Is order entry a physician-only EHR task?

This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.

Debunking the myth

Members of the care team assisting with documentation, including nurses, credentialed medical assistants (MAs), or non-credentialed staff members may enter orders that are guided and overseen by physicians, in a manner consistent with state regulations.  Additionally, there is no current Medicare EHR incentive program that requires computerized provider order entry (CPOE).¹ 

Background

CPOE is the process of electronic entry of physician and APP orders for diagnosis and treatment of patients (e.g., prescription medications, lab and imaging tests, referrals, etc.). 

The Centers for Medicare & Medicaid Services (CMS) eliminated the previously required CPOE and clinical decision support (CDS) objectives and associated measures.¹ Similarly, The Joint Commission has eliminated previous prohibitions on documentation assistants entering orders on behalf of physicians.²

Physicians must take care that the staff-entered orders do not involve medical decision making. Medical decision making not only includes order selection, but the diagnosis linked to the order and the rationale for the order. Approaches to order entry may vary depending on practice type and organizational policies. For example:

1. Trained scribes who work at the physician’s side may enter all types of orders as directed by the physician. The physician is responsible for the accuracy of the order details (test name and code, diagnosis code, etc.) Scribes pend all orders for physicians to review and sign.
2. Allow staff to independently place only those orders that lend themselves to the use of standing orders or an algorithmic approach. This excludes prescription medications, high-dollar advanced imaging, referrals, and procedures. The use of policies and standing orders signed by the CMO or medical director allows for three options for finalizing orders—staff sign with no cosign, staff sign with cosign, staff pend. Included are:
   1. Type of order: POC tests
      Basis for order: Signed standing order
      Test selection: Specific test name and order number in SO
      Dx code: Specific ICD10 code in SO
      Indication for order: Chief complaint or symptom leading to POCT
   2. Type of order: Vaccines
      Basis for order: Formal policy and vaccine schedule in chart
      Test selection: Vaccine name and order number in policy
      Dx code: Specific ICD10 code in policy
      Indication for order: n/a
   3. Type of order: Health care maintenance-screening
      Basis for order: Formal policy and HM section in chart
      Test selection: Specific test name and order number in policy
      Dx code: Screening ICD10 codes in policy
      Indication for order: n/a
   4. Type of order: Health care maintenance-disease specific
      Basis for order: Formal policy and HM section in chart
      Test selection: Specific test name and order number in policy
      Dx code: ICD10 on problem list
      Indication for order: n/a

Key takeaway

Delegating order entry to non-physician care team members can increase practice efficiency (especially with closing care gaps and meeting quality benchmarks), reduce physicians’ administrative burden, and encourage non-physician health care professionals to take on new responsibilities and operate at the top of their license. 

It is imperative that organizations develop policies and processes that ensure staff conduct tasks within their scope of practice, are supervised appropriately by physicians, and that the right order is placed for the right patient at the right time.

Resources

• STEPS Forward® Toolkit: Team Documentation
• STEPS Forward Playbook: Taming the EHR
• Download this myth: Is order entry a physician-only EHR task? (PDF)

References

1. Centers for Medicare & Medicaid Services (CMS). CMS Finalizes Hospital Outpatient Prospective Payment Changes for 2017. CMS. November 1, 2016. Accessed December 6, 2024. https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-hospital-outpatient-prospective-payment-changes-2017
2. The Joint Commission. Documentation Assistance Provided By Scribes: What Guidelines Should be Followed When Physicians or Other Licensed Practitioners (LP) Use Scribes to Assist with Documentation? The Joint Commission. July 26, 2018. Accessed December 6, 2024. https://www.jointcommission.org/standards/standard-faqs/ambulatory/record-of-care-treatment-and-services-rc/000002210/

Debunking Regulatory Myths overview

Visit the overview page for information on additional myths.

Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.