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Breaking Bad Healthcare: The Story of Healthcare.gov

It’s generally a good principle to not criticize something if you’re not willing to help fix it. That’s what former Microsoft exec Kurt DelBene learned, when he offered feedback on the Healthcare.gov website after its release in 2013, and instead of just providing feedback, he ended up taking the reins to fix the site. At a recent event sponsored by University of Washington’s Foster School of Business, DelBene provided a mini-business case on what went wrong with the project and how his team fixed it. With clarity, modesty, and wit DelBene both highlighted some major flaws in the process and encouraged attendees to consider a stint themselves helping out the government with major technological and business issues.

One of the first problems stemmed from an issue that is far too common in government and business: saying yes to a project before fully understanding the scope. In this case, and internal Whitehouse IT team, essentially signed up to deliver a website with requirements of something like Amazon.com without ever having built something that big. While most of us think of the consumer interface of Healthcare.gov, and the trouble that happened on that end, the actual site is extremely complex in needing to connect to hundreds of insurance plans among the major payers, and also to the IRS to verify income levels. Any facet of the site’s interface, up-time requirements, and integration needs was a daunting prospect, and the original architects didn’t have the full requirements set, and possibly the experience to know what was missing when they signed up.

Next, they chose two inappropriate technologies. One was a semi-structured database No-SQL database called MarkLogic, which they had always wanted to try out. The database choice itself was not necessarily the problem, but trying a new technology where the team did not have prior expertise for a project of this scale is risky and they chose the database without understanding the project specs. The second, was trying to use a flow-charting application that automatically generated screens to design the website. This type of application might be appropriate for an internal process application used by a small number of technical users, but it is not appropriate for a large scale consumer facing website that is intended to reach the general population, including those whose first language is not English or with a wide range of education. Software has not gotten to the point where it can design user-friendly versions of itself no matter what you read about artificial intelligence.

Another major, and widely publicized failure was delegating different parts of the project to at least 6 different contracting firms. No one took responsibility for the overall integration, and the contractors continued to point fingers about whose technology was failing.

These were only some of the problems that DelBene inherited with a hard deadline to launch the site. Other issues in site design included no failover system, no beta testing, and no instrumentation or telemetry to understand where the site might be failing. Within the development process there were also failings, for example no tracking of bugs and how much work was left to do.

DelBene started by listening, and this included to all team members not just senior leaders. Although he had to hit the ground running: briefing the President two days into the job, and famously, exiting a meeting into a closet instead of the hallway.

He then had the team prioritize what could be fixed for launch and what couldn’t.

While the site wasn’t conceived as cloud-based (in fact the original team expected the insurers to install servers in their datacenters to connect with the Healhtcare.gov site), DelBene says it was an excellent candidate for the cloud which would have been more secure and more scalable. The team did rebuild many consumer-facing parts of the site on Amazon Web Services and continued to iterate and test capabilities as the site was deployed by sending some groups of users to the new interfaces.

While DelBene was extremely modest, always citing the team, which included recruits from Google and Facebook but strangely not Microsoft, he did have some very specific advice for how to successfully run this type of government project in the first place.

The recommendations can be summed up as “run any consumer-facing government IT project the way you’d run a commercial software project.” Hire the right team, plan, test, and iterate, hold people accountable, and encourage honesty.

Solutions for Government IT Projects

So much of this project’s initial issues were due to a lack of coherent team, and a lack of experience. Developing internal IT infrastructure and commercial software that is used by millions of people is very different, and requires a different skill set. As well, it requires humility as end-users outside your organization will let you know if something doesn’t work as evidenced by the negative press the original roll-out received.

Opportunties

DelBene, who used to run the $11B Office business for Microsoft, described this experience and work as the most important he’s done, and he ended the session by encouraging the audience of MBA candidates and alumni to consider how they could help the country. New programs like the White House Digital Services and 18F Organizations are specifically designed for people from private sector to be able to lend their expertise to government organizations for short periods of time. Considering that the future of all government transactions is digital, this is more important than ever.

