Lab Soft News

Cognitive Decline Documented in the U.S. Southern "Stroke Belt" States

A tier of U.S. Southern states is commonly referred to as the "stroke belt" because of its high prevalence of this condition (see: Drop Me Off at the ER as Soon as I Finish My Fried Fish Dinner). Now comes evidence that people in the this same area  also have a higher risk of cognitive decline as a component of this neurologic spectrum (see: U.S. South Has Higher Risk of Cognitive Decline). Below is an excerpt from the article

U.S. South Has Higher Risk of Cognitive Decline For decades public health researchers have known that individuals living in the American South displayed an increased risk of stroke and other forms of cardiovascular disease. A new study finds that individuals living in this region also have a greater incidence of cognitive decline compared to other regions of the country. The region is generally considered to be an 11-state cluster including Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia. Researchers believe shared risk factors are to blame for the increased chance of cardiovascular events and cognitive decline. Risk factors have been hypothesized to include increased rates of hypertension, low socioeconomic status, high fat diet, cultural lifestyle, quality of health care facilities, smoking, and infections. In 1965, the “Stroke Belt” first appeared in medical literature to describe the southeastern region of the U.S. where stroke mortality rates were 50 percent higher than the remaining U.S. regions. In the new study, called The Reasons for Geographic and Racial Differences in Stroke (REGARDS), [the lead investigator] recruited over 30,000 U.S. adults aged 45 or older from 2003 through 2007 and is following them for stroke and cognitive decline....Risk of cognitive impairment was 18 percent higher in residents of the Stroke Belt than in those living in non-Belt states after adjusting for the influences of age, sex, race, and education level. The research team suggests that future studies should examine the impact of migration patterns, urban versus rural residence, socioeconomic factors, and educational quality on cognitive decline. 

For me, the key sentence in this article addresses the etiologic factors underlying strokes in particular and cognitive decline in general in the South: hypertension, low socioeconomic status, high fat diet, cultural lifestyle, quality of health care facilities, smoking, and infections. To this list I would also add lower educational levels which, of course, is a facet of lower socioeconomic status. Education correlates strongly with health status (see: Low Health Literacy and the Chance of Death; Correlation of Sociodemographic Status with Personal Engagement in Cancer Screening Programs) Obviously, this is a very long list and many of these problems are not amenable to quick fixes. I had never personally associated cognitive decline with a later predisposition to stroke but the correlation definitely makes sense. The brain is dependent on its arterial blood supply for nutrition and oxygen. If that supply is slowly diminished by athero- and arteriosclerosis, brain function will certainly decline over time . Obviously, such a decline may be subtle but the article quoted above describes the test methods used to assess it.

Clinical Trials Increasingly Move Offshore, Many to China

Clinical trials are increasingly moving offshore for a number of reasons (see: Status and Challenges of Offshore Clinical Trials). They include lower costs and the ready availability of "treatment-naive" subjects such that recruitment can be accomplished more easily than in the U.S. Moreover, it also easier to recruit subjects in poorer countries where they hope to obtain treatment that would otherwise not be available for them. A recent article provides some interesting insights into clinical trials in China (see: Drug makers seeking global guinea pigs). Below is an excerpt from it

For now, the world's emerging economies still play second fiddle to the United States when it comes to testing drugs. Clinicaltrials, a website run by the U.S. National Institutes of Health, currently lists more than 106,000 trials around the world, of which just over 50 percent are in the United States. But the balance is shifting, particularly when it comes to the big late-stage trials that really matter in deciding whether a drug is approved for sale. U.S. centers account for only 43 percent of the nearly 19,000 trials in final Phase III testing. As in so many other areas of life, the rising star is China, which already has a total of more than 2,700 clinical trials and is experiencing exponential growth....China has already leapfrogged the likes of Germany and France to become the world's third largest market for pharmaceuticals, and by 2015 it is set to overtake Japan as the second-biggest, behind only the United States, according to pharmaceutical market information company IMS Health....Independent expert Dr. Rory Collins, a professor of medicine at the University of Oxford and co-director of its Clinical Trial Service Unit, is a big fan of the power that Chinese clinical research can bring to medicine and is deeply impressed by how far the country has come in two decades....Six years ago, Collins's Oxford team led a huge 46,000-patient study in China -- the biggest ever seen in the country -- to test the blood thinner Plavix and a beta-blocker in the emergency treatment of heart attacks...."That study would never have been done if we couldn't have run this very streamlined trial in China at very low cost," says Collins, who is currently working on another pivotal heart drug study for Merck that contains no U.S. patients. "My preference would be not to do any trial in North America because it is so inefficient and so costly." 

