Editorial

As we approach the 6th year since the Institute of Medicine's Crossing the Quality Chasm offered a new vision for the American health care system, we still have a marked mismatch between the demand for health care quality and the supply of know‐how to deliver it. What the field of quality improvement (QI) still needs is merely this: QI practitioners in every care setting, a working vocabulary, a predictive framework for the mechanisms of reliable care, and rational therapies rigorously studied.13 Fortunately, the field of QI has attracted enough empiricistsworking in the lab of the hospital and other care settingsto lurch forward. But few would argue that we still have far less insight into the delivery of quality care than into the delivery of myocardial blood flow.

For ischemic heart disease we have classes of therapies, each of which is grounded in basic and clinical science: antiplatelets, beta‐blockers, vasodilators, lipid‐lowering agents. For care delivery we have the makings of analogous therapy classes, derived and introduced rather recently in a large review, Closing the Quality Gap: A Critical Analysis of the Quality Improvement Literature.4, 5 To facilitate their review of the evidence, the authors, including 2 prominent hospitalists, developed a new taxonomy of QI strategies (see Table 1). Though their effect size, relative efficacy, and interactions are not yet clear, many of these strategies can be applied to the inpatient setting, perhaps no less rationally than a well‐constructed antianginal regimen.

Where in the pathophysiology of a hospital do these QI therapies act? A plurality target the level of the provider: provider education, provider reminders, audit‐and‐feedback of provider performance, and facilitated relay of clinical data to providers. Remaining strategies target the patient (patient education, promotion of self‐management, and patient reminders), the immediate system within which care is delivered (organizational change), and the methodology of problem solving (continuous quality improvement). Only one strategy (financial incentives, regulation, and policy) fails to act directly at the level of the patient or provider, arguably the only level at which care actually can be improved.6

The value of the Quality Gap taxonomy is still largely untapped. If QI researchers and practitioners were to adopt its language as a standard, we could ramp up the power with which we communicate, interpret, and ultimately conduct improvement initiatives. In this issue of the Journal of Hospital Medicine, Cohn and colleagues profile a quality improvement initiative that achieved an impressive new level of performance. For an inpatient metric with a baseline institutional performance of 47%and an international benchmark of 39%the investigators executed a QI initiative that appears to have raised the rate of VTE prophylaxis to 85%.7 Despite a study design that weakens validity (beforeafter without controls) and a setting that diminishes applicability (medical patients in a single academic center), the authors have made a solid contribution to the QI literature simply by using the Quality Gap taxonomy. The authors specifically name and profile at least 3 distinct classes of QI strategies: provider education, a provider reminder element (ie, decision support), and an audit‐and‐feedback layer.

Even though provider education is unlikely to be sufficient as a lone QI strategya large review showed consistent but only modest benefitsit is often necessary.8 The provider education executed by Cohn and colleagues was frequent and regular. In the beginning of each month the chief resident oriented incoming house staff about venous thromboembolism (VTE) risk factors and the need for prophylaxis. They were given decision support pocket cards. Posters on display in nurse and physician work areas highlighted VTE risk factors. The provider education element also included discussions with the division chief about the topic. As robust as it was, however, the provider education was just a single component of the larger QI effort.

The second element, decision support, included VTE risk factor pocket cards with prophylaxis options listed. Introduced initially with the provider education, the pocket cards were handed out monthly by the chief resident. It is critical to recognize this decision support layer as a distinct core QI strategyand that it may even be fundamental to the success of the other strategies. Placed into the clinical workflow as a durable item, the decision support pocket card has the power to overcome provider uncertainty at moments of medical decision making. Generally speaking, a decision support layer, whether a pocket card, computer alert, or algorithm on a preprinted order form, can function as a shared baseline. Shared baselines or protocols reduce unnecessary variation in practice, a common source of poor quality care. Any mechanism that encourages groups of providers to deliver the same recommended care to groups of similarly at‐risk patients, while allowing customization of the protocol to meet the special needs of any individual patient, will have the net effect of raising overall quality of care.

This QI initiative may have achieved its greatest performance gainsas well as its greatest loss in terms of applicability to other settingsfrom its third facet, the audit‐and‐feedback layer. As a QI strategy audit‐and‐feedback has been defined as a summary of clinical performance for health care providers or institutions, performed for a specific period of time and reported either publicly or confidentially.1 It has demonstrated small to moderate benefits, with variations in effect most likely related to the format.9 As profiled in this study, it is hard to imagine a more powerful audit‐and‐feedback arrangement. The division chief of General Internal Medicine not only performed the audits, but also directly delivered the feedback to the house staff. In a deliberate, systematic, and successful way the investigators constructively used an existing authority gradient to leverage the Hawthorne effect, a change in worker behavior triggered by knowledge of being observed. Although it contributed to the impressive new VTE prophylaxis rates, this component did diminish generalizability and sustainability. Nonacademic centers may struggle to replicate these results, a point the authors dutifully point out. But even other academic centers might struggle in the absence of an authority figure with comparable influence and dedication to VTE prophylaxis. At the study hospital itself, similar rates of improvement would not be expected in patient populations outside the purview of the division chief.

Several alternatives to the before‐after study design could have produced richer information. Simultaneous data on VTE prophylaxis rates in a nonintervention population in the same or a similar hospital could have controlled for background or secular effects. An interrupted time series design may even have been feasible and could have provided more confidence in causality and more information on effect size. For example, what would be the effect on performance, if any, with removal of the decision support pocket card at 10 or 15 months? How much would performance rebound after its reintroduction? What could we have learned had the authors chosen instead to measure performance after sequentially introducing each component?

Using the language of the Quality Gap taxonomy, what conclusions can we draw from this improvement initiative? The introduction of a portable provider reminder (the decision support pocket card), when preceded by a program of provider education and followed by high‐intensity audit‐and‐feedback within an existing provider hierarchy, may have the power to raise VTE prophylaxis rates to 85% over an 18‐month period. With the large effect size somewhat mitigating the design flaws that weaken causality, we might risk an inference that these 3 classes of QI strategies can be reasonably successful in combination. But would we introduce them in our own medical centers? Using the clarity afforded by the taxonomy, we can identify several potential limitations, all attributable to the specifics of the audit‐and‐feedback arrangement: stringent preconditions of the practice setting, guaranteed inability to spread the initiative to other patient populations within the same medical center, limited scalability to include other QI projects, and reliance on the role of a single individual. Although clopidogrel 300 mg daily in the last week of every month is one way to pursue antiplatelet activity, other schedules or alternative agents may be preferable for the vast majority of patients.

The taxonomy can be used to compare, contrast, and more fully understand other QI studies. For example, among acutely ill medical inpatients not receiving VTE prophylaxis, Kucher and colleagues found that an electronic alert nearly doubled prophylaxis rates compared to those in a control group.10 Before trying to emulate their experience, a similarly equipped hospital would do well to recognize that the electronic alert was deployed as a composite of provider education, provider reminder, and facilitated relay of clinical information strategies, increasing prophylaxis rates for high risk patients from a baseline of 85% to 88%.

On the 21st‐century side of the quality chasm there is still something to be learned from QI research that falls short of recently proposed standards.3 This may be true as long as the key question remains: what are the mechanisms of reliable and sustainable performance improvement? We have not yet reached the day where a predictive framework, the clarity of our inquiry, the rigor of our study design, and the strength of our evidence churn out coherent answers. But we do have insights from a wealth of ongoing QI activity triggered by such forces as the Institute for Healthcare Improvement's 100,000 Lives Campaign and the advent of mandatory public reporting of hospital performance measures. By adding to this primordial mix the taxonomy offered by Closing the Quality Gap and its uptake into our vernacular by reports such as the one by Cohn in this issue of the Journal of Hospital Medicine, we are acquiring the language and experience to conduct intelligent and intelligible QI research.

As we approach the 6th year since the Institute of Medicine's Crossing the Quality Chasm offered a new vision for the American health care system, we still have a marked mismatch between the demand for health care quality and the supply of know‐how to deliver it. What the field of quality improvement (QI) still needs is merely this: QI practitioners in every care setting, a working vocabulary, a predictive framework for the mechanisms of reliable care, and rational therapies rigorously studied.13 Fortunately, the field of QI has attracted enough empiricistsworking in the lab of the hospital and other care settingsto lurch forward. But few would argue that we still have far less insight into the delivery of quality care than into the delivery of myocardial blood flow.

