Contents
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.
Computerized provider order entry (CPOE) is a process of electronic entry of medical practitioner instructions for the treatment of patients under the physician’s care. Physicians use CPOE to increase efficiency and reduce errors by submitting orders in the EHR.
The myth
Only physicians can pend, or enter, orders into the EHR—and a nurse, certified medical assistant (MA) or other non-credentialed staff can't pend or send orders in the EHR as requested by the physician.
Debunking the myth
All members of the care team (PDF), including nurses, credentialed medical assistants (MAs), or non-credentialed staff members can enter orders in the EHR, as requested by the physician.1 Additionally, there is no Medicare EHR incentive program that requires CPOE. Clinical and clerical staff can pend orders or send orders per the physician’s instruction (i.e. as conveyed verbally or through written checklist), as long as this is consistent with state and institutional policies.
Regulatory clarification
New guidance was issued from the Centers for Medicare & Medicaid Services in 2017.
“In the 2017 OPPS rule, we finalized the elimination of the CPOE and CDS objectives and associated measures for eligible hospitals and Critical Access Hospitals (CAHs). The elimination of the CPOE and CDS objectives and associated measures also applies to dual-eligible hospitals that are attesting to CMS for both the Medicare and Medicaid EHR Incentive Programs.
However, the CPOE and CDS objectives and measures are still required for the Medicaid EHR Incentive Program to successfully attest to meaningful use.
Please also note we did not include CPOE and CDS objectives and associated measures as part of the advancing care information performance category, thus, they are not required for reporting by MIPS eligible clinicians.”2
CPOE objectives remain in the Medicaid EHR Incentive program (PDF). Within this program, “any 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 (PDF) can enter orders in the medical record, per state, local and professional guidelines.”3
Medicare Quality Payment Program Overview (PDF)
Resources
Download this myth: Is order entry a physician-only EHR task? (PDF)
References
- Medicaid Eligible Professionals Promoting Interoperability Program Stage 3. Objectives and Measures for 2018. The Center for Medicare & Medicaid Services, June 2018
- FAQ #22349. Objectives & Measures FAQ. The Center for Medicare & Medicaid Services
- Documentation Assistance Provided by Scribes. Perspectives Newsletter – The Official Newsletter of The Joint Commission, 38 (8). The Joint Commission, August 2018
Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
Contact us
AMA seeks to aid physicians and care teams by helping them understand medical regulatory requirements. Help us help you—submit a myth you'd like clarification on.
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.
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