This article provided me with a new insight into the increased tempo of migration of clinical trials to China. As noted above, China is currently the world's third largest market for pharmaceuticals and by 2015 will become the second largest. Not only can clinical trials be performed for a lower cost in China but the market for pharmaceuticals in the country is also huge. One of the objections to clinical trials overseas for drugs that will be sold in the U.S. is that the research subjects are genetically different than the U.S. population. Here's an excerpt from an article that raises this issue (see: Clinical trials overseas raises quality control issues):

[Seth Glickman, M.D., a senior scholar at Duke's Fuqua School of Business] says social ecology and genetics may also play a role in trial outcomes, and may limit their applicability to patients who do not share such characteristics. For example, healthcare-rich economies produce patients with one set of characteristics, while participants with little access to healthcare may have quite different profiles. "It is conceivable that use of the same drug in both populations would produce markedly different results." Likewise, genetic polymorphisms, or "signatures" in some populations can affect response to certain drugs, making it inappropriate to apply results from studies in these populations to patients who do not share those characteristics.

With regard to clinical trials in China, and perhaps India, the pharmaceutical companies derive benefit in two ways. First, they can manage their clinical trials more efficiently and less expensively. Secondly, the "genetic signatures" of the subjects in the trials would be close to that of the patients in China for whom the drugs would eventually be prescribed.

More (and Interesting) Discussion about Incidentalomas

I recently posted a note about so-called incidentalomas, lesions often "accidentally" discovered during CT scans that have been ordered on the basis of other diagnostic concerns. You may want to refer to it to refresh your memory about the topic (see: How to Avoid the Risks of a CT Incidentaloma). Dr. Mark Pool who blogs over at The Daily Sign Out has posted a a well-thought-out note that extends this discussion in some interesting ways (see: Incidentalomas revisited). Below is an excerpt from it:

Dr. Bruce Friedman posted a thoughtful blog on Lab Soft News recently concerning "incidentalomas" ....This post happened to coincide with a new working committee at my hospital commissioned with developing a virtual clinic for following patients who have incidental lung nodules discovered. Perhaps unlike other sites, there are widely disseminated radiographic recommendations for following lung nodules (Fleishner criteria)....One issue that we will be challenged with is how to track these patients across multiple different providers for appropriate follow-up.  One model we are considering is already in place: using a breast "navigator" to follow-up patients with abnormal mammograms.  This issue arose recently because of a series of patients presented at our Tumor Board who had incidental lung nodules identified but were not followed appropriately and then were re-discovered with inoperable advanced stage disease months later....While I concur with the basic premise of the post (i.e. that one shouldn't jump into a full-blown diagnostic work-up of an incidental finding), I think we should also insist on developing evidence-based criteria for managing these types of findings such as Fleishner criteria for lung nodules.

Mark does a great job in his note of teasing out a key issue regarding incidentalomas that I had not considered. If an when an incidentaloma is discovered during a patient's care episode, how can his or her physicians ensure that the followup of the lesion is appropriate? Here's a brief description of the breast navigator program about which Mark makes mention above. Such individuals are assigned the specific task of ensuring continuity of care for breast patients (see: Breast Cancer Navigator Certification Program):

In 2008, the NCBC [National Consortium of Breast Centers] recognized the need for a standardization of the Breast Patient Navigator's role. Just as the breast care/cancer diagnosis and treatment process may differ from facility to facility, so do the definitions, activities, knowledge and job descriptions of a breast patient navigator. These disparities can adversely affect the breast care/cancer treatment provided to women across the nation and around the world. In an effort to minimize and eventually eliminate the variances in a breast patient's continuum of care and the definition/function of a breast patient navigator providing care within that continuum, the NCBC created this program.

