The overwhelming majority of health care compliance professionals surveyed for a new study agreed with this statement: “If a clinician’s action is not documented it is not ‘done.’” 

That sets up an unrealistic expectation for physicians and other health professionals, said Christine Sinsky, MD, the AMA’s vice president of professional satisfaction and co-author of the study, published this month in The Permanente Journal.

“It simply isn’t possible to record every action one takes in the course of the workday. Attempts to do so have led to the situation where many physicians feel like they spend more time documenting care than delivering care,” Dr. Sinsky said.

Further, she added, the idea that everything can and should be documented is hazardous for patients.

“It leads to patients receiving less undivided attention from their physicians, who are often forced to be typing into the EHR instead of facing the patient—meaning there is less listening and observing without distraction,” she said. “It also contributes to diminished access to care for patients. Time spent on documentation is time that can’t be offered for patient care.”

This sentiment about documentation was one of several regulation and rule-related issues explored in the study, funded by the AMA Practice Transformation Innovation Research Grant Program, involved surveying compliance professionals in 70 federally qualified health centers (FQHCs). Sixteen professionals responded to the survey and researchers then conducted semistructured interviews with four of the compliance professionals. Fifteen of the 16—94%—agreed with the statement regarding a task not being considered done if it was not documented. 

The study of compliance professionals—about one-third of whom had formal training—also discovered that 69% agreed with the statement, “It is safer to err on the side of more documentation than less.” Compliance professionals also misinterpret regulations and standards that policymakers and accrediting bodies put into place, says the study, whose lead author is Jeffrey Panzer, MD. It was co-written by Lindsey E. Carlasare of the AMA, along with Maggie Hamielec, MPH, and Jodi Simon, DrPH.

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When researchers presented respondents with scenarios designed to assess the accuracy and understanding of specific regulatory and compliance issues, “there was high variability among participants’ views.” Some participants, for example, noted “noncompliance with regulations in situations that were not actual regulatory infractions or standards violations.” 

Specifically, some believed that the Centers for Medicare & Medicaid Services (CMS) prohibits medical assistants from placing orders in the EHR on behalf of the ordering physician. However, that is allowed. Some also believed that The Joint Commission requires pain assessments at every primary care visit—another regulatory myth.

“It’s important to clarify what is actually required,” Dr. Sinsky said.

The AMA’s Debunking Regulatory Myths series aims to do just that. In fact, the series has debunked the myth that CMS doesn’t allow medical assistants to enter orders on behalf of the ordering clinician. The AMA’s experts also set the record straight to clarify that pain assessments are not required at every primary care visit. 

The AMA also has resources that explain the 2020 evaluation-and- management (E/M) coding guidelines that decreased the documentation required to meet a given service level, Dr. Sinsky said. 

Researchers said there are several potential factors that lead to compliance professionals to err on the side of excessive documentation. These factors include:

• Sometimes purposefully vague regulations that are complicated and can lead to ambiguity in understanding and application.
• Multiple individuals, entities and steps can be involved when interpreting a regulation to apply to front-line health care workflows and that can become akin to a game of telephone where the potential for misunderstanding increases.
• Cultural norms regarding how regulations and standards are incorporated into local policies and practices.

The researchers offered several recommendations to ensure regulations and standards are designed, interpreted and enforced in ways that don’t create barriers to effective and efficient patient care. Some steps to close the gap between written regulations and implementation include:

• Regularly reviewing the organization’s local policies and de-implementing practices that aren’t required.
• Striving for evidence-based policies, which will reduce waste associated with well-intended, but ineffectual or counterproductive policies. 
• Actively involving physicians, nurses and other front-line health professionals in developing or revising policies and learning how the rules impact them.

While this study looked at federally qualified health centers, a larger study is underway to examine these questions in other health care settings. 

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