When Linda Moody and her husband Clifford moved from Florida to Albuquerque, New Mexico, three years ago, they had to pick both a doctor and a health insurer. Moody’s boss recommended Presbyterian Healthcare Services, an eight-hospital system with its own health plan and 600 doctors and other clinicians on staff.
Moody, 66, director of business and finance at the National Education Association of New Mexico, is very glad she listened to her boss. Within a year, Clifford, 67, was rushed to Presbyterian Hospital with breathing problems resulting from an egg-sized tumor in his throat. Though doctors warned “he might not make it out of surgery,” Moody says, today he is cancer-free.
Besides the operation, she says, it was what happened afterward that brought them through the crisis. “Kristin,” she says, “came into our lives.”
Kristin Berg is half of Presbyterian Hospital’s “intensive transition of care team,” tasked (along with a social worker) with figuring out which patients are apt to land back inside and making sure they don’t. Besides cancer, Clifford Moody would be dealing with a tracheostomy and a new diagnosis of diabetes. So, in addition to chemo and radiation and care by an oncologist, he would need to see his otolaryngologist, pulmonologist, primary care doctor and a dietitian.
Berg, a nurse case manager, lined up medical appointments and home services, accompanied Clifford to see his primary care doctor and was on call for the Moodys 24/7. She worked with Clifford’s doctors to fine-tune his medicines, expedited orders when there were problems with the trach tube, secured a suction machine and trained the nurse caring for him to use it. “I probably saved them four to five ER visits,” she says. “The goal was to avert rather than react to a crisis.”
This, in a nutshell, is where health care is headed. Far from being a fortress with beds full of sick people, the hospital of the future will be a dynamic system whose tentacles reach deep into the community, aimed at keeping people well and making sure they “get the right care at the right time in the right setting,” says James Hinton, Presbyterian Healthcare’s president and CEO, who is also chairman of the board of trustees at the American Hospital Association.
From coast to coast, the medical profession is experimenting with ways to care for people differently. Hospitals are hiring primary care doctors and coaching the people in their communities to stay well. They’re sending doctors on house calls, and putting nurses in the YMCA. A growing number are now screening patients for mental and behavioral health problems, which so often complicate or cause disease and interfere with treatment. And they’re using telemedicine and mobile devices to help patients better care for themselves.
The big motivator behind all this outreach, of course, is money. The end appears to be coming for fee-for-service payment systems that encourage a piling on of tests and treatments even when less would be more. Indeed, payment systems are changing in all sorts of ways that reward hospitals for keeping people well and make it costly to admit them.
Some insurance plans provide predetermined monthly payments per patient, and hospitals have to provide all care for that amount or lose money. Others hand over a lump sum for every element of care related to a heart attack or knee replacement, say, so hospitals have an incentive to keep stays short and provide treatment at home.
Tightly integrated health systems like Presbyterian and Intermountain Healthcare in Salt Lake City have a head start, partly because they are putting patient data to good use. By culling electronic records to look for good candidates for house calls, Presbyterian has been able to send doctors and nurses out to treat some 900 pneumonia, heart failure and other patients in their own bedrooms, for example. Telemonitoring allows instant access to clinicians and the checking of vital signs between daily visits.
Compared to traditional patients, the people participating in this “Hospital at Home” program die at rates 2.6 percent lower, get readmitted 7 percent less often, are more satisfied, and are some 20 percent less costly to care for.
“There’s no question about it, this was better than being in the hospital,” says Ben Guhrke, 87, who recently underwent surgery to repair a broken femur and had some post-surgical edema treated as a Hospital at Home patient. The service, he marvels, was “so responsive.”
Intermountain Healthcare, a system of 22 hospitals and 185 clinics in Utah and Idaho, relies on sophisticated number-crunching and is developing predictive analytics to identify its highest-cost patients – the 1 percent who account for fully a quarter of spending on care – and is changing the way it attends to them. These “hotspotter” patients visited hospitals or doctors an average of 41 times each in five years, versus six times for the typical patient. That doesn’t cut it in a system where a growing proportion of patients are served through an affiliated health plan that provides fixed premium payments to cover all the care they need.
Betting that “a better investment might be in helping patients to help themselves,” Intermountain this year launched two different interventions for hotspotters, says Scott Pingree, chair of high-cost patients and hotspotting.
