Addressing Recent Concerns About Order Entry

The Centers for Medicare and Medicaid Services (CMS) Blog recently posted these articles dealing with forthcoming changes to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs:

EHR Incentive Programs: Where We Go Next

Comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan Annual Health Care Conference, Jan. 11, 2016

In the wake of these pieces, there has been some concern about the potential effects on medical assistants’ ability to enter orders into the computerized provider order entry (CPOE) system for meaningful use purposes. I have addressed these concerns in a memorandum to AAMA leaders. The body of this message is as follows:

January 22, 2016

Within the last 10 days the Centers for Medicare and Medicaid Services (CMS) has issued statements about forthcoming changes in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Incentive Programs) required by the passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015, referred to as “MACRA.”

Congress enacted MACRA on April 16, 2015.  This legislation replaces the current meaningful use (MU) payment adjustment provisions with the Merit-Based Incentive Payment System (MIPS), effective January 1, 2019.  According to CMS, MIPS will incorporate some meaningful use elements of the current program and will introduce new elements.

There has been a groundswell of concern that MACRA will do away with the requirement that only third-party-credentialed medical assistants, licensed health care professionals, and third-party-credentialed individuals “who hold a more specific title than ‘medical assistant’ because their duties include only parts of the medical assisting scope of practice, or because of the specialization of the overseeing eligible professional (EP),” are permitted to enter medication, laboratory, and diagnostic imaging orders into the computerized provider order entry (CPOE) system for meaningful use calculation purposes under the Incentive Programs.

In my legal opinion, this concern is not warranted because of the following:

  1. The order entry credentialing requirement of the Incentive Programs was established by CMS rule, not by federal statute.
  2. No provisions of MACRA impact the CMS order entry credentialing requirement.
  3. The legislative history of MACRA does not indicate that Congress was concerned about the CMS order entry credentialing requirement.

CMS regulations implementing MACRA and MIPS are scheduled to be published for comment in 2016.  I do not anticipate that these forthcoming regulations will include any changes to the credentialing requirement of the CMS MU order entry rule.  However, if changes are proposed that could potentially harm patients by lowering the credentialing requirement for medical assistants who enter orders into a CPOE system, the American Association of Medical Assistants will be quick to point this out to CMS decision makers, and to persuade them to maintain or increase the current requirement.

About Donald A. Balasa

Donald A. Balasa, JD, MBA, chief executive officer and legal counsel for the American Association of Medical Assistants, keeps his eye on what is happening in the profession.
This entry was posted in Certification and the CMA (AAMA) Credential, Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Meaningful Use, Medicaid, Medicare, On the Job, Scope of Practice and tagged , , , , , , , , , , , . Bookmark the permalink.

16 Responses to Addressing Recent Concerns About Order Entry

  1. Christina Clapperton, CMA (AAMA) says:

    Sadly at the clinic that I work at now, there are medical assistants who are not credentialed , that are given the exact credit as a credentialed. There is also a nurses aid who is doing medical assistant duties, fro injections to placing orders and the list leads on. Sometimes makes me wonder what is the point in keeping up my credentials. A non-credentialed medical assistant who just graduated from Carrington college is making the same amount as I am and I have been a CMA (AAMA) for 11 years. Things with the CMS will change nothing, I fear.

    • Thank you for your comment. I am saddened to hear about the situation at your place of work. I can assure you that what you describe is not the situation in many outpatient settings throughout the United States.

      If your employer is not complying with the CMS rules, there could be serious consequences.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  2. Jacqueline Powers says:

    I, too, work in a clinic where some medical assistants still have NO credentials at all and they are allowed to perform all tasks I, an AAMA certified CMA, am allowed to. I find this disheartening. It was my understanding that as of last October, no uncertified medical assistants were supposed to even access the EMR for rooming patients, entering orders, or refilling prescriptions. I feel as if I have wasted my money getting not certification and my Associate’s in Medical Assisting. The benefits do not outweigh my costs.

    • I am sorry to hear about the situation you are facing. I will respond to your question to your e-mail address.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  3. stayci says:

    I too am in the same position as the above. I went to school for 2 years to earn my certification where in fact I keep it up to date by CEUs. I work with ladies now that never went to school and do the same job I do and make the same amount as I do. So I agree with the above what is the point of going to school, it sure doesn’t pay.

    • Jacqueline Powers says:

      Stayci, I think unless our AAMA leaders lobby harder for stricter guidelines on EMR usage, we shall see our workload rise and our pay decrease or stay the same. I hope our cries are heard.

  4. Kendall Gaston says:

    The way our EHR system works, the MA (licensed or not) as well as any staff member can enter refills, labs, etc but then they all get sent to the doctor to actually approve. [example: patient comes to the front desk and tells the staff they need a refill, she then accesses the patient chart and selects the medication, indicated if it’s for 30 or 90 days and selects the pharmacy to send it to] With prescriptions it allows the providers to approve them in bulk, but with other orders it must done patient by patient. This is not done as part of the workflow for actual encounters/office visits that are counting towards meaningful use. What is the guideline in this situation?

