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Director’s Forum

Big Data: Implications for Health System Pharmacy

Laura B. Stokes, PharmD*; Joseph W. Rogers, PharmD, MS†; John B. Hertig, PharmD, MS, CPPS‡; and Robert J. Weber, PharmD, MS, BCPS, FASHP, FNAP§

Big Data refers to datasets that are so large and complex that traditional methods and hardware for collecting, sharing, and analyzing them are not possible. Big Data that is accurate leads to more confident decision making, improved operational efficiency, and reduced costs. The rapid growth of health care information results in Big Data around health services, treatments, and outcomes, and Big Data can be used to analyze the benefit of health system pharmacy services. The goal of this article is to provide a perspective on how Big Data can be applied to health system pharmacy. It will define Big Data, describe the impact of Big Data on population health, review specific implications of Big Data in health system pharmacy, and describe an approach for pharmacy lead- ers to effectively use Big Data. A few strategies involved in managing Big Data in health system pharmacy include identifying potential opportunities for Big Data, prioritizing those opportuni- ties, protecting privacy concerns, promoting data transparency, and communicating outcomes. As health care information expands in its content and becomes more integrated, Big Data can enhance the development of patient-centered pharmacy services.

INTRODUCTION Health care is becoming increasingly complex

with the advent of new treatments, evolving provider roles, changing legislation and payment models, and health information technology. The electronic medi- cal record (EMR) is a form of health care technology used by providers and patients to access and manage medical information. Computer desktops, laptops, and mobile devices provide efficient and effective ways of viewing and processing medical information. EMRs also have interoperable capabilities; various applications can be viewed in one program providing a comprehensive view of a patient’s medical history.

Big Data has been associated with nuclear phys- ics, supercomputers, and defense simulations. Tech- nology advances, particularly in banking and retail, enable the use of Big Data in business. For example, retail vendors use Big Data to enhance the understand- ing of consumer demand; purchasing patterns can be tracked using reward cards and loyalty programs so that decision makers can more effectively interpret customer needs.1 The Human Genome Project was the

first science and health care program to use Big Data; the magnitude of computing required to sequence the massive amount of genetic information challenged paradigms in data-processing capacity.

Big Data can also be a powerful tool for phar- macy directors regardless of the size of their depart- ments. Leaders must understand the concept of Big Data, how organizations can use it, and pharmacy’s role in that plan. The goal of this article is to provide perspective on how Big Data can be applied to health system pharmacy. It will define Big Data, describe the impact of Big Data on population health, review specific implications of Big Data in health system pharmacy, and describe an approach for leaders to effectively use Big Data. As health care information expands and becomes more integrated, Big Data will enable the growth and expansion of patient-centered pharmacy services.

BIG DATA DEFINITION Big Data is defined as data sets that are so large

and complex that traditional computing methods are

*PGY1 Health System Pharmacy Administration Resident; The University of Texas MD Anderson Cancer Center, Houston, Texas; † PGY2 Health System Pharmacy Administration Resident, Memorial Hermann Health System, Houston, Texas; ‡Asso- ciate Director, Purdue University College of Pharmacy, Fishers, Indiana; §Administrator, Pharmacy Services, The Ohio State University Wexner Medical Center, Columbus, Ohio

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not capable of handling the information.2 Big Data results from the rapid assimilation of information that is complex, is large in byte size, and is from many different sources. Big Data gathers and stores health care outcomes resulting from advances in technology, treatments, and analytics and transmits this infor- mation very quickly to data warehouses. Common examples of how Big Data is used today include Net- flix’s ability to predict how you will rate a given film using a variety of complex variables3 and Facebook’s use of subscriber information to target posts and advertisements of interest.4 A few examples of Big Data in health care include the demonstration of how medication prescribing patterns differ in relation to outcomes in various locations or the prediction of a patient’s therapy success based on models built from data from similar patients.