For ischemic heart disease we have classes of therapies, each of which is grounded in basic and clinical science: antiplatelets, beta‐blockers, vasodilators, lipid‐lowering agents. For care delivery we have the makings of analogous therapy classes, derived and introduced rather recently in a large review, Closing the Quality Gap: A Critical Analysis of the Quality Improvement Literature.4, 5 To facilitate their review of the evidence, the authors, including 2 prominent hospitalists, developed a new taxonomy of QI strategies (see Table 1). Though their effect size, relative efficacy, and interactions are not yet clear, many of these strategies can be applied to the inpatient setting, perhaps no less rationally than a well‐constructed antianginal regimen.

Where in the pathophysiology of a hospital do these QI therapies act? A plurality target the level of the provider: provider education, provider reminders, audit‐and‐feedback of provider performance, and facilitated relay of clinical data to providers. Remaining strategies target the patient (patient education, promotion of self‐management, and patient reminders), the immediate system within which care is delivered (organizational change), and the methodology of problem solving (continuous quality improvement). Only one strategy (financial incentives, regulation, and policy) fails to act directly at the level of the patient or provider, arguably the only level at which care actually can be improved.6

The value of the Quality Gap taxonomy is still largely untapped. If QI researchers and practitioners were to adopt its language as a standard, we could ramp up the power with which we communicate, interpret, and ultimately conduct improvement initiatives. In this issue of the Journal of Hospital Medicine, Cohn and colleagues profile a quality improvement initiative that achieved an impressive new level of performance. For an inpatient metric with a baseline institutional performance of 47%and an international benchmark of 39%the investigators executed a QI initiative that appears to have raised the rate of VTE prophylaxis to 85%.7 Despite a study design that weakens validity (beforeafter without controls) and a setting that diminishes applicability (medical patients in a single academic center), the authors have made a solid contribution to the QI literature simply by using the Quality Gap taxonomy. The authors specifically name and profile at least 3 distinct classes of QI strategies: provider education, a provider reminder element (ie, decision support), and an audit‐and‐feedback layer.

Even though provider education is unlikely to be sufficient as a lone QI strategya large review showed consistent but only modest benefitsit is often necessary.8 The provider education executed by Cohn and colleagues was frequent and regular. In the beginning of each month the chief resident oriented incoming house staff about venous thromboembolism (VTE) risk factors and the need for prophylaxis. They were given decision support pocket cards. Posters on display in nurse and physician work areas highlighted VTE risk factors. The provider education element also included discussions with the division chief about the topic. As robust as it was, however, the provider education was just a single component of the larger QI effort.

The second element, decision support, included VTE risk factor pocket cards with prophylaxis options listed. Introduced initially with the provider education, the pocket cards were handed out monthly by the chief resident. It is critical to recognize this decision support layer as a distinct core QI strategyand that it may even be fundamental to the success of the other strategies. Placed into the clinical workflow as a durable item, the decision support pocket card has the power to overcome provider uncertainty at moments of medical decision making. Generally speaking, a decision support layer, whether a pocket card, computer alert, or algorithm on a preprinted order form, can function as a shared baseline. Shared baselines or protocols reduce unnecessary variation in practice, a common source of poor quality care. Any mechanism that encourages groups of providers to deliver the same recommended care to groups of similarly at‐risk patients, while allowing customization of the protocol to meet the special needs of any individual patient, will have the net effect of raising overall quality of care.

This QI initiative may have achieved its greatest performance gainsas well as its greatest loss in terms of applicability to other settingsfrom its third facet, the audit‐and‐feedback layer. As a QI strategy audit‐and‐feedback has been defined as a summary of clinical performance for health care providers or institutions, performed for a specific period of time and reported either publicly or confidentially.1 It has demonstrated small to moderate benefits, with variations in effect most likely related to the format.9 As profiled in this study, it is hard to imagine a more powerful audit‐and‐feedback arrangement. The division chief of General Internal Medicine not only performed the audits, but also directly delivered the feedback to the house staff. In a deliberate, systematic, and successful way the investigators constructively used an existing authority gradient to leverage the Hawthorne effect, a change in worker behavior triggered by knowledge of being observed. Although it contributed to the impressive new VTE prophylaxis rates, this component did diminish generalizability and sustainability. Nonacademic centers may struggle to replicate these results, a point the authors dutifully point out. But even other academic centers might struggle in the absence of an authority figure with comparable influence and dedication to VTE prophylaxis. At the study hospital itself, similar rates of improvement would not be expected in patient populations outside the purview of the division chief.

Several alternatives to the before‐after study design could have produced richer information. Simultaneous data on VTE prophylaxis rates in a nonintervention population in the same or a similar hospital could have controlled for background or secular effects. An interrupted time series design may even have been feasible and could have provided more confidence in causality and more information on effect size. For example, what would be the effect on performance, if any, with removal of the decision support pocket card at 10 or 15 months? How much would performance rebound after its reintroduction? What could we have learned had the authors chosen instead to measure performance after sequentially introducing each component?

Using the language of the Quality Gap taxonomy, what conclusions can we draw from this improvement initiative? The introduction of a portable provider reminder (the decision support pocket card), when preceded by a program of provider education and followed by high‐intensity audit‐and‐feedback within an existing provider hierarchy, may have the power to raise VTE prophylaxis rates to 85% over an 18‐month period. With the large effect size somewhat mitigating the design flaws that weaken causality, we might risk an inference that these 3 classes of QI strategies can be reasonably successful in combination. But would we introduce them in our own medical centers? Using the clarity afforded by the taxonomy, we can identify several potential limitations, all attributable to the specifics of the audit‐and‐feedback arrangement: stringent preconditions of the practice setting, guaranteed inability to spread the initiative to other patient populations within the same medical center, limited scalability to include other QI projects, and reliance on the role of a single individual. Although clopidogrel 300 mg daily in the last week of every month is one way to pursue antiplatelet activity, other schedules or alternative agents may be preferable for the vast majority of patients.

The taxonomy can be used to compare, contrast, and more fully understand other QI studies. For example, among acutely ill medical inpatients not receiving VTE prophylaxis, Kucher and colleagues found that an electronic alert nearly doubled prophylaxis rates compared to those in a control group.10 Before trying to emulate their experience, a similarly equipped hospital would do well to recognize that the electronic alert was deployed as a composite of provider education, provider reminder, and facilitated relay of clinical information strategies, increasing prophylaxis rates for high risk patients from a baseline of 85% to 88%.

On the 21st‐century side of the quality chasm there is still something to be learned from QI research that falls short of recently proposed standards.3 This may be true as long as the key question remains: what are the mechanisms of reliable and sustainable performance improvement? We have not yet reached the day where a predictive framework, the clarity of our inquiry, the rigor of our study design, and the strength of our evidence churn out coherent answers. But we do have insights from a wealth of ongoing QI activity triggered by such forces as the Institute for Healthcare Improvement's 100,000 Lives Campaign and the advent of mandatory public reporting of hospital performance measures. By adding to this primordial mix the taxonomy offered by Closing the Quality Gap and its uptake into our vernacular by reports such as the one by Cohn in this issue of the Journal of Hospital Medicine, we are acquiring the language and experience to conduct intelligent and intelligible QI research.

As we approach the 6th year since the Institute of Medicine's Crossing the Quality Chasm offered a new vision for the American health care system, we still have a marked mismatch between the demand for health care quality and the supply of know‐how to deliver it. What the field of quality improvement (QI) still needs is merely this: QI practitioners in every care setting, a working vocabulary, a predictive framework for the mechanisms of reliable care, and rational therapies rigorously studied.13 Fortunately, the field of QI has attracted enough empiricistsworking in the lab of the hospital and other care settingsto lurch forward. But few would argue that we still have far less insight into the delivery of quality care than into the delivery of myocardial blood flow.

For ischemic heart disease we have classes of therapies, each of which is grounded in basic and clinical science: antiplatelets, beta‐blockers, vasodilators, lipid‐lowering agents. For care delivery we have the makings of analogous therapy classes, derived and introduced rather recently in a large review, Closing the Quality Gap: A Critical Analysis of the Quality Improvement Literature.4, 5 To facilitate their review of the evidence, the authors, including 2 prominent hospitalists, developed a new taxonomy of QI strategies (see Table 1). Though their effect size, relative efficacy, and interactions are not yet clear, many of these strategies can be applied to the inpatient setting, perhaps no less rationally than a well‐constructed antianginal regimen.