    During encounters/ office visits with the providers, the MA takes vitals, enters the HPI and if the patient needs refills on any medications, the MA selects the medications to be refilled. The doctor actually approved the refill when they finish the encounter and signs off on it. The MA is not ordering any new medications, simply refilling what we already have on file. What would the guideline be here for an MA that is not licensed?

    *to claify the not licensed MA, she completed all of the course work and testing for her MA school but never took the state or national test to become certified or registered. She is eligible to do so, but never has.

    • Thank you for your question. For electronic entry of medication/prescription orders to count toward meeting the meaningful use thresholds under the Medicare and Medicaid Incentive Programs, the person entering the order and seeing any clinical decision support alerts that appear must be either a “credentialed medical assistant” or a licensed health care professional. Note my following entry:

      Clinical Decision Support Alerts and Credentialed Medical Assistants
      Posted on July 9, 2014 by Donald A. Balasa
      We have detailed who can perform computerized provider order entry (CPOE) for meaningful use objectives, as well as the potential costs of improper CPOE. Naturally, the broader question in this discussion is why only licensed health care professionals or credentialed medical assistants are allowed to perform CPOE.
      These rulings are made with patient protection as the primary goal. One way the limits on CPOE help ensure that protection involves a function of the CPOE system known as clinical decision support alerts.
      Robert Anthony of the Centers for Medicare and Medicaid Services spoke about these alerts and their importance for patient safety in his presentation. The full text and video are below:
      “The purpose of this really is to make sure that when information goes into a system, and it is done obviously prior to any action being taken on the orders … that somebody who has some clinical expertise or authority is able to see any of the clinical decision support alerts that pop up and say, ‘You may not want to prescribe this medication because of a contraindication.’ Then they can take action on that for patient safety, whereas I as a lay person might see a clinical decision alert, have no idea what that means, and ignore it completely. So that’s really the whole idea behind having a licensed health professional or a CMA (AAMA) to look at that.”
      For meaningful use calculation purposes, having a non-credentialed medical assistant enter a medication order and pend it, and perhaps see a clinical decision support alert, and then have the delegating physician approve the medication/prescription orders in bulk, and not see the clinical decision support alerts, does not meet the CMS rule and cannot be counted toward meaningful use.

      I hope this is helpful.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  5. I have a question specific to the definition of licensed health professional. I manage HR for a large healthcare organization. We have two unique roles that we hire a few into – 1) Limited license x-ray tech/medical assistant; 2) Radiology tech/medical assistant. The few that are in this role perform both duties, but with most of their time spent performing x-rays. Question: Is the x-ray license acceptable for MU purposes of entering medications, lab (and xray) into the medical record, or must we have these few obtain their MA certification?

    • Thank you for your question. I am assuming that the radiography credentials are indeed licenses, as you have stated. The answer is that these licensed radiographers are permitted to enter orders for meaningful use calculation purposes under the CMS rules for the Medicare and Medicaid Incentive Programs as long as they have the knowledge to enter orders competently, including the knowledge to handle appropriately any clinical decision support alerts, which would include appropriate referrals to the overseeing provider.

      Of course they would have a good likelihood of having sufficient knowledge to appropriately enter radiography orders. They would have to have sufficient knowledge regarding entering of medication and laboratory orders in order to be able to enter these for MU calculation purposes. Don

      Sent from my iPhone

  6. Jacqueline Powers says:

    Donald, on the point above: Radiology was one of the courses I took during my CMA degree; however, to get a radiology certificate, you had to pass another exam, which I never took. I still have my CMA certification, but not a radiology certification. Therefore, is it not possible that you could take all the classes for both of these 2 certifications, never take the state examination and pass it, and still be working in Radiology as an “MA”? Would that not then nullify their MU contribution?

  7. Kelly Bradley says:

    I am a CMA working in an orthopedic clinic. I have nursing assistants working as medical assistants and were basically bumped up to that position. I was asked to go back to school and get my certification. I am the only certified medical assistant in clinic. Some of my duties will be entering medications, radiology orders, entering lab orders, calling in medications to pharmacy, and drawing up certain steroid injections. I feel i have worked hard for what i have and the other girls are getting away with it without having to go through school and everything else i went through. Am i looking at this wrong or is this not right? I wouldnt feel comfortable as a patient coming in if i knew they hadnt went to school for drawing up medications, knowing what my medications were for, and calling in the medication to the pharmacy. Our orthopedic clinic is a part of a hospital so is this why they are getting away with it at this time or is their time coming? I would appreciate a response via email if possible.

    • Thank you for your question. Could you please tell me in what state you are located? The laws vary somewhat from state to state. I will answer your question after you respond.

      Donald A. Balasa, JD, MBA
      Chief Executive Officer, Legal Counsel
      American Association of Medical Assistants
      Ph: 800/228-2262 | Fax: 312/899-1259 | http://www.aama-ntl.org
      The CMA (AAMA): Health Care’s Most Versatile Professional®

  8. Cindy Meierhofer, CMA says:

    In our facility the policy is that only an RN or licensed provider can enter VORB’s. The policy is being revised, and I am looking for a list of the scope of practice for CMA’s/MA’s, as this is documentation that is being asked for. Can you provide me with a site or the “Scope of Practice Guidelines” that can be printed. Thank you

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