On September 29, 2013, I gave a joint presentation with Robert Anthony, deputy director of the Health Information Technology Initiatives Group of the Centers for Medicare and Medicaid Services (CMS), to the House of Delegates at the 57th Annual Conference of the American Association of Medical Assistants (AAMA) in Atlanta. The presentation dealt with the CMS rule for meaningful use order entry. In addition to providing an overview of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs, Deputy Director Anthony affirmed the key points that I had presented in previous articles and speeches. What follows is a brief summary of that presentation.

Key points of EHR Incentive Programs

Anthony pointed out that the Medicare and Medicaid EHR Incentive Programs are actually two different programs, although they have many common elements. Doctors of optometry, podiatric medicine, and chiropractic are eligible only for the Medicare program. Nurse practitioners, certified nurse midwives, and physician assistants working at federally qualified health centers or rural health clinics led by a physician assistant are Medicaid-only eligible professionals. Doctors of medicine, osteopathy, and dental medicine or surgery could be eligible both for the Medicare and Medicaid Incentive Programs.

All of these health care providers are defined as “eligible professionals” (EPs) in the statute creating the EHR Incentive Programs. Anthony remarked that incentive payments are based on each individual EP—not a practice or group of EPs—meeting the requirements. Hospital-based EPs (defined as providers who perform at least 90 percent of their covered professional services in an inpatient or emergency room of a hospital) are not eligible for incentive payments.

The requirements for EPs under the Stage 1 Incentive Programs include meeting 15 core objectives, and five of 10 menu objectives, for a total of 20 objectives. One of the 15 core objectives is “computerized physician/provider order entry (CPOE).” In Stage 2, EPs must meet 17 core objectives, three of six menu objectives, and 20 total objectives.

Anthony emphasized that patient engagement is a key focus of Stage 2. For example, under Stage 2, more than 5 percent of patients must send secure messages to their eligible professional, and more than 5 percent of patients must access their health information online. Anthony further explained that CMS is introducing exclusions based on broadband availability in the EP’s county.

Another hallmark of Stage 2 is actual use of electronic information exchange. Anthony recounted that Stage 2 requires providers to send a summary of care record according to the following parameters:

  1. Send a summary for more than 50 percent of transitions of care and referrals.
  2. Electronically send a summary for more than 10 percent of transitions of care and referrals.
  3. Electronically send at least one summary to a recipient with a different EHR vendor, or to a CMS test EHR.

The U.S. Department of Health and Human Services (HHS) has established the following six National Quality Strategy domains:

  1. Patient and Family Engagement
  2. Patient Safety
  3. Care Coordination
  4. Population and Public Health
  5. Efficient Use of Healthcare Resources
  6. Clinical Processes/Effectiveness

Stage 2 also requires that eligible professionals select “clinical quality measures” from at least three of these six National Quality Strategy domains.

Anthony encouraged the attendees to visit the website of the Electronic Health Records Incentive Programs for more detailed information at http://www.cms.gov/EHRIncentivePrograms/. Questions can be directed to him at robert.anthony@cms.hhs.gov.

AAMA impact and points of interpretation

The CMS Stage 1 rule stipulated that only “licensed health care professionals” would be allowed to enter orders into the CPOE system for purposes of having such entry count toward meaningful use under the Medicare and Medicaid EHR Incentive Programs. Partly in response to testimony submitted by the AAMA, the August 23, 2012, CMS final rule for Stage 2 of the EHR Incentive Programs indicated that “credentialed medical assistants”—including CMAs (AAMA)—as well as “licensed health care professionals” would be permitted to enter medication, laboratory, and radiology orders into the CPOE system in order to have such entry count toward meeting the meaningful use requirement. Specific points I have made about the Stage 2 rule, as well as objections about those interpretations, were then addressed.

How does CMS define “credentialed medical assistants”?

The CMS rule specifies that the “credential” carried by the medical assistant must be awarded by a third-party credentialing body, not by the entity that employs the medical assistant. Medical assisting credentials given by health systems, clinics, and other employers, therefore, would not meet the CMS definition, and medication, laboratory, and radiology orders entered into the CPOE system by medical assistants with these “in-house” credentials could not be counted toward meeting the meaningful use thresholds of the EHR Incentive Programs.

Anthony agreed, and emphasized the fact that CMS places emphasis on the “third-party” aspect of medical assisting credentials.

When did this “credentialed medical assistants” requirement go into effect?

There has been a great deal of confusion about when the August 23, 2012, CMS Stage 2 rule went into effect. I have maintained that the rule about “credentialed medical assistants” went into effect January 1, 2013. However, there have been many challenges to this opinion, the most common one being that the Stage 2 rule would not go into effect until January 1, 2014.

 Anthony affirmed that the rule requiring CPOE to be done by “credentialed medical assistants,” and not by “any” medical assistant, or by another employee, such as a “scribe,” did indeed go into effect January 1, 2013. Since 2014 is not far off, the point becomes largely moot, in my opinion.

Does the CMS rule only apply to entry of orders under Stage 2?

Another common misconception is that the “credentialed medical assistant” requirement only applies to entry of orders under Stage 2 of the EHR Incentive Programs, and not Stage 1. The CMS Frequently Asked Question (FAQ) 7693, which is posted on the EHR Incentive Programs website, clearly states that the “credentialed medical assistant” requirement of the CMS rule applies to entry of orders under Stage 1 and Stage 2 of the EHR Incentive Programs, and will apply to Stage 3 when it goes into effect. Anthony agreed with this interpretation.

Will CMS enforce the “credentialed medical assistant” requirement?

There is some thinking that CMS EHR Incentive Programs audits of EPs will not inquire about whether the medical assistants who have entered orders into the CPOE system have met the requirement of being “credentialed.” Anthony opined that there is no basis in fact for this thinking. He indicated that there are some electronic health records that keep track of who makes each entry, and that auditors could ask for this entry log, and could determine whether medication, laboratory, and radiology orders were indeed entered by either licensed health care professionals or credentialed medical assistants. If some entries of orders into the CPOE do not meet this requirement, the EP may not meet the core objective, and may thus be ineligible to receive the incentive payment under the EHR Incentive Programs.

Call to EPs and CMAs (AAMA)

Eligible professionals participating in one or both of the Medicare or Medicaid EHR Incentive Programs are urged to make sure their medical assistants entering orders into the CPOE system are credentialed. They also should keep in mind that the CMA (AAMA) credential is the only medical assisting credential that requires successful completion of an accredited postsecondary medical assisting program and uses the National Board of Medical Examiners (NBME) as test consultant. These high standards enable CMAs (AAMA) to work to the full extent of their practice scope with far better patient care outcomes.

In addition, CMAs (AAMA) should keep their credential current, because a medical assistant with a noncurrent CMA (AAMA) is not permitted to use the credential, and therefore would not meet the “credentialed medical assistant” requirement of the EHR Incentive Programs.

Questions? Contact Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or 800/228-2262.