I hate to admit this, but our heath system is so fragmented that I have little confidence that many/most incidentalomas would receive adequate followup after they are discovered, particularly if a patient changes providers. And by the way, these lesions occur frequently enough that this constitutes a real problem. My first idea was an "incidentaloma bracelet" that radiologists or clinicians could hand out to patients. However, this would only serve as an alert the next time that a patient was admitted to the hospital for an acute problem and not necessarily ensure proper followup. I am stumped. This is a generalized alert/followup challenge in our healthcare delivery system -- we can't just continue to patch specific problems.

"Usability Failures" of EMRs Frustrate Physician Users

The fact that EMRs have been failure prone is no secret (see: The Causes of EMR System Implementation Failure). The cause of such failures is multifactorial. Lab Soft News has also covered this topic in the past (see: EMR Failures and a Recipe for Their Avoidance in the Future; Modeling the Costs of IT System Failures Globally). However, I firmly believe that physicians, like most professionals, will avidly embrace any type of information technology that will improve their productivity. This is particularly true these days when healthcare reform requires physicians to work more efficiently. It follows that a large part of the rejection of EMRs by clinicians is based on the fact that they are not well designed. A recent article discusses this issue (see: Complexity of EMRs discourages new users, doctors tell HHS panel),. Below is an excerpt from it:

Physicians say they want electronic medical records to be fast, accurate and easily customized, but they are reporting that usability of EMRs doesn't appear to be the focus of the federal government when establishing meaningful use standards and certifying products. Physicians are frustrated with newly purchased EMRs, doctors told a Dept. of Health and Human Services panel that makes recommendations on health information technology policy. They said physicians might not be as tech-savvy as other professionals and are encountering problems with the technology while trying to earn potentially tens of thousands of dollars in Medicare and Medicaid EMR bonuses. Physicians discussed the usability issue during an April 21 hearing of the Certification/Adoption Workgroup, part of the HHS Health Information Technology Policy Committee. Some physicians using the technology have become deeply discouraged, said [a physician at the hearing]. For instance, one primary care physician told her it takes 10 minutes to navigate drop-down menus to order a routine mammogram. The same task should take no more than a few seconds of a clinician's time....At the hearing, the American Medical Association recommended that future certification of EMR systems by HHS-approved groups include testing and tracking usability. Excessive click-through screens, design limitations and alert overload are factors discouraging doctors from using EMRs. Failing to take usability into consideration can lead to unintended patient safety issues, the Association said. Examples include computer screens with too much information, nonintuitive steps to gain key data, small font sizes and the potential for selecting the wrong patient when multiple records are open at one time.

The question of EMR "usability" is understood by anyone who has worked with computers. The key question if how efficiently a particular task can be performed using the system. The particular task can be ordering a lab test or reviewing the details of the last hospital admission. It's no surprise to me that the "usability of EMRs doesn't appear to be the focus of the federal government when establishing meaningful use standards and certifying products." I am sure that such standards were largely developed by government officials, vendors, EMR consultants, and organizations such as HIMSS with hardly an end-user physician in sight. As I have noted before, HIMSS is joined at the hip with vendors and CIOs whose primary concerns will be distant from system usability (see: HIMSS Describes Itself as a "Trade Association" in a Press Release; Multiple Privileges Extended to Hospital CIOs at HIMSS).

What I find most interesting about this article is the focus it places on how EMRs affect patient safety. My guess is that the issue of "usability" from a physician efficiency perspective would elicit only a yawn from regulators. Therefore, the only way to get their attention is to link usability to patient safety. Here's where the irony comes into play. Computer-alert-overload is cited above as one of the factors that can dull the senses of physicians and potentially harm patients. Why were EMRs originally designed with multiple patient alerts in the first place? This was a feature offered to ensure patient safety. All of this underscores the fact that most of today's leading EMRs were designed with insufficient, effective input from the physicians who are now being asked to use them as one of their primary work tools in hospitals.

Should Hospitals Set Up Private Social Networks for Their Patients?

