with the use of a correlation statistic without first considering the distribution of the data. The authors also fail to recognize the role of process measures in improving care. We know from well-vetted, peer-reviewed research that specific processes can improve overall care. Therefore, it only makes sense that such mea- sures should be set as a minimum standard to be expected by all patients, all the time. The Institute of Medicine has defined qual- ity using a broad, multifaceted framework, in- cluding measures of effective- ness, efficiency, patient safety, patient-centeredness, equity, and access. We must cease the practice of presenting practitioners and patients with what amounts to a false choice between measures of outcomes and measure of processes. Useful measures of quality must incorporate both. Richard Bankowitz Premier Inc. Philadelphia, Pennsylvania Report Card Measuring: The Authors Respond We thank Richard Bankowitz for his inter- est in our paper (Mar/Apr 09). We support process measurement and public reporting in hip and knee arthroplasty. It is an interim step on the road to higher quality. However, a level of scientific rigor is needed as quality pro- grams go from simple measurement and re- porting to financial incentives and penalties. Our data document that current systems for measuring quality are not ready to make that leap: the variation in process measurement is too low, and the outcome measures are too crude. Our paper indeed notes that there was some correlation between surgical volume and composite quality measures. But the system was best for discriminating low-quality/low- volume hospitals and could not truly differen- tiate average- from high-quality hospitals. Our patients and payers are seeking the ability to accurately identify hospitals and surgeons with outstanding outcomes. Timothy Bhattacharyya for the authors Suburban Hospital Bethesda, Maryland Computerized Order Entry The seven-country com- parison of computerized prescriber-order entry (CPOE) implementation in hospitals by Jos Aarts and Ross Koppel (Mar/Apr 09) of- fers a platform for discussing information technology (IT) applications in hospital medi- cation use. Data collected by the American Society of Health-System Pharmacists further elucidate the status of CPOE in the United States. 1 In 2007, 18 percent of hospitals had implemented CPOE, and two-thirds of them had clinical decision-support systems. In 16 percent of hospitals with CPOE, medication orders still needed to be manually reentered into pharmacy computer systems (thereby di- luting one benefit of CPOE). Slightly more than half of the hospitals without CPOE said that they planned to implement it within three years. Hospital IT priorities should exploit the opportunities to improve patient safety in each step of the medication-use process. The poten- tial for harm is nearly equal in the prescribing and drug-administration steps. 2 Thus, it is noteworthy that 24 percent of hospitals have invested in bar-code drug administration tech- nology, and 56 percent of the rest plan to do so within three years. 3 Computerized infusion pumps that check doses against preset limits are used by 44 percent of hospitals; 47 percent of the rest plan to acquire this technology within three years. Hospitals are investing significant human resources in the application of IT to the medi- Letters HEALTH AFFAIRS ~ Volume 28, Number 4 1231 “Our patients and payers are seeking the ability to accurately identify hospitals and surgeons with outstanding outcomes.”