Posted in: Health Regulations, Lean Healthcare

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Wellpepper’s Top Health Tech Stories of 2013

It’s the time of year to reflect and make lists! It’s been a great year for Wellpepper: our first full year in business. We’ve enjoyed bringing new features to our users and learning more about the needs of both patients and healthcare providers. We’re committed to building useful tools that patients and providers love to use. We’ve been inspired at conferences meeting with end-users, hospital administrators, and other startups who share the same mission of changing how patients and providers engage around their health. We’ve experienced the power of social media, met new friends through Twitter, and learned so much from Tweetchats. As a young company, it’s been a year of firsts for us that, while monumental for us, pale in comparison with the changes going on in health IT, so rather than telling you more about us, let’s talk about the year in Health Tech.

There is no scientific basis to this list, just what we think stands out from the year in Health Tech.

Healthcare.gov

The beleaguered website was definitely the top Health IT story of the year. At Wellpepper we were unable to make it through the registration process ourselves, and ended up going to a broker to find out our healthcare options. As the news came out on why the site was so bad, it was pretty obvious there was a lack of accountability and no project management. It’s really unfortunate that the Affordable Care Act was mired in this mess of an implementation, but we’re very excited that former Microsoft exec Kurt DelBene is taking the reins. Ship It!

Quantified-Self Hits the Mainstream

tec-gift-guide-fitness-trackers.jpeg-1280x960Or, “everyone is tracking.” The mainstream press started writing about fitness gadgets and our Facebook feeds were full of friends who got new FitBits for Christmas. Not sure what this means about the trend though. We have found the FitBit to be really interesting to calibrate activities, for example, a game of Ultimate Frisbee but after you know how inactive or active you are do you really need to track? And do you become okay with your activity or lack thereof?

Meaningful Use Phase Delayed

The Centers for Medicare and Medicaid have delayed the deadlines for implementing Meaningful Use Stage 2. Stage 2 will be extended through 2016 and Stage 3 won’t begin until at least fiscal year 2017 for hospitals. Meaningful Use Stage 2 focuses on patient engagement, which is very minimally defined as patients interacting with healthcare information electronically. We’ve always said that electronic medical records vendors are not the best equipped to deliver tools that patients (ie consumers) want to use, so it’s not surprising that healthcare providers are struggling with this phase. That said, m-health is poised to deliver on these requirements.Wellpepper2-1195a

M-Health Comes of Age

While we can definitely debate where we are in the m-health hype cycle, there is no question that M-Health is a formidable category. The FDA is now monitoring and releasing guidelines, albeit with little clarification. Eric Topol made headlines by using an iPhone EKG on a plane to diagnose a heart attack and and advise the captain to make an emergency landing. Most positively, we’re hearing less talk of ‘apps’, and more talk of integrating mobile health into the overall patient experience and the official hospital records.

23andMe Ignores FDA

Source: Wikipedia commons

You might consider this one to be a bit specific, but it’s representative of a number of key stories in 2013: big data, the explosion of healthcare investing, and the dramatic gulf between current Health IT and other technologies, and between Silicon Valley and the FDA. 23andMe, which does cheap DNA testing, direct to consumer, was forced to stop providing genetic results and only include ancestry after effectively ignoring FDA warnings for over a year. Speculation is that they were trying to get to a million tests (they are at about 500K) so that they could prove their tests were valid and thereby circumvent long FDA approval processes. Those on the side of the FDA saw this as Silicon Valley thumbing their nose at patient safety and regulations. Those on the side of 23andMe saw this as tech disruption at its purest. As recipients of some of the last full genetic and ancestry tests before the shut-down, expect more from us on this topic. 😉

This one is not healthtech, but we’d be remiss if we didn’t mention the focus on costs of care. Time Magazine, and the New York Times both published rather scathing interactive features on the costs of healthcare in the US. One of Reddit’s top threads right now is about a $50,000 appendectomy. It’s great to see these issues called to light. Let’s hope we see progress in solving them in 2014.


NewYearWP

We’re pretty excited to see what 2014 brings Wellpepper and what new innovations, disruptions, and improvements are brought to the healthcare industry as a whole. Best to you and yours from all of us at Wellpepper!

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health

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