Members of a new community care management team (a primary care doctor, a nurse, a care manager, a pharmacist, a social worker and a “transitionist”) travel to see them, coaching and cajoling them to better manage their medication, eat well and call on team members for home health visits rather than go to the ER. The team also helps get patients in touch with other assistance that can be key in heading off a health crisis, from Meals on Wheels to fuel or housing help to a contractor to fix a mold problem or to add a ramp or railing.
Helping patients help themselves is not a traditional hospital competency, but mobile technology is laying a pathway for it to become one. Davie Rivera of New York City, 41, says the text messages he began getting last fall from Montefiore Medical Center, which were programmed in by his care manager, have “helped a lot” in his effort to lose weight.
On disability for scoliosis and weighing more than 300 pounds a year ago, Rivera felt paralyzed by a lack of confidence. Getting regular texts reminding him of appointments with his nutritionist and for his spine condition and offering personal affirmations and tips for healthy eating helped him drop almost 100 pounds. They made him feel that the hospital “is in your corner,” he says.
Montefiore started its own health plan and began tightly managing patients two decades ago, as part of a struggle – in one of the country’s poorer counties, the Bronx – to stay solvent. Today, it’s one of the nation’s most successful Pioneer Accountable Care Organizations, a new government-supported model emphasizing prevention and high-quality care that avoids redundant or unnecessary tests and procedures and readmissions. ACOs share in any money they save Medicare, or they share the losses.
Montefiore was able to collect $14 million in shared savings for 2013, says Andrew Racine, senior vice president and chief medical officer, by moving a big proportion of care outside the hospital walls and substantially reducing readmissions.
As at Presbyterian, a “Medical House Calls” program brings doctor to patient. People who have suffered heart failure are equipped with smart scales that record and transmit daily weights to their providers, who can actively manage their condition using real-time data. The unacceptably high local diabetes rate has prompted a concerted effort by doctors and social workers to make sure patients understand their treatment plans and follow them. And Montefiore has set up more than 20 primary care locations throughout the area.
Most of these are “patient-centered medical homes” that provide primary and preventive care for every stage of life, with a focus on wellness and improved health. Medical homes combine the advantages of the old-fashioned family doctor, who makes the time to sit and talk with you, with a modern team approach to care that supports patients with psychologists, pharmacists, care managers and social workers. Evening and weekend hours help to accommodate busy schedules. By visiting MyMontefiore.net, patients can email their doctor, request a medication refill, create their own personal health record and access a library to help them find answers to their health concerns.
Presbyterian, too, has organized its 130 primary care providers, all of whom are on the payroll, into 10 patient-centered medical homes. In addition to routine care, doctors and nurse practitioners tell overweight patients to use the walking trails along the Rio Grande river, and prescribe fresh fruit and vegetables at the local farmers’ markets. Doctors can refer patients to mental health professionals down the hall.
Clinic care managers run weekly reports showing which of 14,000 patients with diabetes are overdue to get their hemoglobin A1C, LDL and blood pressure levels checked. Those patients are contacted to schedule appointments. “We’ve honed in on prevention that works,” says Dion Gallant, director of primary care services.
In some places, the hospital front lines are moving into other institutions. Carolinas HealthCare System, a 7,800-bed network based in Charlotte, North Carolina, embeds registered nurses, dietitians and athletic trainers in a dozen YMCA locations around the city. People dealing with diabetes or heart disease, say, or who are trying to lose weight, can get health coaching and exercise regimens to reach goals set by their doctors. The Y-based clinicians can view medical records and update them. So far, more than half of the people in the program who started off with above-normal blood pressure have lowered it significantly, and those with high LDL cholesterol levels have seen reductions averaging 15 points.
In Wyoming, Delaware, Susan Hoffmann, a school nurse at W.B. Simpson Elementary School, recently assembled a care plan for a first-grade boy who had just been diagnosed with diabetes. Hoffmann was able to access the boy’s medical information through an electronic health records system that Nemours/Alfred I. DuPont Hospital for Children created with schools in the state earlier this year so the Wilmington children’s health system could enlist other pediatric clinicians in an effort to improve kids’ health. Hoffmann’s plan included steps his teachers and school bus driver should follow if the boy became hypoglycemic. “It made a huge difference in the child’s seamless transition back to school,” she says.
