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