Point-of-Care Diagnostics in CVS' MinuteClinics

Samantha Lewis:

Hello and welcome to a CHI podcast on point-of-care diagnostics in rapid clinics. My name is Samantha Lewis, and I'm a conference producer with CHI. Today I'm speaking with Daniel Kerls, who is the director of ambulatory operations at CVS' Minute Clinic. Also joining us is Alexander Sbordone, who is the Minute Clinic operations manager at CVS. Welcome Dan and Alex, and to start, I think it's relevant to bring up one of the points you had made to me in a previous conversation: Which is that CVS has nurse practitioners and physician's assistants doing the diagnostic testing and the retail clinic within the pharmacy and not at the pharmacy. What made you choose this route as opposed to having existing pharmacy employees do the testing?

Daniel Kerls:

I think one of the big things is that the Minute Clinic was launched to be a wholly operational medical clinic inside the walls of CVS, so it really is completely separate from the pharmacy. And we staff the Minute Clinic with nurse practitioners and physician's assistants, so when you look at the point-of-care diagnostic testing that we do, we feel that the background of the nurses and the physician's assistants lends well to doing the point-of-care diagnostic testing.

Alexander Sbordone:

Based on those results, the provider is able to sometimes write a prescription that the patient could then go fill at the pharmacy. It's almost like a one-stop-shop that you can get your results, get a prescription, or get a treatment core, all within one visit.

Samantha Lewis:

Many people, specifically on the diagnostic sign of things, don't fully understand the capabilities of retail clinics. Since it's pretty crucial for these two sides to work together, how have you been overcoming this barrier?

Daniel Kerls:

I think that we need to do a little bit of a better job of just getting out what Minute Clinic can actually do as far as lab diagnostics. We've been in a phase that we've been growing and growing and growing our model but we haven't done as much marketing as to what we actually do as opposed to we've just been growing and growing. I think one of the things that we could do is to start to put out there what exactly we do in the clinics because we do have some diagnostic testing that we run. We're doing litmus testing, we're doing glucose testing, we do pregnancy testing, mono testing, flu and strep testing, and it's all done through the nurse practitioners and physician's assistants. I think to just continue to educate everyone, the general public as well as the diagnostic side of things that we have that capability. I think it's also important to structure, or to let people know the structure that we have, we really only perform CLIA waived testing that has very quick, rapid results. Because of our model, we don't really want to send out too much lab testing; we like to have our results immediately during the time of the visits so we can close the visit. I think it's good to know, to let everyone know that's the model that we're in.

Alexander Sbordone:

I think also what we've done when we have vendors who are interested in showing us their equipment, a lot of times we may take them on a tour of the clinic so they better understand. One of the constraints we have with testing is that we're a limited-size clinic, maybe a ten by ten space. And so that does - and limited counter space, that limits the size of equipment, the number of outlets we have. That's also something that we try to work with the diagnostics on and exactly, here we are in this limited space, we need to be able to bring in equipment that would fit in that space.

Samantha Lewis:

What, in your experience, has worked particularly well in rapid clinics, and is there anything that you think could never work?

Daniel Kerls:

What's worked particularly well is that we used CLIA waived capillary draw, point-of-care care testing with rapid results and quick turnaround time. I think that's, sort of, our value proposition: That somebody could come in and 99% of the time get the answers right away about whether they have strep or whether they have the flu. We do a lot now with employee group and insurance plans who want their clients or employees to get glucose testing with the testing wellness screen - annual screens that are provided through insurance companies. We're able to do that pretty quickly and then provide those results back very quickly and that allows [Inaudible 03:57], we have some companies who will reduce a person's insurance bill for the year if they go and get their annual wellness screen. We're able to do that and that's still working very well. I think because of the limited space we're in, we've been sticking to capillary and point-of-care testing because of the type of waste that it generated with more moderately complex labs. That's been a challenge that we really do stick to: The quicker caps that produce minimal amount of waste because we're not in a hospital so we don't have a separate clean and dirty utility areas as well.

