Walgreens: Purveyor or Provider?


An intriguing question emerged from last week’s merger announcement from Walgreens Boots Alliance and Rite Aid.  Led by CEO Stefano Pessina and his largely European executive team, will Walgreens be purveyor focused on retail sales or provider engaged with a transforming U.S. health care system?

The signals are mixed.  A tea-leaf reading of last week’s investor call suggests Walgreens is destined to be a purveyor, focused on selling products and services.  Today, however, Walgreens announced a big technology move that points to a provider future, closely integrated with payers and providers.

Purveyor or provider?  Read on.

Tobacco:  To Sell or not to Sell

“Are you considering eliminating tobacco,” Barclays Capital analyst Meredith Adler asked Walgreens president Alex Gourley during the investor call as the company fielded questions about earnings and the merger.

Gourley had just praised RiteAid for its new, sales-increasing wellness format, saying it was an opportunity for Walgreens, which also is seeing success with its new health, wellness and beauty positioning.

“It seems pretty clear,” said Adler, explaining her question, “that providers and payers feel uncomfortable working with a retail pharmacy that still sells tobacco.”  In the background was the 2014 tobacco sales halt of CVS Health, which boasts 49 clinical affiliations, including Cleveland Clinic.

Gourley’s answer:  No.

Walgreens would instead continue investing in smoking cessation.  Anyway, he noted, only about three percent of all tobacco sales occur in a drugstore.  He did not pivot to emphasize how Walgreens is working with providers and payers, notwithstanding tobacco sales.

A tea-leaf saying “purveyor”? Perhaps.

Outposts in Seattle

Gourley could easily have drawn the analyst’s attention to a Walgreens announcement just two months previously.  In August, Walgreens and Seattle-based Providence Health & Services launched a new “strategic clinical collaboration.”

Providence will own and operate clinics in 25 Washington and Oregon Walgreens stores under its Providence and Swedish brand names.  The first three will open in early 2016, with the remainder following in two years.

Rite Aid made a similar move in the Seattle market in May when it announced a joint venture between its RediClinic subsidiary and MultiCare Health System.   The joint venture will operate clinics in 11 stores staffed by board certified MultiCare Nurse Practitioners in collaboration with MultiCare affiliated physicians.

Seattle, home to only three CVS stores, will provide a sheltered environment for Walgreens and Rite Aid to test the strategy of developing “deeper and more strategic relationships” with health systems.  In particular, Providence is quite a catch, having directly contracted with Boeing to provide health care for the aircraft maker’s employees.

The EpicCare Connection

However, the nation’s 1,000 CVS MinuteClinics dwarf both Walgreens 400 Healthcare Clinics and Rite Aid’s small number of in-store RediClinics.  Surpassing 25 million patient visits since the opening of its first clinic, CVS says it is opening three new MinuteClinics a week.   Aiming for 1,500 clinics by 2017, CVS is acquiring all of Target’s 1,660 pharmacies and 80 clinics.

CVS is converting all of its MinuteClinics to the market leading EpicCare electronic medical records (EMR) system.  Used broadly across health care, Epic also has strong interoperability with other EMR systems.   This will provide seamless data exchange with most American hospitals.

“EpicCare will help us work more closely with physician practices as part of the medical home team, facilitate co-management of patients, and advance our mission to make health care more accessible, convenient and affordable for Americans,” said MinuteClinic chief medical officer Nancy Gagliano, M.D.

Dr. Patrick Carroll agrees.  Today, the chief medical officer for Walgreens Healthcare Clinics announced the clinics would begin moving to EpicCare early next year.  “As our clinics play an increasingly important role in health care, supporting the health care system, provider practices and patients’ medical homes, care coordination can be critical,” he echoed.

So, a provider future for Walgreens?  It certainly looks like it.  “This will benefit our patients, clinic providers and partners, and serves as an instrumental part of our strategic growth plan [emphasis added],” explained Carroll.

Confusing Signals

However, as recently as May, Walgreens quietly shuttered 35 clinics, a move two former employees described to Crains Chicago Business as signaling “uncertainty whether Walgreens really wants to spend more on primary care and in particular upgrading the clinics’ electronic medical record systems.”   Today’s announcement erases some of that uncertainty, at least with respect to the EMR system.