A recent article about how Toyota is setting up a private social network for its customers stimulated my thinking about how this idea might apply to hospitals and their patients (see: Toyota Owners To Get a Private Social Network). Below is an excerpt from it:

Toyota has teamed up with Salesforce.com to create Toyota Friend, a private social network for owners of Toyota cars. The network will be accessible through PCs, tablets and smartphones, giving Toyota customers the ability to connect with their dealerships, cars and Toyota itself. For example, your car could send you an alert when its battery needs recharging, and you would be able to connect to your dealership to get maintenance tips and service information. Toyota Friend will primarily be a private network for Toyota car owners, but customers will be able to connect and expand the experience through public social networks such as Facebook and Twitter. The network will be powered by enterprise social network Salesforce.com’s Chatter and Toyota’s telematics platform. The first cars to be shipped with social networking capabilities will be Toyota’s first battery electric vehicles and plug-in hybrid cars, which are coming next year.

The idea of alerting Toyota owners to the need for car maintenance suggested to me that hospitals could copy this idea for their patients. Imagine a hospital social network that enabled patients to perform functions such as the following: (1) make physician appointments; (2) receive alerts about upcoming appointments; (3) access family inoculation records; (3) review lab test and radiology results; (4) access health education videos and pamphlets; (5) review billing records; (6) join, and interact anonymously, in on-line chat sessions with other patients about medical problems. These latter sessions could be moderated by healthcare professionals to ensure that they don't stray off topic or provide inappropriate advice. They would also be free of drug company influences as is the case currently with many disease-oriented web sites.

In my mind, such a resource would combine the best features of personal health records (PHRs) plus many of the most popular health-related web sites (see: Developing an Electronic Medical Record Ecosystem (Network); Some Hospitals Hold Hostage the Medical Records of Their Patients; Cancer Survivor Launches Cancer Commons Web Site Focusing on Melanoma). I have been disappointed by the relative lack of popularity of PHRs although they have been deployed by the most innovative health systems like Kaiser and the Cleveland Clinic (see: Personal health record). I suspect that some of the early hospital-sponsored PHR projects could naturally evolve into private social networks. This seems to me to be logical progression given the huge success of Facebook in the last two years. Many people have now grown accustomed to the social network model for daily interaction and access to information. Applying it to health education and healthcare delivery seems to me to be a logical next step (see: Why and How Hospitals Should Market Themselves to Consumers on the Web).

::Update on 5/25/2011 @ 9:30 a.m.

(see: Musings on PHRs & Consumer Engagement)

As we have stated many times before, consumers are not terribly interested in a digital file cabinet for their records. What they are interested in is what that data can do for them, particularly on the transaction side. In the “what’s in it for me” category, consumers seek convenience in all aspects of their lives. If they are presented with a system that not only grants them access to their records, but helps them schedule appts, directly communicate with their care team via email, do Rx refill requests, etc. then you’ll see some adoption.....But even then it may not see strong adoption if clinicians are not strong advocates of its use. In deference to the first comment above from the researcher, trust does matter and patients/ consumers do trust their doctors. If the doctor encourages use, adoption will follow. Unfortunately, sites like Google Health, HealthVault and Dossia  as well as a slew of other independent PHR companies are one step removed from these types of transactions and their use is not actively encouraged by clinicians, leading to anemic adoption rates. And even within healthcare organizations, there is often not strong support among clinicians for patients to use the organization’s sponsored, tethered PHR.

One-Time PSA before Age 50 Can Stratify Risk for Subsequent Prostate Cancer

The value of PSA for the diagnosis of cancer of the prostate continues to interest me (see: Solid Advice for Older Men Regarding PSA Screening for Prostate Cancer). The test has always had its critics but it seems to have met the test of time and no other test has supplanted it in popularity thus far. Now comes the idea that a one-time PSA measurement before age 50 can stratify men at risk for subsequent cancer (see: Single PSA Before Age 50 Stratifies Men at Risk). Below is an excerpt from the article:

