Public Health Law Map - Beta 5 - Medical and Public Health Law Site

protocols become generic documentation for those conditions. As long as the
physician can convince a court that the protocols are enforced, the protocol becomes
evidence of a pattern of behavior. In this case, the burden of proof is shifted to the
plaintiff, who seeks to dispute that the protocol was followed. If the office does not
rigorously enforce the use of protocols, each patient encounter must be fully
documented. In effect, the core of what would be the protocol must be written as a
chart entry every time the condition is treated. Failing in this repetitive
documentation shifts the burden of proving what care was rendered to the physician.
6. Physician Protocols
Many group practice organizations use physician protocols to standardize medical
practice within the group. The goal may be to improve consistency of care when a
patient is likely to be seen by different doctors, to limit the number of drugs in the
formulary, or to ensure that the physicians are following recognized standards, such
as Centers for Disease Control (CDC) protocols, in their practices. Physician
protocols do not place legal limitations on the physicians; they are characterized by
their allowance for independent medical judgment. They are a voluntary or
contractual agreement by the physicians to follow certain patterns when practicing
within the group.
A common example is a protocol for treating an MCO patient for essential
hypertension. Typically this protocol would not include a definition of essential
hypertension; every treating physician would be expected to be able to make the
diagnosis. The protocol would contain a list of the diagnostic procedures to be done
on a new patient. These might be arrived at by consensus after an analysis of the
costs and benefits of each test. Every patient might have a blood count but only those
over age 40 years would have an electrocardiogram. The protocol would then list the
drugs to be prescribed for certain types of patients. A beta- blocker might be first
choice, with an alpha- blocker substituted if the patient does not respond well or is
over 60 years old. The drugs on the list also would be in the formulary.
The physician protocol guides rather than dictates patient care. If a physician wants
to use a different drug from the established standard, the reasons for deviation should
be documented, but the physician is legally free to make the change (subject,
however, to discipline by the MCO). In contrast, an NPP would not be allowed to use
such a protocol becasue it leaves the diagnosis open and allows choice in the use of
medicines, both of which require exercising medical judgment.
7. Teaching Protocols
Teaching protocols, also called teaching algorithms, fall somewhere between strict
protocols and physician protocols; they guide students through the exercise of
professional judgment. Teaching protocols thus fill the dual purpose of providing
consistency of care and helping students learn how to make good judgments.
The hallmark of a teaching protocol is a differential diagnosis list, which is
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