Chapter 4: Making the Best Outpatient Care Choices

Appendices

Training of Nurses (RN) and Nurse Practitioners (NP)

In these sections on training requirements for healthcare providers, we deliberately give more information than usual for two reasons. First, many people have told us “Gee, I had no idea of their training and find it very interesting and relevant”. Second, it will allow more informed confidence in your dealings with all these providers regarding both the differences and overlaps in their professional training and clinical skills. So, let’s begin with Nurse Practitioners (NPs) who are first trained as RNs and then do advanced training to become NPs.

A national licensing exam is required to become an RN. There is more than one educational pathway to become eligible to take the exam. At the undergraduate level there is a Diploma in Nursing, available through hospital-based schools of nursing. There is also an Associate Degree in Nursing (ADN), which is a two-year degree offered by community colleges and hospital-based schools of nursing. There is also a Bachelor of Science in Nursing (BS/BSN), which is a four-year degree offered at colleges and universities. The first two years concentrates on psychology, human growth and development, biology, microbiology, organic chemistry, nutrition, anatomy, and physiology. The final two years often focus on adult acute and chronic disease, maternal/child health, pediatrics, psychiatric/mental health nursing, and community health nursing. This training offers a deeper understanding of the cultural, political, economic, and social issues that affect patients and influence healthcare delivery. The curriculum includes nursing theory, physical and behavioral sciences, and humanities with additional content in research, leadership, and may include such topics as healthcare economics, health informatics, and health policy.

RN training at the graduate level offers three further levels of degrees and specialization: Master’s Degree (MSN) programs for Advanced Practice Nurses¹, nurse administrators, and nurse educators; Doctor of Philosophy (PhD) programs for teaching and/or conducting research; and Doctor of Nursing Practice (DNP) programs for clinical practice or leadership roles.

After completing their nursing curriculum, nurse practitioners take advanced training. The American Association of Nurse Practitioners (AANP)² stipulates that NPs must complete a master’s or doctoral degree program and have advanced clinical training beyond RN training. Didactic and clinical courses prepare nurses with specialized knowledge and clinical competency to practice in primary care, acute care, and long-term healthcare settings.

Training of Physician Assistants (PAs)

We learn from the American Academy of Physician Assistants (AAPA)³ that applicants typically need to complete at least two years of college coursework in basic and behavioral sciences before applying to a PA program. The majority of PA programs have the following prerequisites: Chemistry; Physiology; Anatomy; Microbiology; Biology. Many PA programs also require prior healthcare experience with hands-on patient care. Most PA programs are approximately twenty-six months (three academic years) and award master’s degrees. They include classroom instruction and clinical rotations. Classroom instruction includes: Anatomy; Physiology; Biochemistry; Pharmacology; Physical diagnosis; Pathophysiology; Microbiology; Clinical laboratory science; Behavioral science and Medical ethics. There are more than more than 2,000 hours of clinical rotations, including: family medicine, Internal medicine, Obstetrics and Gynecology, Pediatrics, General Surgery, Emergency Medicine, and Psychiatry.

Skills and Training of Medical Assistants

According to the American Association of Medical Assistants⁴, MAs have clinical skills previously outlined and also typical administrative duties such as:

• Using computer applications
• Answering telephones
• Greeting patients
• Updating and filing patient medical records
• Coding and filling out insurance forms
• Scheduling appointments
• Arranging for hospital admissions and laboratory services
• Handling correspondence, billing, and bookkeeping

There are two pathways to becoming a Medical Assistant: either a Certified Medical Assistant (CMA) or a Registered Medical Assistant (RMA). Both must complete a training program that is accredited through either the Accrediting Bureau of Health Education Schools (ABHES) or the Commission on Accreditation of Allied Health Education Programs (CAAHEP). Typically, these programs take around a year to complete and include coursework as well as hands-on practical experience. The education, training, and job responsibilities of CMAs and RMAs are essentially the same⁵. The Registered Medical Assistant credential, or RMA credential is offered through the American Medical Technologists (AMT). The CMA certification, is offered through the American Association of Medical Assistants (AAMA).

Accreditation of Outpatient Facilities

Accreditation is available as a voluntary process by which a facility or providers can measure the quality of their services and performance against nationally recognized standards. A current accreditation is a strong “plus” concerning the quality of care you can expect. There are multiple organizations that can offer potential accreditations and the following gives you an idea of their number and website address for further information.