In Seattle, Walgreens will provide in-store space, overseeing any needed build out.  Providence will be using its own Epic system.  “Patients will experience a seamless patient experience through our existing electronic health record system, providing direct connectivity to the clinics and billing systems, which will ensure better continuity of patient care and collaboration among providers,” said Providence senior vice president of physician services Mike Waters.   Now, Walgreens will be able to connect directly.

Convincing Collaborations

In Seattle, a provider land lord; in Tampa, still a provider.  There, Walgreens partners with a multi-specialty practice, assuming risk in an accountable care organization (ACO), Diagnostic Clinic Walgreens Well Network.  Serving 7,500 patients, the ACO saved $1.5 million or 2% in costs.  However, Walgreens has exited ACO partnerships with Baylor Scott & White in the Dallas-Fort Worth area and New Jersey’s Advocare.  The company continues a clinical affiliation with Baylor Scott & White.

Meanwhile, Walgreens has launched additional collaborations with CHE Trinity Health, a 30-hospital, Michigan-based system, Arizona Priority Care, a unit of California’s Heritage Provider Network, and Mercy Health – Cincinnati.  Leading Trinity Health is former Medicare official Dr. Richard Gilfillan, chair of the Health Care Transformation Task Force; Mercy Health is part of the nation’s largest not for profit health system, Ascension Health; and Arizona Priority Care specializes in accountable care.

In Baltimore, Walgreens has a long-standing relationship with Johns Hopkins Medicine (JHM).  The company provides grants for population health research overseen by a joint committee.  Two years ago, it opened a store, including a Healthcare Clinic, adjacent to the JHM campus.  In this case, Walgreens’ board certified nurse practitioners staff the clinic, although they and company pharmacists can work with JHM faculty.

Rite Aid’s Health Alliance program should dovetail nicely with Walgreens provider collaboration initiatives.  The program brings together physicians, pharmacists and special care coaches to provide care and support to individuals with chronic and poly-chronic health conditions, helping them achieve health improvement goals established by their physicians.

Eight provider organizations currently are participating in Health Alliance, which leverages Rite Aid’s population health subsidiary, HealthDialog.  Another 11 reportedly are be interested.  On average, patients participating in the Rite Aid Health Alliance are 36% more adherent to their medications; they have lost an average of 7.7 pounds; they have a 39% reduction in blood pressure; and they have lowered their blood sugar by 36%, reports Drug Store News.

Big Bet on Consumer Technology

Rite Aid is also bringing Cleveland Clinic physicians into some of its Ohio stores via telehealth start up HealthSpot.  Installed in the stores is a kiosk, enclosed for privacy, which includes a video connection with a physician and the capability to take and transmit vital signs to the physician.

Opting for mobile, Walgreens is using the Pager platform, designed by an early Uber architect, to connect customers with physicians.  It also is relying on the MDLive platform for telemedicine, and working with WebMD on a wellness app, and with PatientsLikeMe enabling people to share medication experiences with each other.

Walgreens has been a leader in using technology to engage its customers.  Its app is the third most downloaded retail app in the U.S. and the number one brick and mortar pharmacy app, reports mobihealthnews.  Fourteen million people visit a Walgreens app or website each week and Walgreens fills more than one mobile prescription every second.

Walgreens’ Epic Catch-Up

However, until the EpicCare announcement today, Walgreens lagged in using technology to engage providers.  Its electronic record system could not easily communicate with other systems, forcing stores to use secure fax and email to communicate with physicians and other providers.   That raised serious questions about the future of its provider collaborations and role as a provider.

Now, EpicCare means Walgreens can be more than a purveyor.  It can also be a provider, fully integrated into the new health care.

SSM Health: Baldrige Pioneer Now Value-Based Care Model?

SSM Health
In 1872 St. Louis, all that would later become SSM Health could fit in the basket Mother Mary Odilia Berger, SSM., carried from house to house – bread for the poor, medical supplies for the sick and clean linens for her patients.  As she walked “with a very purposeful step,” people she met on the street would slip a donation in her basket.