A big part of keeping people physically healthy, it turns out, is making sure that their mental health needs are met. Not only do issues like substance abuse and depression cause physical harm and exacerbate ailments, but also they interfere with patients’ ability to comply with doctors’ orders. Montefiore this year established behavioral health services for children and adults in each of its primary care sites so it can quickly get them needed treatment; Intermountain has also been moving the two types of care into single clinics.
“Untreated childhood mental health problems cause more than half of the chronic medical problems in the country,” says Michael Hogan, former commissioner of the New York State Office of Mental Health. A report this past spring by Seattle-based consulting firm Milliman concluded that integrating the two can save the nation as much as $48 billion annually.
At Carolinas, the goal is to build access to mental health screening and consults into all locations, from the hospital bedside to the ER to the doctor’s office, so emotional well-being becomes “another vital sign,” says John Santopietro, chief clinical officer of behavioral health.
Since 1997, Carolinas has been providing telepsychiatry to people in the ER; some 300 consults a month now occur in the Charlotte area, a number expected to triple over the next year. Next, Carolinas is poised to beam the support of mental health professionals farther outward, to vulnerable people in hospital beds and primary care offices across its network.
The Patient Protection and Affordable Care Act may have provided health care insurance to an estimated 20 million Americans who lacked coverage, but it has not eased the demand on the nation’s emergency departments. In fact, since the law’s passage, reliance upon the nation’s emergency rooms for non-emergency care has increased.
That’s the finding of a study published online in the American Journal of Emergency Medicine by a second-year medical student at the Wayne State University School of Medicine and his colleagues.
In “Access to care issues and the role of EDs in the wake of the Affordable Care Act,” lead author Alexander Janke notes that Americans who received public insurance under the Affordable Care Act now use the emergency room more frequently than before they were insured. The overwhelming reason: Many urban and rural areas of the nation lack primary health care providers, so the emergency department becomes the only source of health care.
“Of course, we are not the first to highlight the significance of the general problem of lack of access to primary care,” said Janke, originally from Grand Rapids, Mich. “Part of the challenge is political: We need more resources in communities with many un- and underinsured, as in Detroit. Managed care approaches to health care delivery, and especially case management, have found success reducing emergency department utilization for high-frequency users. The Patient Centered Medical Home is a great example of an innovative care delivery model that makes primary care relevant to patients, high-frequency emergency department users or not, who might otherwise visit the emergency department. These kinds of innovations are certainly part of the overall solution. Emergency departments, which remain very much at the front lines of this problem, can also play a role.”
Co-authors and study researchers include Daniel Overbeek, a fourth-year student graduating in May and applying to residency programs in emergency medicine; Justin Bedford, a second-year student and a coordinator for the student Emergency Medicine Interest Group; Aaron Brody, M.D., clinical assistant professor of Emergency Medicine; Robert Welch, M.D., M.Sc., associate professor of Emergency Medicine; and Phillip Levy, M.D., M.P.H., associate professor of Emergency Medicine.
The team reviewed data from the 2013 National Health Interview Survey, administered by the U.S. Department of Health and Human Services. Their analysis utilized 7,233 respondents who reported at least one emergency department visit in the preceding 12 months.
Among emergency room users who reported no usual source of care and who reported relying on the emergency room, 27.7 percent and 35.1 percent, respectively, said lack of access forced them to the emergency room. None of those said their issue was a true emergency.
Patients lacking a stable usual source of health care were more likely to report using the emergency room because it was their “usual place to get care,” it was their “closest provider” or because they “didn’t have another place to go.”
Previous research has shown that Americans who lack access to a usual source of care, such as a family physician, use emergency departments more frequently. This study, the authors said, is the first population-level study to demonstrate their propensity for turning to emergency rooms in the face of a dearth of primary care access.
Emergency departments, the study said, will need to “evolve into outlets that service a wider range of health care needs rather than function in their current capacity, which is largely to address acute issues in isolation.” Otherwise, the overcrowding of emergency rooms for non-emergency issues will remain problematic.