Where in the pathophysiology of a hospital do these QI therapies act? A plurality target the level of the provider: provider education, provider reminders, audit‐and‐feedback of provider performance, and facilitated relay of clinical data to providers. Remaining strategies target the patient (patient education, promotion of self‐management, and patient reminders), the immediate system within which care is delivered (organizational change), and the methodology of problem solving (continuous quality improvement). Only one strategy (financial incentives, regulation, and policy) fails to act directly at the level of the patient or provider, arguably the only level at which care actually can be improved.6

The value of the Quality Gap taxonomy is still largely untapped. If QI researchers and practitioners were to adopt its language as a standard, we could ramp up the power with which we communicate, interpret, and ultimately conduct improvement initiatives. In this issue of the Journal of Hospital Medicine, Cohn and colleagues profile a quality improvement initiative that achieved an impressive new level of performance. For an inpatient metric with a baseline institutional performance of 47%and an international benchmark of 39%the investigators executed a QI initiative that appears to have raised the rate of VTE prophylaxis to 85%.7 Despite a study design that weakens validity (beforeafter without controls) and a setting that diminishes applicability (medical patients in a single academic center), the authors have made a solid contribution to the QI literature simply by using the Quality Gap taxonomy. The authors specifically name and profile at least 3 distinct classes of QI strategies: provider education, a provider reminder element (ie, decision support), and an audit‐and‐feedback layer.

Even though provider education is unlikely to be sufficient as a lone QI strategya large review showed consistent but only modest benefitsit is often necessary.8 The provider education executed by Cohn and colleagues was frequent and regular. In the beginning of each month the chief resident oriented incoming house staff about venous thromboembolism (VTE) risk factors and the need for prophylaxis. They were given decision support pocket cards. Posters on display in nurse and physician work areas highlighted VTE risk factors. The provider education element also included discussions with the division chief about the topic. As robust as it was, however, the provider education was just a single component of the larger QI effort.

The second element, decision support, included VTE risk factor pocket cards with prophylaxis options listed. Introduced initially with the provider education, the pocket cards were handed out monthly by the chief resident. It is critical to recognize this decision support layer as a distinct core QI strategyand that it may even be fundamental to the success of the other strategies. Placed into the clinical workflow as a durable item, the decision support pocket card has the power to overcome provider uncertainty at moments of medical decision making. Generally speaking, a decision support layer, whether a pocket card, computer alert, or algorithm on a preprinted order form, can function as a shared baseline. Shared baselines or protocols reduce unnecessary variation in practice, a common source of poor quality care. Any mechanism that encourages groups of providers to deliver the same recommended care to groups of similarly at‐risk patients, while allowing customization of the protocol to meet the special needs of any individual patient, will have the net effect of raising overall quality of care.

This QI initiative may have achieved its greatest performance gainsas well as its greatest loss in terms of applicability to other settingsfrom its third facet, the audit‐and‐feedback layer. As a QI strategy audit‐and‐feedback has been defined as a summary of clinical performance for health care providers or institutions, performed for a specific period of time and reported either publicly or confidentially.1 It has demonstrated small to moderate benefits, with variations in effect most likely related to the format.9 As profiled in this study, it is hard to imagine a more powerful audit‐and‐feedback arrangement. The division chief of General Internal Medicine not only performed the audits, but also directly delivered the feedback to the house staff. In a deliberate, systematic, and successful way the investigators constructively used an existing authority gradient to leverage the Hawthorne effect, a change in worker behavior triggered by knowledge of being observed. Although it contributed to the impressive new VTE prophylaxis rates, this component did diminish generalizability and sustainability. Nonacademic centers may struggle to replicate these results, a point the authors dutifully point out. But even other academic centers might struggle in the absence of an authority figure with comparable influence and dedication to VTE prophylaxis. At the study hospital itself, similar rates of improvement would not be expected in patient populations outside the purview of the division chief.

Several alternatives to the before‐after study design could have produced richer information. Simultaneous data on VTE prophylaxis rates in a nonintervention population in the same or a similar hospital could have controlled for background or secular effects. An interrupted time series design may even have been feasible and could have provided more confidence in causality and more information on effect size. For example, what would be the effect on performance, if any, with removal of the decision support pocket card at 10 or 15 months? How much would performance rebound after its reintroduction? What could we have learned had the authors chosen instead to measure performance after sequentially introducing each component?

Using the language of the Quality Gap taxonomy, what conclusions can we draw from this improvement initiative? The introduction of a portable provider reminder (the decision support pocket card), when preceded by a program of provider education and followed by high‐intensity audit‐and‐feedback within an existing provider hierarchy, may have the power to raise VTE prophylaxis rates to 85% over an 18‐month period. With the large effect size somewhat mitigating the design flaws that weaken causality, we might risk an inference that these 3 classes of QI strategies can be reasonably successful in combination. But would we introduce them in our own medical centers? Using the clarity afforded by the taxonomy, we can identify several potential limitations, all attributable to the specifics of the audit‐and‐feedback arrangement: stringent preconditions of the practice setting, guaranteed inability to spread the initiative to other patient populations within the same medical center, limited scalability to include other QI projects, and reliance on the role of a single individual. Although clopidogrel 300 mg daily in the last week of every month is one way to pursue antiplatelet activity, other schedules or alternative agents may be preferable for the vast majority of patients.

The taxonomy can be used to compare, contrast, and more fully understand other QI studies. For example, among acutely ill medical inpatients not receiving VTE prophylaxis, Kucher and colleagues found that an electronic alert nearly doubled prophylaxis rates compared to those in a control group.10 Before trying to emulate their experience, a similarly equipped hospital would do well to recognize that the electronic alert was deployed as a composite of provider education, provider reminder, and facilitated relay of clinical information strategies, increasing prophylaxis rates for high risk patients from a baseline of 85% to 88%.

On the 21st‐century side of the quality chasm there is still something to be learned from QI research that falls short of recently proposed standards.3 This may be true as long as the key question remains: what are the mechanisms of reliable and sustainable performance improvement? We have not yet reached the day where a predictive framework, the clarity of our inquiry, the rigor of our study design, and the strength of our evidence churn out coherent answers. But we do have insights from a wealth of ongoing QI activity triggered by such forces as the Institute for Healthcare Improvement's 100,000 Lives Campaign and the advent of mandatory public reporting of hospital performance measures. By adding to this primordial mix the taxonomy offered by Closing the Quality Gap and its uptake into our vernacular by reports such as the one by Cohn in this issue of the Journal of Hospital Medicine, we are acquiring the language and experience to conduct intelligent and intelligible QI research.

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

On my first day as a nervous, third‐year medical student, a nurse offered to orient me to the pediatric ICU. I expected a litany of facts to memorize. Instead, she pointed at each room in turn and described the tragedies they had hosted.

Room 1: a little girl just died of meningitis there. Room 2: that boy's liver transplant failed, and he had a massive stroke. The father sat holding the jaundiced hand of his unresponsive son, whose stapled abdomen held back tense ascites. His wife died of cancer 2 months ago. Now he has no one. Room 3: teen with cystic fibrosis; she'll be OK. Room 4 I will never forget. A teenager died of leukemia there and refused all painkillers. He wanted to be lucid for his family, and they huddled on his bed and sang Amazing Grace until he died. Most beautiful thing I have seen.

I had thought, Beautiful? How can you even come to work?

Five years later, I remembered that conversation as if it had just happened. I was the senior resident in the medical ICU, it was 3 AM, and I was gathering my thoughts amid the whooshes, beeps, and flickering monitors of the sleeping unit. I was preparing to go tell Betsy that Joe, her 31‐year‐old husband, needed prone ventilation. Joe lay dying from, of all things, chickenpox. He was receiving 12 infusions, including 4 pressors, sedatives, antibiotics, acyclovir, full‐strength bicarbonate, his 26th amp of calcium, and liter number‐who‐knows‐what of saline. He sprouted 2 IVs, 2 central lines, a Foley catheter, endotracheal and orogastric tubes, an arterial line, and an array of monitor leads. His blood pressure would plummetfrom a systolic of 80whenever we interrupted his bicarb drip to spike a new bag, so we knew moving him might kill him. Every nurse raced to finish tasks on other patients, preparing to help.