The long-term risk for prostate cancer can be predicted from a 1-time prostate-specific antigen (PSA) test before 50 years of age, according to a study presented here at the American Urological Association (AUA) 2011 Annual Scientific Meeting.  The study, which comes from a population of more than 20,000 Swedish men, indicates that men with a PSA value above 1.5 ng/mL between the ages of 45 and 49 years account for nearly half of the prostate cancer deaths over the next 30 years or so. Only 10% of the men in the study had such high PSA values at this relatively young age, noted lead author Andrew Vickers, PhD....The "take-home message" from the study is that, on the basis of a PSA value obtained in a man's 40s, "you can stratify risk," [according to] Dr. Vickers...."This study shows whom we really need to focus on," he added. The young men in this "top 10%" need "aggressive follow-up," such as reminder phone calls for doctors' appointments, and should have either annual or biennial PSA tests, he said...."Currently, a lot of these men would be told: 'You're fine'," he said. And they are fine, to a large extent. Their absolute risk of dying from prostate cancer is low, said Dr. Vickers.

I don't know if this research will be validated in subsequent studies but it's fascinating in terms of its simplicity. The majority of men who receive periodic physicals will have at least one PSA in their 40's. Patients whose result is "above 1.5 ng/mL between the ages of 45 and 49 years" need to be more closely followed than other men in this cohort for prostate cancer. This, of course, does not mean that the remaining 90% of men should be ignored. They will require routine periodic PSA testing. Another decision point occurs at about age 60 (see: Single PSA Before Age 50 Stratifies Men at Risk). Here's a quote from this latter note:

If you are a male who is 60 years old and your PSA is 2.0 or higher, you need to be very vigilant and continue to be tested for PSA and also undergo periodic physical exams. If you are the same age and your PSA is 1.0 or lower, you seem to be out of the woods, at least as far as cancer of the prostate is concerned.

The "True Cost" of Implementing an EMR or LIS

Mr. HIStalk came up with another gem of a observation recently: software license fees are often nearly irrelevant to overall project cost, especially on the often-forgotten cost of internal labor (see: Monday Morning Update 5/16/11). Below is his exchange with a reader:

From Former CIO: “Re: high price of Epic. In my experience, the price of Epic software is competitive with others (at least the big guys). The difference is that they drive the customer to look at the true cost of implementation and plan for the resources, internal and external, training, etc. The other vendors hope you won’t actually add it all up until you sign the software contract. This is the best part about Epic since it gets the organization to accept the budget, even if difficult. If you are not prepared to spend the money then they may walk away. In the end, Epic is not necessarily more costly than the others would be.”

Mr. HIStalk response: An excellent reminder that I often need. Software license fees are often nearly irrelevant to overall project cost, especially on the often-forgotten cost of internal labor. It would be interesting to survey recently implemented hospitals to find out how implementation budget overruns correlate to specific vendors.

I will assume for this discussion that the "Former CIO" is correct in his observations that (1) Epic software is competitive in the marketplace; and (2) the company drives their customers to assess the true cost of implementation of a system. Mr. HIStalk adds that the cost of internal labor should be included in the analysis of the true cost of system implementation. This latter figure is the cost of the the effort spent by employees (e.g., nurses, medical technologists, physicians) interacting with vendor personnel, preparing the system for deployment, and training on the system.

Some, but certainly not all, of the cost of internal labor, is hidden. During the deployment of a new LIS, for example, lab personnel often redouble their work efforts in order for the project to succeed . They generally believe in the effort and look forward to working with a new and hopefully more efficient LIS. However, it may be difficult to assign a cost to this increased work efficiency. And, eventually, the increased work tempo takes its toll on lab personnel, resulting in increased stress levels and burnout. In the short-term, some of these problems can be ameliorated by paying overtime for the increased workload but additional FTEs are certainly required for a long-term effort. This brings to light at least part of the additional cost of internal labor.