“We found that insurance status is a far less significant predictor of lack of access-based emergency department utilization than usual source of care,” Janke said. “As health care services utilization increases in the era of the Affordable Care Act, the shortcomings of primary care accessibility will become increasingly salient. Many patients will simply present to our nation’s emergency departments. Policymakers should consider providing resources for emergency departments in under-resourced communities to address the full range of health care needs for patients lacking a stable usual source of care.”
The study also points out that if newly insured patients cannot access primary care and instead rely upon the emergency rooms, they may not enjoy the full benefits of health care services provided under the act.
Research has shown that poor health and disruptions in access to primary health care providers are key predictors of emergency room use. The study authors predict that reliance upon emergency rooms will increase as enrollment under the ACA continues. The trend is troubling because prior research indicates stable access to primary care providers is critical for effective health care services utilization. Moreover, studies have found that Americans with an established usual source of care are more likely to follow recommended preventive care measures, and demonstrate better rates of awareness, treatment and control of chronic conditions such as hypertension and elevated cholesterollevels.
The authors recommend the emergency department serve as a case study in accessibility, as well as a “fulcrum to contain costs through improved resource utilization.” They recommend new policies that provide incentives for emergency departments to participate in more holistic care for patients lacking a stable usual source of care.
“We are moving toward a more patient-centered and integrated health care system,” Janke said. “The emergency department has many desirable qualities for patients: accessibility, diagnostic testing, procedures and a full range of provider expertise. In the paper we say ‘policymakers should provide emergency departments with resources and incentives to better address the full range of their patients’ health care needs, especially as utilization picks up under the Affordable Care Act.’ Emergency departments can coordinate better referral and follow-up, and address health issues not related to patients’ acute or emergent conditions, for example, as a checkpoint in long-term hypertension management. Ultimately, though, we will need substantial financial investment to do these things. Emergency department staff already have plenty to do.”
CDC recommends vaccination and rapid treatment with antiviral drugs for people at high risk from flu
January 5, 2015 – Flu continues to expand its reach in the United States this season, with the latest CDC FluView report showing that 43 states are experiencing either high or widespread flu activity, mostly resulting from circulation of drifted H3N2 viruses. Patient visits to doctors for influenza-like-illness (ILI) are now almost even with the peak of 2012-2013 season, the last time H3N2 viruses predominated. Relatively higher flu hospitalization rates seen so far this season are similar to what has been observed during some past H3N2-predominant seasons. CDC continues to encourage influenza vaccination and prompt treatment with flu antiviral drugs for people at high risk of serious flu complications, including people 65 and older, children younger than 5 years (and especially those younger than 2 years), pregnant women and any person with certain health conditions.
For the week ending December 27, 2014, ILI visits accounted for 5.9% of all clinic visits, and had been elevated for 6 consecutive weeks. For the past 13 seasons, ILI has remained elevated for between 1 and 19 weeks each season, with an average of 13 weeks.
Also for week 52, overall flu-related hospitalizations were 12.6 per 100,000 people, which is comparable to the 13.3 per 100,000 overall hospitalization rate seen during the same week of the 2012-2013 season, but higher than the 8.9 per 100,000 rate observed during week 52 of 2013-2014, which was an H1N1-predominant season. Hospitalization rates are almost always highest among people 65 years and older. During week 52 this season, the hospitalization rate for people 65 and older was 51.8 per 100,000 people. During week 52 of the 2012-2013 season, the hospitalization rate for people 65 and older was 52.8 per 100,000. During 2013-2014, it was 16.4 per 100,000. Hospitalization rates are cumulative, so this season’s rates will likely continue to rise. The end-of-season hospitalization rate for people 65 and older during 2012-2013 was 183.2 per 100,000.
Additionally, another 6 flu-associated pediatric deaths are being reported this week, bringing the total number of flu pediatric deaths that have been reported this season to 21. With the exception of the pandemic, the number of flu-associated pediatric deaths has ranged from 37 to 171 since 2004-2005, when pediatric flu deaths became nationally reportable.
Another indicator used to track deaths associated with influenza is the 122 Cities Mortality Reporting System — which tracks the total number of death certificates processed in 122 representative cities and the number of those for which pneumonia or influenza (P&I) is listed as the underlying or contributing cause of death. Last week P & I was at the “epidemic threshold” for that week (6.8%), meaning more deaths than expected were being seen, but this week, P & I is once again below epidemic threshold. Flu seasons typically follow a pattern where influenza-like illness rises, followed by increases in hospitalizations, which are in turn followed by an increase in reported of deaths. P & I is likely to rise again before the season concludes. During 2012-2013, P & I peaked at 9.9 percent. This was the highest recorded P & I in nearly a decade, but was comparable to recorded percentages for past severe seasons, including 2003-2004 when P&I reached 10.4 percent.