Nearly 145 years later, woven in today’s SSM Health “basket” are 30,000 people – including 1,300 employed physicians – working in four states at 19 hospitals and more than 60 outpatient clinics.  In addition, the system operates an insurance company, two nursing homes, comprehensive home care and hospice services, a telehealth company and two Accountable Care Organizations (ACO).

Among the hospitals is the system’s first academic medical center, Saint Louis University Hospital, which it acquired earlier this year from Tenet, and a children’s hospital.  Most of the outpatient clinics and many of the physician employees arrived with the 2013 acquisition of Wisconsin’s Dean Health System.  Dean also brought a health system rarity, ownership of a growing pharmacy benefit manager along with a string of retail pharmacies and eye care centers.

Process, Purpose, Patient

The base of today’s SSM Health “basket,” with its focus on process, purpose (mission) and patient, took shape in the hands of another purposeful leader, Sister Mary Jean Ryan, FSM.  It took a dozen years, beginning four years into her leadership of a newly centralized system:

  • Process (1990): She and the system’s leaders committed to continuous quality improvement.  They aimed to “create a culture in which every employee at every facility and at every level of the organization would constantly seek to improve processes – every single day.”
  •  Purpose (Mission) (1998): Three thousand system employees, at all levels, in all locations, condensed a wide variety of mission statements into one succinct declaration:   “Through our exceptional health care services, we reveal the healing presence of God.”  The system had discovered it needed develop a more compelling mission after practicing with the Malcolm Baldrige National Quality Award criteria.
  •  Patient (2002): The system attributes its 2002 Baldrige Award to a focus on its core customers, patients, and “connecting the dots” from Baldrige criteria through core processes and results.  SSM Health had begun submitting applications as soon as health care organizations became eligible for the award, in 1999, and became the first in the category to win.

In July of this year, Quality Management Journal published a study comparing 34 Baldrige winners, including SSM Health, with their 153 geographically closest competitors.  It found that the “award recipients provided care equal to or better than competitors while at the same time providing a better patient experience.”

The “patient, purpose, process” culture SSM Health created as it pursued the award, and nurtured thereafter, has proven to be a dependable guide for the system amidst health care’s transformation from volume- to value-based care.

To Join or Not to Join

Earlier this year, SSM Health committed to put 75 percent of its business into value-based arrangements that focus on providing higher quality at lower costs by 2020.  It did so as one of 24 provider organizations participating in the Health Care Transformation Task Force, which also includes payers and employers among its members.  Dr. Gauroy Dayal, health care delivery vice president for SSM Health noted that the system “began working on transforming itself five years ago….when it began assuming risk and responsibility for improving the quality of care while lowering costs.”

On the other hand, because of its unique culture, SSM Health knows what not to join.  Several years ago, the system chose not to participate in the Medicare Shared Savings Program (MSSP) by creating a Medicare Accountable Care Organization (ACO).  It had concluded that the assignment of beneficiaries based on claims history, not choice, was inconsistent with SSM Health’s transparent, patient centered care model.

Instead, SSM Health embarked on a path to “True North,” as it explained in a Mayo Clinic Proceedings article, “The SSM Health Care Approach to Achieving ‘True North’:  Improving Health Care Quality While Reducing Costs.”   True form, it created a process based on a functional definition of accountable care.  The system then chartered five teams to design “an organization capable of assuming and managing global clinical and financial responsibility for the care of a defined population.”

The Volume to Value Process

Flashes of process appear continually from SSM Health as it makes the change from volume to value.  For example, the system has:

  • Created a methodology to eliminate unjustified variation in their medication formulary using available data from purchase history, quality management systems and electronic health records.
  • Established a “single source of terminology truth” that effectively manages and maps data to industry standards, ensuring accuracy across the enterprise in advance of ICD-10.
  • Developed more efficient processes for utilizing hospitalists, decreasing readmissions.
  •  Deployed a digital app, which learns and adapts to self-reporting patients, reducing 30-day hospital readmissions by 57%.

Even the legal department is doing its part, earning recognition as a 2015 Association of Corporate Counsel Value Champion.

