As Healthcare.gov again faces glitches, HealthSherpa.com continues to sign people up

As an open enrollment deadline draws near, HealthCare.gov​ is once again having issues, according to a USA Today report.

HealthSherpa___Fast__Easy_Obamacare_Enrollment

The folks at Healthsherpa.com, however, tell me that it’s working fine. Last year, Ning Liang, one of the founders of the site, wrote me last year to tell me about updates to the site. Ling said that they can now enroll people in ACA marketplace plans, including subsidies.

According to Liang, as of June 2014 they were “the only place besides Healthcare.gov where this is possible. We have signed an agreement with CMS as a web based entity to do this. We are directly integrated with the federal data hub, so going through us is identical to going through Healthcare.gov.”

To date, they’ve helped more than 110,000 people sign up for insurance under the Affordable Care Act.

What a missed opportunity to have created a thriving ecosystem of other Web-based entities that are alternatives to the default government website.

With major pharmacies on board, is the Blue Button about to scale nation-wide?

blue_button_for_homepage1The Obama administration announced significant adoption for the Blue Button in the private sector today. In a post at the White House Office of Science and Technology blog, Nick Sinai, U.S. deputy chief technology officer and Adam Dole, a Presidential Innovation Fellow at the U.S. Department of Health and Human Services, listed major pharmacies and retailers joining the Blue Button initiative, which enables people to download a personal health record in an open, machine-readable electronic format:

“These commitments from some of the Nation’s largest retail pharmacy chains and associations promise to provide a growing number of patients with easy and secure access to their own personal pharmacy prescription history and allow them to check their medication history for accuracy, access prescription lists from multiple doctors, and securely share this information with their healthcare providers,” they wrote.

“As companies move towards standard formats and the ability to securely transmit this information electronically, Americans will be able to use their pharmacy records with new innovative software applications and services that can improve medication adherence, reduce dosing errors, prevent adverse drug interactions, and save lives. ”

While I referred to the Blue Button obliquely at ReadWrite almost two years ago and in many other stories, I can’t help but wish that I’d finished my feature for Radar a year ago and written up a full analytical report. Extending access to a downloadable personal health record to millions of Americans has been an important, steadily shift that has largely gone unappreciated, despite reporting like Ina Fried’s regarding veterans getting downloadable health information.  According to the Office of the National Coordinator for Health IT, “more than 5.4 million veterans have now downloaded their Blue Button data and more than 500 companies and organizations in the private-sector have pledged to support it.

As I’ve said before, data standards are the railway gauges of the 21st century. When they’re agreed upon and built out, remarkable things can happen. This is one of those public-private initiatives that has taken years to take fruit that stands to substantially improve the lives of so many people. This one started with something simple, when the administration gave military veterans the ability to download their own health records using from on MyMedicare.gov and MyHealthyVet and scaled progressively to Medicare recipients and then Aetna and other players from there.

There have been bumps and bruises along with the way, from issues with the standard to concerns about lost devices, but this news of adoption by places like CVS suggests the Blue Button is about to go mainstream in a big way. According to the White House, “more than 150 million Americans today are able to use Blue Button-enabled tools to access their own health information from a variety of sources including healthcare providers, health insurance companies, medical labs, and state health information networks.”

Notably, HHS has ruled that doctors and clinics that implement the new “BlueButton+” specification will be meeting the requirements of “View, Download, and Transmit (V/D/T)” in Meaningful Use Stage 2 for electronic health records under the HITECH Act, meaning they can apply for reimbursement. According to ONC, that MU program currently includes half of eligible physicians and more than 80 percent of hospitals in the United States. With that carrot, many more Americans should expect to see a Blue Button in the doctor’s office soon.

In the video below, U.S. chief technology officer Todd Park speaks with me about the Blue Button and the work of Dole and other presidential innovation fellows on the project.

Lawmakers release proposed draft to codify US CTO role, create U.S. Digital Government Office (DGO)

After months of discussion regarding how the government can avoid another healthcare.gov debacle, legislative proposals are starting to emerge in Washington. Last year, FITARA gathered steam before running into a legislative impasse. Today, a new draft bill introduced for discussion in the United House of Representatives proposes specific reforms that substantially parallel those made by the United Kingdom after a similar technology debacle in its National Health Service.