Some major sources for Big Data in health care are the electronic medical record (EMR), administra- tive claims information, and clinical decision support databases, like First Databank. EMRs include real- time clinical data, such as patient identifiers (admis- sion numbers), vital signs, diagnoses, and coded therapies. Administrative data include information from the Centers for Medicare & Medicaid Services or commercial insurance claims. All of these data are relevant and accessible to health system phar- macy leaders. Table 1 summarizes different types and sources of health care data.5

IMPACT OF BIG DATA ON POPULATION HEALTH Population health is defined as the health out-

comes of a group of individuals, including the distribu- tion of such outcomes within the group.6 Big Data may provide population health statistics for various medi- cation-related indicators such as readmissions, patient triage and prioritization, adverse drug events, and expensive medications. Bates and colleagues described the need for enhanced methods of identifying high- cost and high-risk patients to ensure effective interven-

tion. If patients are incorrectly identified as high risk, the benefit of enhanced care management interven- tions is lost. Additionally, in the case of readmission and triage, clinical workflow algorithms can be used to help identify patient-specific parameters, prioritize patients according to risk factors, and minimize the time to appropriate therapy. Big Data may be used to measure the effectiveness of this algorithm.7

Innovation in health care is influenced by finan- cial models, patient needs, provider motivation, and technology advances. Big Data may play an impor- tant role in driving health care innovation. Table 2 summarizes how Big Data supports health care inno- vation through data demand, supply, technology, and government assistance.8

Future cost projections suggest that health care expenditures in the United States will continue to increase. The aging baby boomer population, increased prevalence of chronic disease states, technological advances, costly end-of-life care, and other operational issues contribute to this projection.1 Health care legis- lation is moving toward measuring quality health care outcomes. Additionally, incentives and reimbursement for services depend on quality outcomes. In a chang- ing health care landscape, where accountable care organizations and patient-centered medical homes are becoming the norm, the implications of Big Data are at the forefront of progressive operational change.

Big Data may be most effectively used to pro- vide patients and providers with information based on population statistics to determine the best treat- ment options.2 EMR data can be used on a large scale to provide insight on patient outcomes. These data include length of stay, risk factors for compli- cations, or disease progression; all of these data can be extrapolated to populations to predict outcomes. Using real-time data in intensive care units or emer- gency departments to rapidly detect changes in patient status and apply appropriate treatments is another example of the use of Big Data.1

Table 1. Types of health care data5

Type Source Attributes

Administrative •   Government (CMS) •   National surveys (Medical Expenditure Panel Survey) •   Commercial vendors (health plans, PBMs, etc)

•   Insurance billing •   Financial reporting •   Lacks clinical detail

Clinical •   Hospital EMR •   Physician EMR •   Integrated delivery network EMR •   Clinical database

•   Clinical data collected for patient care

Note: CMS = Centers for Medicare & Medicaid Services: EMR = electronic medical record; PBMs = pharmacy benefit manager.

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Each stakeholder within the health system has different goals for the use of Big Data. Patients may utilize these data to empower their health care deci- sions, whereas providers may use Big Data to obtain real-time information about their patients or for deci- sion support. Health applications – or “apps” – have been created to help manage many chronic disease states, including diabetes, and to enable smoking ces- sation and improve nutrition. Ochsner Health Sys- tem, New Orleans, Louisiana, has implemented a stand-alone “O Bar,” where patients can walk in at any time to ask questions about health apps they are using and receive recommendations about other apps and technologies for wellness.9

Pharmaceutical and medical device companies may use the data to better understand the mechanisms of diseases and their progression to develop safe, targeted therapies with the fewest possible adverse events. Analysis of large datasets can enable predictive modeling, which will result in a more efficient medica- tion therapy development process. Advanced statisti- cal analysis and optimized study designs will result in stronger therapy trials with medications and their intended populations. Big Data will also be a useful tool in surveillance for adverse medication events, both before and after market. The ideal impact of Big Data on the pharmaceutical industry is to ensure that the right patient has the right medication at the right time.1 Medical device companies market prod- ucts for home monitoring of medication levels and as surrogate markers of chronic diseases. A health care provider often transmits data electronically from the patient’s home device to the EMR for review.