cation-use process. For example, 36 percent of hospitals employ dedicated pharmacy person- nel to collaborate with physicians, nurses, and IT staff in this cause. Karl F. Gumpper and William A. Zellmer American Society of Health-System Pharmacists Bethesda, Maryland NOTES 1. C.A. Pedersen and K.F. Gumpper, “ASHP Na- tional Survey of Informatics: Assessment of the Adoption and Use of Pharmacy Informatics in U.S. Hospitals—2007,” American Journal of Health- System Pharmacy 65, no. 23 (2008): 2244–2264. 2. L.L. Leape et al., “Systems Analysis of Adverse Drug Events,” Journal of the American Medical Associ- ation 274, no. 1 (1995): 35–43. 3. Pedersen and Gumpper, “ASHP National Sur- vey.” Computerized Order Entry: The Authors Respond We welcome the additional information on computerized prescriber order entry (CPOE) adoption in the United States, in response to our paper (Mar/Apr 09). Although Craig Pedersen and Karl Gumpper’s study (Note 1 in Gumpper and William Zellmer’s letter) was not available when we submitted our paper, the figures concur with our findings and esti- mates. Their work also reflects how hard it is to obtain reliable data on CPOE market pene- tration, which we also pointed out. Gumpper and Zellmer, however, also ob- serve that about half of the hospitals currently without CPOE reported that they intend to implement it within the next three years. Here we differ with their views. We doubt the ve- racity of that prediction (but neither their re- porting nor the honest intentions of the re- spondents). A dramatic shift of that scale is unlikely both because of the recent economic crisis and, more important, because of the painstaking and difficult process of imple- menting CPOE in reality. We agree that bar- coded medication administration systems will reduce pharmacy dispensing errors. However, the evidence to date does not suggest that such systems are as effective in reducing adminis- tration errors because of design and imple- mentation faults and the resulting staff workarounds that mitigate the efficacy of bar- coding. 1 Jos Aarts Erasmus University Rotterdam (The Netherlands) Ross Koppel University of Pennsylvania Philadelphia, Pennsylvania NOTE 1. R. Koppel et al., “Workarounds to Barcode Medi- cation Administration Systems: Their Occur- rences, Causes, and Threats to Patient Safety,” Journal of the American Medical Informatics Association 15, no. 4 (2008): 408–423. Improved Models Of Health Care Delivery Janet Corrigan and Dwight McNeill (Mar/ Apr 09) conclude that new organizational models will be needed to improve the way health care is delivered in this country. What their paper fails to point out, and what has been left out of much of the debate on health reform, is that physicians have already created a new delivery model that works well, im- proves the quality of care, and reduces costs for both payers and consumers. Ambulatory surgery centers (ASCs) pro- vide exactly the focus and care environment outlined by Corrigan and McNeill. This comes from being owned by physicians who have risked their own capital to create a model that delivers outstanding care efficiently, and that is patient-focused and cost-effective. ASCs are the “focused factory” that health care expert Regina Herzlinger says are critical to fixing our health care system. For more than twenty years there has been a steady movement of surgical procedures from inpatient acute care hospitals to ASCs and other outpatient surgical facilities. More than 40 percent of the fifty million surgical 1232 July/August 2009 Letters
L e t t e r s
with the use of a correlation statistic without tiate average- from high-quality hospitals. Our
patients and payers are seeking the ability to
first considering the distribution of the data.
The authors also fail to recognize the role of accurately identify hospitals and surgeons
process measures in improving care. We know with outstanding outcomes.
from well-vetted, peer-reviewed research that
Timothy Bhattacharyya for the
specific processes can improve overall care.
authors
Therefore, it only makes sense that such meaSuburban Hospital
sures should be set as a minimum standard to
Bethesda, Maryland
be expected by all patients, all the time.
The Institute of Medicine has defined quality using a broad, multifaceted framework, in- Computerized Order Entry
The seven-country comcluding measures of effectiveparison of computerized
ness, efficiency, patient safety,
“Our patients and
prescr iber- order entr y
patient-centeredness, equity,
payers are seeking
(CPOE) implementation in
and access. We must cease
the ability to
hospitals by Jos Aarts and
the practice of presenting
accurately identify
Ross Koppel (Mar/Apr 09) ofpractitioners and patients
fers a platform for discussing
with what amounts to a false
hospitals and
information technology (IT)
choice between measures of
surgeons with
applications in hospital medioutcomes and measure of
outstanding
cation use. Data collected by
processes. Useful measures of
outcomes.”
the American Society of
quality must incorporate
Health-System Pharmacists
both.
further elucidate the status of CPOE in the
Richard Bankowitz
United States.1 In 2007, 18 percent of hospitals
Premier Inc.
had implemented CPOE, and two-thirds of
Philadelphia, Pennsylvania
them had clinical decision-support systems. In
16 percent of hospitals with CPOE, medication
Report Card Measuring: The
orders still needed to be manually reentered
into pharmacy computer systems (thereby diAuthors Respond
We thank Richard Bankowitz for his inter- luting one benefit of CPOE). Slightly more
est in our paper (Mar/Apr 09). We support than half of the hospitals without CPOE said
process measurement and public reporting in that they planned to implement it within three
hip and knee arthroplasty. It is an interim step years.