The draft bill is embedded below.

The subtext for the ‘Reforming Federal Procurement of Information Technology Act’ (RFP-IT), is the newfound awareness in Congress and the nation at large driven by the issues with Healthcare.gov that something is profoundly amiss in the way that the federal government buys, builds and maintains technology.

“Studies show that 94 percent of major government IT projects between 2003 and 2012 came in over budget, behind schedule, or failed completely, said Representative Anna G. Eshoo (D-CA), ranking member of the House Communications and Technology Subcommittee, and co-sponsor of RFP-IT, in a statement. “In an $80 billion sector of our federal government’s budget, this is an absolutely unacceptable waste of taxpayer dollars. Furthermore, thousands of pages of procurement regulations discourage small innovative businesses from even attempting to navigate the rules. Our draft bill puts proven best practices to work by instituting a White House office of IT procurement and gives all American innovators a fair shake at competing for valuable federal IT contracts by lowering the burden of entry.”

Specifically, RFP-IT would:

  • Make the position of the U.S. chief technology officer and Presidential Innovation Fellows program permanent
  • Create a U.S. Digital Government Office (DGO) that would not only govern the country’s mammoth federal information technology project portfolio more effectively but actively build and maintain aspects of it
  • Increase the size of a contract for IT services allowable under the Small Business Act from $100,000 to $500,000
  • Create a U.S. DGO fund supported by 5% of the fees collected by executive agencies for various types of contracts

“In the 21st century, effective governance is inextricably linked with how well government leverages technology to serve its citizens,” said Representative Gerry Connolly (D-VA), ranking member of the House Oversight and Government Reform Subcommittee, and co-sponsor of RFP-IT, in a statement. “Despite incremental improvements in federal IT management over the years, the bottom line is that large-scale federal IT program failures continue to waste taxpayers’ dollars, while jeopardizing our Nation’s ability to carry out fundamental constitutional responsibilities, from conducting a census to securing our borders. Our RFP-IT discussion draft recognizes that transforming how the federal government procures critical IT assets will likely require bolstering ongoing efforts to comprehensively strengthen general federal IT management practices with targeted enhancements that promote innovative and bold procurement strategies from the White House on down.”

The legislative proposal earned qualified praise from Clay Johnson, former Presidential Innovation Fellow and CEO of the Department for Better Technology, whose advocacy for reforming government IT procurement and fixing the issues behind Healthcare.gov seemed to be on every cable news channel and editorial page last fall and winter.

“This, I think, really works well alongside FITARA, which calls for increased agency CIO authority,” wrote Johnson. “What will hopefully end up happening if both bills pass, is that good talent can get inside of government, and agencies that perform well can operate independently, and agencies that don’t can be pulled back in and reformed, while still having operational continuity (meaning: while that reform is happening, IT projects can still be done well, and run by the DGO).”

In 2014, digital government supports open government. What’s unclear is whether this proposal from two Democratic lawmakers can gain a Republican co-sponsor in the GOP-controlled legislative body or if a federal IT reform-minded Senator like Mr. Carper or Mr. Booker will take it up in the Senate.

This is singular bill isn’t a panacea, however, Johnson emphasized, pointing to the need to fix SAM.gov, the error-prone website for contractors to register with the federal government, and reforms to registration for “set-aside” business.

“We’re not sure how Congress writes a ‘stop throwing errors when a user clicks submit on sam.gov’ law,” wrote Johnson. “That’s going to take hearings, and most likely, a digital government office to fix. And we think this is a bill that complements Issa’s FITARA. Since this bill is at the discussion draft stage, perhaps soon we’ll see some Republicans jump on board.

UPDATE:
On July 30, RFP-IT was officially introduced. (Full text of the bill, via Rep. Eshoo’s office): “The Reforming Federal Procurement of Information Technology (RFP-IT) Act, introduced by Rep. Anna G. Eshoo (D-Calif.), Ranking Member of the Communications and Technology Subcommittee, Rep. Gerry Connolly (D-Va.), Ranking Member of the Oversight and Government Reform Subcommittee, Rep. Richard Hanna (R-N.Y.), Chairman of the Small Business Subcommittee on Contracting and Workforce, and Rep. Eric Swalwell (D-Calif.), Ranking Member of the Committee on Science, Space and Technology’s Energy Subcommittee, and Rep. Suzan DelBene (D-Wash.)”