Providers review the data and make adjustments to medications or the therapy plan over the phone. Providers can monitor patients for safety and adverse events without seeing them in person. This gives patients increased access to health care without the cost and inconvenience of an in-office visit. This is common practice in blood glucose level monitoring

and international normalized ratio (INR) testing for warfarin therapy; in the future, this mechanism of care delivery will be increasingly prevalent. Pay- ers may use Big Data to develop sustainable business models secondary to the transition away from the fee-for-service payment model. Finally, governmen- tal agencies may use Big Data to reduce health care costs and enforce health care regulations related to the quality of patient outcomes.1 Each stakeholder within the health system will use Big Data in unreal- ized capacities in the future.

As information technology grows more capable of translating Big Data, evidence-based guidelines may not be as applicable to patient care. Some of the popu- lation health outcomes may demonstrate treatment approaches different than those suggested by some guidelines. Providers may use clinical decision support tools to help ensure the safety and appropriate use of medication therapy given patient-specific factors such as weight and creatinine clearance. As Big Data becomes more prevalent in practice, providers will use this infor- mation to develop treatment plans for each patient.

Another challenge related to the use of Big Data is the impact on Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy standards. There is debate among health care lead- ers as to the public benefit of Big Data and the pro- tection of patient privacy (HIPAA concerns). The integration of multiple systems and the combina- tion of data from a variety of sources is concerning to some patients. HIPAA does not directly address the complexity of data manipulation today; much work is necessary to truly understand the real pri- vacy risks associated with using Big Data in popu- lation health.

APPLICATION OF BIG DATA TO HEALTH SYSTEM PHARMACY

Most EMRs have clinical decision support tools to guide the most appropriate prescribing of medication.

Table 2. Aligning Big Data to support health care innovation8

Demand for data •   Cost pressures •   Need to act quickly (first movers show impact, while late adopters only “keep up”)

Supply of data •   Clinical data available across continuum of care •   Non–health care consumer data readily accessible

Technological capability •   Advances in combining administrative claims data with clinical data •   Analytics

Market changes •   Government emphasis on transparency •   Interoperable standards between competitors in the private sector

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Clinical decision support tools related to pharmacy include medication dose buttons, medication alerts such as duplicate therapy or drug-drug interaction alerts, and warning pop-ups to alert users of poten- tially unsafe practice. Clinical decision support tools can also be used in other aspects of patient care to increase efficiency and improve the quality of care provided.1 Potential applications include database maintenance, increased metrics and tools available in inpatient and outpatient areas, and tools targeting pop- ulation trends. The clinical data maintained within the EMR can be used to identify patients who are at risk for complications and would benefit from early inter- ventions or proactive care. This concept will become more applicable with increasing advances in informa- tion technology and advanced analytical skills.2

EMRs also contain financial, operational, and genetic data that can be used to evaluate the appropriateness of treatment options for individual patients. Over the past 5 years, the amount of data

generated has significantly increased. As information technology can better organize and analyze the data, the opportunity to use data as benchmarking tools between institutions will continue to increase. Clini- cal benchmarking databases can be used to identify best practices, sources of waste within a workflow, and resource utilization.10 These data can be used by directors of pharmacy to identify problems and devise strategies for resolution or cost reduction.

GUIDING PRINCIPLES FOR USING BIG DATA As health care moves toward utilizing Big Data to

optimize patient care outcomes while reducing health care costs, pharmacy leaders can use the following guid- ing principles to effectively use Big Data (Figure 1).11 Improve the core business first. By evaluating the core business, leaders can identify all of the potential opportunities for Big Data within their organization. If this step is not taken, all of the benefits of the data may not be realized due to unidentified applications.