Joe's admission began, like several of his earlier ones, with a chief complaint of Crohn's flare. This time, however, he had a new rash, and although John's ward team suspected medications were to blame, they soon started him on acyclovir. In days, hepatitis, acute renal failure, and pneumonia prompted his ICU transfer. He required intubation hours later. His course since had been like watching a pedestrian struck by a truck in slow motion: a sudden, jolting, irreversible crueltydrawn out over hours. Anasarca had folded his blistering ears in half and forced us to revise his endotracheal tube taping 3 times so it would not incise his cheeks. He had unremitting hypotension. His transaminases climbed above 6000 and his creatinine to 6; his arterial pH dropped to 7.03, and his platelets fell to 16,000. His partial pressure of oxygen sank below 60 mm Hg despite paralysis, every conceivable ventilator adjustment, and 100% oxygen. Crossing that terrible threshold felt like drifting below hull‐crush depth in a submarine. I waited for the walls and windows of the ICU to groan with the strain as disaster neared.

My intern followed me to the waiting room where Betsy slept. She hadn't left the hospital in days. I knelt beside her cot and woke her, and she supported her pregnant abdomen with her hand as she rolled to face me. We smiled. Then she remembered where she was.

Is something wrong? she asked.

No, he's about the same. But the other things we tried didn't help. We need to do what I mentioned beforeturn him over so he can use his lungs better. She nodded. We're very careful, but he has so many IV lines right now. If he loses one, he could get much worse. So I wanted to make sure you spent some time with him now, just in case.

Her eyes teared. He could die?

Just a small chance. But possible.

And if it works, he might get better?

I paused. He's very sick.

There are other things you can do?

We have to really hope this works.

This isn't supposed to happen. I don't know if I can raise 2 children without Joe. I can't be a widow at 29. I sensed I could have talked hersleep deprived and stunnedback into sleep, into a conviction her nightmare would pass by morning. Instead I squeezed her hand and listened.

We need to do this, OK? You'll have 10 minutes to talk. Remember how his blood pressure rose when they cleaned him? He's still in there. I believe he can hear you. So you tell him to keep fighting.

Betsy wiped her eyes and searched for her shoes. As we walked briskly back to the unit, I composed myself and told my intern, I'll be 29 in 3 weeks.

Me too. What day?

May 28th.

Same as mine, he said.

It took 25 minutes to prone Joe with every nurse assisting, but the maneuver went well. His oxygenation improved, but his relentless decline resumed within hours. The following afternoon, Betsy held Joe's hand and told him it was OK for him to go, and that she would look after their children. Joe's blood pressure eventually dwindled to nothing, leaving only sinus tachycardia on the monitor and the rhythmic puffs of the ventilator. Then, within 2 weeks, the resident team managed a series of unexpected tragedies: we lost young mothers to acetaminophen overdose and lung cancer, and cared for 2 young adults with septic shock and a perimenopausal woman for whom the cost of pneumonia was her first and probably only pregnancy.

Five years before, when I first stepped into an ICU, I imagined the residents held a dozen lives in their hands and faced critical illness at all hoursalone. By the time Joe died of disseminated varicella, I realized the truth was far from that vision. Joe's nurse had worked in the ICU as long as I'd been alive, and expert respiratory therapists guided his mechanical ventilation. I had coresidents and consultantseven a rabbi when I guided a family meeting on declaring CPR not indicated. Our institution's overnight attending assisted me throughout the night, and the primary attending drove in at 2 AM to supervise nitric oxide therapy. At no point did I ever care for Joe alone.

Instead, the challenge lay in facing the winning smiles of our patient Joe and his 10 month‐old son Jacob waving from a recent photo taped by the head of his bed and a young wife refusing to leave her increasingly unrecognizable husband as his body failed, despite her conspicuous 7‐month pregnancy. And it lay in the surprising futility of all our interventions. Perhaps most of all, the challenge was in the persistence of the sights and sounds and smells of that night and many others. I've seen the expression a pathologist makes on learning his daughter has anaplastic thyroid cancer. I've heard the sound a daughter makes when her mother has a ventricular free‐wall rupture while welcoming us into her room. I've smelled a teenager who had burned to the bone while conscious yet pinned in his car. I've felt the crackle of subcutaneous emphysema after chest tubes for malignant pleural effusions that was so severe the patient could not open his eyes or close his hands. And the papery skin and tremulous handshake of a man after my news of his wife's prognosis promised their 64th year of marriage would be the last.

Far from alone, I spend much of my time in the company of these ghosts, as must many health care workers. How we make our peace with them is up to us. With tears? Humor? Alcohol? Sometimes it is by numb indifference; you might wonder from most of the businesslike discussions physicians hold if these ghosts even existed. Or, we can make our peace with words. I am grateful for a chance to speak with Betsy some days after Joe died to assure her that although we did ask Joe to fight, in the end no effort could have saved him. I am grateful she later wrote us to celebrate the healthy birth of their second son, Joshua. She assured me Joe would live on for her in their sons and live on for them through her memories. Her strength helped me welcome Joe's ghost, and many others, into my life.

After 5 years of clinical medicine, I finally understood the lesson I received from the pediatric ICU nurse. Our ghost stories help us grieve, and they celebrate healing, or if there was no healing, then release. At the very least, great tragedy reminds us of the great meaning of our calling.

Of the many skills a hospitalist nurtures and develops, seeing and processing visual images is paramount. From the moment we enter the hospital each day, we look at patient faces, trying to fathom their levels of pain, of illness, and of response to therapy. We look at their rashes, facial droops, surgical wounds, and neck vein elevation. When we are done visually scrutinizing our patients, we inspect their rhythm strips or electrocardiograms and then move on to their X‐rays and advanced imaging.

Although we are, in a sense, slaves to the images before us, we also enjoy medicine for the challenge that these images providethere is always something novel to see. For the experienced clinician, a deep sense of satisfaction perfuses our limbic system with the quick recognition of the delta wave of Wolf‐Parkinson‐White on an EKG or the first vesicle of a zoster outbreak in a patient with initially unexplained cutaneous pain. What we recognize easily tends to come from having seen something beforefor better or worse, we depend on pattern recognition.

Unfortunately, we are all busier than we like and receive more journals than we have time to read. To make JHM even more germane and stimulating, we are initiating Hospital Images Dx. The main goal of Hospital Images Dx will be to show interesting images that a hospitalist might encounter, both the common and the obscure. Images, whether subtle or awe‐inspiring, should generally be able to speak the proverbial thousand words. To supplement those thousand words spoken by the submitted image, accompanying text will be limited to 250 words. The text should give a brief clinical summary of the patient's problem, relevant adjunct data, and 1 or 2 succinct teaching points related to the image. Our goal, simply stated, is for the reader to walk away after reading Hospital Images Dx with an image and a couple of key teaching points stored away for a rainy day.

We anticipate a substantial number of exciting submissions to Hospital Images Dx. Health care providers clearly get excited about the things they see as well as about the recordsthe imagesthat document both mundane and unusual encounters with a patient or a patient's data. We hope to tap into this enthusiasm and to teach a few things along the way. The editors look forward to receiving your Hospital Images Dx submission soon!

Of the many skills a hospitalist nurtures and develops, seeing and processing visual images is paramount. From the moment we enter the hospital each day, we look at patient faces, trying to fathom their levels of pain, of illness, and of response to therapy. We look at their rashes, facial droops, surgical wounds, and neck vein elevation. When we are done visually scrutinizing our patients, we inspect their rhythm strips or electrocardiograms and then move on to their X‐rays and advanced imaging.

Although we are, in a sense, slaves to the images before us, we also enjoy medicine for the challenge that these images providethere is always something novel to see. For the experienced clinician, a deep sense of satisfaction perfuses our limbic system with the quick recognition of the delta wave of Wolf‐Parkinson‐White on an EKG or the first vesicle of a zoster outbreak in a patient with initially unexplained cutaneous pain. What we recognize easily tends to come from having seen something beforefor better or worse, we depend on pattern recognition.

Unfortunately, we are all busier than we like and receive more journals than we have time to read. To make JHM even more germane and stimulating, we are initiating Hospital Images Dx. The main goal of Hospital Images Dx will be to show interesting images that a hospitalist might encounter, both the common and the obscure. Images, whether subtle or awe‐inspiring, should generally be able to speak the proverbial thousand words. To supplement those thousand words spoken by the submitted image, accompanying text will be limited to 250 words. The text should give a brief clinical summary of the patient's problem, relevant adjunct data, and 1 or 2 succinct teaching points related to the image. Our goal, simply stated, is for the reader to walk away after reading Hospital Images Dx with an image and a couple of key teaching points stored away for a rainy day.