Here’s the quick summary of revised RFP-IT Act:

1) It would officially establish a Digital Government Office within the White House Office of Management and Budget (OMB), with the U.S. CIO at its head as a Senate-confirmed presidential appointee, reporting to the head of the OMB, shifting from “electronic government” to “digital government.”
2) It would codify the Presidential Innovation Fellows program.
3) It would expand competition for federal IT contracting under a simplified process that would ease the regulatory and compliance burden upon smaller companies bidding, bumping the threshold for information tech projects up to $500,000.
4) Establish a digital service pilot program
5) Direct the General Services Administrator to conduct an in-depth analysis of IT Schedule 70.
6) Direct the Comptroller General of the United States to produce three reports to Congress within 2 years of the law passing, on 1) the effectiveness of the 18F program of the General Services Administration, 2) IT Schedule 70, and 3) “challenges and barriers to entry for small business technology firms.”

HHS CISO: “no successful security attacks on Healthcare.gov”

obamacare-hackOne of the persistent concerns about Healthcare.gov regards the security of the federal health insurance exchange marketplace, as I reported for Politico Magazine this month. At least one glaring security flaw remained unpatched until the end of October. Despite the “big fix” announced on December 1, the security of the website and the backend systems behind it have not only remained in doubt, given issues that have come out in Congressional testimony but have now become the subject of contentious exchanges between the United States House Oversight Committee and the Department of Health and Human Services, which operates them.

Today, Democrats on the House Energy and Commerce Committee released a memorandum regarding a security briefing on the Affordable Care Act (embedded below) that includes a summary of a classified briefing from Dr. Kevin Charest, the HHS Chief Information Security Officer, and Ned Holland, HHS Assistant Secretary for Administration. The memorandum states that “there have been no successful security attacks on Healthcare.gov. In it, Dr. Charest is quoted as saying that “no person or group has hacked into Healthcare.gov, and no person or group has maliciously accessed any personally identifiable information from users.”

The authors of the memorandum, Representatives Henry A. Waxman and Diana DeGette, write that “the information provided in the briefing was reassuring,” given the assurances of the chief information security officer that “the security of Healthcare.gov has not been breached, and hackers have had no access to personally identifiable information.”

Despite this letter, it’s not clear whether the Healthcare.gov security concerns that TrustedSec has highlighted have been addressed. Given the continued focus of Congressional committees on the issue, expect more assessments and audits to emerge in the future.

Why HealthSherpa.com is not a replacement for Healthcare.gov [UPDATED]

UPDATE: In June 2014, Ning Liang, one of the founders of HealthSherpa, wrote in about updates to the site. Ling said that they can now enroll people in ACA marketplace plans, including subsidies. According to Liang, “we are the only place besides Healthcare.gov where this is possible. We have signed an agreement with CMS as a web based entity to do this. We are directly integrated with the federal data hub, so going through us is identical to going through Healthcare.gov.”

Earlier tonight, Levick director of digital content Simon Owens discovered HealthSherpa.com, thought it was cool, and read a Daily Dot post about it that framed it as 3 20-something San Francisco Bay-area resident coding up an alternative to Healthcare.gov.

Could it be that easy, wondered Owens? Could these young coders have created a simpler, better way to shop for health insurance than the troubled Healthcare.gov?

healthsherpa

Well, yes and no. As is so often the case, it’s not quite that simple, for several reasons.

1) As always, note the disclaimer at the bottom of HealthSherpa.com: “The information provided here is for research purposes. Make sure to verify premiums and subsidies on your state exchange or healthcare.gov, or directly with the insurance company or an agent.”

Why? The site is based upon the publicly available data published by the Department for Health and Human Services, individual state exchanges and Healthcare.gov for premium costs, like this dataset of premiums by county at data.healthcare.gov.

Unfortunately, there appear to be data quality issues, as CBS News reported, that may be an issue on both sites.

When I compared searches for the same zipcode in Florida for a 35 year old, single non-smoking male, I found the same 106 plans but was quoted different premiums: $128.85 on HC.gov vs $150.24 on HealthSherpa. Hmm.