H3N2 viruses continue to predominate in the United States this season, accounting for more than 95 percent of all influenza reported to CDC from U.S. WHO and NREVSS collaborating laboratories. In the past, H3N2-predominant seasons have been associated with more severe illness and higher mortality, especially in older people and young children, relative to H1N1- or B-predominant seasons. Between 1976 and 2007, for example, CDC estimates that an average of 28,909 people died from flu during H3N2 seasons, compared to 10,648 people during non-H3N2 predominant years. Estimates of the number of flu deaths among people older than 18 are not available for this season. Only pediatric flu deaths are nationally reportable. CDC uses modeling to estimate the total number of deaths each season but this data won’t be available until after the season has concluded.
Most of the H3N2 viruses circulating are “drifted” or different from the H3N2 vaccine virus; suggesting that the vaccine’s ability to protect against those viruses may be reduced. Two factors play an important role in determining the likelihood that flu vaccines will protect a person from flu illness: 1) characteristics of the person being vaccinated (such as their age and health), and 2) the similarity or “match” between the flu viruses in the vaccine and those spreading in the community.
CDC conducts studies throughout each influenza season to help determine how well flu vaccines are working. These studies are called “vaccine effectiveness” studies or “VE” studies, for short. Recent studies by CDC researchers and other experts indicate that flu vaccine reduces the risk of doctor visits due to flu by approximately 60% among the overall population when the vaccine viruses are like the ones spreading in the community. If the viruses in the vaccine are different from circulating flu viruses, vaccine effectiveness can be lowered. For example, during 2007-2008, drifted H3N2 viruses circulated during the flu season. VE estimates against H3N2 during that season were 43%. CDC anticipates publishing vaccine effectiveness estimates for the current season in mid- to- late January.
CDC continues to recommend flu vaccination even when there are drifted viruses circulating because the vaccine can still prevent infection and also prevent serious flu-related complications in many people. Anyone who has not gotten vaccinated yet this season should do so now. This includes people who may already have gotten the flu this season because flu vaccines protect against three or four different viruses and it’s possible that other viruses will circulate later in the season. It’s fairly common for there to be two waves of flu activity during a season, the second wave is often caused by an influenza B virus. The Flu Vaccine Finder may be helpful locating vaccine.
As of December 5, 2014, an estimated 145.4 million doses of seasonal flu vaccine had been distributed. As of early November, only 40% of people in the U.S. had reported getting a flu vaccine this season. Final vaccine uptake estimates for this season are expected in the fall of 2015.
CDC also recommends flu antiviral drugs for treatment of influenza illness in people who are very sick with flu or people with the flu who are at high risk of serious flu complications. Influenza antiviral drugs are a second line of defense against the flu to treat flu illness. These prescription drugs work best when started soon after influenza symptoms begin (within 2 days), but persons with high-risk conditions can benefit even when antiviral treatment is started after the first two days of illness. People at high risk from flu should see a doctor if they develop flu-like symptoms. While doctors may prescribe antiviral drugs for non-high risk patients with flu, all high risk patients with suspected influenza should be receiving antiviral drugs. There are now three flu antiviral drugs approved and recommended for use this season: oseltamivir (Tradename Tamiflu®), zanamivir (Tradename Relenza®) and peramivir (Rapivab®), the latter is an intravaneous formulation approved for use in people 18 and older by the Food and Drug Administration (FDA) this season.
Nationally the country is likely to continue to experience several more weeks of flu activity as flu spreads to other states that have not yet had significant activity. Activity has been elevated in the Southern states for six weeks now. The mid-west saw increases in activity more recently. Most of the northeast and west of the country has yet to experience the full brunt of the flu season.
