Stage 2 “Meaningful Use” Rule a Major Victory for
Registered Medical Assistants

                On August 23, the Centers for Medicare and Medicaid Services (CMS) issued a final rule establishing “meaningful use” requirements that providers must meet to receive funding under the second phase of the federal electronic health record (EHR) incentive program. 

                The final Stage 2 rule includes a significant victory for Registered Medical Assistants by allowing “credentialed medical assistants” to enter orders into the Computerized Physician Order Entry (CPOE) system for medication and for laboratory and radiology services.  The Stage 1 rule, which included only medication orders, had limited those who could use the CPOE system to licensed providers. 

                When it published a proposed Stage 2 rule in March, CMS proposed to expand the CPOE system to include orders for lab and imaging services.  The agency also invited public comment on whether it should continue to restrict those who can use the CPOE function to only licensed healthcare professionals, or if the computerized order entry should be expanded to include nonlicensed healthcare professionals. 

                In commenting on the proposed rule, AMT supported CMS’s proposal to expand CPOE to encompass lab and radiology orders as well as medication orders.  AMT also strongly urged the agency to allow properly credentialed medical assistants to make entries into the CPOE system.  AMT noted that RMAs are trained to perform a wide variety of both front-office (administrative) and back-office (clinical) tasks in a medical practice setting. These duties typically include the completion of requisitions for laboratory and radiology services, as well as the transcription of prescription orders for patients of the medical practice or clinic, pursuant to an order by the attending physician.

                In issuing the final rule, CMS mentioned that it had received support from various commenters for four different scenarios as to who can enter the order into certified electronic health records technology (CEHRT) for it to count as CPOE: 

(1) only the ordering provider be able to enter the order into CEHRT;
(2) any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines can enter the order into CEHRT (current policy);

(3) an expansion to any licensed, certified or appropriately credentialed healthcare professional (some commenters replaced medical assistant with healthcare professional) who can enter orders into the medical record per state, local and professional guidelines; or
(4) an expansion to allow anyone, including those commonly referred to as scribes, to enter the orders into the medical record per state, local and professional guidelines.

                To the gratification of the medical assisting community, CMS chose a variation of the third option – i.e., an expansion to allow appropriately credentialed, nonlicensed professionals to enter the orders – but limited it to medical assistants.  CMS explained its decision:

Many EPs [eligible practitioners] practice without the assistance of other licensed healthcare professionals. These EPs in their comments urged the expansion indicated in the third possibility of credentialed healthcare professionals/medical assistants. We believe that this expansion is warranted and protects the concept that the CDS [clinical decision support] interventions will be presented to someone with medical knowledge as opposed to a layperson. The concept of credentialed healthcare professionals is over broad and could include an untold number of people with varying qualifications. Therefore, we finalize the more limited description of including credentialed medical assistants. The credentialing would have to be obtained from an organization other than the employing organization. . . . We do not believe that a layperson is qualified to do this, and as there is no licensing or credentialing of scribes, there is no guarantee of their qualifications. [77 FR 53986 (emphasis added).]

                Although CMS did not specify what type of credential a medical assistant would be required to have, it imposed an important condition: the credential must be obtained from an organization other than the MA’s employer.  That insures that an employing organization cannot simply administer a quick-and-dirty in-service training program to unlicensed personnel to produce “appropriately credentialed” MAs.  The rule can most reasonably be interpreted to require a medical assistant certification by a national organization accredited by the National Commission for Certifying Agencies (NCCA) or the American National Standards Institute (ANSI).  AMT’s RMA certification program has been NCCA-accredited by since the inception of that accreditation.

                The final Stage 2 rule represents a significant achievement for RMAs and other reputably credentialed MAs.  CMS has recognized the unique and important role played by certified MAs in the healthcare delivery system, and the attributes that set them apart from other allied health personnel. 

                What is “Meaningful Use”? – The Stage 2 Meaningful Use rule was adopted as part of a series of regulations implementing the Health Information Technology for Economic and Clinical Health (HITECH) Act.  Under that law, doctors, healthcare professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt and meaningfully use certified electronic health record (EHR) technology.  The HITECH Act also imposes Medicare payment penalties on providers who don’t meet meaningful use standards by the year 2015.

                According to CMS, more than 120,000 eligible healthcare professionals and more than 3,300 hospitals have qualified to participate in the program and receive an incentive payment since it began in January 2011.  That includes more than half of all eligible hospitals and critical access hospitals and 1 out of every 5 eligible health care professionals.  The program is divided into three stages:

• Stage 1 sets the basic functionalities electronic health records must include such as capturing data electronically and providing patients with electronic copies of health information.
• Stage 2 (which will begin as early as 2014) increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information.
• Stage 3 will continue to expand meaningful use objectives to improve health care outcomes.

                In each stage CMS establishes a number of “core objectives” and measures to achieve those objectives.  Objectives established at one stage are carried over, often with modifications, into the subsequent stages. One of two new core objectives adopted in the Stage 2 final rule is for physicians to use secure electronic messaging to communicate relevant health information with patients.  The final rule also adds "outpatient lab reporting" to the program's menu objectives for hospitals and "recording clinical notes" as a menu objective for both physicians and hospitals.

                AMT will continue to monitor CMS’s implementation of the EHR meaningful use standards to insure that the role of appropriately credentialed medical assistants is properly acknowledged.