Unlocking Practice Patterns at Scale: A Framework for Developing Clinical Insights Using Epic's Cosmos

Abstract

Background

Real-world data from vendor-aggregated health information exchanges represent a powerful resource for retrospective clinical research. Epic's Cosmos platform, a large-scale centralized data warehouse, enables querying deidentified electronic health record data.

Objectives

We describe the iterative development of a generalizable clinical informatics workflow for retrospective studies using Cosmos.

Methods

We applied the Plan-Do-Study-Act cycle to iteratively refine a collaborative research process using Cosmo's SlicerDicer interface, focusing on setting, team, technical preparation, and workflow.

Results

We identified multiple areas of improvement to facilitate streamlined collaborative studies. Our institutional review board confirmed Cosmos studies as nonhumans subject research. We expanded collaborations across institutions. We identified key insights for team definition across clinical, research, and skill domains. We expanded our team based on technical skills, domain expertise, and educational aims. We optimized query building and cohort construction, data analysis and validation, and communication processes. We clarified and optimized a collaborative workflow across clinical and informatics expertise.

Conclusion

Our collaborative approach to secondary data analysis in Cosmos supports the development of meaningful clinical evidence to support high-quality, well-evidenced patient care. This study demonstrates the application of the Plan-Do-Study-Act cycle to a collaborative workflow for clinically focused secondary data analysis. Our approach allows rapid, reproducible cohort construction and analysis, is adaptable across clinical domains, and scales to multiorganizational collaboration. This approach offers a model for others seeking to develop key clinical insights via retrospective studies within the Cosmos data aggregation tool.

Keywords

health information exchanges - clinical data management - integrated information systems - process improvement - workflow - data warehousing and data marts - science of team science - system improvement

Protection of Human and Animal Subjects

This work was deemed nonhuman subject research by Rush University's Institutional Review Board.

