[Slide 1]{.underline}

**Abandoning the Silos: Population Segmentation that Enables Clinical
Excellence, and Useful HIT**

March 22^nd^, 2006

Joanne Lynn, MD, OCSQ

joanne.lynn@cms.hhs.gov

Co-Authors:

Barry Straube, MD, Director OCSQ and Chief Medical Officer CMS

Karen Bell, MD, MMS, Director, Office of HIT Adoption, ONC

Steve Jencks, MD, OCSQ

Robert Kambic, PHD OCSQ

[Slide 2]{.underline}

**The Silos: Disease categories organize medical knowledge**

Hypertension

Diabetes

Stroke

Alzheimer's Dementia

Et cetera

[Slide 3]{.underline}

**The Silos: Providers slash sites organize health care delivery**

Hospital

Doctor's office

Nursing home

Hospice

Et cetera

[Slide 4]{.underline}

**Claims of excellence fall in a crosshatch: one setting, one disease**

In a table, the five rows represent medical diagnoses: hypertension,
diabetes, stroke, dementia, et cetera. The five columns represent
program sites: hospital, doctor's office, nursing home, hospice, et
cetera. Internal cells remain blank.

**But people with serious chronic illness have multiple diagnoses and
use multiple settings. Thus, our understanding of excellence fails**

[Slide 5]{.underline}

**Building a Better Concept**

Can't reflect current provider array

Can't defend current dysfunctions

Can anchor in service to the patient

Can build on shared priorities of groups

Can enable point-of-service customization

Try it out: serious illness, last years of life

[Slide 6]{.underline}

**Divisions by Health Status, in the Population and Among Persons with
Eventually Fatal Chronic Illness**

A pie graph shows 66 percent Healthy; 31 percent Mild Chronic,
Consistent with Usual Role; and 2 percent Chronic, Progressive,
Eventually Fatal Illness. The last piece is taken aside and highlighted
in three line graphs, labeled Cancer, Organ System Failure, and Dementia
slash Frailty. On each of these graphs, the x-axis is labeled Time and
the y-axis is labeled Function. Function with cancer keeps rather
steadily high for a considerable time but takes a very sharp dive
shortly before the person's death. Function with organ system failure
starts out moderate. The main downward trend is steady and gradual, but
several episodes see brief, fairly sharp drops, the last of which turns
fatal. Function with dementia or frailty is always quite low and pretty
unsteady, though decreasing overall.

[Slide 7]{.underline}

**First Quote, End of Life, Unquote Trajectory**

On a line graph, the y-axis represents time, from the onset of cancer
until death, and the y-axis represents function. The line remains high,
straight, and nearly level for the most part, with a slight downward
trend. This curves into a sharp drop, ending at the bottom with death.
Next to the beginning of the curve is a downward arrow labeled Possible
Hospice Enrollment. Beneath the point of death are these words: Often a
few years, but usually decline less than 2 months.

[Slide 8]{.underline}

**Second Quote, End of Life, Unquote Trajectory, mostly heart and lung
failure**

On a line graph, the y-axis represents time and the y-axis represents
function. The line starts out moderate. The main downward trend is
steady and gradual, but several episodes see brief, fairly sharp drops,
the last of which quickly descends to the bottom for death. Beneath
where the line starts are these words: Begin to use hospital often,
self-care becomes difficult. Beneath the point of death are these words:
About 2 to 5 years, but death usually seems, quote, sudden, unquote.

[Slide 9]{.underline}

**Third Quote, End of Life, Unquote Trajectory: Mostly Multi-factorial
Frailty, Half with Dementia**

On a line graph, the y-axis represents time and the y-axis represents
function. The line starts moderately low with an overall downward trend.
It is unsteady but has no particularly sharp rises or drops, even right
before death. Beneath where the line starts are these words: Onset could
be deficits in ADL, speech, ambulation. Beneath the point of death are
these words: Quite variable, up to 6 to 8 years

[Slide 10]{.underline}

**Quote, Esther, Unquote in Health Care Planning**

Esther with colon cancer

Esther with heart failure

Esther with dementia

All of us can count on good care at the end of life if Esther can

[Slide 11]{.underline}

**Managing Marriott**

Would you build just one kind of hotel?

Would you wait to design the hotel until a sleepy person showed up
looking for a room?

