CMS and “Licensed Health Professionals” Language

On February 23 the Centers for Medicare & Medicaid Services (CMS) published a Notice of Proposed Rulemaking regarding Stage 2 of the “Meaningful Use” of Electronic Health Record (EHR) Technology.

The American Association of Medical Assistants is concerned about language in Stage 1 of the rules because it seems to limit to licensed health professionals the entry of information into the computerized physician/provider order entry (CPOE) system. This language is being interpreted (wrongly, in my opinion) as prohibiting physicians from delegating to medical assistants the entry of physician-approved information and orders into the CPOE.

The request for comments on the proposed rule for Stage 2 offers the AAMA an opportunity to protect the medical assistant’s right to practice. Perhaps partly in response to my below letter of December 23, 2011, CMS has included the following language in the NPRM:

With this new proposal, we invite public comment on whether the stipulation that the CPOE function be used only by licensed healthcare professionals remains necessary or if CPOE can be expanded to include non licensed healthcare professionals…

The AAMA Board of Trustees and I will continue to protect the medical assistant’s right to practice in this important area. I will keep you informed through posts to Legal Eye and articles in CMA Today.


December 23, 2011

Elizabeth S. Holland
Director, HIT Initiatives Group
Office of E-Health Standards and Services
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services

Dear Ms. Holland:

I am writing on behalf of the American Association of Medical Assistants (AAMA), a professional society based in Chicago, Illinois, with over 28,000 medical assistant members throughout the United States.

The AAMA took note of the following language in the Final Rule on Medicare and Medicaid Programs; Electronic Health Record Incentive Program, published in the Wednesday, July 28, 2010 Federal Register:

(f) Stage 1 core criteria for eligible hospitals or CAHs [Critical Access Hospitals]. 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 [computerized provider order entry] 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.] (pages 44568 and 44569)

(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.] (page 44570)

The American Association of Medical Assistants has studied the following comment and response on page 44332 of the Final Rule:

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 American Association of Medical Assistants is to promote patient safety and well-being and to protect the public from substandard allied health services. Therefore, the AAMA agrees with the position of the Centers for Medicare & Medicaid Services (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 Computerized Provider Order Entry (CPOE) system. However, there are many allied health professionals who are not licensed, but who are formally educated in their discipline, have a current certification awarded by a recognized national credentialing body, and have the competence and knowledge to be able to enter orders into the CPOE system as directed by an overseeing healthcare 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 an accredited postsecondary medical assisting program, and who hold a current medical assisting credential awarded by a certifying body that is accredited by the National Commission for Certifying Agencies (NCCA) and/or the American National Standards Institute (ANSI).

Given the reality that a significant number of allied health professionals are not licensed by state law, the AAMA respectfully requests that CMS alter the wording of the forthcoming Stage 2 proposed regulations to read as follows:

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

Allowing credentialed, as well as licensed, healthcare professionals to enter orders into the CPOE system as directed by a healthcare provider would lessen disruption of the current division of labor within the healthcare system without subjecting patients to a greater risk of incorrect information being entered into their electronic health records. Retaining the qualifying clause “who can enter orders into the medical record per state, local, and professional guidelines” provides another safeguard against incompetent personnel entering incorrect data in the CPOE system.

Thank you for your consideration, Ms. Holland. I would be happy to discuss this further with you and your Centers for Medicare & Medicaid Services colleagues—either by telephone or in person. Please let me know how the American Association of Medical Assistants can be of assistance to you.

Very truly yours,

Donald A. Balasa, JD, MBA
Executive Director, Legal Counsel
American Association of Medical Assistants

About Donald A. Balasa

Donald A. Balasa, JD, MBA, executive director and legal counsel for the American Association of Medical Assistants, keeps his eye on what is happening in the profession.
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13 Responses to CMS and “Licensed Health Professionals” Language

  1. Elizabeth Peace says:

    I agree that credentialed healthcare providers should be included in the new wording for the use of CPOE.

  2. Karen says:

    Hi Mr. Balasa:
    Has there been any feedback on this issue? I am trying to make a decision to go into this field. I will be putting forth my time, effort and money to receive my certificate. Do you think the future of medical assisting will be jeopardized by this as well as the new health care laws coming about?

    Thnaks, Karen

    • Thank you for your question. I am happy to respond.