We anticipate a substantial number of exciting submissions to Hospital Images Dx. Health care providers clearly get excited about the things they see as well as about the recordsthe imagesthat document both mundane and unusual encounters with a patient or a patient's data. We hope to tap into this enthusiasm and to teach a few things along the way. The editors look forward to receiving your Hospital Images Dx submission soon!

Of the many skills a hospitalist nurtures and develops, seeing and processing visual images is paramount. From the moment we enter the hospital each day, we look at patient faces, trying to fathom their levels of pain, of illness, and of response to therapy. We look at their rashes, facial droops, surgical wounds, and neck vein elevation. When we are done visually scrutinizing our patients, we inspect their rhythm strips or electrocardiograms and then move on to their X‐rays and advanced imaging.

Although we are, in a sense, slaves to the images before us, we also enjoy medicine for the challenge that these images providethere is always something novel to see. For the experienced clinician, a deep sense of satisfaction perfuses our limbic system with the quick recognition of the delta wave of Wolf‐Parkinson‐White on an EKG or the first vesicle of a zoster outbreak in a patient with initially unexplained cutaneous pain. What we recognize easily tends to come from having seen something beforefor better or worse, we depend on pattern recognition.

Unfortunately, we are all busier than we like and receive more journals than we have time to read. To make JHM even more germane and stimulating, we are initiating Hospital Images Dx. The main goal of Hospital Images Dx will be to show interesting images that a hospitalist might encounter, both the common and the obscure. Images, whether subtle or awe‐inspiring, should generally be able to speak the proverbial thousand words. To supplement those thousand words spoken by the submitted image, accompanying text will be limited to 250 words. The text should give a brief clinical summary of the patient's problem, relevant adjunct data, and 1 or 2 succinct teaching points related to the image. Our goal, simply stated, is for the reader to walk away after reading Hospital Images Dx with an image and a couple of key teaching points stored away for a rainy day.

We anticipate a substantial number of exciting submissions to Hospital Images Dx. Health care providers clearly get excited about the things they see as well as about the recordsthe imagesthat document both mundane and unusual encounters with a patient or a patient's data. We hope to tap into this enthusiasm and to teach a few things along the way. The editors look forward to receiving your Hospital Images Dx submission soon!

In addition to marking my initial transition from student to physician, the commencement address by the medical informatics pioneer, Larry Weed, is my most enduring memory of medical school graduation. A provocative thinker in the field of decision support and structured medical records, Weed was credited by my teachers with developing the organized SOAP note. During his address he depressingly equated all the knowledge we had digested during the preceding mentally strenuous 4 years to shoveling a mountain of manure with a teaspoon. Although I agreed that some of the information I learned seemed to lack relevance (still don't know why I needed to learn the details of the Krebs cycle), as I began caring for patients as an intern, I found that much of it mattered. As I launched into residency training, I also discovered that lifelong learning would be a perpetual component of my medical career.

Despite becoming a passionate advocate of practicing evidence‐based medicine (EBM), I also recognized the impossibility of keeping up with the medical literature, given the relentless arrival of journals in the mail. Learning all the evidence is impossible, so we must develop information management skills and allow others to help us in identifying, reviewing, and summarizing salient and valid clinical information.1 One of my vital goals as editor of the Journal of Hospital Medicine is to ensure we provide our readers with useful clinical information that is concise, easily digested, and usable.

To that end we are introducing Patient‐Oriented Evidence that Matters, or POEMs. As described on the InfoPOEMs website (www.infopoems.com), POEMs have to meet three criteria:

• They address a question that we face as clinicians.

• They measure outcomes that we and our patients care about: symptoms, morbidity, quality of life, and mortality.

• They have the potential to change the way we practice.

We are not the first journal to do this and join the company of the British Medical Journal and the Cleveland Clinic Journal of Medicine.2, 3 Staff physicians at InfoPOEMs screen more than 100 peer‐reviewed medical journals for relevant articles that practicing physicians can use at the point of care, the patient. A trained physician poet then summarizes selected articles in a standardized manner into a POEM. A POEM begins with a clinical question and then provides a bottom line answer from a recently published journal article. This is followed by a structured abstract that includes the study design and setting, followed by a synopsis of the article.

We will start with at least 2 POEMs per issue focused on clinical topics relevant to hospitalists. Soon, an experienced academic hospitalist and knowledgeable expert in EBM, Dr. Jennifer Kleinbart, will be writing POEMs for hospitalists. We look forward to your opinions about whether we should increase this content. Let me know.

In addition to marking my initial transition from student to physician, the commencement address by the medical informatics pioneer, Larry Weed, is my most enduring memory of medical school graduation. A provocative thinker in the field of decision support and structured medical records, Weed was credited by my teachers with developing the organized SOAP note. During his address he depressingly equated all the knowledge we had digested during the preceding mentally strenuous 4 years to shoveling a mountain of manure with a teaspoon. Although I agreed that some of the information I learned seemed to lack relevance (still don't know why I needed to learn the details of the Krebs cycle), as I began caring for patients as an intern, I found that much of it mattered. As I launched into residency training, I also discovered that lifelong learning would be a perpetual component of my medical career.

Despite becoming a passionate advocate of practicing evidence‐based medicine (EBM), I also recognized the impossibility of keeping up with the medical literature, given the relentless arrival of journals in the mail. Learning all the evidence is impossible, so we must develop information management skills and allow others to help us in identifying, reviewing, and summarizing salient and valid clinical information.1 One of my vital goals as editor of the Journal of Hospital Medicine is to ensure we provide our readers with useful clinical information that is concise, easily digested, and usable.

To that end we are introducing Patient‐Oriented Evidence that Matters, or POEMs. As described on the InfoPOEMs website (www.infopoems.com), POEMs have to meet three criteria:

• They address a question that we face as clinicians.

• They measure outcomes that we and our patients care about: symptoms, morbidity, quality of life, and mortality.

• They have the potential to change the way we practice.

We are not the first journal to do this and join the company of the British Medical Journal and the Cleveland Clinic Journal of Medicine.2, 3 Staff physicians at InfoPOEMs screen more than 100 peer‐reviewed medical journals for relevant articles that practicing physicians can use at the point of care, the patient. A trained physician poet then summarizes selected articles in a standardized manner into a POEM. A POEM begins with a clinical question and then provides a bottom line answer from a recently published journal article. This is followed by a structured abstract that includes the study design and setting, followed by a synopsis of the article.

We will start with at least 2 POEMs per issue focused on clinical topics relevant to hospitalists. Soon, an experienced academic hospitalist and knowledgeable expert in EBM, Dr. Jennifer Kleinbart, will be writing POEMs for hospitalists. We look forward to your opinions about whether we should increase this content. Let me know.

In addition to marking my initial transition from student to physician, the commencement address by the medical informatics pioneer, Larry Weed, is my most enduring memory of medical school graduation. A provocative thinker in the field of decision support and structured medical records, Weed was credited by my teachers with developing the organized SOAP note. During his address he depressingly equated all the knowledge we had digested during the preceding mentally strenuous 4 years to shoveling a mountain of manure with a teaspoon. Although I agreed that some of the information I learned seemed to lack relevance (still don't know why I needed to learn the details of the Krebs cycle), as I began caring for patients as an intern, I found that much of it mattered. As I launched into residency training, I also discovered that lifelong learning would be a perpetual component of my medical career.

Despite becoming a passionate advocate of practicing evidence‐based medicine (EBM), I also recognized the impossibility of keeping up with the medical literature, given the relentless arrival of journals in the mail. Learning all the evidence is impossible, so we must develop information management skills and allow others to help us in identifying, reviewing, and summarizing salient and valid clinical information.1 One of my vital goals as editor of the Journal of Hospital Medicine is to ensure we provide our readers with useful clinical information that is concise, easily digested, and usable.

To that end we are introducing Patient‐Oriented Evidence that Matters, or POEMs. As described on the InfoPOEMs website (www.infopoems.com), POEMs have to meet three criteria:

• They address a question that we face as clinicians.

• They measure outcomes that we and our patients care about: symptoms, morbidity, quality of life, and mortality.

• They have the potential to change the way we practice.

