Computerized provider order entry (CPOE) involves electronically inputting instructions for patient care into the EHR and is used to boost efficiency while reducing errors during the submission of orders into the electronic record.
This perceived efficiency, however, can be lost by the belief that regulations mandate that only physicians can enter orders into the EHR and that this task cannot be delegated to nurses, medical assistants or other noncredentialled staff.
The reality is that all members of the care team, including nurses, credentialed medical assistants or non-credentialed staff can enter orders in the EHR, as requested by the physician.
Clinical and clerical staff can enter or send orders per the physician’s instruction, which can be conveyed verbally or through a written checklist, as long as this is consistent with state and institutional policies.
The AMA is spreading that message as part of the “Debunking Regulatory Myths” series, which provides clarification to physicians and their care teams in an effort to reduce the administrative burdens that divert doctors’ attention from the delivery of patient care.
For more clarity on verbal orders, see the “Debunking Regulatory Myths” article “Are verbal orders prohibited?”
The series is part of the AMA’s practice-transformation efforts and gives physicians and their care teams resources to reduce guesswork and administrative burdens so their focus can be on streamlining clinical workflow processes, improving patient outcomes and increasing satisfaction.
The AMA STEPS Forward® “Reducing Regulatory Burden Playbook” goes a step further, giving physicians specific strategies to avoid overinterpreting the rules and help advocate for changes in their health systems.
As the leader in physician well-being, the AMA is reducing physician burnout by removing administrative burdens and providing real-world solutions to help doctors rediscover the Joy in Medicine™.
Other CPOE myths debunked
Another myth is that Medicare’s EHR incentive programs require CPOE. Not true.
The Centers for Medicare & Medicaid Services removed previously required CPOE and clinical decision support objectives and related measures. The Joint Commission also has weighed in on using scribes for documentation and order entry.
“All types of personnel performing documentation assistance may, at the direction of a physician or another LP [licensed professional], enter orders into an EMR,” The Joint Commission says. “The use of repeat-back of the order by the documentation assistant is encouraged, especially for new medication orders.”
Earn CME credit
Learn more with the “AMA Debunking Medical Practice Regulatory Myths Learning Series,” which is available on AMA Ed Hub™. For each topic completed, a physician can receive CME for a maximum of 0.25 AMA PRA Category 1 Credit™.
Physicians are encouraged to submit questions or ideas they have about potential regulatory myths. The AMA’s experts will research the matter. If the concern turns out to be a bona fide regulation that unnecessarily burdens physicians and their teams, the AMA can advocate for regulatory change.
Get the latest news on physician well-being
Subscribe for insights and real-world solutions delivered straight to your inbox.
