Scope of Practice

Laboratory and Radiology Orders with the CPOE System

Since the Centers for Medicare and Medicaid Services (CMS) issued a final rule permitting “credentialed medical assistants” to enter medication orders into the computerized provider order entry (CPOE) system as directed by an eligible professional (e.g., a physician or osteopath), many questions have followed. The issue of whether this final rule permits credentialed medical assistants to enter laboratory and radiology orders into the CPOE is one of particular interest.

The wording of the final rule, although open to some debate, supports the conclusion that credentialed medical assistants are authorized to enter medication, laboratory, and radiology orders into the CPOE. Please note the following:

1. On page 53985 of the Federal Register, the following CMS Proposed Objective is presented:

Use computerized provider order entry (CPOE) for medication, laboratory, and radiology orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local, and professional guidelines to create the first record of the order.  [Emphasis added.]

2. The CMS receives feedback and narrows the decision down to a few different options (described in the previous entry on this blog).

3. The CMS essentially chooses the third option and concludes on page 53986 that “credentialed medical assistants” should be permitted to enter orders into the CPOE (as described in the previous entry on this blog).

4. CMS issues its modified objective on page 53987:

After consideration of the public comments received, we are modifying this objective for EPs as § 495.6(j)(1)(i) and for eligible hospitals and CAHs [critical access hospitals] at § 495.6(l)(1)(i) to use the same language as Stage 1 (with the addition of laboratory and radiology orders), as we did not finalize our proposed changes to when the order must be entered: “Use computerized provider order entry (CPOE) for medication, laboratory, and radiology orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local, and professional guidelines.”  [Emphasis added.]

The CMS objective clearly expands CPOE to laboratory and radiology orders, as well as medication orders. However, it seems as though the wording of this finalized order contradicts the excerpts quoted above and the wider context of the comments and the CMS responses.

A fundamental rule of reconciling conflicting statements in a legal document is that the specific supersedes the general. Based on this principle, it is apparent that the general wording of the modified CMS objective contradicts the specific findings and conclusions in the body of the final rule. Therefore, a correct rendering of the final rule would be as follows:

“Use computerized provider order entry (CPOE) for medication, laboratory, and radiology orders directly entered by an licensed health care professional or credentialed medical assistant who can enter orders into the medical record per state, local, and professional guidelines.”  [Emphasis added.]