Meaningful Use and Data Entry Into a Certified EHR

Does Meaningful Use require physicians do the data entry?

One intriguing Meaningful Use question arrived by email last week. The question boiled down to this: “Does the Eligible Professional have to actually be the one that enters data into their Certified EHR to receive the CMS incentives? Can a designated staff member actually input all the data for the provider?” Well, the answer is that with minor exceptions the provider does not even have to directly interact with the EHR. It is perfectly acceptable for providers to have a staff member function as what has become known as a “scribe” to enter all documentation into a patient’s electronic record. Under the CMS Stage 1 EHR Incentive Programs there is no requirement that the EP who receives the incentives must input the data.

The meaningful use requirements are focused on having a patient’s electronic records used in certified EHR technology, not on who might have entered the data. For Stage 1 there is no requirement for a provider to be the one that enters or signs off on orders, adds problems to the problem list, or updates the med list. All this can be done by what CMS call a “licensed healthcare professional”. From my research it appears that the only action that must absolutely be performed by the provider is e-prescribing which requires them to be the individual actually logged into the system to legally issue the prescription.

CMS has provided clarifying guidance on this issue in their FAQs. Question: “Is the physician the only person who can enter information in the electronic health record (EHR) in order to qualify for the Medicare and Medicaid EHR Incentive Programs? Answer: “No. The Final Rule for the Medicare and Medicaid EHR incentive programs, specifies that in order to meet the meaningful use objective for computerized provider order entry (CPOE) for medication orders, any licensed healthcare professional can enter orders into the medical record per state, local, and professional guidelines. The remaining meaningful use objectives do not specify any requirement for who must enter information.”

Jim Tate is a nationally recognized expert on the CMS EHR Incentive Program, certified technology and meaningful use and author of The Incentive Roadmap® The Meaningful Use of Certified Technology: Stage 1.