Steps to Prevent the Progression of Prediabetes to Diabetes

Prediabetes is a common condition in the U.S. as is, of course, the disease itself (see: The Staggering Cost of Treating Diabetes). The so-called metabolic syndrome is one specific form of prediabetes (see: Metabolic Syndrome: The Problem You May Never Have Heard About). Below is an excerpt from an article that discusses prediabetes in a clear fashion (see: Prediabetes: 7 Steps to Take Now):

If you’ve just learned you have prediabetes, you’re not alone. According to the American Diabetes Association, there are 79 million people in the U.S. who have elevated blood sugars, but who don’t yet qualify for a diagnosis of diabetes. About 11% of people with prediabetes go on to develop type 2 diabetes within three years. The same factors that cause prediabetes also cause diabetes. That includes lifestyle (diet and physical activity) and any risk you inherited from your family. Prediabetes can be diagnosed based on various blood tests, including the fasting blood glucose test, the oral glucose tolerance test, and the A1C glycated hemoglobin blood test. The results of those tests, in someone with prediabetes, are out of the healthy range but fall short of the diabetes range.... As scary as a prediabetes diagnosis might be, it’s best to treat this news as a wake-up call. “It’s an opportunity to initiate lifestyle changes or treatments, and potentially retard progression to diabetes or even prevent diabetes,” says [an expert in the field].... Here’s what experts recommend you do to stop the progression to diabetes: 1. Become More Active....2. Lose Some Weight....The Diabetes Prevention Trial found that people who had prediabetes who did 30 minutes a day of moderate exercise and lost 5% to 7% of their body weight were able to cut their odds of getting diabetes by 58%. For someone who weighs 200 pounds, that means losing just 10-14 pounds.

How often can the most appropriate treatment for a disease be encapsulated in six simple words: Become more active. Lose some weight. This advice is doubly important because there are few good drug treatment options for prediabetes (see: Few Good Treatment Options for Pre-Diabetes and Metabolic Syndrome). I fully understand that many patients would prefer to take a drug than even consider lifestyle changes. Unfortunately, drugs are not a good option when faced with the diagnosis of prediabetes. Here are some interesting facts about Weight Watchers (see: Taking Measure of Weight-Loss Plans, and the Studies of Them).

Weight Watchers has conducted dozens of published studies of its program. In those studies, dieters are given free access to meetings, but no free food. In the real world, Weight Watchers participants can often join the program for no charge but pay about $14 a week to attend meetings. Last year, Weight Watchers published an analysis of all dieters who joined the program in Germany during 2009. Among those who attended at least two weekly meetings, the average length of participation was 17 weeks and the average loss about 12 pounds. About 20 percent of participants achieved weight loss of 10 percent or more, according to the report, published in Obesity Facts.

Overuse of Colonoscopy in a Medicare Cohort

It probably will not come as a surprise to veteran observers of our healthcare delivery system that colonoscopies are overordered. This particular procedure is a major source of revenue for gastroenterologists and many healthcare consumers understand the advantages of preventive medicine. The key question, then, revolves around the question of how often to perform the procedure by age group. A recent article addresses this overutilization topic (see: 'Large' Overuse of Screening Colonoscopy in Medicare Cohort), Below is an excerpt from it:

About half of a sample of 24,071 Medicare patients who had a negative screening colonoscopy were rescreened again in less than 7 years — well before the recommended interval of 10 years, according to a new study. And nearly half of the retested patients had no "clear indication" for the early rescreen, the study authors say. The findings indicate that a "large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended," write the authors....The authors also put any possible overzealous endoscopists on notice. The new analysis, when applied to the larger Medicare database, "should be able to identify individual endoscopists with patterns of potential overuse," they write. "Such findings could then trigger audits involving medical chart review." ....A community-based gastroenterologist interviewed by Medscape Medical News thinks that the study is a very limited analysis, that the vast majority of clinicians performing colonscopies are "doing a good job," and that any would-be abusers are "few and far between."....It's time to publicize more than just the benefits of colorectal cancer screening, [the study authors added]. "Public information campaigns that emphasize both the necessity for colorectal cancer screening as well as the dangers of overuse may prove beneficial in reducing overuse."

I am a strong advocate of preventive medicine (see: Preventive and Predictive Medicine as Components of the Healthcare Continuum; Will Large Health Systems Embrace Preventive Medicine and Wellness?; The Need for a Preventive Medicine Infrastructure in the U.S.). Nevertheless and as this article suggests, we need to strike more of a balance in our public information campaigns between the value of a procedure, its risks, and the recommended frequency (see: What are the Recommendations for Colonoscopy Screenings?).

The American Cancer Society and the U.S. Preventive Services Task Force recommend that people receive colonoscopy screenings every 10 years beginning at age 50 and up to age 75. Those aged 76 to 84 should receive screenings on a case-by-case basis, while the over the age of 85 generally do not receive screenings.