That could be user error, but… it looks like Healthcare.gov continues to underestimate costs.

Healthsherpa may actually be doing better, here. Good job, guys.

2) Regardless, this is not a replacement for everything Healthcare.gov is supposed to do.

The federal and state exchanges aren’t just about browsing plans and comparing premiums for options in a given zipcode in the “marketplace.” After a user knows decides which plan he or she want, the software is supposed to:

1) Register them as a user (registration was up front initially, which was a controversial, important choice, relevant to the site crashing at launch)
2) Authenticate them against government data bases
3) Verify income against government data bases
4) Calculate relevant subsidies, based upon income
5) Guide them through the application process
6) Send that form data on to insurance companies for enrollment.

The tech that underpins the test and graphics website on the front end of those process continues to hold up well.

The rest of the software that is supposed to enable visitors to go through steps 1-6 software, not so much. 16 state exchanges and DC are having varying degrees of success, with HHS Secretary Kathleen Sebelius acknowledging issues with data quality in Step 6 in her testimony to Congress.

3) While it has a subsidy calculator, otherwise Healthsherpa doesn’t replace Healthcare.gov.

Healthsherpa enables you to find a relevant plan and then gives you contact info for the relevant insurer.

For instance:

“Call Humana Medical Plan, Inc. at (800) 448-6262.
Use their menu or ask the operator to speak to someone about purchasing coverage.
Tell them you would like to purchase health exchange coverage, specifically the Humana Connect Basic 6350/6350 Plan for Hillsborough County, FL.
Follow their instructions to complete the application process.”

It does not place calls to the data hub to calculate steps 1-6.

That limited functionality, however, has been good enough for U.S. Senator Angus King to recommend HealthSherpa as a temporary alternative to Healthcare.gov.

“HealthSherpa offers a user-friendly platform to quickly browse through available health insurance plan options, including monthly premium costs, coverage plans, and possible premium subsidies,” Senator King said. “I recommend that Mainers who are having trouble with Healthcare.gov use HealthSherpa as a temporary alternative until the federal website functions properly.”

4) There are OTHER private healthcare insurance brokers that could be doing this.

Back in May 2013, the Center for Medicare and Medicaid Services issued official guidance for private sector brokers in online health insurance marketplaces. (PDF)

Former U.S. chief technology officer Aneesh Chopra said that these “Web-based entities” will be online this fall, operated by entities like eHealthInsurance.com and GetInsured.

For some reason, however, private sector insurance brokers have been stymied by the federal government from selling ACA insurance policies.

That’s unfortunate, given that the Obama administration could use a Plan B, just in case the progress on Healthcare.gov doesn’t lead to a functional federal health insurance exchange twenty days from now.

Update: Jonathan Cohn, writing for the New Republic, looked into Healthcare.gov’s backup plan and comes up with an interesting detail: issues with the so-called data hub could be holding back deployment of private online health insurance brokers.

…administration officials have been huddling with insurers about how to make more use of direct enrollment. Step one is to make sure that “side door” enrollment works smoothly. It doesn’t function well right now, because—you guessed it—it relies on the same information technology system that powers healthcare.gov. Fixing that portal, which techies tell me is called an “application programming interface,” is high on the administration’s to-do list. But it’s not clear (to me) whether improving the portal might require design modifications—or to what extent its success depends upon other, ongoing repairs to the federal website.

So, here’s some speculation: While it’s hard to know for sure, but it’s quite likely that that “portal” is the data hub that’s behind Healthcare.gov, and that it may not be up to additional volume from private sector demand.

The federal exchange and state exchanges both rely upon it, and, while federal officials have said that it’s working, a report by the New York Times yesterday that some state health insurance exchange are continuing to battle tech problems indicated that it’s not holding up under demand:

Even states whose websites are working well say they are hampered by a common problem: the federal website, particularly the data hub that checks every applicant’s identity and eligibility. That hub has stopped working on several occasions, preventing applications in the states from being completed.

If that’s happening now, concerns about the ability of the hub to hold up under the pressure of private sector online insurance brokers could well be justified. If I learn anything more definitive, I’ll share it.

