The Medicaid Promoting Interoperability Program (formerly the Medicaid Electronic Health Record [EHR] Incentive Program) will be ending December 31, 2021. In furtherance of its Mission Statement goal of advocating for quality patient-centered health care and its Core Value of promoting patient safety and well-being and as authorized by the Board of Trustees of the American Association of Medical Assistants® (AAMA), the AAMA launched its national Order Entry Competence (OEC) initiative on July 11, 2021. The purpose of the OEC outreach is to persuade third-party payers to incorporate into their agreements with licensed providers the requirement that their orders be entered into the computerized provider order entry (CPOE) system by either credentialed medi­cal assistants or licensed health care profes­sionals who are competent in order entry.

The OEC initiative is anticipated to create several effects:

  • A decrease in the number of incorrect orders
  • An improvement in health outcomes
  • An avoidance of the monetary and pain-and-suffering costs resulting from inaccurate order entry

The following history of the Promoting Interoperability Programs provides justifi­cation for the need for the OEC outreach.

The HITECH Act

In 2009 the U.S. Congress enacted into law the Health Information Technology for Economic and Clinical Health (HITECH) Act. Although not as well-known as the Patient Protection and Affordable Care Act, the HITECH Act has also had a profound and far-reaching impact on American health care.

The HITECH Act created the Medicare and Medicaid Promoting Interoperability Programs and directed the Centers for Medicare & Medicaid Services (CMS) to issue rules for these new programs. The two Promoting Interoperability Programs provided annual payments to licensed providers and health care institutions who demonstrated—in addition to other requirements—meaningful use of their EHR systems by meeting or exceeding various quantitative measures established by the CMS. Specifically, for each reporting year, a certain percentage of medication orders, a certain percentage of laboratory orders, and a certain percentage of diagnostic imaging (initially just radiology) orders had to be entered into the CPOE system.

Who Should Be Allowed to Enter Orders?

A point of major debate during the early years of the Medicare and Medicaid Promoting Interoperability Programs was who should be permitted to enter orders into the CPOE system for meaningful use calculation pur­poses. Early versions of the CMS rules stated that orders had to be entered by licensed health care professionals. The CMS “invited public comment on whether the stipulation that the CPOE function be used only by licensed health care professionals remains necessary or if CPOE can be expanded to include non-licensed health care profes­sionals.”1 Comments received by the CMS included opinions that “any individual (licensed or not) who receives the order from the ordering provider [should] be permitted to perform CPOE.”2

After evaluating these comments, the CMS tentatively concluded that CPOE for Promoting Interoperability Programs’ pur­poses may be done by “any licensed health care professional [who] can enter orders into the medical record per state, local, and professional guidelines.”2 Before incorporat­ing this language into the final Promoting Interoperability Programs rule, the CMS gave the public another opportunity to comment.

The AAMA Submits Comments to the CMS

On April 24, 2012, the AAMA submitted comments3 to the CMS regarding the proposed final rule.

The comments outlined the reasons competent and knowledgeable medical assis­tants who are credentialed by a third-party entity—such as an independent certifying body—should be incorporated into the CMS rule. The AAMA requested that the wording be amended to allow “any licensed or appropriately credentialed health care professional [emphasis added]”3 to enter medication, laboratory, and diagnostic imaging orders into the CPOE system for meaningful use calculation pur­poses under both the Medicare and Medicaid Promoting Interoperability Programs.

The CMS Accepts AAMA Recommendations

After reviewing the second round of com­ments, on August 23, 2012, the CMS promulgated its final rule for Stage 2 of the Promoting Interoperability Programs. In a major victory for the AAMA and the medical assisting profession, the CMS tacitly agreed with the AAMA’s comments and decided that credentialed medical assistants, in addition to licensed health care professionals, would be allowed to enter orders into the CPOE system for meaningful use calculation pur­poses. The CMS articulated its reasons in the August 23, 2012, Federal Register:

We are particularly concerned with CPOE usage by [eligible professionals (EPs) such as physicians, osteopaths, and podiatrists] in this regard. Many EPs practice without the assistance of other licensed health care professionals. These EPs in their comments urged the expansion [to any licensed, certi­fied, or appropriately credentialed health care professional who can enter orders into the medical record per state, local, and pro­fessional guidelines]. We believe this expan­sion is warranted and protects the concept that the [clinical decision support (CDS)] interventions will be presented to someone with medical knowledge as opposed to a layperson [emphasis added]. The concept of credentialed health care professionals is over broad and could include an untold number of people with varying qualifica­tions. Therefore, we finalize the more limited description of including credentialed medi­cal assistants. The credentialing would have to be obtained from an organization other than the employing organization [emphasis added].1

Reasons for the OEC Initiative

Why is there a need for a private sector cam­paign to ensure competence in order entry? The simple answer is that patient welfare is dependent on not only accurate order entry but also clinically correct responses by allied health professionals to CDS mes­sages and proposed interventions. The CMS emphasized this in additional rationale for its August 23, 2012, final rule:

Based on public comments received, ques­tions submitted by the public … and dem­onstrations of [certified EHR technology (CEHRT)] we have participated in, it is apparent that the prevalent time when CDS interventions are presented is when the order is entered into CEHRT, and that not all EHRs also present CDS when the order is authorized [by the licensed provider] (assuming such a multiple step ordering pro­cess is in place). This means that the person entering the order could be required to enter the order correctly, evaluate CDS either using their own judgment or through accurate relay of the information to the ordering provider, and then either make a change to the order based on the CDS intervention or bypass the intervention. We do not believe that a layperson is qualified to do this [emphasis added].1

In light of what competent and safe clinical order entry entails, the AAMA holds the position that the OEC outreach is needed to remind third-party payers and licensed providers that clinical knowledge is neces­sary when a clinical order is entered, not just when the licensed provider subsequently authorizes the order.

Assistance Requested

It is both imperative and appropriate that the AAMA—as the voice of the medical assisting profession and a tireless advo­cate for high quality and readily accessible health care—create and lead the OEC ini­tiative. However, for the OEC outreach to be successful, the AAMA needs help from medical assisting practitioners, managers, educators, and representatives of our other communities of interest. Please provide the contact information for any executives and board members of health insurance carriers by emailing me at DBalasa@aama-ntl.org.

Thank you in advance for helping the AAMA protect the health and safety of patients throughout the United States!

Questions may be directed to AAMA CEO and Legal Counsel Donald A. Balasa, JD, MBA, at DBalasa@aama-ntl.org.