When there are deviations from this recommendation and as noted above, the medical records need to document the reason for the different approach. Hopefully, we will soon have an accurate non-interventional lab screening test for colonic cancer. I personally don't think that virtual colonoscopy provides the answer that we are seeking.

The Major Incentive for Mining and Analyzing "Raw Data" in Hospitals

A recent article I came across examines how the mining and analysis of "raw data" in various industries will provide an opportunity for innovation (see: New Ways to Exploit Raw Data May Bring Surge of Innovation, a Study Says). Below is an excerpt from it:

Math majors, rejoice. Businesses are going to need tens of thousands of you in the coming years as companies grapple with a growing mountain of data. Data is a vital raw material of the information economy, much as coal and iron ore were in the Industrial Revolution. But the business world is just beginning to learn how to process it all. The current data surge is coming from sophisticated computer tracking of shipments, sales, suppliers and customers, as well as e-mail, Web traffic and social network comments. The quantity of business data doubles every 1.2 years, by one estimate. Mining and analyzing these big new data sets can open the door to a new wave of innovation, accelerating productivity and economic growth. Some economists, academics and business executives see an opportunity to move beyond the payoff of the first stage of the Internet, which combined computing and low-cost communications to automate all kinds of commercial transactions. The next stage, they say, will exploit Internet-scale data sets to discover new businesses and predict consumer behavior and market shifts. Others are skeptical of the “big data” thesis. They see limited potential beyond a few marquee examples, like Google in Internet search and online advertising....In health care, the biggest slice of the $300 billion gain [from the deployment of new IT systems] is expected to come from more effectively using data to inform treatment decisions. The tools include clinical decision support to assist doctors, and comparative effectiveness research to make more informed decisions on drug therapy....Skeptics say the economic payoff from harnessing big data sets is mostly wishful thinking so far. The nation’s technology-assisted increase in productivity began in 1995 and continued through 2004, having trailed off since, despite investments in data analytics.

Put me down as a skeptic regarding how large hospital data sets will be used (1) to inform treatment decisions and (2) for comparative effectiveness research to make better decisions about drug therapy. First of all, most clinical information systems deployed in hospitals (e.g., LISs, RISs, PACSs, and EMRs) are designed primarily to support healthcare delivery rather than as research systems. For example, you can query AP-LIS databases but this feature is generally used to collect surgical pathology cases for subsequent analysis. The use of LIS databases as the basis for studies about clinical laboratory utilization is relatively infrequent. I believe that EMR databases will definitely be used for "research" purposes but not in the way that the authors of the article above envision. Here's a quote from a Deloitte web page, a leading healthcare consultant, suggesting where clinical data analysis in hospitals is headed (see: Clinical Effectiveness: Achieving Results – Not Just the Latest Buzzword):

The provider community faces a vital challenge in the coming years: how to deal with financial pressures generated by reimbursement cuts, increasing costs and uncompensated or undercompensated care in a responsible and innovative way....While traditional operational benchmarks help to identify potential cost reduction opportunities, these methods do not actively engage the physicians and nurses who are expected to comply with the subsequent recommendations many times in the midst of broken or damaged processes. By collaborating with physicians to define key cost drivers, sharing relevant data and leading practices, and developing the tools through which they can address those cost drivers while taking steps to ensure patient safety, CE2 [Clinical Effectiveness and Efficiency] initiatives can yield measurable, and sustainable, improvements in cost performance and quality of care.

Although comparative effectiveness and clinical effectiveness sound the same, they are not (see: Comparative Effectivenss, Healthcare Cost Reduction, and Virtual Decision Trees). In order to accurately analyze the clinical practices and performance of nurses and physicians working in a hospital, it will be necessary to analyze the clinical database, the EMR. The major cost drivers for a hospital can be then be identified using these data which, in turn, can result in "measurable, and sustainable, improvements in cost performance and quality of care." In short and for hospital executives, the primary goal of the analysis of EMR data will be to improve their financial bottom-line. There is no doubt that quality improvements can also be gained by such projects but the major driver will always be financial.