Wednesday, April 6, 2011

Orwell on writing

George Orwell - author of Animal Farm and Nineteen Eighty-Four, you know the guy - took on the doublespeak that passes for political prose in a 1946 essay titled "Politics and the English Language." He offered six rules for writing clearly that all of us would do well to follow:

1. Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.

2. Never use a long word where a short one will do.

3. If it is possible to cut a word out, always cut it out.

4. Never use the passive where you can use the active.

5. Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent.

6. Break any of these rules sooner than say anything outright barbarous.

Saturday, April 2, 2011

SPC and healthcare

I think Atul Gawande, surgeon, New Yorker staff writer, MacArthur Award winner, etc., etc., is the best healthcare writer around for two reasons. First, his writing epitomizes the best New Yorker nonfiction, which I’ve been reading ever since cutting my teeth on John McPhee’s inquires into everything from Bill Bradley’s basketball chops to birch-bark canoes. Second, and more important, Gawande, unlike many writers who approach healthcare as proverbial blind men, sees the whole elephant. He looks at the woes of U.S. healthcare from a Deming-like systemic perspective that would behoove anyone concerned with healthcare reform anywhere in the world. Remember W. Edwards Deming?

Gawande’s most recent foray into the healthcare wilds, “The Hot Spotters" takes us to Camden, New Jersey, where a family physician named Jeffrey Brenner got the city’s three main hospitals to give him access to their medical billing records and analyzed the data on a desktop computer. He discovered that “just one percent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of [the city’s entire healthcare] costs.”

Brenner then set up a program to provide these “super-utilizers” of healthcare with greater attention and more education. The results: Over the long term, the hospital visits of the first 36 patients in the program were reduced by 40 percent per month and their average total monthly hospital bill dropped by 56 percent from $1.2 million to just over $500,000. Gawande points out that the net savings are lower (because of the extra attention these patients need from primary care physicians, among other things), “but they remain, almost certainly, revolutionary.” Clearly, if they could be extrapolated over Camden’s 1,000 one percenters, they could put a real dent in the city’s overall healthcare costs.

Gawande says Brenner’s program is “a strange new approach to health care: to look for the most expensive patients in the system and then direct resources and brainpower toward helping them.” This “new” approach is, of course, classic statistical process control – analyze your process outcomes, pick out the biggest variations from the mean, and address them. It’s SOP for manufacturers. If it was for healthcare systems, too, lots of low-hanging fruit would surely be revealed. But healthcare systems aren’t like manufacturing plants and their supply chains.

The major players in healthcare – doctors, hospitals, and insurers – are drowning in data, but they aren’t sharing it. The fact that Brenner got three hospitals to hand him their medical records is nothing short of amazing. And if providers and payors did start pooling and analyzing their patient data, who’s going to address the outliers that are revealed? Brenner had to scare up grants to run his program because, as Gawande writes, “that’s not how the health-insurance system is built.” That alone seems like a pretty good argument for rebuilding it.