Alexander Sbordone:

We're experimenting, exploring doing CLIA waived testing through venipuncture or venous draws in some markets currently, but the base model has been to use capillary blood draws. I know you'd ask if there's anything that we think could never work, and I think anything that takes a long time to process really wouldn't work in our setting, so we do utilize references laboratories to perform confirmatory strep testing. And we will be doing urine cultures in the near future just because we don't have the physical space to house specimens over a longer period of time. We really need to limit our lab testing to tests that do not take up a lot of space from a physical footprint standpoint and do not take a lot of time from an actual minutes perspective. That eliminates a lot of testing that would require a larger analyzer. We have looked in to potentially moving into the area of testing that would require a moderately complex lab through CLIA, but from a regulatory standpoint we just feel that Minute Clinic doesn't want to move down that path right now, thinking about all the policies, procedures and oversight we'd have to have in place to move into that top of lab testing. I think, at least for the immediate future we will continue to be a CLIA waived lab, doing the majority of our testing through capillary finger stick tests.

Samantha Lewis:

What are some of the more surprising obstacles that have come up in implementing diagnostic testing in retail clinics?

Alexander Sbordone:

I think one of the obstacles that we've had is: As we look to expand our services globally in what we like to do some of those services would require lab testing that would need a venipuncture, and that's an obstacle. If you think about maybe running a basic metabolic panel on a patient, you can't really run that test through a finger stick, so one obstacle that we would have would be to make the decision on whether we would want to train our providers to do venipuncture in the clinics. One of the challenges that we find there is, under our model, the nurses and physician's assistants are there by themselves in Minute Clinics; there's not even a receptionist. If you think about trying to obtain a venous draw on a patient that doesn't have very good veins, if that one person can't do it, they have no one to turn to. Dan and I come from hospital environments where there's a lot of these teams and they have people who are dedicated to drawing blood every day. But our providers are really there to do everything. If a patient comes in and needs a venipuncture done, and they have not greatest veins, that would become an obstacle for us. We're trying to figure out the best ways to get around that.

Daniel Kerls:

I think as we talked earlier, I think the other obstacle is the actual physical size of the clinic itself. And also the scope of practice for both nurse practitioners and physician assistants that somehow limit us. Because right now we're in approximately 30 states and we try to offer the same thing in every state, we have to really go with the most restrictive group of practice throughout the country. That, at times, does limit us as well, too.

Samantha Lewis:

What do you see as the next steps for diagnostics in rapid clinics?

Alexander Sbordone:

I think for Minute Clinic, we'll continue to review emerging technology and diagnostics. One of the jobs that I do here is I meet with potential vendors of partners who'd like to work with Minute Clinic, and they're showing us emerging technology. Because we like to make the visits as quick as possible, but have excellent quality of care. One example is I can give is: We recently switched, we use a small analyzer for strep testing. We previously were doing a manual read for strep test confirmation and we've moved to an analyzer for strep test confirmation, which takes the human element out of the diagnostic part. We like the fact that there's new, emerging technology that allows machines to perform an accurate diagnosis of strep and/or flu. I think next steps are to continue to analyze what's coming down the road as far as point-of-care diagnostic testing and a CLIA waived environment. We'll continue to look to pilot those. Like I said: We want to adapt with the environment to provide. What I would love to see is a small, handheld device that can do everything that we like to do in the clinics, but we haven't seen that yet. We do have a variety of different devices, so we'll continue to look to the future to see how we can leverage technology to better support our providers in the clinics.

Daniel Kerls:

The Minute Clinic will continue to be a convenient place for the diagnosis and treatment of mildly acute illness but we are looking into exploring the management of chronic conditions, and as we do that, we will rely on technology to perform lab testing to give us certain blood-level results as we help those patients. I think that's something we'll be doing in the future. I think as we grow we've already started to do it. We have affiliations and alliances with various healthcare systems throughout the country such as: Cleveland Clinic is a good example or Emory in Atlanta. I think what we would do is continue to partner with them in that, perhaps, some of their follow-up labs could be done quickly in a clinic, and then their primary care physician is able to pull those results up and be able to, sort of a co-management of some of the chronic care conditions. That's something that some of our affiliations and alliances are looking for us to do, so I do see us maybe to expand in that area.

Samantha Lewis:

Thank you so much, Dan and Alex, for your time. This has been a CHI podcast with Daniel Kerls and Alexander Sbordone of CVS. For more information and dates for CHI's upcoming diagnostics events, you can visit healthtech.com.


Premier Sponsors

NeoGenomics

Seegene