This column addresses a specific meaningful use requirement each month, looking at how it connects to health care quality priorities and previewing possible updates to the measure in future stages of meaningful use.

 e-Prescribing (eRx)

Health Outcomes Policy Priority:	Improving quality, safety, efficiency, and reducing health disparities.
Objective:	Generate and transmit permissible prescriptions electronically (eRx).
Measure:	More than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.
Exclusion:	Any EP who writes fewer than 100 prescriptions during the EHR reporting period.

Background:
It is important to make the distinction: e-prescribing is not the same objective as the computerized provider order entry (CPOE) of medications that was discussed in last month’s article. Where CPOE of medication orders is the entry of those orders into an EMR system in a discrete data format, e-prescribing is the electronic transmission of that order to a pharmacy. Even though e-prescribing is not yet widely considered a standard of practice (perhaps surprisingly to some), it is the most widely adopted form of electronic exchange occurring and has been proven to reduce medication errors. Given its proven benefits, e-prescribing is specifically mentioned in the HITECH Act as an example (the only one, in fact) of the meaningful use of certified EHR technology; and as such it is included in the core set of objectives for Stage 1.

As one of the motivating interests in establishing meaningful use, the writers at CMS initially suggested a rather high threshold of 75% for compliance, but commenters quickly countered with two chief concerns. The first is that providers are dependent upon an external receiver of electronic health data for the success of this function. Unfortunately, the capability of pharmacies around the country to receive such exchanges varies significantly, and the writers do not have the ability to impose requirements on pharmacies through the HITECH legislation.

Secondly, patients often request a printed prescription to take in hand after a visit. The reasons for this vary too—wanting to shop for the best price, for example—and providers understandably do not want to limit this preference. With regard to this second barrier, the writers initially considered removing instances of requested paper prescriptions from the measure denominator, but the burden of tracking this was quickly seen as too cumbersome. Thus, the denominator includes all prescriptions written by the provider during the reporting period.

Finally, although the Department of Justice has recently drafted a rule that allows the e-prescribing of controlled substances, at the writing of the Stage 1 meaningful use rule this was not the case. Thus, the determination of “permissible prescription” must be based on the guidelines for prescribing Schedule II-V controlled substances in effect on or before January 13, 2010.

Stage 2 Proposals:
Largely, Stage 2 for the e-prescribing objective is a continuation of the work begun in Stage 1 but with a higher threshold. Building on Stage 1, EPs should continue to use eRx, but with the threshold moving up to 50% of all medication orders.

Notably, as hospitals were exempt from this objective in Stage 1, they should start out at a 10% threshold for the measurement.