Hospital IT priorities should exploit the
on the road to higher quality. However, a level
of scientific rigor is needed as quality pro- opportunities to improve patient safety in each
grams go from simple measurement and re- step of the medication-use process. The potenporting to financial incentives and penalties. tial for harm is nearly equal in the prescribing
Our data document that current systems for and drug-administration steps.2 Thus, it is
measuring quality are not ready to make that noteworthy that 24 percent of hospitals have
leap: the variation in process measurement is invested in bar-code drug administration techtoo low, and the outcome measures are too nology, and 56 percent of the rest plan to do so
within three years.3 Computerized infusion
crude.
Our paper indeed notes that there was pumps that check doses against preset limits
some correlation between surgical volume and are used by 44 percent of hospitals; 47 percent
composite quality measures. But the system of the rest plan to acquire this technology
was best for discriminating low-quality/low- within three years.
Hospitals are investing significant human
volume hospitals and could not truly differenresources in the application of IT to the medi-
H E A L T H A F F A I R S ~ Vo l u m e 2 8 , N u m b e r 4
1231
L e t t e r s
cation-use process. For example, 36 percent of
hospitals employ dedicated pharmacy personnel to collaborate with physicians, nurses, and
IT staff in this cause.
Karl F. Gumpper and William A.
Zellmer
American Society of Health-System
Pharmacists
Bethesda, Maryland
NOTES
1.
C.A. Pedersen and K.F. Gumpper, “ASHP National Survey of Informatics: Assessment of the
Adoption and Use of Pharmacy Informatics in
U.S. Hospitals—2007,” American Journal of HealthSystem Pharmacy 65, no. 23 (2008): 2244–2264.
2. L.L. Leape et al., “Systems Analysis of Adverse
Drug Events,” Journal of the American Medical Association 274, no. 1 (1995): 35–43.
3. Pedersen and Gumpper, “ASHP National Survey.”
Computerized Order Entry: The
Authors Respond
We welcome the additional information on
computerized prescriber order entry (CPOE)
adoption in the United States, in response to
our paper (Mar/Apr 09). Although Craig
Pedersen and Karl Gumpper’s study (Note 1 in
Gumpper and William Zellmer’s letter) was
not available when we submitted our paper,
the figures concur with our findings and estimates. Their work also reflects how hard it is
to obtain reliable data on CPOE market penetration, which we also pointed out.
Gumpper and Zellmer, however, also observe that about half of the hospitals currently
without CPOE reported that they intend to
implement it within the next three years. Here
we differ with their views. We doubt the veracity of that prediction (but neither their reporting nor the honest intentions of the respondents). A dramatic shift of that scale is
unlikely both because of the recent economic
crisis and, more important, because of the
painstaking and difficult process of implementing CPOE in reality. We agree that barcoded medication administration systems will
reduce pharmacy dispensing errors. However,
1232
the evidence to date does not suggest that such
systems are as effective in reducing administration errors because of design and implementation faults and the resulting staff
workarounds that mitigate the efficacy of barcoding.1
Jos Aarts
Erasmus University Rotterdam
(The Netherlands)
Ross Koppel
University of Pennsylvania
Philadelphia, Pennsylvania
NOTE
1.
R. Koppel et al., “Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety,”
Journal of the American Medical Informatics Association
15, no. 4 (2008): 408–423.
Improved Models Of Health Care
Delivery
Janet Corrigan and Dwight McNeill (Mar/
Apr 09) conclude that new organizational
models will be needed to improve the way
health care is delivered in this country. What
their paper fails to point out, and what has
been left out of much of the debate on health
reform, is that physicians have already created
a new delivery model that works well, improves the quality of care, and reduces costs
for both payers and consumers.
Ambulatory surgery centers (ASCs) provide exactly the focus and care environment
outlined by Corrigan and McNeill. This comes
from being owned by physicians who have
risked their own capital to create a model that
delivers outstanding care efficiently, and that
is patient-focused and cost-effective. ASCs are
the “focused factory” that health care expert
Regina Herzlinger says are critical to fixing
our health care system.