Process at SSM Health may be very rewarding, but it is certainly not easy.  Take clinical device technology.  Teams now have data at their fingertips enabling business decisions based on fact, data such as mean-time-between-failure, according to Heidi Horn.  However, “It took a vision and years of work and tenacity by all 100+ team members of Clinical Engineering Service,” she added.

SSM Health’s commitment to process likely played a decisive role in its merger with Dean.  Although both organizations had worked together for decades, neither assumed a successful integration would necessarily follow.  In fact, SSM paid “an excessive amount of attention” to culture, according to Dr. Dayal, who originally had been with Dean.   An “organizational heath index” of several hundred parameters characterized the two cultures, identifying the presence or absence of overlaps.

SSM Health More Like Dean

Trustee Magazine reports that, as a result, SSM Health has become more like Dean since the merger, putting doctors on the board and appointing Dayal and another physician to lead two of its three divisions.  Objective accomplished, because SSM Health acquired Dean not for its financial assets, but for its talent, knowledge and capabilities, especially around health plan and physician practice management.  As Dayal explained, the 90-year-old, fiercely independent, physician-run Dean has given SSM the capabilities needed to transform into an integrated value based organization.

Operating a health plan since the 1980s and a population health model since 2009, Dean can accept performance risk for almost 70% of its business.  An innovative medical value program brought clinicians, staff and data analysts together to identify opportunities to improve clinical processes and care management.  The program used claims data from Dean’s insurance arm and electronic health records from area hospitals owned by SSM Health – before the merger.

Now, after the merger, the fully integrated SSM Health Care of Wisconsin now offers some of the lowest public exchange health insurance costs in the state for Janesville-Beloit consumers in Rock County south of Madison, on the Illinois border.  It did so through its St. Mary’s Janesville Hospital, Dean Health System and Dean Health Plan.

In fact, when Rock County consumers select health coverage, they choose between health providers, not health insurers.  Competing in the same area is a similar fully integrated health system, also with an insurance component, Mercy Health System.  Citizen Action of Wisconsin, which compiled the rate comparisons, gave both Dean and Mercy four-star ratings.  Only Gunderson Health Plan received five stars.

“Vertical integration has a lot to do with the lower rates,” explained Dean’s Jamie Logsdon.  “When you’ve got a network, such as Dean and St Mary’s Janesville in that market, they are all working together to provide more efficient care.”

Twenty-five years in the weaving, the “basket” that is SSM Health could very well be a model for value-based health care.

Telemedicine: Bad for Antibiotic Stewardship?

telemedicine2Sandy Walsh is a breast cancer activist and, assuming she is like one in seven adult Americans each year, a sinusitis “survivor” too.

She served as the first-ever consumer advocate on the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) panel that recently updated the adult sinusitis clinical practice guideline.

Patient Education and Watchful Waiting

Novel, too, was the panel’s emphasis on patient education and its expansion of watchful waiting (without antibiotic therapy) as an initial management strategy.  The latter now applies to all patients with uncomplicated acute bacterial rhinosinusitis (ABRS) regardless of severity.  The prior guideline limited the antibiotic-free approach only to patients with “mild” illness.

Patients may not even need to see a doctor.  “For the first time we’ve really made it crystal clear how to self-diagnose your own bacterial sinus infections without going to the doctor, with a high degree of accuracy,” Dr. Richard Rosenfeld told National Public Radio.  He led the AAO-HNS guideline panel.

Not seeing a doctor for a sinus infection might actually have its advantages.  The doctor a patient sees, not the patient’s condition, largely determines treatment, according to an Annals of Internal Medicine study published this month.  Physician preference or “style” largely determined antibiotic use, not patient related factors like fever, age, setting, or comorbid conditions.

Telemedicine and Antibiotics

What happens when telemedicine makes physicians more accessible, convenient and less expensive to “see” for ailments like sinusitis?   Antibiotic prescribing rates for acute respiratory infections were similar regardless of whether the encounter was face-to-face or via telemedicine, according to a JAMA Internal Medicine study published this month.

