Certification and the CMA (AAMA) Credential, CMS Rule, Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Meaningful Use, On the Job, Scope of Practice

AAMA Submits Comments on Stage 3 Final Rule

In its efforts to stay abreast of state and federal laws pertaining to the medical assisting profession, the AAMA recently submitted comments to the Centers for Medicare and Medicaid Services regarding some specific language from the October 16, 2015 Federal Register. What follows are those comments.

The following comments are being submitted on behalf of the American Association of Medical Assistants (AAMA), the national organization representing the medical assisting profession at the federal and state levels.

There appears to be an accidental inconsistency between the following language on page 62944 of the final rule, and the following language on pages 62949 and 62950 of the final rule:

Page 62944, third column:

(3) Computerized provider order entry. (i) Objective. Use computerized provider order entry for medication, laboratory, and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines.

Page 62949, third column, and page 62950, first column:

(4) Computerized provider order entry (CPOE).—(i) EP CPOE—(A) Objective. Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant, who can enter orders into the medical record per state, local, and professional guidelines. …

(ii) Eligible hospital and CAH CPOE—(A) Objective. Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines.

The American Association of Medical Assistants believes that there is an inconsistency between the above excerpts because of the following language in the analysis of, and responses to, public comments:

Page 62798, second column:

Response: In the Stage 2 final rule (77 FR 53986) and in subsequent guidance in FAQ 9058,6 we explained for Stage 2 that a licensed health care provider or a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant may enter orders. We maintain our position that medical staff must have at least a certain level of medical training in order to execute the related CDS for a CPOE order entry. We defer to the provider to determine the proper credentialing, training, and duties of the medical staff entering the orders as long as they fit within the guidelines we have proscribed. We believe that interns who have completed their medical training and are working toward appropriate licensure would fit within this definition. We maintain our position that, in general, scribes are not included as medical staff that may enter orders for purposes of the CPOE objective.

However, we note that this policy is not specific to a job title but to the appropriate medical training, knowledge, and experience.

Page 62839, first column:

Response: As noted in the Stage 3 proposed rule (80 FR 16751), we require that the person entering the orders be a licensed health care professional or credentialed medical assistant (or staff member credentialed to the equivalency and performing the duties equivalent to a medical assistant). We defer to the provider’s discretion to determine the appropriateness of the credentialing of staff to ensure that any staff entering orders have the clinical training and knowledge required to enter orders for CPOE.

The American Association of Medical Assistants therefore recommends that the above language on page 62944, third column, be expanded to include “credentialed medical assistants,” as do the above excerpts from page 62949, third column, and page 62950, first column.

Certification and the CMA (AAMA) Credential, Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Meaningful Use, Medicaid, Medicare, On the Job, Scope of Practice

CMS Final Rule Reaffirms Credentialing Requirement for Medical Assistants

On October 6, 2015, the Centers for Medicare and Medicaid Services (CMS) issued its final rule for the Electronic Health Record (EHR) Incentive Programs. In responding to comments urging that the “credentialed medical assistant” requirement be made less stringent, CMS reaffirmed that medical assistants must have a third-party credential (such as the CMA (AAMA)), and must have sufficient knowledge to handle properly clinical decision support (CDS) alerts.

One party commenting on the CMS notice of proposed rulemaking for the EHR Incentive Programs made the suggestion “that if a standard for medical assistant CPOE [computerized provider order entry] is required, then the standard should be that the medical assistant must be appropriately trained for CEHRT [certified electronic health record technology] use (including CPOE) by the employer or CEHRT vendor in order to be counted [toward meeting the meaningful use requirements of the Incentive Programs].” (page 322 of the attached document)

CMS responded as follows:

We [CMS] disagree that the training on the use of CEHRT is adequate for the purposes of entering an order under CPOE and executing any relevant action related to a CDS. We believe CPOE and CDS duties should be considered clinical in nature, not clerical.  Therefore, CPOE and CDS duties, as noted, should be viewed in the same category as any other clinical task, which may only be performed by a qualified medical or clinical staff. (page 323 of the attached document)

This position of CMS is a resounding affirmation of the fact that only professionally-credentialed medical assistants (such as CMAs (AAMA)) are qualified to enter orders safely into the CPOE system.

More information about the CMS final rule will be forthcoming in Legal Eye: On Medical Assisting and CMA Today.

