in for things that don’t fall within our treatment protocols. A huge part of what I do is help people decide what level of care they need to access. I also spend a good deal of time talking with people about why they need to establish a primary care provider. In other words, I spend a lot of time apart from what is going on in the computer and certainly hope that I provide additional value. I believe we are a vital part of healthcare services in our community as evidenced by the flow of referrals we get daily from internists, pediatrician, emergency departments and others.

  12. I love all the antibiotics given for colds, “bronchitis” and sinus infections! Unnecessary antibiotics is a $2 BILLION a year racket! The CDC “get smart” campaign is a good resource for patient education…and maybe even some provider education!
    John, those are Nurse Practitioners at MinuteClinic. NP would be a more accurate abbreviation than nurse.

  13. I know that this thread has been going on for a while, but I just wanted to clarify that Family Nurse Practitioners work at MinuteClinics, not a “nurse”. I am surprised with a PhD behind your name that you do not know the difference. MinuteClinics provide a much needed health service to individuals short on time and needing medical advice.

  14. Because Dr. Goodman is a phD writing about the practice of medicine, which he knows nothing about. As for midlevels like yourself, I never implied that there isn’t a role for you. There certainly is as a physician extender, which is what you are trained to do. What you should never be doing is acting as a point of entry in primary care without direct on site physician supervision. You have no idea “where I’m coming from”, as you don’t have the training or experience to know how little you do know.

  15. Why the snarkiness of your interjected “Dr”?? Don’t bother with a reply. I probably know where you are coming from…given that I am one of “those” physician assistants with minimal if nonexistent training that you purport. You are correct. We are useless. I, of course, have NEVER seen any form of incompetence from board certified doctors. Hmmm…was that snarky?

  16. The specialty of family medicine requiring a three year residency was created when it became obvious that physicians who did a one year “rotating internship” after four years of medical school were still ill equipped for the challenges of general practice. Yet somehow experts like “Dr” Goodman think a Nurse with two extra years of training or a PA with even less is somehow qualified to,function in the same role. Stop with the algorithms and protocols. Medicine is an art and science which requires real training. All physicians can tell you how much incompetence we see from this type of approach on a regular basis.

  17. Indeed, I just cared for a patient in the CCU who was protocol treated for a cough, who had heart failure from an MI.

    I am shocked, literally shocked, that this failure of nationwide medical care infrastructure has been ignored by this blog and its bloggers:


    It matters not how these devices satisfy meaningfully useless guidelines when thousands of patients are put at risk at once.

    Computer protocols??

    This is an illness.

  18. “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.”

    Wow, that’s great. They’re better than doctors. And what’s more – they know when to refer to doctors. Makes you want to ask who needs doctors at all? Um, wait a minute…

  19. I don’t know where to start with this craziness. 1. As a health care economist, he should know that the money spent in Minute Clinics is budget dust compared to end of life care where the last month costs more than the entire medical bill up to that point. 2. So CVS has a list of his prescriptions. What about those at Walgreens, Rite-Aid, etc. New EMRs have the ability to pull prescriptions from all pharmacies, as long as they were paid for by insurance companies and insurance data is entered. But the real reason there is no system for immediate sharing of medical records is that, by design, they were created so this could not happen. It needed to be as difficult as possible for a doctor to fire his EMR company, so easy transfer of records was not allowed. 3. Despite having all these wonderful algorithms, I spend more time in my office undoing the poor care that people get in Minute Clinics, Urgent Care centers and EDs. The antibiotics for :bronchitis”, the steroids for allergic reactions. More importantly, it is the missed findings. All the computers in the world don’t enable someone to diagnose even a simple ear infection properly. They don’t allow you to give appropriate vaccines when you don’t have the vaccine records. And they surely don’t let you figure out which kids should rightlfully be excluded from sports participation because of risk factors. A medical home is not somewhere you go to get the prescription you have decided you need from the computer symptom check list. It is a place of ongoing care over time. It is a place to coordinate the care given by mulitple specialists. It is a place to prevent a lot of the problems that are rampant in medicine before they become problems. Minute Clinics may score ok for a cold,but how do they score in the preventive medicine department?

  20. You can input all the answers you want into an app. The question is, what will you do with the answer it spits out.

    You just better hope that the doctor that you will need to interpret the results didn’t read this rhetoric.

    Knowledge will tell you that a tomato is a fruit. Wisdom will tell you that it doesn’t go in a fruit salad.


  21. I’ve used Minute Clinics and for simple things, I think they are a great alternative. You do need SOMEONE to check you to an extent, brief though it is, because they can be variations that the algorithms wouldn’t pick up. For things like routine immunizations, a mild upper respiratory infection, bladder infection, I’ll go there instead of waiting 2 weeks for an appt. with my doctor. As an RN, not currently practicing, I think we’re going to need to look at more options like this with the insufficient number of primary care type docs once health care reform really hits.

  22. The reason that you can not do it is because you do not have an M.D.! behind your name and neither does that darn computer software program.

    George Rogu M.D.

  23. Margalit is right. The key to making Minute Clinic work is its narrow bandwidth. The parts of the health system we’re really having trouble with are the complex interventions and the huge, lucrative conflicts of interest biasing us in the direction of intervention. We’re also really having trouble with the yawning abyss of chronic care and how to manage it.

    Minute Clinic doesn’t help us very much with those.

  24. “Here’s my prediction: Within five years we’ll all have MinuteClinic decision trees on our personal laptop computers.”

    My bet is that they will still be closer to glorified symptom checkers we have today. You still have the huge issue that the average American reading grade level is between 8th/9th grade and we have huge health literacy issues in this country with vast segments of the population that isn’t going to be dramatically raised in 5 years either.

  25. Let me echo Barry. This is not where any real money is to be saved. Not sure why John writes about this. I am more interested in the sharing information part. My experience is that this worst with hospitals who are competitors. I cannot get any data w/o great difficulty on treatments or procedures done at our competing facilities.


  26. “Why can’t I do it myself?’
    You can and you will, for the dozen or so preselected conditions on the MinuteClinic menu, which usually resolve without treatment anyway.
    For everything else, there’s MasterCard because most triage decision trees end up with “seek medical care within XX hours” or “call 911”.

  27. “Within five years we’ll all have MinuteClinic decision trees on our personal laptop computers.”

    Even if we did it wouldn’t save much money because primary care for minor problems is not where the money is in healthcare. It’s in hospital based care, imaging and prescription drugs plus long term custodial care and home healthcare.

  28. “After entering the clinic a thought occurred to me: why do we need doctors? Then a second thought: why do we need nurses?”

    The real question is: “Why do we need economists, particularly health care economists?” There are certainly more scientific ways to run a continuous experiment in health care financing.

  29. Nurse call centers that provide services for the VA Health System use decision-support algorithms to advise callers whether their condition is serious. Some of these tools are available to everybody online at FreeMD.com, written by DSHI Systems physicians. Many nurse practitioners and physicians even use these types of tools. Numerous websites exist (such as WebMD) that allow patients to peruse symptoms. I suspect these decision-support tools 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 clues to health status. Of course, laboratory blood work and urinalysis is very common. But I once read an article on the power of massaspectrometrie to diagnose diseases and conditions.

  30. Why do we need a medical system at all with WebMed. Do it from home and get the script delivered as well. Then again why do we need politicians or government, just vote electronically on each bill. We could use cute little thumbs up, thumbs down icons.

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