That the prescribing rates were similar represents an improvement – of sorts.  A study published two years ago, also by JAMA Internal Medicine, found that telemedicine physicians were more likely to prescribe an antibiotic.

Other research shows that acute respiratory tract infections account for 75% of all outpatient antibiotic prescribing.  Half those prescriptions are unnecessary because a large portion of those infections are likely viral, not bacterial.

Even more troubling, telemedicine physicians in the 2015 study were more likely to use broad-spectrum antibiotics, raising concerns because “overuse increases costs and contributes to antibiotic resistance.”  The study suggests telemedicine physicians may have been prescribing more conservatively due to limited diagnostic information.

To decrease antibiotic prescribing, the study’s authors want telemedicine operators to change physician behavior with timely feedback.  They also recommend “direct education to patients to influence demand.”

Do It Yourself for Patients

Sandy Walsh, the consumer advocate, is ready with patient education — specifically “do-it-yourself” diagnostic tools for sinusitis sufferers.  She and her co-authors have written a plain language, adult sinusitis summary, including patient information sheets, based on the new AAO-HNS clinical practice guideline.   The summary, already available online, will appear in the August issue of Otolaryngoly – Head Neck Surgery.

According to Dr. Rosenfeld, the key to this “do it yourself” approach is learning how to tell whether the infection is viral or bacterial.  As he told NPR, if you have been sick less than 10 days and you are not getting worse, it is most likely viral and an antibiotic would have no effect.

If you do not improve or get worse in 10 days, it is probably bacterial.  Still, Dr. Rosenfeld advises that, even then, an antibiotic would play little role in what is largely a battle between your body and the infection.  “There’s a good chance you’re going to get better on your own,” says Dr. Rosenfeld.

Integrate Telemedicine and Education

Telemedicine providers would do well to follow Dr. Rosenfeld’s example.  Fully integrate patient education as first line therapy for sinusitis, help patients learn how to diagnose and care for themselves, and reserve antibiotics for true need.   Make telemedicine good for antibiotic stewardship.

And, get the help of consumer advocates like Sandy Walsh!

Self Service Medicine: It’s Clinical Now!

Self-service medicine – it’s now more than using an appointment-scheduling kiosk, conversing with a phone robot or ordering electronic prescriptions.  Already mastered by many, these essentially administrative tasks – the equivalent of supermarket self-checkout – are looking a lot like false summits to patients climbing the healthcare learning curve.

In truth, the climb continues.  Patients are learning that self-service medicine now includes self-diagnosis, self-medication, self-entered histories, self-care, self-management and self-monitoring, with the latter sometimes relying on clever gadgets attached to app-equipped smartphones.  The clinical realm clearly is no longer off limits to patient self-service.

Not too long ago, clinicians frowned on patients arriving for appointments with print-outs in hand, having researched and self-diagnosed their symptoms on the Internet.   Now, some physicians are encouraging patients to prepare for appointments by consulting reliable symptom checkers, as reported recently by the Wall Street Journal.  These include the widely used WebMD, as well as symptom checkers available from the Mayo Clinic, the American Academy of Pediatrics, and companies such as A.D.A.M, iTriage and Isabel.

Why the turnabout?  As Dr. George Reynolds, chief information officer of Omaha’s Children’s Hospital and Medical Center told the Journal, “We are giving them a much better tool than just googling a bunch of stuff.”  Dr. Mark Graber, president of the Society to Improve Diagnosis in Medicine, observed that “suggesting a range of possibilities to your M.D. might help prevent the premature closure errors that underlie so many diagnostic errors.”  Isabel founder and chief executive officer, Jason Maude, explained that “patients are experts on their symptoms and doctors are experts on working out their probably causes.”

Driving self-diagnosis and self-service medicine into the mainstream will be additional factors closely aligned with self-service expansion throughout the economy.  These include saving time during office visits, more productive consultations and potentially better clinical outcomes, for example in helping doctors think of something they hadn’t considered and preventing diagnostic errors.   In other words, self-service medicine such as self-diagnosis helps drive down provider cost and increases quality.

