OVERVIEW
Retail medical clinics have recently emerged as an alternative to the current healthcare delivery system. They can be found nationwide in major retail chains such as Minute-Clinic (CVS), RediClinic (WalMart) and Take Care (Rite Aide/Walgreens). These retail chains are working with selected U.S. markets, including Tennessee, to test this new delivery system. This article presents a description of a fast-growing alternative healthcare delivery system and the state requirements for physicians who participate by supervising nurse practitioners.

BACKGROUND
“The clinical care and business models of these clinics vary by operator and location but all have a common value proposition: they offer consumers a limited menu of simple health services within a walk-in retail environment.” The in-store clinics have a simple layout consisting of a reception desk and one or two examination rooms. The average floor plan measures between 200 and 500 square feet. Nurse practitioners and physician assistants are generally the on-site staff, supervised by physicians in varying degrees. The clinics treat patients on a walk-in basis, and are often open seven days a week with evening hours.

In theory, these retail clinic models promise to lower costs by doing away with expensive overhead, using less expensive labor and eliminating patient billing. However, from both a business and medical care perspective, the retail clinic model “is still very much in flux.” Primary care physicians and pediatricians have been vocal about the downsides of this alternative healthcare service. They have expressed concerns regarding the quality and continuity of care, particularly the treatment of patients with serious or chronic conditions. These physician groups urge close physician oversight of non-physician providers working in the retail clinic setting.

STATE REGULATION AND PHYSICIAN OVERSIGHT
Regulation of retail clinics varies from state to state. In Tennessee, physician supervision of certified nurse practitioners (CNPs), regardless of where the CNP practices, is governed by various boards within the Department of Health. Nurse practitioners (NPs) in Tennessee are regulated by the State Licensing Board of Nursing. The physicians who supervise these NPs are regulated by the Tennessee Board of Medical Examiners. According to the regulations…“[A]ny licensed physician who supervises the services of a certified nurse practitioner who practices in a manner that is inconsistent with the Tennessee Medical Practice Act shall be subject to disciplinary action.” Consequently, supervising and substitute supervising physicians should be familiar with these regulations. To prescribe and practice under the indirect supervision of a physician, an NP in Tennessee must be a Certified Nurse Practitioner (CNP). To be a CNP, the NP must hold a state RN’s license; hold a masters degree or higher in a clinical specialty area; have certain minimum pharmacology training; hold national professional nursing certification in the appropriate specialty; and receive from the Board of Nursing an Advanced Practice Nurse (APN) certificate, with a certificate of fitness to prescribe. Once received, NPs must then file a notice with the Board of Nursing containing the name of the supervising physician, and a copy of the formulary describing categories of legend drugs to be prescribed, among other requirements.

In Tennessee, the collaboration requirements do not require the continuous and constant onsite presence of a supervising physician, but the physician must be available to the CNP for consultation at all times or make arrangements for a substitute physician. The supervising physician and CNP are required to jointly develop and approve written protocols that serve as guidelines for medical management. The CNP is required to practice within the scope of these guidelines. These guidelines are to be updated biennially. Supervising physicians are responsible for ensuring compliance with applicable standard of care and developing guidelines, in collaboration with the CNP, that include a method for documenting consultation and referral. Although not required by the regulations, risk management objectives may lead supervising physicians to define the scope of practice for supervisees to exclude certain patient populations.

Supervising physicians are required to personally review at least 20 percent of the charts monitored or written by the CNP every 30 days or every 10 business days when medically indicated, requested by the patient or when certain prescription conditions apply. Supervising physicians are required to visit any remote site at least once every 30 days. Physicians reviewing charts and visiting remote sites should not only examine the quality of care, but also examine compliance with the written protocols established for the practice as well as state regulations. Special attention should be given to the prescribing regulations found at Rules of Tennessee Board of Medical Examiners (Tenn. Comp. R. & Regs), Chapter 0880-6-.02(5)(e), (7)(c)-(e), (11), & (12).

Since the regulations require the supervising physician be responsible for “ensuring compliance with the applicable standard of care” as posted in Tenn. Comp. R. & Regs Chapter 0880-6-.02(5)(b),(6), the physician needs to be aware of the possible liability exposure for malpractice committed by the practitioners they supervise. Thus, supervising physicians and substitute supervising physicians should disclose their supervision responsibilities to their malpractice carriers and should have the nurse practitioner(s) or physician assistant(s) they supervise listed as additional insureds in the declaration of coverage.

CONCLUSION
Whether or not the retail medical clinic model becomes a permanent feature of the healthcare system, the premise behind it, a limited scope of service in a convenient retail environment, may influence the design of future delivery systems. To ensure quality of care and continuity of services, these clinics must build effective relationships with local primary care physicians and pediatricians in order to treat and track patients who have multiple and chronic medical conditions. Supervising physicians should become familiar with Tennessee state rules and regulations regarding supervision. They should also notify their malpractice carriers of their supervising role. For additional information on physicians and retail medical clinics, please see the TMA “Supervising Physician” Kit at www.medwire.org.

References:
1. Scott MK: Health Care in the Express Lane: The emergence of retail clinics. Cal HlthCar Found, Jul 2006. Available at www.chcf.org/documents/poligy/HealthcareInTheExpressLaneRetailClinics.pdf. Accessed Jan 2007.
2. Sullivan D: Retail clinics are rolling your way. Fam Pract Mgmt, May 2006. Available at http://www.aafp.org/fpm/20060500/65reta.pdf. Accessed Jan 2008.

Dr. Judy Regan is an associate clinical professor of psychiatry at Vanderbilt University School of Medicine and an associate with North, Pursell & Ramos (NPR), PLC, in Nashville; Mr. Hadley is a partner with NPR, with a practice that includes defending physicians in malpractice and licensure actions. Ms. Wright is a certified administrative professional in the Division of Clinical Leadership, Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD), Nashville.