No: the trick is to design hotels around the priorities of the most
likely populations, then customize for individuals as needed

And the same thinking works for health care

[Slide 12]{.underline}

**Populations Providers**

1\. Healthy Offices, public info, self

2\. Maternal and infant Offices, delivery suites

3\. Acutely ill Clinics, hospitals, EMS

4\. Chronic condition Offices, self-care, registry

5\. Stable disabled Community services

6\. EOL, short decline Hospice

7\. EOL, erratic with sudden dying Complex disease manage

8\. EOL, long dwindling course Elder care, nursing home

[Slide 13]{.underline}

  ------------------------ ---------------- --------------- --------------
  **Population**           **Number**       **Dollars per   **Total
                                            person per      billions of
                                            year**          dollars per
                                                            year**

  1\. Healthy              Circa 170        Circa 700       Circa 120
                           million                          

  2\. Moms and babies      Circa 6 million  Circa 10,000    Circa 60
                           babies, moms                     

  3\. Acutely ill          Circa 60 million Circa 10,000    Circa 600

  4\. Chronic              Circa 50 million Circa 7,000     Circa 350

  5\. Serious disability   Circa 7 million  Circa 35,000    Circa 250

  6\. EOL, short decline   Circa one half   Circa 40,000    Circa 20
                           million                          

  7\. Erratic and sudden   Circa 1 million  Circa 45,000    Circa 50
  death                                                     

  8\. Long dwindling       Circa 5 million  Circa 50,000    Circa 250

  Totals                   300 million                      1.7 trillion
  ------------------------ ---------------- --------------- --------------

[Slide 14]{.underline}

**Institute of Medicine Quote, Quality Chasm, Unquote Aims for Care**

Safe

Effective

Efficient

Patient Centered

Timely

Equitable

[Slide 15]{.underline}

Chronic Conditions: 50 Million

  ----------- ------------------------------ ----------------------------
  **Aim**     **Interpretation**             **HIT Opportunities**

  Safe        No medication errors, safe     PHR with CDS, EHR's
              devices                        

  Effective   Secondary prevention,          Reminder systems, EHR's
              prescription to goals          

  Efficient   Coordinated DX services,       EHR's, patient centric PMS,
              successful prescriptions, no   care communities
              admin bur                      

  Patient     Individual care plans          PHR's, shared care plan
  Centric     attentive to circumstance,     management, monitoring
              ability to self-manage         device

  Timely      Access to care from remote     E-visits, E-prescribing,
              settings                       E-scheduling

  Equitable   Respect for cultural           Multilingual,
              differences, geography         telecommunications
  ----------- ------------------------------ ----------------------------

[Slide 16]{.underline}

**Organ System Failure:** 1 Million

  ----------- -------------------------------- ---------------------------
  **Aim**     **Interpretation**               **HIT Opportunities**

  Safe        No preventable ADE's, safe       Interoperable EHR slash
              environment, safe devices        PHR, monitoring of care

  Effective   Aggressive evidence-based        Home monitoring devices,
              prescription to prevent          patient ed, coordinate
              exacerbations                    regional services

  Efficient   No screenings or treatments for  Shared decision support
              conditions beyond life span      information for
                                               intervention

  Patient     Clarity about prescription       Electronically accessible
  Centric     options and value, care plans,   care plans, interactive
              life closure planning            decision aids

  Timely      Rapid response to change         E-visits, regional delivery
                                               coordination

  Equitable   Available to all                 Multilingual,
                                               telecommunications
  ----------- -------------------------------- ---------------------------

[Slide 17]{.underline}

**Common Themes for HIT**

Decreased administrative burden

Remote access to care: e-visits and monitoring

Reliable 24 7 communication

Portable health information

Patient slash consumer control and focus

Continuity of care across settings

Informed patient engagement

Protections from preventable ADE's

Regionalization of records, coverage, and services

[Slide 18]{.underline}

**Outstanding Issues**

Governance: who controls data flow

Financing: for sustainability

Privacy and security

Standards and interoperability

Prioritization

System redundancy and backup

[Slide 19]{.underline}

**Orbis Terrarum, 1675 by Visscher**

The slide shows an antique map of the world, titled Orbis Terrarum Nova
et Acuratissima Tabula. It is displayed as two side views and two polar
views of a globe. Aside from the distortions inherent in such an
arrangement, there are a few clear inaccuracies, such as Baja California
as a large island, and incomplete borders where the cartographer was
uncertain, as in the northwestern part of North America and the
southeastern part of Australia. Fanciful paintings adorn the outside of
the map.