Misinterpreted regulations create unnecessary work for physicians and their teams  

Wrongly interpreted regulations create unnecessary burden in health care, impede efficiency, and contribute to professional dissatisfaction, according to a recent study published in The Permanente Journal.

Researchers presented 16 compliance professionals with five clinical scenarios and found high variability in their interpretations of regulatory adherence, with some participants noting noncompliance in situations where there was none and others offering ambiguous interpretations. The clinical scenarios were based on the American Medical Association's Debunking regulatory myths series and focused on the following topic areas:

1. Order entry by medical assistant (MA) at the direction of a physician.

Per the study, federal regulations allow "any licensed health care professional, credentialed MA, or medical staff member credentialed to and performing equivalent duties of a credentialed MA" to enter orders in the EHR as requested by the physician, as long as state and local policies permit.

2. Protected health information (PHI) disclosure to specialist.

Per the study, HIPAA does not require clinicians to obtain patient consent to disclose PHI to another "covered entity" for treatment purposes, unless the information contains psychotherapy notes.

3. Food or drink in work area.

Per the study, while OSHA prohibits workers from consuming food and beverages in areas where there is a reasonable likelihood of exposure to blood or other potentially infectious material (OPIM), it does not specify locations. Therefore, it depends on whether the work area is located where there is a possibility of blood/OPIM exposure.

4. Completion of pain assessment.

Per the study, federal regulations do not require pain assessment at every visit. Joint Commission standards require organizations to establish policies to “assess and manage patient’s pain” but do not specify frequency or visit type.

5. Redocumentation of the history of present illness (HPI) by physician.

Per the study, Medicare documentation requirements allow physicians to “review and verify” documentation entered by nurses, students, or other members of the team rather than redocumenting the information, if consistent with state and institutional policies.

Takeaway lessons for organizations

Researchers urged health care organizations to evaluate how their local intepretations of regulations may unnecessarily add to the administrative burden on physicians and teams.

Recommended steps include the following:

• Regularly review your organization’s local policies to ensure they do not misinterpret or overly interpret regulations,
• Deimplement policies that are not required,
• Strive for evidence-based policies,
• Learn how policies affect physicians, nurses, and other frontline workers,
• Involve them in developing or revising local policies.

— Brandi White, managing editor of FPM

Posted on April 15, 2025, by FPM Editors.