We are not the first journal to do this and join the company of the British Medical Journal and the Cleveland Clinic Journal of Medicine.2, 3 Staff physicians at InfoPOEMs screen more than 100 peer‐reviewed medical journals for relevant articles that practicing physicians can use at the point of care, the patient. A trained physician poet then summarizes selected articles in a standardized manner into a POEM. A POEM begins with a clinical question and then provides a bottom line answer from a recently published journal article. This is followed by a structured abstract that includes the study design and setting, followed by a synopsis of the article.

We will start with at least 2 POEMs per issue focused on clinical topics relevant to hospitalists. Soon, an experienced academic hospitalist and knowledgeable expert in EBM, Dr. Jennifer Kleinbart, will be writing POEMs for hospitalists. We look forward to your opinions about whether we should increase this content. Let me know.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

I was a newly appointed head of a department of medicine. Supervising the care of 44 patients and instructing interns and residents was a new and thrilling experience. Some patients presented complex problems, which satisfied my detective instincts and provided a stimulating intellectual challenge. Many others were less intellectually demanding, but I loved the personal interaction, the ability to change things for the better, and the endless variability.

It amazes me to reflect on how uncritical I was at the time, adopting and following common clinical practices with little questioning. It never really crossed my mind that medicine could be practiced in a different and better way. When I managed after some months to set aside one day a week to continue basic research, I was overjoyed. On that day, I became a scientist, putting each assumption to rigorous testing. At the hospital however, I was much more self‐assured and complacent. It was during a break between experiments at the research institute that I slumped wearily into an armchair in the library and picked up a shabby copy of the Green Journal. Being too tired for anything serious, I started reading what looked like a fairy tale. It was titled In a stew, by Michael LaCombe, whom I knew to be a gifted medical writer.1 Soon I found myself immersed in the story. The princess is seriously sick, and all the court doctors are baffled. She already has had 4 CT scans, 3 MRIs, and dozens of other tests. All the tests were fine, but the princess remains very sick, and the king is terribly worried. Then, somebody remembers an old, forgotten clinician who has been relegated to a small dusty den somewhere in the basement. For his services to be rendered, all he demands is that someone find him his stethoscope and that he be allowed to have a pupil. Using observation, knowledge, and wisdom (but no further tests), he elegantly elicits the relevant history and makes the correct diagnosis, which has eluded all the sophisticated court doctors armed with their batteries of high‐tech tests but with little regard for old‐fashioned clinical methods.

This was good fun, but though I enjoyed it very much, I had no idea that it would remain in my mind and shape my thinking, my practice, and my teaching. Nevertheless, I gradually found myself during rounds reflecting on this story with the patient who had had 2 CT scans done before anyone bothered to listen to him or examine him and with the patient who had been studied for months before a simple fact that should have been noted at once was finally revealed, which led to a single test that was diagnostic and to the patient's recovery.2 Then there was the patient who underwent a procedure, which looked innocent enough, but resulted in an adverse event that cascaded into months of life‐threatening illness.3 Was the procedure really necessary?

One night, a couple of years later, I woke up and instead of going back to sleep, sat in the silent living room, suddenly thinking of our departmental routine and realizing somehow that many things we physicians do may be seriously flawed: taking a superficial history and performing a perfunctory exam; having a light finger on the trigger of test ordering even if imaging and tests may mean little out of the clinical context and often beget more unnecessary testing; skipping significant information only because it is not immediately available but has to be found at another hospital or clinic or by calling the primary physician; disregarding the ubiquitous and influential emotional aspect or the patient's perspective and health literacy, which are essential for shared decisions; and the repeated underuse4 of highly effective medications and especially of proven preventive measures that are not pharmacological and hence not vigorously promoted by the large pharmaceutical companies.

The seed for this heresy was sown by the fable, and it colored my clinical life with a vein of skepticism and self‐criticism. Slowly it also grew into a long‐term commitment to teaching about and research on avoidable pitfalls in patient care.5

Thus, Lacombe's little piece often comes back to me, teaching me that a fairy tale can sometimes be more powerful than a randomized controlled study of 10,000 patients.

Self‐check‐in kiosks started to appear in airports in the late 1990s, and within a few years, they seem to have become ubiquitous in the airline industry. Today, almost 70% of business travelers use them, and other sectors of the travel industry are beginning to experiment with the technology.1 Compared to this innovation in the airline industry, adoption of computerized physician order entry (CPOE) in U.S. hospitals, first pioneered in the early 1970s,2, 3 has taken a much more leisurely pace. Despite numerous studies documenting its benefits,47 promotion by prominent national patient safety advocacy groups such as LeapFrog,8 and numerous guides on best adoption practices.912 fewer than 10% of U.S. hospitals have fully adopted this technology.13 Moreover, as Lindenauer et al.14 pointed out, most hospitals that have successfully implemented CPOE are academic medical centers that rely on house staff to enter orders. With notable exceptions,3 adoption of CPOE in community hospitals where attending physicians write most orders remains anemic.

Although an increasing number of scholarly articles has documented the reasons for this slow rate of adoption even in hospitals that have the resources to invest in this technology, much of that research is based on expert opinion and case studies.11, 1519 In this context, Lindenauer et al.14 should be commended for using empirical evidence to delineate the predictors of adoption. Lindenauer et al. found that physicians who trained in hospitals with CPOE were more likely to be frequent users of CPOE in their new environment. Although the analysis did not account for possible confounding such as employment status of the physician, this result does confirm the conventional wisdom that physicians‐in‐training are more malleable and that residency is an important opportunity to expose physicians to safety technologies. If this finding is borne out by further research, it would bode well for the adoption of CPOE, as many physicians are trained in academic institutions, which are more likely to have CPOE,20 and almost all physicians spend part of their training in a VA hospital, which has uniformly adopted CPOE. Similarly, Lindenauer et al. found that physicians who use computers for personal purposes are more likely to be frequent users of CPOE. Given the increasingly ubiquitous use of computers in all spheres of life, time is on the side of increasing acceptance of CPOE.

However, a closer examination of the data presented by Lindenauer et al. raises several concerns. First, the substantial number of infrequent users across all demographic subgroups and clinical disciplines, even among users who were exposed to CPOE during training or those who used computers regularly for personal purposes, highlights the absence of shortcuts to the universal acceptance of CPOE. Second, whereas 63% of surveyed physicians believed that CPOE would reduce the incidence of medication errors and 71% believed that CPOE would prevent aspects of care from slipping through the cracks, only 42% of the surveyed physicians were frequent users of CPOE. This implies that even when physicians believe in the safety and quality benefits of CPOE, that belief alone may not be sufficient to convince all of them to adopt this technology wholeheartedly; other factors such as speed, ease of use, and training are likely important prerequisites. Third, although 66% of orders placed in person at the 2 study hospitals were entered through CPOE, acceptance of this technology, as measured by Lindenauer et al, was moderate at both institutions. This suggests that even when organizations have reached the 70% threshold set by Leapfrog as the proportion of orders placed in CPOE that qualifies as full implementation, they may continue to face resistance to full acceptance of the technology.

Compared to their academic counterparts, community hospitals face additional hurdles as they implement CPOE. Not only does their smaller size make it difficult to achieve economies of scale, they are also at a disadvantage because of the relationship the community hospital has with its physicians. Unlike physicians‐in‐training in academic medical centers, physicians in community hospitals function as largely autonomous agents over whom the hospital administration has little control. Although these physicians and their hospitals share the common goals of patient safety and quality, the financial incentives for the adoption of CPOE are often misaligned. For example, a recent cost benefit analysis21 showed the enormous potential for hospitals to cut costs if physicians fully adopt a CPOE system with rich decision support features. However, those savings typically accrue to the hospital, not to the physicians who use the system. Assuming the typical learning curve that accompanies the use of any new technology, physicians in community hospitals may have little incentive to invest the time to learn to use the system efficiently.

So what can be done to overcome these seemingly formidable barriers to full adoption of CPOE? Emerging research, which has so far largely focused on CPOE implementation at academic hospitals, suggests there is no silver bullet. Instead, it has taught us how the complex interplay among vendor capability, organizational behavior, clinician work flow, and implementation strategy determines the success or failure of adoption.11, 17, 18, 22 Although physician characteristics will play a role in determining whether an individual adopts this technology, local factors such as the presence of champions, governance model for the project, support for staff throughout the process, and relationship between administration and physicians are likely important determinants of success at both academic and community hospitals. In addition, organizations that embark on CPOE implementation need to understand the enormity of the task at hand and must devote not only sufficient financial but also human capital over time.11, 18 In the words of a chief medical information officer, Implementing CPOE should not be thought of as an event, but a long‐term commitment.