Inspired by Mary Meeker’s annual Internet trends presentation, HealthPopuli author Jane Sarasohn-Kahn recently observed, “the more consumers can do for themselves in remote monitoring, on-time efficacious care, and safe aging at home, the more providers can manage their risk for that patient’s conditions” within the context of value based healthcare and risk management.  So the more Medicare and commercial insurers (e.g. UnitedHealth Group) move away from fee for service to value or population based reimbursement, the more self-service medicine will grow.

Here are some additional examples:

    • According to Physicians Practice, patient entered histories can effectively address problems with traditional physician-patient interviews identified in a Mayo Clinical Proceedings article.  The Mayo review noted that 50% of psychiatric problems are missed, about 50% of patient problems go unaddressed and patient and physician do no% t agree on the primary complaint 50% of the time.  And, there’s less work for providers.  As Physicians Practice observed:  “Whether you are writing a note, using dictation, or typing into an EMR, documenting the subjective part of the note can be time consuming.  Why not have patients tell (i.e. document) their own stories?
      • The 2013 TEDMED conference in Washington, DC, featured “The Smartphone Physical” exhibit, where attendees saw how a special cell phone case doubled as a one-lead EKG, an attachment snapped pictures of the inside of a subject’s eye and another attachment produced a “picture perfect” magnification of the inner ear.  Harvard medical student Ravi Parikh wrote in the Washington Post that smartphone medical applications cost less, produce better quality results and more fully engage patients – once again, the factors driving expansion of self service medicine. As the curator of the exhibit, Johns Hopkins medical student Shiv Gaglani told Parikh:  “Some of the smartphone devices are already being used by patients to collect and store their data, so when they see their clinicians they can have productive and informed conversations.”

Underlying each of these examples of self-service medicine, from self-diagnosis to self-service physicals, is a technology platform for use on the Web but typically also available via a smartphone.   So, with the growth of self-service medicine, how many people, unable to own smartphone or access such a device or the Web, will find themselves on the wrong side of a healthcare “digital divide?”

Not as many as might be feared.  According to the Pew Internet Project, 85% of U.S. adults use the Internet, 91% own a cell phone and 56% own a smartphone.  Of these, 31% of cell phone owners and 52% of smartphone owners have used their phone to look up health or medical information.  Notably, Pew, observes that young people, Latinos and African Americans are significantly more likely than other groups to have mobile Internet access.

However, some are concerned that smartphone prices may go up, hampering widespread access, due to a pending decision by the International Trade Commission in a battle between Apple and Samsung over Samsung smartphone imports.  The controversy is arcane, involving Apple’s claimed exclusive rights to the rounded rectangular touchscreen design.  If the ITC rules in Apple’s favor, the concern is that prices could go up.  That could impact the next 100 million new smartphone users, who BI Intelligence predicts will be older and/or lower income.

Meanwhile, Boston’s safety net hospital, Boston Medical Center (BMC) will offer low-income patients access to the OneHealth online and mobile platform to promote self-management of chronic diseases, offer peer support and engage them in between office visits.  As BMC’s Dr. Robert L. Sokolove told MobiHealthNews, “Many of our patients can’t use a desktop because they don’t have a desk, but they do have smartphones.”

Patients Have Stopped Going to the Doctor

Patients have stopped going to the doctor.  Instead, the doctor is going to patients, intercepting them at work, at home and in grocery stores, malls, offices, shopping centers, drug stores, big box stores and on farms. In person and electronically, they’re showing up where patients live, work, shop and play.

They’re not alone.  They’ve got the whole team and more:  Nurse practitioners, physician assistants, nurses, pharmacists, community health workers, self-management trainers, iPhone app, cell phone text reminders, etc.

“Location, location, location,”

That’s how Direct Primary Care (DPC) pioneers Dr. Randy Robinson and Mason Reiner explained it in their recent Physician News Digest article:

“In today’s intense working environment where 85.8% of males and 66.5% of females work more than 40 hours per week, DPC addresses the burden of traveling for care. By locating near commercial centers, and integrating email, text messaging, and telemedicine capabilities into the practice, DPC can deliver convenient, time-efficient, high-quality care – a benefit for patients as well as employers.