CMS Final Rule (10/6/15), pages 322-323

CMS Stage 2 Rule, Computerized Provider Order Entry (CPOE), EHR Incentive Programs

CMS NPRM Expands Category of Radiology Orders, Thresholds

As a follow-up to my post yesterday, the March 20, 2015, Centers for Medicare and Medicaid (CMS) notice of proposed rulemaking (NPRM) for Stage 3 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs has expanded the category of radiology orders to include diagnostic imaging other than radiology.  Also, the thresholds for medication, laboratory, and diagnostic imaging orders have been increased for Stage 3.  Note the following excerpts from the CMS NPRM:

We propose to continue our policy from the Stage 2 final rule that the orders to be included in this objective are medication, laboratory, and radiology orders, as such orders are commonly included in CPOE implementation and offer opportunity to maximize efficiencies for providers. However, for Stage 3, we are proposing to expand the objective to include diagnostic imaging, which is a broader category including other imaging tests such as ultrasound, magnetic resonance, and computed tomography in addition to traditional radiology. This change addresses the needs of specialists and allows for a wider variety of clinical orders relevant to particular specialists to be included for purposes of measurement.

Based on our review of attestation data from Stages 1 and 2 demonstrating provider performance on the CPOE measures, we propose to increase the threshold for medication orders to 80 percent and to increase the threshold for diagnostic imaging orders and laboratory orders to 60 percent.

Certification and the CMA (AAMA) Credential, Computerized Provider Order Entry (CPOE), EHR Incentive Programs, On the Job, Scope of Practice

Breaking News: Proposed CMS Rule is Favorable for CMAs (AAMA)

On March 20, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a notice of proposed rulemaking (NPRM) for Stage 3 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.  I am pleased to report that the Proposed Objective for computerized provider order entry (CPOE) in the NPRM is very favorable for credentialed medical assistants such as CMAs (AAMA).  Note the following excerpts from the Notice of Proposed Rulemaking:

Proposed Objective: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines.…

In Stage 3, we propose to continue the policy from the Stage 2 final rule at

77 FR 53986 that orders entered by any licensed healthcare professional or credentialed medical assistant would count toward this objective. A credentialed medical assistant may enter orders if they are credentialed to perform the duties of a medical assistant by a credentialing body other than the employer. If a staff member of the eligible provider is appropriately credentialed and performs assistive services similar to 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, orders entered by that staff member would be included in this objective. We further note that medical staff whose organizational or job title, or the title of their credential, is other than medical assistant may enter orders if these staff are credentialed to perform the equivalent duties of a credentialed medical assistant by a credentialing body other than their employer and perform such duties as part of their organizational or job title. We defer to the provider’s discretion to determine the appropriateness of the credentialing of staff to ensure that any staff entering orders have the clinical training and knowledge required to enter orders for CPOE.…

However, as stated in the Stage 2 final rule at 77 FR 53986, it is apparent that the prevalent time when CDS [Clinical Decision Support] interventions are presented is when the order is entered into CEHRT [Certified Electronic Health Record Technology], and that not all EHRs also present CDS when the order is authorized (assuming such a multiple step ordering process is in place). This means that the person entering the order would be required to enter the order correctly, evaluate a CDS intervention 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 information provided by the CDS intervention or bypass the intervention. The execution of this role represents a significant impact on patient safety; therefore, we continue to maintain for Stage 3 that a layperson is not qualified to perform these tasks. [Emphasis added]

The full document can be found here. I will provide further excerpts and summaries later this week and next week.

Certification and the CMA (AAMA) Credential, Computerized Provider Order Entry (CPOE), On the Job

Scribes Not Permitted to Enter Orders for Meaningful Use

The Centers for Medicare and Medicaid Services (CMS) recently issued an important clarification regarding meaningful use order entry. See the following quote from a report by the American Academy of Ophthalmologists:

EHR Meaningful Use Update: CMS Comes Out Against Scribes
Despite Academy efforts, the Centers for Medicare & Medicaid Services clarified this week that medical scribes − even those who are certified − are not permitted to enter electronic medication, laboratory, or radiology orders into electronic health record systems. The Academy believes that changes to the criteria for satisfying the EHR Meaningful Use Program’s Computerized Provider Order Entry measure lacked clarity regarding appropriate personnel who may perform this task.

In communication to the Academy, CMS explained that it is not permitting scribes to enter medical data under the CPOE measure. Medical staff entering orders into EHRs for purposes of satisfying the CPOE measure must be, at minimum, a certified medical assistant or equivalent, which includes certified ophthalmic technicians, certified ophthalmic technologists, and certified ophthalmic assistants.