Beyond following proposed best practices for the implementation of CPOE, community hospitals may need to adopt additional strategies to address their unique challenges. Given the misalignment of incentives for physicians' use of CPOE, leadership in community hospitals must be particularly skilled at articulating the benefits of CPOE to physicians. These benefits include not only decreased professional liability from improved patient safety and better quality of care, but also fewer pharmacy callbacks, remote access, and rapid ordering through order sets. Hospitals may also want to elicit support from physicians early by empowering them to create order sets for their disciplines. Mechanisms for hospitals and physicians to engage in mutual cost‐sharing arrangements may provide addition opportunities for hospitals to entice physicians to adopt the technology. Finally, and of particular interest to the readership of this journal, as hospitalists become more prevalent and take care of an increasing proportion of hospitalized patients,23 they are often ideal candidates to lead the implementation of CPOE in community hospitals. Because hospitalists spend most of their time in the hospital, they are often in the best position to get fully trained on CPOE, to define their own order sets, and to redesign care processes in order to take full advantage of CPOE capabilities. In addition, as many hospitalists are directly employed or supported by the hospital, their goals for quality, safety, and efficiency are usually better aligned with those of the hospital.

The stakes involved in implementing CPOE are high. Hospitals invest enormous sums of money in these systems, and many will not have the financial or political capital to attempt a second implementation after an initial failure. In addition, as recent research has pointed out,24 inappropriate implementation strategies may lead to delays in essential care and direct patient harm. In many ways, the complex task of implementing CPOE is not unlike other endeavors in patient care, where optimal outcomes require sound knowledge and reliable processes and where disaster can strike for lack of attention to detail or common sense. If Hippocrates were alive today, he might have this to say about CPOE implementation: Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult.

Self‐check‐in kiosks started to appear in airports in the late 1990s, and within a few years, they seem to have become ubiquitous in the airline industry. Today, almost 70% of business travelers use them, and other sectors of the travel industry are beginning to experiment with the technology.1 Compared to this innovation in the airline industry, adoption of computerized physician order entry (CPOE) in U.S. hospitals, first pioneered in the early 1970s,2, 3 has taken a much more leisurely pace. Despite numerous studies documenting its benefits,47 promotion by prominent national patient safety advocacy groups such as LeapFrog,8 and numerous guides on best adoption practices.912 fewer than 10% of U.S. hospitals have fully adopted this technology.13 Moreover, as Lindenauer et al.14 pointed out, most hospitals that have successfully implemented CPOE are academic medical centers that rely on house staff to enter orders. With notable exceptions,3 adoption of CPOE in community hospitals where attending physicians write most orders remains anemic.

Although an increasing number of scholarly articles has documented the reasons for this slow rate of adoption even in hospitals that have the resources to invest in this technology, much of that research is based on expert opinion and case studies.11, 1519 In this context, Lindenauer et al.14 should be commended for using empirical evidence to delineate the predictors of adoption. Lindenauer et al. found that physicians who trained in hospitals with CPOE were more likely to be frequent users of CPOE in their new environment. Although the analysis did not account for possible confounding such as employment status of the physician, this result does confirm the conventional wisdom that physicians‐in‐training are more malleable and that residency is an important opportunity to expose physicians to safety technologies. If this finding is borne out by further research, it would bode well for the adoption of CPOE, as many physicians are trained in academic institutions, which are more likely to have CPOE,20 and almost all physicians spend part of their training in a VA hospital, which has uniformly adopted CPOE. Similarly, Lindenauer et al. found that physicians who use computers for personal purposes are more likely to be frequent users of CPOE. Given the increasingly ubiquitous use of computers in all spheres of life, time is on the side of increasing acceptance of CPOE.

However, a closer examination of the data presented by Lindenauer et al. raises several concerns. First, the substantial number of infrequent users across all demographic subgroups and clinical disciplines, even among users who were exposed to CPOE during training or those who used computers regularly for personal purposes, highlights the absence of shortcuts to the universal acceptance of CPOE. Second, whereas 63% of surveyed physicians believed that CPOE would reduce the incidence of medication errors and 71% believed that CPOE would prevent aspects of care from slipping through the cracks, only 42% of the surveyed physicians were frequent users of CPOE. This implies that even when physicians believe in the safety and quality benefits of CPOE, that belief alone may not be sufficient to convince all of them to adopt this technology wholeheartedly; other factors such as speed, ease of use, and training are likely important prerequisites. Third, although 66% of orders placed in person at the 2 study hospitals were entered through CPOE, acceptance of this technology, as measured by Lindenauer et al, was moderate at both institutions. This suggests that even when organizations have reached the 70% threshold set by Leapfrog as the proportion of orders placed in CPOE that qualifies as full implementation, they may continue to face resistance to full acceptance of the technology.

Compared to their academic counterparts, community hospitals face additional hurdles as they implement CPOE. Not only does their smaller size make it difficult to achieve economies of scale, they are also at a disadvantage because of the relationship the community hospital has with its physicians. Unlike physicians‐in‐training in academic medical centers, physicians in community hospitals function as largely autonomous agents over whom the hospital administration has little control. Although these physicians and their hospitals share the common goals of patient safety and quality, the financial incentives for the adoption of CPOE are often misaligned. For example, a recent cost benefit analysis21 showed the enormous potential for hospitals to cut costs if physicians fully adopt a CPOE system with rich decision support features. However, those savings typically accrue to the hospital, not to the physicians who use the system. Assuming the typical learning curve that accompanies the use of any new technology, physicians in community hospitals may have little incentive to invest the time to learn to use the system efficiently.

So what can be done to overcome these seemingly formidable barriers to full adoption of CPOE? Emerging research, which has so far largely focused on CPOE implementation at academic hospitals, suggests there is no silver bullet. Instead, it has taught us how the complex interplay among vendor capability, organizational behavior, clinician work flow, and implementation strategy determines the success or failure of adoption.11, 17, 18, 22 Although physician characteristics will play a role in determining whether an individual adopts this technology, local factors such as the presence of champions, governance model for the project, support for staff throughout the process, and relationship between administration and physicians are likely important determinants of success at both academic and community hospitals. In addition, organizations that embark on CPOE implementation need to understand the enormity of the task at hand and must devote not only sufficient financial but also human capital over time.11, 18 In the words of a chief medical information officer, Implementing CPOE should not be thought of as an event, but a long‐term commitment.

Beyond following proposed best practices for the implementation of CPOE, community hospitals may need to adopt additional strategies to address their unique challenges. Given the misalignment of incentives for physicians' use of CPOE, leadership in community hospitals must be particularly skilled at articulating the benefits of CPOE to physicians. These benefits include not only decreased professional liability from improved patient safety and better quality of care, but also fewer pharmacy callbacks, remote access, and rapid ordering through order sets. Hospitals may also want to elicit support from physicians early by empowering them to create order sets for their disciplines. Mechanisms for hospitals and physicians to engage in mutual cost‐sharing arrangements may provide addition opportunities for hospitals to entice physicians to adopt the technology. Finally, and of particular interest to the readership of this journal, as hospitalists become more prevalent and take care of an increasing proportion of hospitalized patients,23 they are often ideal candidates to lead the implementation of CPOE in community hospitals. Because hospitalists spend most of their time in the hospital, they are often in the best position to get fully trained on CPOE, to define their own order sets, and to redesign care processes in order to take full advantage of CPOE capabilities. In addition, as many hospitalists are directly employed or supported by the hospital, their goals for quality, safety, and efficiency are usually better aligned with those of the hospital.

The stakes involved in implementing CPOE are high. Hospitals invest enormous sums of money in these systems, and many will not have the financial or political capital to attempt a second implementation after an initial failure. In addition, as recent research has pointed out,24 inappropriate implementation strategies may lead to delays in essential care and direct patient harm. In many ways, the complex task of implementing CPOE is not unlike other endeavors in patient care, where optimal outcomes require sound knowledge and reliable processes and where disaster can strike for lack of attention to detail or common sense. If Hippocrates were alive today, he might have this to say about CPOE implementation: Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult.