Accreditation of Retail Health Clinics (RHCs)

Some RHCs are accredited by the Accreditation Association for Ambulatory Health Care (AAAHC)⁶ such as some of Walgreens Healthcare Clinics. Others are accredited by The Joint Commission⁷ such as many of CVS Caremark’s MinuteClinics.

Accreditation of Urgent Care Centers (UCCs)

UCC accreditation is a complex area in which there are three organizations that may become the accrediting agency. The organizations include: the National Urgent Care Center Accreditation program (NUCCA)⁸; the Joint Commission⁹; and the Urgent Care Association of America (UCAOA)¹⁰. Adding to the complexity are several levels of accreditation (NUCCA: accredited or preferred; Joint Commission: certified or accredited; UCAOA: certified). These distinctions significantly reflect whether the UCC is free-standing or affiliated with other institutions such as a doctors group or a hospital. Don’t hesitate to ask whether or not the UCC is accredited.

Accreditation of Patient-Centered Medical Home (PCMH)

Accreditation or certification of PCMH practices come from several organizations. The Joint Commission has offered additional certification to already accredited programs calling these programs Primary Care Medical Homes. A list of certified programs is available¹¹. Another certifying organization is the National Committee for Quality Assurance (NCQA)¹² where approved PCMH practices can be found on their Clinician Directory¹³. For those interested, a comparison of criteria used by the Joint Commission and NCQA is available¹⁴. There are other organizations also involved in this process such as The Accreditation Association for Ambulatory Health Care (AAAHC)^{15 16}. However, it is difficult to find the list of approved PCMHs on their website.

Accreditation of Telemedicine Providers

The accrediting agency is the American Telemedicine Association (ATA)¹⁷.

Illnesses Treated and Services Available

Here we give supplemental information about what are appropriate expectations at the different outpatient facilities to see which is the best one for you with a given condition. Some of the information is somewhat dated (say some 4-5 years old) but should still be useful. If anything, there is growing overlap between RHCs and UCCs as each broaden their clinical reach. The following is a more detailed compilation of illnesses and services concerning the different facilities. There is obvious overlap. A guide is that if you have a single acute condition it is fine to go to any facility that says it treats that problem. However, when you have one or more chronic conditions in addition to the acute illness, it is probably best to go to your PCP or to an Urgent Care Center.

Services at Retail Health Clinics

A report of the Association of State and Territorial Health Officials (www.astho.com) in March 2011 indicates that the following clinical ailments and screenings represented 90% of RHC visits: upper respiratory infection, sinusitis, or bronchitis; sore throat; immunizations; ear infection; conjunctivitis (eye inflammation); urinary tract infections; and screening lab tests or blood pressure checks. Some additional non-illness related capacities include recommended seasonal vaccinations (such as flu season) and physical exams (for school and camp).

Services at Urgent Care Centers

An important distinction between RHCs and UCCs is that the UCCs have the capability to perform procedures like suturing cuts and casting broken bones. Some other examples of appropriate conditions include: allergic reactions; infections (such as sinuses; ear; eye; sore throat; upper respiratory; vaginitis); rash; fever; nausea; vomiting; diarrhea; abscess; insect bites; sprains or strains. Examples of milder conditions that UCCs may also treat include: removal of ear wax (where flushing equipment may be needed); splinter removal; menopausal complications; sexually transmitted diseases; pregnancy tests. Examples of preventive/early detection screenings include: blood pressure; cardiac lipid profile; diabetes blood sugar; drugs of abuse; prostate PSA; TB skin test; thyroid panel. Examples of preventive measures may include vaccines such as: Diphtheria/tetanus/pertussis (DPT); Measles/mumps/rubella; flu (seasonal); Hepatitis A and B; travel vaccines. Additional non-illness services may include physical exams for various purposes such as: school and sports exams; Department of Transportation medical certification exams for drivers of commercial vehicles; insurance physicals; employer pre-employment exams.

Services at Workplace On-Site Clinics

The American Medical Association News [19] notes that the health care that employees can get in workplace clinics has broadened from mainly work-related injuries. The article cites a 2011survey of large employers by Benfield Research (“Employer & Coalition Market Overview and Trends—Spring 2011”) showing the following services available: Immunizations (89%); Health education (82%); Screenings (79%); Workplace injury treatment (68%); Preventive care (66%); Fitness for duty exams (63%); Nutrition/weight management counseling (53%); Travel medications (53%); Primary care (47%); Smoking cessation (45%); Physical or occupational therapy (37%); Maternity support (18%); Other [for example: work-related evaluations (such as physical stresses on joints and environmental factors like air quality or noise levels or improper lighting) and fitness centers] (8%).

