We live in the golden age of distributed computing. Public cloud platforms now offer virtually unlimited compute and storage resources on demand. At the same time, the Software-as-a-Service (SaaS) model brings enterprise-class systems to users who previously could not afford such systems due to their cost and complexity. Alas, traditional data warehousing systems are struggling to fit into this new environment. For one thing, they have been designed for fixed resources and are thus unable to leverage the cloud's elasticity. For another thing, their dependence on complex ETL pipelines and physical tuning is at odds with the flexibility and freshness requirements of the cloud's new types of semi-structured data and rapidly evolving workloads. We decided a fundamental redesign was in order. Our mission was to build an enterprise-ready data warehousing solution for the cloud. The result is the Snowflake Elastic Data Warehouse, or "Snowflake" for short. Snowflake is a multi-tenant, transactional, secure, highly scalable and elastic system with full SQL support and built-in extensions for semi-structured and schema-less data. The system is offered as a pay-as-you-go service in the Amazon cloud. Users upload their data to the cloud and can immediately manage and query it using familiar tools and interfaces. Implementation began in late 2012 and Snowflake has been generally available since June 2015. Today, Snowflake is used in production by a growing number of small and large organizations alike. The system runs several million queries per day over multiple petabytes of data. In this paper, we describe the design of Snowflake and its novel multi-cluster, shared-data architecture. The paper highlights some of the key features of Snowflake: extreme elasticity and availability, semi-structured and schema-less data, time travel, and end-to-end security. It concludes with lessons learned and an outlook on ongoing work.

Since its introduction in 1998, the VHA National Pain Management Strategy has introduced and implemented a series of plans for promoting systems improvements in pain care. We present the milestones of VHA efforts in pain management as reflected by the work of the Strategy. This includes the development of the Strategy and its current structure as well as a review of important initiatives such as "pain as the fifth vital sign" and the stepped care model of pain management. KEYWORDS Pain, Pain management, Primary care, VeteransAccording to the Institute of Medicine's recently published report on the state of pain care in the United States, "Relieving Pain in America: A Blueprint for Transforming Pain Prevention, Care, Education, and Research" [1], as many as one-third of Americans experience persistent pain at a cost of as much as $635 billion. The report noted that military Veterans are a particularly vulnerable group with data documenting a particularly high prevalence of pain and extraordinary rates of complexity associated with multiple medical and mental health comorbidities.Data document that as many as 50% of male Veterans treated at Veterans Health Administration (VHA) primary care clinics report the presence of pain [2], and the prevalence may even be as high as 75% among female Veterans returning from Afghanistan in Operation Enduring Freedom (OEF) or Iraq in Operation Iraqi Freedom (OIF) [3]. Painful musculoskeletal conditions are the most highly prevalent cluster of diagnosed medical conditions among OEF/OIF Veterans surpassing the rates of all diagnosed mental health conditions combined. Published observational data document that pain is one of the most frequent presenting complaints for OEF/OIF Veterans treated in the VHA particularly in patients with polytrauma [4][5][6]. In addition, reports suggest that the prevalence of pain complaints among Veterans is growing steadily with each passing year [7,8].Pain is associated with serious and diverse health problems. The presence of pain among Veterans receiving primary care in VHA facilities, relative to those not reporting pain, is associated with poorer self-rated health, greater utilization of healthcare resources, greater prevalence of health risk behaviors and factors such as tobacco use, excessive alcohol use, weight concerns, decreased social and physical activity, lower social support, and greater ratings of affective distress [9]. Among women Veterans, pain is associated with high rates of military and nonmilitary sexual harassment and trauma [10]. Finally, pain is also among the most costly disorders treated in VHA settings [11].This article describes a comprehensive VHA National Pain Management Strategy and its ambitious agenda for improving pain care for Veterans receiving care in its healthcare facilities. It includes a review of ongoing implementation efforts over the 1 PRIME Center/11ACSLG, VA Connecticut Healthcare System, West Haven, CT 06516, USA Implications Practice: A process including qualitative content evaluation, usabilit...

Through a multifaceted comprehensive implementation approach, primary care providers demonstrated increases in guideline-concordant pain care practices. Findings suggest that engagement of interdisciplinary teams and partnerships to promote organizational improvements is a useful strategy to increase the use of integrated, multimodal pain care for veterans, consistent with VHA's SCM-PM.

Chronic pain is one of the most common presenting problems in primary care. Standards and guidelines have been developed for managing chronic pain, but it is unclear whether primary care providers routinely engage in guideline-concordant care. The purpose of this study is to develop a tool for extracting information about the quality of pain care in the primary care setting. Quality indicators were developed through review of the literature, input from an interdisciplinary panel of pain experts, and pilot testing. A comprehensive coding manual was developed, and inter-rater reliability was established. The final tool consists of 12 dichotomously scored indicators assessing quality and documentation of pain care in three domains: assessment, treatment, and reassessment. Presence of indicators varied widely. The tool is reliable and can be utilized to gather valuable information about pain management in the primary care setting.

Recent national estimates from the U.S. reveal that as many as one-third of all Americans experience chronic pain resulting in high prevalence rates of visits to primary care clinics (PCC). Indeed, chronic pain appears to be an emerging global health problem. Research has largely ignored the perspective of PCC staff other than physicians in providing care for patients with chronic pain. We wanted to gain insights from the experiences of Registered Nurses (RNs) and Health Technicians (HTs) who care for this patient population. Krippendorff’s method for content analysis was used to analyze comments written in an open-ended survey from fifty-seven primary care clinic staff (RNs-N=27 and HTs-N=30) respondents. This represented an overall response rate of 75%. Five themes emerged related to the experience of RNs and HTs caring for patients with chronic pain: 1) Primacy of Medications and Accompanying Clinical Quandaries; 2) System Barriers; 3) Dealing with Failure; 4) Primacy of Patient Centered Care; and 5) Importance of Team Based Care. This study demonstrates that nursing staff provide patient-centered care, recognize the importance of their role within an interdisciplinary team and can offer valuable insight about the care of patients with chronic pain. This study provides insight into strategies that can mitigate barriers to chronic pain management while sustaining those aspects that RNs and HTs view as essential for improving patient care for this vulnerable population in PCCs.