For more than twenty years there has been
a steady movement of surgical procedures
from inpatient acute care hospitals to ASCs
and other outpatient surgical facilities. More
than 40 percent of the fifty million surgical
J u l y /A u g u s t 2 0 0 9
Eine der Folgen von Digitalisierung und Künstlicher Intelligenz in der Gesellschaft war die Entstehung von Big Data, dem Data Mining, das neue Grundlagen für die frühere statistische und soziologische Forschung legte. Große Sprachmodelle wie ChatGPT können in den neuesten Versionen eine so große Menge an angesammeltem Wissen in Sekundenschnelle zuverlässig darstellen, dass die bisherigen Vorstufen einer wirklich originellen Forschung – empirische Faktensammlung und relevante theoretische Aspekte – radikal verkürzt werden können. Das fast vollständige Wissen, dass sich die Version von ChatGPT4o bereits nähert, aber die 5. Version, die in naher Zukunft veröffentlicht werden soll, möglicherweise bereits realisiert wird, ermöglicht den Wechsel zu einer neuen Art des Wissenserwerbs, dem Knowledge Mining. Diese neue Art des Erkenntnisgewinns führt den Forscher an die Grenzen des Wissens, und neben und teilweise anstelle der grundlegenden Arbeiten des erforschten Themas verkürzt dieses blitzschnelle Knowledge Mining die Zeit, um wirklich originelle Entdeckungen zu machen. Obwohl wir von großen Sprachmodellen nicht erwarten können, dass ursprünglich neues Wissen entsteht, können wir erwarten, dass das angesammelte Wissen blitzschnell rezipiert wird. Und da eine sehr große Anzahl von Universitätsprofessorinnen und -professoren beim Verfassen von universitärer Lehre und Lehrmaterialien eigentlich nur an den Grenzen des Wissens arbeiten, aber originär nichts schaffen, können ihre Schreibtätigkeiten im Studium bereits weitgehend mit Hilfe von ChatGPT4o erfolgen. Aber nicht in Monaten und Jahren, sondern in Stunden, Tagen und Wochen.
Hier ist das bloße Stellen von Fragen ein menschlicher intellektueller Zusatz zu ChatGPT4o, aber natürlich ist eine Reihe aufeinanderfolgender Fragen zu einem bestimmten Thema von grundlegender Bedeutung für das Ergebnis des Knowledge Mining, das aus dem Gesamtwissen der künstlichen Intelligenz zu diesem Thema hervorgehen wird. Ich selbst habe in den letzten 45 Jahren Studien in breiter Rechtswissenschaft (Rechtstheorie, Rechtsdogmatik, Rechtsgeschichte), soziologischer Theorie, Rechtssoziologie, politischer Soziologie, Wissenschaftssoziologie und Politikwissenschaft verfasst und bereits Vorstudien zu einer Vielzahl von Fragestellungen des Knowledge Mining absolviert. Aber selbst auf einer allgemeinen intellektuellen Wissensbasis kann praktisch das gesamte Feld der Sozial- und Geschichtswissenschaften von jedem genutzt werden, um eine Reihe von vertiefenden, miteinander verbundenen Fragen zu einem bestimmten Thema zu stellen und so aus dem Gesamtwissen von ChatGPT4o Wissen auf Studienniveau zu gewinnen. Es sollte natürlich darauf hingewiesen werden, dass ich bereits Studien zu einigen der hier stattfindenden Geistesuntersuchungen gelesen habe, obwohl sie nur dazu gedacht waren, mir zu helfen, andere Zusammenhänge zu verstehen, aber ich hätte es nicht unternehmen können, eine eigenständige Studie auf diesem Gebiet durchzuführen, auch nicht auf der Ebene des zusammenfassenden Wissens. Aber jetzt für ChatGPT4o, um Fragen zu stellen, waren sie nützlich, also war ich ein wenig über dem Niveau des allgemeinen intellektuellen Wissens in diesem Bereich hinaus.
The ancient harbour of Amathus lies today underwater, at a maximum depth of 4 metres. It is situated at the west of Ayios Tychonas village, with the ancient city of Amathus being on the opposite hill. The underwater excavations conducted in the 1980s by a team led by Dr. Jean-Yves Empereur contributed to the better understanding of the Hellenistic period
in Cyprus. This article provides a short review of the underwater excavations, their findings, and the role of Amathus harbour in the overall harbour network during the Hellenistic period.