Optimization of clinical decision

support tools

Formulary management and adverse

event monitoring

Measure the quality of care

and patient outcomes

Better care transitions via data related to

medication adherence

Enhanced application of

evidence-based medicine

Claims and cost data that provide

information on utilization

Big Data uses within Health

System Pharmacy

Figure 1. Using Big Data to promote health system pharmacy operations and management.11

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Define organizational model and talent strategy. Deter- mining who will design and implement Big Data initiatives within an organization is one of the first steps necessary when planning a process change. Successful strategies include initiatives led within or across business units, through functional groups, or at the executive level. Make it a priority. Especially within health care, it is imperative that leaders buy in to the application of Big Data as a tool to improve patient care outcomes. If the application of Big Data is a priority beyond the initial planning stages, the organizational workforce will be ready for the changes. Additionally, leadership should focus on recruitment of the right talent and concentrate significant efforts on strategic areas. Establish a vision from the top-down; establish innovation from the bottom-up. When leaders set a vision and a strat- egy, it allows end users to innovate and increases oppor- tunities. However, this is only possible in an environ- ment where local innovation is the culture. The vision set for the use of Big Data must go beyond performance metrics and should encompass transformational change within the institution in order to get necessary buy in from front-line personnel. Engaging employees to exe- cute the vision results in empowered employees com- mitted to the established goals. Set diverse goals. Goals associated with the implica- tions of Big Data should vary in size and target date. By establishing short-, medium-, and long-term goals, momentum is established early on and maintained throughout the life of the project. Strive for transparency. Data transparency in health care is important in terms of regulatory compliance. To meet regulatory standards in health care, the data must be HIPAA compliant and secure. Understanding how the data is procured and providing transparency about the strengths and limitations of the data is nec- essary for health care leaders. Additionally, making data available for internal and external benchmark- ing can be mutually beneficial for patient outcomes, workflow efficiencies, resource utilization, and health care expenditure. Internal and external communication. Transparent communication with stakeholders, both internal and external, will help leaders refine viewpoints and ensure congruency of agendas.

CONCLUSION Big Data is generated by the rapid assimilation

of technology from a variety of resources that range from simple to complex in their content. Health sys-

tem pharmacy leaders must understand Big Data and how they can use its elements to improve their phar- macy practice model. Medication use outcomes can be predicted by Big Data provided there is a strategy for its application. The strategies offered in this arti- cle should guide the pharmacy director in the future when handling Big Data. As health care information expands in its content and becomes more integrated, Big Data will be a valuable tool for enhancing the development of patient-centered pharmacy services.

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2. Bates D, Saria S, Ohno-Machado L, Shah A, Escobar G. Big data in health care: Using analytics to identify and manage high-risk and high-cost patients. Health Affairs. 2014;33(7):1123-1131.

3. Krumholz H. Big data and new knowledge in medicine: The thinking, training, and tools needed for a learning health system. Health Affairs. 2014;33(7):1163-1170.

4. De Montcheuil T. Facebook: A decade of big data. Wired. http://www.wired.com/insights/2014/03/facebook-decade- big-data/. Published March 2014. Accessed April 26, 2016.

5. Aparasu R, ed. Research Methods for Pharmaceutical Prac- tice and Policy. Gurnee, IL: Pharmaceutical Product Press; 2010.

6. Kindig D, Stoddart G. What is population health? Am J Publ Health. 2003;93(3):380-383.

7. Raghupathi W, Raghupathi V. Big data analytics in health- care: Promise and potential. Health Information Sci Syst. 2014;2(3):1-10.

8. Groves P, Kayyali B, Knott D, Van Kuiken S. The big data revolution in healthcare. Center for US Health System Reform Business Technology Office. http://www.mckinsey. com/industries/healthcare-systems-and-services/our-insights/ the-big-data-revolution-in-us-health-care. Published January 2013. Accessed April 1, 2015.

9. Ochsner’s O bar uses interactive health technology to enhance patient engagement. New Orleans, LA: Ochsner Health System Public Relations Department; July 30, 2014. https://news.ochsner.org/news-releases/ochsners-o-bar-uses- interactive-health-technology-to-enhance-patient-engage/. Accessed May 11, 2016.

10. O’Neal B, Weber R. Director’s Forum: Benchmarking drug prescribing using clinical databases: A tool for practice model enhancement. Hosp Pharm. 2011;46(10):809-814.

11. Ma C, Smith HW, Chu C, Juarez D. Big data in pharmacy practice: Current use, challenges, and the future. Integrated Pharm Res Pract. 2015;4:91-99. 

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