Percentage of Visits for Influenza-like Illness (ILI) Reported by the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet), Weekly National Summary, 2014-15 and Selected Previous Seasons
This graph compares data on influenza-like illness (ILI) collected by the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) by week across seven different flu seasons (2003-2004, 2007-2008, 2009-2010 , 2011-2012, 2012-2013, 2013-2014 and the current season, 2014-2015.) The graph illustrates the fact that ILI activity for the current season (2014-2015 ) is most similar to ILI activity during the 2012-2013 flu season. H3N2 viruses were the predominant flu viruses reported during the 2003-2004, 2007-2008, 2011-2012 and 2012-2013 seasons and are currently the predominant flu viruses reported so far this season.
The 2003-2004 season had the highest ILI curve (as high as the pandemic). While 2007-2008 has a similar ILI trajectory to 2012-2013 and to the current season, that year the flu season did not begin until much later.
ILI is defined as fever (100⁰F or higher) and a cough and/or sore throat without a known cause other than flu. (The current national baseline of 2.0% was calculated for the 2014-2015 season and should not be used for previous flu seasons).
Team training takes off as new era in health reform dawns
A growing number of academic medical centers and health systems are offering training to students and working professionals in how clinicians should collaborate to provide coordinated care and work together on new models such as patient-centered medical homes and accountable care networks….
By Andis Robeznieks
Why “care coordination” and why now? Care coordination has been proposed as a solution to many of the seemingly intractable problems of American health care: high costs, uneven quality, and too frequent disappointing patient outcomes. More resources are devoted to health care per capita in the United States than in any other nation, yet our fragmented system is often characterized by communication failures and non-beneficial or redundant healthcare tests and services. This results in an unacceptable risk of error and an increase in cost, in terms of both resources and human suffering.
Many independent elements of U.S. health care are high quality, but these need to be better aligned to serve patients and the people and institutions that care for them. Current financial and structural incentives restrict potential for better patient care outcomes and effective resource allocation. Rather, they intensify the weaknesses inherent in the non-coordinated, independently functioning pieces of our health care system. The development and implementation of effective systems and processes to cure this current misalignment can benefit tremendously from the experience, professional competencies, and long-standing ethos of registered nursing.
Coordination of care is not a new idea, and it is certainly not new to registered nurses. In the context of a partnership guided by patients’ and families’ needs and preferences, the registered nurse is integral to patient satisfaction and care quality, as well as the efficient use of health care resources. Patient-centered care coordination is a core professional standard and competency for all nursing practice. Registered nurses understand that they are an essential component of the care coordination process to improve patients’ care outcomes, facilitate effective inter-professional collaboration, and decrease costs across patient populations and health care settings. What is well known to registered nurses, however, has not often been recognized outside of nursing. This white paper was initiated to highlight both the qualitative and quantitative accomplishments of registered nurses in care coordination.
Health care (or healthcare) is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in human beings. Health care is delivered by practitioners in allied health, dentistry, midwifery-obstetrics, medicine, nursing, optometry, pharmacy, psychology and other care providers. It refers to the work done in providing primary care, secondary care, and tertiary care, as well as in public health.
Healthcare organizations hope big data and analytics projects can help reduce costs and improve care. Consider these innovative examples.
With the mandated adoption of electronic health records (EHRs), many healthcare professionals for the first time got centralized access to patient records. Now they’re figuring out how to use all this information. Although the healthcare industry has been slow to delve into big data, that might be about to change. At stake: not only money saved from more efficient use of information, but also new research and treatments — and that’s just the beginning.
For instance, data from wireless, wearable devices such as FitBits is expected to eventually flood providers and insurers; by 2019, spending on wearables-data collection will reach $52 million, according to ABI Research. Another source of health data waiting to be analyzed: social media. Monitoring what people post can help fight insurance fraud and improve customer service.
These are just two ways big data can be used to improve care while cutting costs, experts say.
“We, as a society, need to start creating our own metrics for how healthcare quality is defined. In the sense of looking at costs, we know where there’s avoidable cost in healthcare. We just need to get folks the data they need to avoid those pitfalls,” said Dr. Anil Jain, senior VP and chief medical officer at Explorys, in an interview. Explorys, which is an innovation spinoff from Cleveland Clinic, is powering Accenture’s Predictive Health Intelligence in a collaboration intended to help life sciences companies determine the combination of treatments and services that can lead to better patient, provider, and economic outcomes for diabetics.
Hosted analytics, partnerships and collaborations, and lower-cost internal applications open the door for smaller organizations to use big data, too.