Self‐check‐in kiosks started to appear in airports in the late 1990s, and within a few years, they seem to have become ubiquitous in the airline industry. Today, almost 70% of business travelers use them, and other sectors of the travel industry are beginning to experiment with the technology.1 Compared to this innovation in the airline industry, adoption of computerized physician order entry (CPOE) in U.S. hospitals, first pioneered in the early 1970s,2, 3 has taken a much more leisurely pace. Despite numerous studies documenting its benefits,47 promotion by prominent national patient safety advocacy groups such as LeapFrog,8 and numerous guides on best adoption practices.912 fewer than 10% of U.S. hospitals have fully adopted this technology.13 Moreover, as Lindenauer et al.14 pointed out, most hospitals that have successfully implemented CPOE are academic medical centers that rely on house staff to enter orders. With notable exceptions,3 adoption of CPOE in community hospitals where attending physicians write most orders remains anemic.

Although an increasing number of scholarly articles has documented the reasons for this slow rate of adoption even in hospitals that have the resources to invest in this technology, much of that research is based on expert opinion and case studies.11, 1519 In this context, Lindenauer et al.14 should be commended for using empirical evidence to delineate the predictors of adoption. Lindenauer et al. found that physicians who trained in hospitals with CPOE were more likely to be frequent users of CPOE in their new environment. Although the analysis did not account for possible confounding such as employment status of the physician, this result does confirm the conventional wisdom that physicians‐in‐training are more malleable and that residency is an important opportunity to expose physicians to safety technologies. If this finding is borne out by further research, it would bode well for the adoption of CPOE, as many physicians are trained in academic institutions, which are more likely to have CPOE,20 and almost all physicians spend part of their training in a VA hospital, which has uniformly adopted CPOE. Similarly, Lindenauer et al. found that physicians who use computers for personal purposes are more likely to be frequent users of CPOE. Given the increasingly ubiquitous use of computers in all spheres of life, time is on the side of increasing acceptance of CPOE.

However, a closer examination of the data presented by Lindenauer et al. raises several concerns. First, the substantial number of infrequent users across all demographic subgroups and clinical disciplines, even among users who were exposed to CPOE during training or those who used computers regularly for personal purposes, highlights the absence of shortcuts to the universal acceptance of CPOE. Second, whereas 63% of surveyed physicians believed that CPOE would reduce the incidence of medication errors and 71% believed that CPOE would prevent aspects of care from slipping through the cracks, only 42% of the surveyed physicians were frequent users of CPOE. This implies that even when physicians believe in the safety and quality benefits of CPOE, that belief alone may not be sufficient to convince all of them to adopt this technology wholeheartedly; other factors such as speed, ease of use, and training are likely important prerequisites. Third, although 66% of orders placed in person at the 2 study hospitals were entered through CPOE, acceptance of this technology, as measured by Lindenauer et al, was moderate at both institutions. This suggests that even when organizations have reached the 70% threshold set by Leapfrog as the proportion of orders placed in CPOE that qualifies as full implementation, they may continue to face resistance to full acceptance of the technology.

Compared to their academic counterparts, community hospitals face additional hurdles as they implement CPOE. Not only does their smaller size make it difficult to achieve economies of scale, they are also at a disadvantage because of the relationship the community hospital has with its physicians. Unlike physicians‐in‐training in academic medical centers, physicians in community hospitals function as largely autonomous agents over whom the hospital administration has little control. Although these physicians and their hospitals share the common goals of patient safety and quality, the financial incentives for the adoption of CPOE are often misaligned. For example, a recent cost benefit analysis21 showed the enormous potential for hospitals to cut costs if physicians fully adopt a CPOE system with rich decision support features. However, those savings typically accrue to the hospital, not to the physicians who use the system. Assuming the typical learning curve that accompanies the use of any new technology, physicians in community hospitals may have little incentive to invest the time to learn to use the system efficiently.

So what can be done to overcome these seemingly formidable barriers to full adoption of CPOE? Emerging research, which has so far largely focused on CPOE implementation at academic hospitals, suggests there is no silver bullet. Instead, it has taught us how the complex interplay among vendor capability, organizational behavior, clinician work flow, and implementation strategy determines the success or failure of adoption.11, 17, 18, 22 Although physician characteristics will play a role in determining whether an individual adopts this technology, local factors such as the presence of champions, governance model for the project, support for staff throughout the process, and relationship between administration and physicians are likely important determinants of success at both academic and community hospitals. In addition, organizations that embark on CPOE implementation need to understand the enormity of the task at hand and must devote not only sufficient financial but also human capital over time.11, 18 In the words of a chief medical information officer, Implementing CPOE should not be thought of as an event, but a long‐term commitment.

Beyond following proposed best practices for the implementation of CPOE, community hospitals may need to adopt additional strategies to address their unique challenges. Given the misalignment of incentives for physicians' use of CPOE, leadership in community hospitals must be particularly skilled at articulating the benefits of CPOE to physicians. These benefits include not only decreased professional liability from improved patient safety and better quality of care, but also fewer pharmacy callbacks, remote access, and rapid ordering through order sets. Hospitals may also want to elicit support from physicians early by empowering them to create order sets for their disciplines. Mechanisms for hospitals and physicians to engage in mutual cost‐sharing arrangements may provide addition opportunities for hospitals to entice physicians to adopt the technology. Finally, and of particular interest to the readership of this journal, as hospitalists become more prevalent and take care of an increasing proportion of hospitalized patients,23 they are often ideal candidates to lead the implementation of CPOE in community hospitals. Because hospitalists spend most of their time in the hospital, they are often in the best position to get fully trained on CPOE, to define their own order sets, and to redesign care processes in order to take full advantage of CPOE capabilities. In addition, as many hospitalists are directly employed or supported by the hospital, their goals for quality, safety, and efficiency are usually better aligned with those of the hospital.

The stakes involved in implementing CPOE are high. Hospitals invest enormous sums of money in these systems, and many will not have the financial or political capital to attempt a second implementation after an initial failure. In addition, as recent research has pointed out,24 inappropriate implementation strategies may lead to delays in essential care and direct patient harm. In many ways, the complex task of implementing CPOE is not unlike other endeavors in patient care, where optimal outcomes require sound knowledge and reliable processes and where disaster can strike for lack of attention to detail or common sense. If Hippocrates were alive today, he might have this to say about CPOE implementation: Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.

This issue of the Journal of Hospital Medicine contains the inaugural article in a planned series addressing key palliative care topics relevant for the practice, teaching, and study of hospital medicine. As was noted by Diane Meier in her article Palliative Care in Hospitals1 and in Steve Pantilat's accompanying editorial, Palliative Care and Hospitalists: A Partnership for Hope,2 hospitalists are well positioned to increase access to palliative care for all hospitalized patients. Achieving this goal will require that hospitalists attain at least basic competence in the components of high‐quality, comprehensive palliative care (assessment and treatment of pain and other symptom distress, communication about goals of care, and provision of practical and psychosocial support, care coordination, continuity, and bereavement services). Palliative care is becoming more prominent in medical school and residency curricula, palliative care fellowship opportunities are proliferating, a number of palliative care resources are available on the Internet, and motivated hospital‐based providers may attain palliative care education via a variety of educational programs and faculty development courses (see Table 1 in the Meier article).1 Some hospital medicine programs have specifically targeted faculty development in palliative care competencies.4

Recognizing the salience of palliative care for the practice of hospital medicine, the Society of Hospital Medicine (SHM) created the Palliative Care Task Force specifically to raise awareness of the importance of palliative care to hospital medicine and charged it with developing relevant palliative care educational materials. The Palliative Care Task Force has selected the Journal of Hospital Medicine as a means of disseminating palliative care content through a series of peer‐reviewed articles on palliative care topics relevant to hospital medicine. The articles will address practical matters relevant to care at the bedside in addition to policy issues. The article in this issue, Discussing Resuscitation Preferences: Challenges and Rewards,3 addresses the common barriers to and provides practical advice for conducting these frequent, but often difficult, conversations. Planned topics, addressing some of the key domains of palliative care clinical practice, include: pain management, symptom control, communicating bad news, caring for the clinical care provider, and importance of a multidisciplinary team approach to end‐of‐life care. Each of these articles will specifically address the relevance and implications of these topics for the practice of hospital medicine.

The Journal of Hospital Medicine looks forward to reviewing these articles from the Palliative Care Task Force and invites additional submissions relevant to the practice, teaching, or study of palliative care in the hospital setting.