      The AAMA submitted its comments to CMS about the “licensed health professionals” language earlier this week. The deadline for submitting comments is March 7, and it will take CMS two or three months to review all the comments and decide on changes of language to the proposed rules. I continue to be confident that the argument we provide in our comments will prevail, and that CMS will change the language.

      It is my opinion that the new health care laws will benefit medical assistants–especially those who have the CMA (AAMA) credential. So, I don’t see the Supreme Court’s review of President Obama’s Patient Protection and Accountable Care Act as a threat to the medical assisting profession.

      I hope this is helpful. We will inform our constituents as soon as we hear of a decision from CMS.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

  3. Kelly Hall says:

    Will this affect Medical Assistants that work in medical offices that use EHR?

    • Yes, it would. A change of wording by CMS could have a positive impact on CMAs (AAMA) working in offices in which they are no longer permitted to enter medication orders into the EHR/EMR.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

  4. Krissa Yocum says:

    I currently work in a office where I have been doing all the meds, scheduling imaging, surgeries, labs, etc. If this goes into effect all I will be doing is entering vital signs into a computer which does not help with the flow of our busy practice. There is one R.N. in our office & myself. No other support staff to help with these in our busy Cancer Practice. I hope someone will fight for us. I would hate to waste the money I spent for the schooling to become a certified medical assistant to not be able to participate in patient care.

  5. Tricia Thompson says:

    Has there been any updates regarding this issue? It is really starting to impact my job and the role that I play.

    • Thank you for your follow up. I heard from a CMS staffer this morning that the decision should be made in September or October.

      I will keep everyone informed through Legal Eye, the AAMA website, and my column in CMA Today.

      Donald A. Balasa, JD, MBA
      Executive Director, Legal Counsel

      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

      Visit us on Facebook! http://www.aama-ntl.org/facebook

      The CMA (AAMA): Health Care’s Most Versatile Professional

  6. Christi Black says:

    I have a question, I am a medical assistant currently working in a physician’s office. I am also a Certified Nursing Assistant with a current state license. Will my CNA License work with the requirements for Stage 2 in Meaningful Use for CPOE?

    • Thank you for your question. The answer is a bit complicated so I will send the answer to your email.

      Sent from my iPhone

      • Michelle Cauler says:

        I am a medical assistant currently working in a physician’s office. I am also a Certified Nursing Assistant with a current state license. (Florida) Will my CNA License work with the requirements for Stage 2 in Meaningful Use for CPOE? I also recently called and spoke with the AAMA and was informed that I am eligible to sit for the CMA exam. I will be receiving the exam information and application via mail. Does this mean that I would still have to become credentialed if I plan on taking the exam?
        Thanks, Michelle

      • Thank you for your question. If you take and pass the CMA (AAMA) Certification Examination and become a CMA (AAMA), you meet the CMS requirement that only “credentialed medical assistants” (as well as licensed health care professionals) are permitted to enter orders into the CPOE system and have such entry count toward meeting the meaningful use requirements under the Medicare and Medicaid Incentive Programs.

        Even though the CNA is a mandatory credential under most state laws, I am not certain that it meets the CMS requirement. Here is an FAQ from the CMS website:
        [EHR Incentive Programs] When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward the measure, or can they have other titles as long as their job functions are those of medical assistants?
        If a staff member of the eligible provider is appropriately credentialed and performs similar assistive services as a medical assistant but carries a more specific title due to either specialization of their duties or to the specialty of the medical professional they assist, he or she can use the CPOE function of CEHRT and have it count towards the measure. This determination must be made by the eligible provider based on individual workflow and the duties performed by the staff member in question. Whether a staff member carries the title of medical assistant or another job title, he or she must be credentialed to perform the medical assistant services by an organization other than the employing organization. Also, each provider must evaluate his or her own ordering workflow, including the use of CPOE, to ensure compliance with all applicable federal, state, and local law and professional guidelines.
        Created: 08/20/2013
        (FAQ9058)

        I am not sure that a certified nursing assistant credential would fall within the category of “appropriately credentialed” in the above.

        I hope this is helpful. The bottom line is that holding the CMA (AAMA) credential meets the CMS requirement.

        Donald A. Balasa, JD, MBA
        Executive Director, Legal Counsel

        American Association of Medical Assistants
        Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org

        Visit us on Facebook! http://www.aama-ntl.org/facebook

        The CMA (AAMA): Health Care’s Most Versatile Professional

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