When a hemoglobin A-1c lab test for a patient comes back grossly elevated, scheduling a 15-20 minute conversation about proactive diabetic management is a necessity. The only difference, utilizing DPC, the physician is in his or her office and the patient is at work as well as on a break. The vast majority of effective primary care is knowledge transfer, communication, and continuity.  The physical point of service is no longer necessary for billing purposes.”

Their characterization of primary care bears repeating:  “The vast majority of effective primary care is knowledge transfer, communication and continuity.” In other words – mutual learning for both the learning physician (about the patient) and the learning patient (about his or her condition). They emphasize that care will neither be patient centric nor physician centered but relationship centered.

The movement of care closer and closer to the patient can only accentuate this relationship-based learning.  In fact, the greatest long term value will come from patients learning to better care for their health and manage their conditions and from physicians and clinicians avoiding the inefficiency and misdirected care that can come from limited knowledge of their patient’s complete situation in context.

How can this closer relationship and mutual learning occur when, paradoxically, patient and physician are located miles apart, but joined by a high definition, telemedicine connection? In fact, patients and physicians are saying that virtual doctor visits may be better than in-person visits.  Reasons include greater convenience, a virtual waiting room that’s better than a real one, greater patient engagement from screen sharing, more convenient record keeping and a feeling by patients that their doctors pay more attention to them during virtual visits.

America’s military medical services have been using telemedicine extensively.  In fact, they are beginning to move from fixed base connections to using smart phones.

In Cleveland, physicians are examining patients remotely in connection with initiatives at University Hospitals, Cleveland Clinic and other institutions, according to a story in this week’s Cleveland Business.   Telemedicine candidates could include people in poor, urban centers or those in rural communities, according to the report.

One 77 year old patient was quoted in the story, saying “it was essentially the same experience as a visit to the doctor, but there was (my doctor) sitting at his desk, and here I was in my apartment.  It was amazing and very enlightening to me. The quality of the image is amazing.”

Meanwhile, in California, big agricultural companies have begun operating free clinics for workers on the farm. As California Healthline reported, “Paramount Agribusinesses, partnering with Kaiser Permanente, recently opened a 1,500-square-foot health and wellness center at its clementine plant in Delano and a temporary facility at its almond-processing plant in Lost Hills.”

“We’re backing up the healthy products we create by offering our employees much better than standard coverage,” said Danny Garcia, director of human resources at Paramount Citrus, according to the publication.

In Indianapolis, three employers are sharing a clinic set up in the Cumberland Crossing shopping center. Interviewed by Indiana Business, Dan Marchetti, Chief Financial Officer of Urschel Laboratories explained: “We see this as being both conveniently accessible and a great cost-savings to our workforce and their families.  Urschel is a global leader in food cutting machinery.

For rural areas across the country, Wal-Mart expects to install primary care clinics in its stores within five years. According to the Advisory Board’s Lisa Bielamowicz, MD, about a third of provider’ patients shop at Wal-Mart on a weekly basis. “It’s the cheapest place to buy groceries and ammunition, and it could become your most formidable competitor,” Dr. Bielamowicz said, as reported by Becker’s Hospital Review.

Already well known are clinics established by Walgreens, Target and CVS in their stores.  At Walgreens, the role of nurse practitioners will be expanded up the full level of education and licensure.

Taking medicine to patients is more than a US phenomenon; it is occurring worldwide, especially in developing countries.  The UN has just launched a campaign to recruit a million health care workers in sub-Saharan Africa. Already, these grassroots health advocates equipped with smart phones and other technology are making a difference in Rwanda and Tanzania. They are helping patients learn about and to manage their conditions – and to know when higher level care is needed.  And, in Zambia physicians from around the world are seeing patients via telemedicine connections.

So, whether you’re in the most remote areas of Africa, miles away from but connected the Cleveland Clinic, at an Indianapolis shopping center clinic, Dr. Robinson’s direct primary care practice in Elkins Park, Pennsylvania, or any number of pharmacy based clinics….you’ve stopped going to the doctor because the doctor, nurse or other clinician has come to you.

And, that means there’s a lot of learning to do.

Thank you for reading.