The AAMA has issued the following comments to the Centers for Medicare & Medicaid Services (CMS) in regard to the language in the CMS rule that could prevent unlicensed allied health professionals such as CMAs (AAMA) from entering medication orders issued by the overseeing physician into the computerized physician order entry (CPOE) system.

The American Association of Medical Assistants (AAMA), a professional society based in Chicago, representing more than 63,500 medical assistants holding the CMA (AAMA) credential, appreciates the opportunity to submit the following comments to the Centers for Medicare & Medicaid Services (CMS) in regard to the proposed rule specifying the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to qualify for Medicare and/or Medicaid electronic health record (EHR) incentive payments. The AAMA notes the following sentence1:

With this new proposal, we invite public comment on whether the stipulation that the CPOE [computerized physician order entry] function be used only by licensed healthcare professionals remains necessary or if CPOE can be expanded to include nonlicensed healthcare professionals such as scribes.

The AAMA previously took note of the following language in the final rule on Medicare and Medicaid Programs; Electronic Health Record Incentive Program2:

(f) Stage 1 core criteria for eligible hospitals or CAHs. An eligible hospital or CAH must meet the following objectives and associated measures except those objectives and associated measures for which an eligible hospital or CAH qualifies for a paragraph (b)(2) of this section exclusion specified in this paragraph:

(1)(i) Objective. Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines. [Emphasis added.] …

(h) Stage 2 criteria for EPs. Beginning when final regulations for Stage 2 are effective, an EP must satisfy the following objectives and associated measures:    

(1)(i) Objective. Use computerized provider order entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.  [Emphasis added.]

The AAMA also studied the following comment and response2:

Comment: Several commenters asked that we further specify who could enter the order using CPOE. Some commenters stated that only the ordering provider should be permitted to enter the order. These commenters stated that the ordering professional needs to be presented with clinical decision support at the time of entry and that the relay of an order to another individual is a source of potential error. Other commenters recommended that any licensed healthcare professional or indeed any individual (licensed or not) who receives the order from the ordering provider be permitted to perform the CPOE. The most common argument presented by these commenters is that this is currently how CPOE is handled in practice and a shift to entry by only the ordering provider would be too disruptive to workflow.

Response: We agree with those commenters who recommend allowing any licensed healthcare professional to enter orders using CPOE. We further refine this recommendation to be that any licensed healthcare professional can enter orders into the medical record per state, local, and professional guidelines. While we understand that this policy may decrease opportunities for clinical decision support and adverse interaction, we believe it balances the potential workflow implications of requiring the ordering provider to enter every order directly, especially in the hospital setting. We disagree with commenters that anyone should be allowed to enter orders using CPOE. This potentially removes the possibility of clinical decision support and advance interaction alerts being presented to someone with clinical judgment, which negates many of the benefits of CPOE.

One of the primary public policy objectives of the AAMA is to promote patient safety and well-being by protecting the public from substandard allied health services. Therefore, the AAMA agrees with the position of the CMS that it would be unwise and potentially harmful to patients to allow any individual—regardless of education, credentialing, or experience—to enter orders into the CPOE system.

However, there are a number of allied health professionals who are not licensed, but who are formally educated in their discipline, have a current certification awarded by an accredited national credentialing body, and have the competence and knowledge to be able to enter orders into the CPOE system as directed by an overseeing health care provider, such as a physician, nurse practitioner, or physician assistant.

A good example of such allied health professionals are medical assistants who have graduated from a programmatically-accredited postsecondary medical assisting program, and who hold a current medical assisting credential that is accredited by the National Commission for Certifying Agencies and/or the American National Standards Institute.

Given the reality that a significant number of allied health professionals are not licensed by state law, but are capable of entering orders into the CPOE as directed by the overseeing health care provider without endangering the health and safety of patients, the AAMA respectfully requests that CMS alter the wording in its existing and proposed regulations to read as follows:

Use computerized physician order entry (CPOE) for medication orders directly entered by any licensed or appropriately credentialed health care professional who can enter orders into the medical record per state, local, and professional guidelines.

Allowing appropriately credentialed, as well as licensed, health care professionals to enter orders into the CPOE system as directed by a health care provider would not increase the risk of inaccurate information being entered into the electronic health care record, but would allow for enhanced patient care resulting from increased attention to patient needs and greater communication among the health care team. It would also lessen disruption of the current division of labor within the health care system. Retaining the qualifying clause “who can enter orders into the medical record per state, local, and professional guidelines” provides another safeguard against unqualified personnel entering faulty data into the CPOE system.

Attached are the Standards and Guidelines for the Accreditation of Educational Programs in Medical Assisting (Standards) of the Commission on Accreditation of Allied Health Education Programs (CAAHEP). The Core Curriculum in the Standards demonstrates that medical assistants who have graduated from a CAAHEP accredited medical assisting program have the knowledge necessary to enter orders into the CPOE as directed.

Also attached is the Content Outline of the CMA (AAMA) Certification Examination. Only graduates of postsecondary medical assisting programs accredited by either CAAHEP or the Accrediting Bureau of Health Education Schools (ABHES) are eligible to sit for the CMA (AAMA) Certification Examination. The Content Outline also demonstrates that medical assistants who have passed the CMA (AAMA) Certification Examination and who have maintained currency of their CMA (AAMA) by recertifying every five years have the knowledge necessary to enter orders into the CPOE as directed.

Once again, the AAMA is grateful for the opportunity to comment on the proposed regulations.

Questions? Contact Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or 800/228-2262.