Patient-Centered Medical Home

History and Evolution

A history of the evolution of the Medical Home concept from 1967 to 2013 is available from the Patient-Centered Primary Care Collaborative¹⁸. Thirteen guidelines were jointly published by four medical organizations that established criteria to operationalize and recognize PCMH programs¹⁹.

Clinical Decision Support (CDS) Software

According to the federal government²⁰ these tools include: computerized alerts and reminders to care providers and patients; clinical treatment guidelines; condition-specific order sets of tests and possible treatments; focused patient data reports and summaries; documentation templates for efficient recording in patient charts; diagnostic support; and contextually relevant reference information, among other tools. CDS is a sophisticated health IT component. The majority of CDS applications operate as components of comprehensive Electronic Health Record systems.

Emergency Rooms Must Treat All Patients

This requirement comes from the1986 Congressional enactment of the Emergency Medical Treatment & Labor Act (EMTALA) which requires public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to evaluate a request for examination or treatment for an emergency medical condition, including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients having such emergency condition(s). If a hospital does not have the capability to satisfactorily stabilize a patient, the hospital should implement an appropriate transfer to a facility that has that capability.

Telemedicine

Insurance Coverage of Telemedicine Services

Medicare has geographically limited telemedicine coverage [see Chapter## for details]. A press release dated April 30, 2015 from UnitedHealthcare²¹ announces it is “expanding options for virtual physician visits…” The broader significance of this is discussed in an article in Forbes on May 5, 2015 entitled “UnitedHealth widens telehealth coverage to millions of Americans”²². It cites UnitedHealth, the nation’s largest health insurer, saying that “20 million Americans could access telemedicine and receive coverage for it by next year”. They note that Cigna and Aetna are already providing such services and working to expand them. UnitedHealth is working with three telemedicine companies: Doctor On Demand; NowClinic; and American Well. Aetna has a relationship with Teladoc since 2011. Cigna began to provide access last year working with telehealth provider MDLive.

Computer Requirements

Computer equipment that is needed by the patient varies. Common hardware specifications include: High-speed Internet access; a webcam or built-in camera; Microphone (most webcams already have microphone built in). Common minimal software requirements include: Windows®7, Vista, or XP or later; or Macintosh OS X (10.6 or later); an appropriate browser [Mozilla Firefox (3.6 or later); Safari (4.0 or later); Google Chrome (4.1 or later)]. Check with your telemedicine provider to confirm all requirements.

Comparison of leading Telemedicine Providers

In the following table we summarize various characteristics of seven well-established telemedicine providers. This will give an overview of the evolving industry as well as information about the individual companies in that telehealth space.

Leading Telehealth Companies: Detailed Information on Each is Available

Sites accessed November 12, 2018

NOTE: Some companies come up often (American Well; Teladoc; Doctor On Demand; MD Live) and may be good ones to start with when looking for a Telehealth service. Each company can also be directly accessed by typing its name into your browser from the lists below.

https://www.healthcareitnews.com/news/comparing-11-top-telehealth-platforms-company-execs-tout-quality-safety-ehr-integrations

In this guide, we gave executives from 11 telehealth company’s a chance to talk about what their products offer and how they are attempting to help healthcare providers gain a stronger expertise with their telehealth solutions.

American Well; Avizia; Carena; Doctor On Demand; MDLive; Philips; Polycom; Sherpaa Health; SnapMD; Teladoc; Zipnosis

https://www.toptenreviews.com/health/services/best-telemedicine-services/

We looked at the 14 best telemedicine services that work directly with customers.

Amwell (Best Overall); Doctor On Demand (Best Value for People Without Insurance); 2nd.MD (Best Specialist); MeMD (Best for Mental Health Treatments); Second Opinions (Best for Second Opinions)

https://www.healthline.com/health/best-telemedicine-companies#1

Here are 17 of the best telemedicine companies.

CareClix; ConsultADoctor; Teladoc; MeMD; iCliniq; American Well; MDlive; MDAligne; StatDoctors; Doctor on Demand; Specialists on Call; LiveHealth Online; Virtuwell; Ringadoc; PlushCare; HealthTap; HealthExpress