Big data meets the electronic medical record: a commentary on "identifying patients at increased risk for unplanned readmission".

When should a patient be discharged from an inpatient hospital stay? The quick answer might be, only after the course of treatment is complete and further diagnosis, treatment, or monitoring is not required. However, that approach suggests an extended length of stay, whereas other considerations might argue for a more accelerated approach to discharge. For example, the patient may be eager to return home to family or friends willing and able to provide continuing care. The hospital can be a dangerous place; prolonged admission exposes the patient to risks of hospital-acquired infection or other misadventure. When continuing treatment is required, care in a less costly setting such as an outpatient clinic or skilled nursing facility may be feasible. Third-party insurance coverage such as Medicare that pays a set amount per admission gives the hospital a financial incentive to shorten length of stay. In short, the decision to discharge may represent a delicate balance of competing objectives. Florence Rothman, age 87, was admitted to Sarasota Memorial Hospital in early 2003 with a diagnosis of aortic stenosis and underwent a routine valve replacement procedure. After an unremarkable course of treatment she was discharged in apparent good health. Four days later she collapsed and was taken to the emergency department where she died as a result of complications of surgery. Stunned by this unexpected turn of events, her sons Michael Rothman and Steven Rothman met with medical staff and hospital officials in an effort to understand how their mother’s precarious condition could have escaped notice at the time of discharge. They were surprised to learn that the hospital’s sophisticated electronic medical records (EMRs) system, while amassing substantial quantities of data over the course of an admission, generated no summary indicators of a patient’s condition or “red flags” that could inform decisions about readiness for discharge. The Rothmans vowed to find a way by which future patients might avoid their mother’s fate (M. Rothman, personal written communication, June 18, 2013). Although neither of the brothers was trained in medicine or health services research, they were no strangers to massive electronic databases. Michael Rothman, who holds a PhD in chemistry, spent much of his career as a computer scientist at the IBM Watson Research Laboratory and then became chief information officer for a major bank. Later he founded a company specializing in large data system design and analytics. Steven Rothman is an electrical engineer who began his career at the MITRE Corporation, a contract research organization spun-off from Massachusetts Institute of Technology. While working on aerospace projects in Colorado and New Mexico he became interested in oil and gas exploration and created a company that applied sophisticated mathematics and data visualization to the analysis of seismic data. With active support from the hospital, the Rothmans put their expertise to work exploring the EMR data repository. Their vision was to create algorithms that would