Scope of Practice

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