Urgent Care and Mini Clinics – the Donut Hole in Syndromic Surveillance

doughnut-1023028-mIn recent years the range and availability of ambulatory care service providers has continued to grow. These include urgent care centers, mini clinics, and so-called “Doc in a box” providers. While the emergence of these services benefits consumers on many levels, it also creates a potentially serious “donut hole” in regional syndromic surveillance. A proliferation of these facilities can lead to diminished accuracy and efficacy of the population health data that’s made available, which can result in potentially serious negative consequences…for both public health officials and the communities they serve.

Urgent care providers fall into two primary categories: those that are affiliated with a larger healthcare system/network, and those that are independent of such a network. With evening and weekend hours, no appointments required, and a range of services that frequently includes x-rays and basic laboratory tests, urgent care centers are able to treat a large percentage of patients who would traditionally turn to a hospital ED. While many practices in the first category report their syndromic data via their affiliated healthcare network, the independent urgent care providers have no such option. Additionally, they frequently do not meet the guidelines that would make them eligible for federal Meaningful Use incentives, giving them little motivation to seek out methods for submitting their data for syndromic surveillance. As a result, in areas with a large number of independent urgent care providers, a number of important healthcare issues—influenza, food poisoning, etc.—are not being accurately detected or reported. This can leave public health officials with a skewed picture of the actual state of their community’s health.

Mini-clinics are staffed by nurses, nurse practitioners, or physician assistants rather than doctors. Though they are unable to treat conditions as serious as those tended to in urgent care clinics, they are increasingly found in national drugstore chains and large retailers, offering the attraction of walk-up service in a location with a pharmacy. Many individuals with mild cold, flu, and gastrointestinal-related symptoms can be effectively treated in mini-clinics quickly and conveniently. This provides some obvious benefits to both patients and Emergency Department waiting rooms, but because these clinics are not tied into larger healthcare networks, the patient data from such facilities is not attainable by Public Health authorities in a timely or useful way.


“Doc in a box” clinics—as they are sometimes pejoratively-called—are increasingly seen popping up in strip malls and retail outlets alongside coffee shops and restaurants. Emphasizing service and convenience, they are staffed by doctors and generally have extended hours, walk-up service, and a posted list of fees for various medical services. By offering quick and low-cost healthcare, these clinics serve an increasingly growing portion of the community. But again, these facilities generally do not share syndromic data for their patients with the Public Health Department.

Effective population health monitoring through syndromic surveillance requires that data is not only timely, but also comprehensive. As we have considered, there is a growing pool of patients—often the very patients who could be key indicators of outbreaks or other issues of public health concern—whose data is going unreported. As a result, it is possible that the actual scale or scope of an outbreak will go undetected, or will be detected much later than it would have been if this patient data was being captured as part of a syndromic surveillance project.

The good news is, the remedy to this problem is not overly complex. All of these providers utilize electronic health records, so locating funding to connect these providers to Public Health’s syndromic surveillance system would remedy the situation. Additionally, a few states have passed legislation that requires healthcare providers to submit this data to the Public Health Department. This not only assures that it is done, but also does so without putting the financial burden on the health department. Recognizing that there is a problem is the first step toward correcting it. Since closing the gap will lead to improved awareness for public health, and ultimately to healthier communities, it’s an effort that would be well worth the investment.