In depth: news and analysis about the troubles behind Healthcare.gov

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Over the past 27 days, as I’ve steadily shared analysis and links on what went wrong in the botched re(launch) of Healthcare.gov on TwitterFacebook and Google+, I’ve also been talking in more depth about what went wrong on various media outlets, including:

Last week, the Obama administration announced a plan to fix the issues with the software behind HealthCare.gov, including putting QSSI in charge of as the “general contractor” and prioritizing fixing errors in 834 file data first, with the goal of have the system functioning end-to-end by November 30.

The teams of Presidential Innovation Fellows and “A List” contractors in the “tech surge” to fix the software have a tough challenge ahead of them. According to reporting from The New York Times and The Washington Post,  Healthcare.gov wasn’t tested as a complete system until the last week of September, when it crashed with only a few hundred users.

Despite the issues revealed by this limited testing, government officials signed off on it launching anyway, and thus was born a historic government IT debacle whose epic proportions may still expand further.

Should the White House have delayed?

“When faced with go live pressures, I tell my staff the following:

‘If you go live months late when you’re ready, no one will ever remember. If you go live on time, when you’re not ready, no one will ever forget.”-Dr. John Halamka, CIO Beth Israel Deaconness Hospital

In retrospect, the administration might have been better served by not launching on October 1st, something that was within HHS Secretary Kathleen Sebelius’ legal purview. After all, would the federal government launch a battleship that had a broken engine, faulty wiring or non-functional weapons systems into an ongoing fight? This software wasn’t simply “buggy” at launch — It was broken. These weren’t “glitches” caused by traffic, although the surge of traffic did expose where the system didn’t work quickly. Now that a reported 90% of users are able to register, other issues on the backend that are just beginning to become clear, from subsidy calculation to enrollment data to insurers reporting issues with what they are receiving to serious concerns about system security.

Based upon what we know about troubles at Healthcare.gov, it appears that people from the industry that were brought in to test the Healthcare.gov system a month ago urged CMS not to go live. It also appears that inside the agency who saw what was going on warned leadership months in advance that the system hadn’t been tested end-to-end. Anyone building enterprise software should have the code locked down in the final month and stopped introducing new features 3-6 months prior. Instead, it appears new requirements kept coming in and development continued to the end. The result is online now. (Or offline, as the case may be.)

On September 30, President Obama could have gone before the American people and said that the software was clearly not ready, explained why and told Americans that his administration wouldn’t push it live until they knew the system would work. HHS could have published a downloadable PDF of an application that could be mailed in and a phone number on the front page, added more capacity to the call centers and paper processing. It’s notable that three weeks later, that’s pretty much what President Obama said they have done.

The failed launch isn’t just about “optics,” politics or the policy of the Affordable Care Act itself, which is a far greater shift in how people in the United States browse, buy, compare and consume health insurance and services. A working system represents the faith and trust of the American people in the ability of government. This is something Jennifer Pahlka has said that resonates: how government builds websites and software matters, given the expectations that people now have for technology. The administration has handed the opponents of the law an enormous club to bash them with now — and they’ll deserve every bit of hard criticism they get, given this failure to execute on a signature governance initiative.

Articles worth reading on Healthcare.gov and potential reforms

  • Whenever I see Fred Trotter, I’m reminded that he’s forgotten more about open source software and healthcare IT than I’m ever likely to learn. Last week, he talked with Ezra Klein about the issues with Healthcare.gov
  • Ezra Klein also talked  to Clay Johnson about the lessons of Healthcare.gov (hint: procurement, project management and insourcing)
  • Tough reporting on failures in e-government is critical to improving those services for all, but particularly for the poor.
  • A post by Development Seed founder Eric Gunderson on the open source front-end for Healthcare.gov: “It’s called Jekyll, and it works.”
  • Rusty Foster on Healthcare.gov: it could have been worse. This failure to (re)launch just happened under vastly more political scrutiny and deadlines set by Congress. The FBI’s Sentinel program, by contrast, had massive issues — but you didn’t see the Speaker of the House tweeting out bug reports or cable news pundits opining about issues. The same is true of many other huge software projects.
  • A must-read op-ed by former Obama campaign CTO Harper Reed and Blue State Digital co-founder and former Presidential Innovation Fellow Clay Johnson on what ails government IT, adding much-needed context to what ailed Healthcare.gov
  • A Mother Jones interview that asked whether Reed and other former campaign staff could fix Healthcare.gov. (Spoiler: No.)
  • If not those folks, then how should the administration fix Healthcare.gov? In the larger sense, either the federal government will reform how it buys, builds and maintains software, through a combination of reforming procurement with modular contracting, bringing more technologists into government, and adopting open source and agile development processes …or this will just keep happening. The problems go much deeper that a “website.”
  • Ezra Klein pulled all of these pieces together in a feature on the “broken promise of better government through technology” at the end of the month. (He may have been heard in the Oval Office, given that the president has said he reads him.) Speaking at an “Organizing for America” event on November 4th, President Obama acknowledged the problem. “…I, personally, have been frustrated with the problems around the website on health care,” he said, “And it’s inexcusable, and there are a whole range of things that we’re going to need to do once we get this fixed – to talk about federal procurement when it comes to IT and how that’s organized…”
  • The issues behind Healthcare.gov cannot only be ascribed to procurement or human resources, as Amy Goldstein and Juliet Eilperin reported in the Washington Post: insularity and political sensitivity were a central factor behind the launch..