Publication History

Received: 29 August 2025

Accepted after revision: 16 February 2026

Accepted Manuscript online:
18 February 2026

Article published online:
27 February 2026

• References

• 1 Campion TR, Sholle ET, Pathak J, Johnson SB, Leonard JP, Cole CL. An architecture for research computing in health to support clinical and translational investigators with electronic patient data. J Am Med Inform Assoc 2022; 29 (04) 677-685
• 2 Carson MB, Gonzales S, Shaw P, Schneider D, Holmes K. Bridging the gap: A library-based collaboration to enhance data skills for clinical researchers. Learn Health Syst 2022; 7 (02) e10339
• 3 Hanauer DA, Hruby GW, Fort DG, Rasmussen LV, Mendonça EA, Weng C. What is asked in clinical data request forms? A multi-site thematic analysis of forms towards better data access support. AMIA Annu Symp Proc 2014; 2014: 616-625
• 4 Jeffers AM, Anderson C. A guide to developing teams for successful healthcare quality improvement projects. Curr Probl Pediatr Adolesc Health Care 2025; 55 (07) 101802
• 5 Smith SE, Bland CM, Branan TN, Sikora A, Hawkins WA. Research and scholarly methods: research collaboration. J Am Coll Clin Pharm 2024; 7: 1122-1132
• 6 Reddy MC, Gorman P, Bardram J. Special issue on Supporting collaboration in healthcare settings: the role of informatics. Int J Med Inform 2011; 80 (08) 541-543
• 7 Tarabichi Y, Frees A, Honeywell S. et al; The Cosmos Collaborative. The Cosmos Collaborative: a vendor-facilitated electronic health record data aggregation platform. ACI Open 2021; 5 (01) e36-e46
• 8 Deming, W. E. The New Economics for Industry, Government, Education. Massachusetts Institute of Technology;
• 9 Gottlieb M, Moyer E, Dissanayake V. et al. Disparities in troponin and ECG testing among emergency department patients with chest pain. Am J Emerg Med 2025; 93: 109-114
• 10 Gottlieb M, Amponsah T, Bernard K, Moyer E. Epidemiology of urinary tract infections in adults among United States emergency departments from 2016 to 2023. Am J Emerg Med 2025; 93: 7-12
• 11 Gottlieb M, Chien N, Moyer E, Bernard K, Peksa GD. Alcohol withdrawal syndrome presentations to emergency departments in the United States from 2015 to 2023. Acad Emerg Med 2025; 32 (07) 785-791
• 12 Gottlieb M, Wusterbarth E, Hlavin R, Bernard K, Moyer E. Epidemiology of sepsis presentations and management among United States emergency departments from 2016 to 2023. Acad Emerg Med 2025; 32 (04) 467-470
• 13 Gottlieb M, Wusterbarth E, Moyer E, Bernard K. Diverticulitis evaluation and management among United States emergency departments over an eight-year period. Am J Emerg Med 2024; 86: 83-86
• 14 Gottlieb M, Moyer E, Bernard K. Epidemiology of heart failure presentations to United States emergency departments from 2016 to 2023. Am J Emerg Med 2024; 86: 70-73
• 15 Gottlieb M, Moyer E, Bernard K. Epidemiology of pulmonary embolism diagnosis and management among United States emergency departments over an eight-year period. Am J Emerg Med 2024; 85: 158-162
• 16 Gottlieb M, Moyer E, Bernard K. Epidemiology of headache presentations to United States emergency departments from 2016 to 2023. Am J Emerg Med 2024; 85: 1-6
• 17 Gottlieb M, Bernard K. Epidemiology of back pain visits and medication usage among United States emergency departments from 2016 to 2023. Am J Emerg Med 2024; 82: 125-129
• 18 Moyer E, Bernard K, Gottlieb M. Epidemiology of deep venous thrombosis in US emergency departments during an 8-year period. Clin Exp Emerg Med 2025; 12 (02) 132-138
• 19 Buell KG, Hlavin R, Wusterbarth E, Moyer E, Bernard K, Gottlieb M. Trends in cardiac arrest care and mortality in United States emergency departments over eight years. Am J Emerg Med 2025; 92: 126-134
• 20 Gottlieb M, Bernard K. Epidemiology of abscess and cellulitis among United States emergency departments from 2016 to 2023. Acad Emerg Med 2024; 31 (12) 1273-1275
• 21 Gottlieb M, Amponsah T, Nguyen N, Shukla O, Bernard K, Moyer E. Epidemiologic trends in pediatric urinary tract infections among United States emergency departments from 2016-2023. Clin Exp Emerg Med 2025;
• 22 Gottlieb M, Wusterbarth E, Moyer E, Bernard K. The role of point-of-care ultrasound for diverticulitis in the emergency department. Am J Emerg Med 2025; 88: 260
• 23 Langabeer J, Gottlieb M, Kraus CK, Lotfipour S, Murphy LS, Langdorf MI. Scholarship in emergency medicine: a primer for junior academics: part II: promoting your career and achieving your goals. West J Emerg Med 2018; 19 (04) 741-745
• 24 Gottlieb M, Chan TM, Sebok-Syer SS. et al; Emergency Medicine Health Professions Education Research Consortium (EMPERC). The next generation of researchers: one-year outcome data from the SAEM Advanced Research Methodology Evaluation and Design in Medical Education (ARMED MedEd) program. AEM Educ Train 2022; 6 (06) e10818
• 25 Carmelli G, Cassara M, Miller DT. et al. From submission to publication: a practical guide to peer review publication for medical educators. AEM Educ Train 2025; 9 (Suppl. 01) S88-S100
• 26 Thabane L, Thomas T, Ye C, Paul J. Posing the research question: not so simple. Can J Anaesth 2009; 56 (01) 71-79
• 27 Handley SC, Gallagher K, Breden A. et al. Birth hospital length of stay and rehospitalization during COVID-19. Pediatrics 2022; 149 (01) e2021053498
• 28 45 CFR 46.102–Definitions for purposes of this policy. https://www.ecfr.gov/current/title-45/part-46/section-46.102
• 29 Montrief T, Haas MRC, Alvarez A, Gottlieb M, Siegal D, Chan T. Thinking outside the inbox: use of slack in clinical groups as a collaborative team communication platform. AEM Educ Train 2020; 5 (01) 121-129
• 30 Aarons GA, Reeder K, Miller CJ, Stadnick NA. Identifying strategies to promote team science in dissemination and implementation research. J Clin Transl Sci 2019; 4 (03) 180-187
• 31 Murphy SN, Visweswaran S, Becich MJ. et al. Research data warehouse best practices: catalyzing national data sharing through informatics innovation. J Am Med Inform Assoc 2022; 29 (04) 581-584
• 32 Knosp BM, Craven CK, Dorr DA, Bernstam EV, Campion TR. Understanding enterprise data warehouses to support clinical and translational research: enterprise information technology relationships, data governance, workforce, and cloud computing. J Am Med Inform Assoc 2022; 29 (04) 671-676
• 33 Visweswaran S, McLay B, Cappella N. et al. An atomic approach to the design and implementation of a research data warehouse. J Am Med Inform Assoc 2022; 29 (04) 601-608
• 34 Li R, Romano JD, Chen Y, Moore JH. Centralized and federated models for the analysis of clinical data. Annu Rev Biomed Data Sci 2024; 7 (01) 179-199
• 35 Ozkaynak M, Unertl K, Johnson S, Brixey J, Haque S. Clinical workflow analysis, process redesign, and quality improvement. In: Finnell JT, Dixon BE. eds. Clinical Informatics Study Guide. Springer International Publishing; Switzerland: 103-118