    Based on interviews with more than two dozen current and former administration officials and outsiders who worked alongside them, the project was hampered by the White House’s political sensitivity to Republican hatred of the law — sensitivity so intense that the president’s aides ordered that some work be slowed down or remain secret for fear of feeding the opposition. Inside the Department of Health and Human Services’ Centers for Medicare and Medicaid, the main agency responsible for the exchanges, there was no single administrator whose full-time job was to manage the project. Republicans also made clear they would block funding, while some outside IT companies that were hired to build the Web site, HealthCare.gov, performed poorly.

  • What could be done next? Congress might look across the Atlantic Ocean for an example. After one massive IT failure too many, at the National Health Service the United Kingdom created and empowered a Government Digital Services team. UK Executive Director of Digital Mike Bracken urged U.S. to adopt a digital core.”
  • In the video below, Clay Johnson goes deep on what went wrong with Healthcare.gov and suggests ways to fix it.

  • Can the White House and Congress take on the powerful entrenched providers in Washington & do the same? I’m not optimistic, unfortunately, given the campaign contributions and lobbying prowess of those entities, but it’s not an impossible prospect. I’ll write more about it in the future.

Following up on the botched (re)launch of Healthcare.gov

Over the weekend, federal officials finally confirmed that coding errors and other tech issues existed with Healthcare.gov, after days of saying high traffic was at issue. As people who have attempted to use the federal site know, however, problems with account creation and subsidy calculations system prevented the vast majority of users from enrolling in the first week. The Wall Street Journal places the tech issues with initial authentication and the system built to calculate insurance subsidies, both built by CGI Global, along with assorted other bugs.

error-message-h-800x624 (1)

In a statement, a spokesperson from the U.S. Department of Health and Human Services claimed that things were getting better:

“The work done to increase access to HealthCare.gov in light of the overwhelming demand is beginning to show results. Call center wait times are seconds, not minutes, and people have been enrolling over the phone 24/7. Our work to expand the site’s capacity has led to more people successfully applying for and enrolling in affordable health coverage online, with wait times being shortened by approximately 50 percent since Friday.”

Separately, a spokesperson for the Center for Medicaid and Medicare Services (CMS) said that several fixes for IT issues went in while the site was down, adding dedicated servers for the registration and authentication components that were preventing the vast majority of users from creating accounts. Unfortunately, it’s not clear whether that fix alone will address other issues people are having.

Specifically, “engineers at Web-hosting company Media Temple Inc. found a glut of stray software code that served no purpose they could identify. They also said basic Web-efficiency techniques weren’t used, such as saving parts of the website that change infrequently so they can be loaded more quickly.”

To put it another way, fixing the account creation and authentication steps could well expose the next set of tech issues with the marketplace on Healthcare.gov, from calculating subsidies to enabling digital enrollment.

What’s behind the mess? Earlier today I made my first appearance on Washington Post TV, breaking down what went wrong with the launch of Healthcare.gov, from why it might have happened to what’s being done to fix it to the really big deadline for it to work, in mid-December.

More to come.

Federal officials are urging patience while engineers make more improvements to the system. To date, only a few thousand people are estimated to have made it through the tech issues to enroll, out of a reported 9 million visitors to date.