The cost and affordability of drugs has been a central theme permeating the pharmaceutical industry for decades. Drugs are believed to be too expensive for patients to cover at the counter, even for those who are insured. The sentiment shared is by both Republicans and Democrats.

The high cost of drugs can have significant repercussions, such as poor health outcomes. Patients who are prescribed an expensive medication often stop taking it, or avoid initiating treatment altogether, because they cannot afford it. It is a dangerous and unfortunate situation.

While pharmaceutical companies do set higher drug prices for new and innovative medicines, which require more resources to develop, they also negotiate with insurers to make prices more affordable. However, in recent years, insurance companies have significantly increased out-of-pocket costs for patients. Often times, patients with the most serious of illnesses end up paying the most at the counter.

Industry executives believe that drug prices can partially be lowered through healthcare reform. While the Affordable Care Act has provided healthcare to more of the population, it has not made an impact when it comes to providing prescription coverage and patient cost-sharing. Insurance has always been intended to make healthcare affordable and provide treatment to patients who need care.

Regeneron’s founder and CEO Leonard Schleifer said, “The co-pays or co-insurances are really what I think [are] most problematic for the people…And I think some relief there will be forthcoming [with the new administration].”

While healthcare reform can help reduce drug prices for patients, other factors can contribute. Regulatory reform, tax reform, and better trade policies can diminish the need for pharmaceutical companies to set higher drug prices.

When asked if the new administration is interested in having lower drug prices in exchange for faster drug development timelines, Pfizer’s Ian Read had this to say: “I would hope this is how the administration’s thinking of it. To the extent that they can remove regulations and make it easier and faster to bring drugs to market, that will make the marketplace a lot more competitive, which will in turn help to bring down drug prices. I believe that this is the philosophy of the administration, to ensure there’s competition in the marketplace, and that would be one way of ensuring that drug prices are modified some way.”

Amgen’s Robert Bradway shares a similar stance on the subject: “We want and expect to work with the President and the administration to be part of the solution in that effort. In participation with the administration and Congress, we will seek to advance changes that enable more Americans to have affordable access to life saving and cost effective medicines.”

To explore several other key issues and perspectives from industry executives that have the potential to significantly impact life sciences companies in 2017 and beyond, download The State of the Life Sciences Industry, our new guide.

In ACA and QRS – Shoot for the Stars Part 1, I laid out the overall domains that are going to be used to score QHP plans offered through the Marketplace. In Part 2, I discussed some factors to consider for the data derived measures. In this blog, we will take a closer look at the survey derived measures and what factors a QHP issuer should consider to achieve high scores.

Again, for reference all 43 of the required measures can be found on the CMS website (click here).

Now let’s take a look at some factors to keep in mind when dealing with the Enrollee Satisfaction Survey (ESS) derived measures:

Leverage CAHPS Processes
As mentioned in Part 2, it was required to get Health Plans Accredited to offer on-market. In addition, CMS aligned required QRS ESS measures with current CAHPS measures that are typically required during accreditation. And just as an organization should leverage HEDIS for data, make sure to leverage current investments in CAHPS to keep initial costs low while jump starting ESS efforts.

Guide Provider Interactions
A good number of the ESS questions revolve around services performed by providers. These questions cover domains like access to care, provider communication, care coordination, etc. Questions in these domains are related to specific interactions between providers and members. Therefore, an issuer must understand how providers within the QHP network are meeting the criteria being measured by the survey. Having a strong provider programs aimed at improving areas covered in the ESS is key. An issuer must work with its Providers to understand gaps and create initiatives that drive more positive interactions to improve scoring.

Tailor Communications
Let’s face it, understanding Healthcare is not easy for the average consumer. Most consumers are worried about addressing an immediate need and are not thinking about some of the longer term objectives that are represented in the ESS. To that end, an issuer should develop communications that make it easy to understand what the consumer should expect and what to ask if they are not being delivered information or services. Effective communications can help turn the consumer into an advocate for an issuers requirements within the network, leading to higher compliance and better scores.

Provide a Robust Portal for Members
In a digital world, having a robust portal for communications and interaction is integral to achieving ESS success. Providing tools and various communications in a tailored format can really help in ESS domains such as cultural competence, care management, and plan services. A good portal provides valuable resources for the consumer while accommodating language and communication style differences.

Make it Mobile
And don’t forget Mobile! In addition to having a good portal, issuers should also look to have a suite of mobile products to provide tools and communications to consumers. Mobile can provides access to information when it is not feasible to log in to a portal. Not to mention that mobile can be used to remind consumers of key action items related to requirements.

To recap, in my short ACA and QRS – Shoot for the Stars series, we took a look at some factors to consider to improve QRS scores. Although it is not an exhaustive list of items to consider, I hope you have found this information helpful.

In ACA and QRS – Shoot for the Stars Part 1, I laid out the overall domains that are going to be used to score QHP plans offered through the Marketplace. In this blog, we will take a closer look at the data derived measures and what factors a QHP issuer should consider to achieve high scores.

For reference all 43 of the required measures can be found on the CMS website (click here).

Now let’s take a look at some factors to keep in mind when dealing with the data derived measures:

Leverage Accreditation Processes

It was required to get Health Plans Accredited to offer on-market. In addition, CMS aligned required QRS data measures with HEDIS measures that are typically required during accreditation. So, make sure to leverage current investments to keep initial costs low while jump starting QRS efforts.

Solution for Disparate Data Sources

The data measures published on CMS, as with HEDIS, cover a variety of areas. Some examples from the Beta Test Measure Set are Annual Dental Visit, Cervical Cancer Screening and Proportion of Days covered. This means that a plan must gather data from many areas like dental, medical and pharmacy. Look at creating a dedicated area for collecting, storing and analyzing the required data.

Find the Data

Due to the nature and history of the industry, there are numerous ways that patient information can be documented. When it comes to data measures, QHP issuers have to identify where the data might be located for each of the measures and ensure that the data source has the integrity required by NCQA to include in the measurement process used for QRS scoring.

Partner with Providers

Work with Providers to develop initiatives that will drive more accurate data into the system. This can be accomplished in a variety of ways from making integration of systems easier for reporting clinical data to modifying incentive programs to drive data needed.
So what factors should a QHP issuer take into consideration when evaluating the data requirements?

In my next blog, I will list some factors to consider for the survey data.

Last month I posted “ACA’s Quality Rating System – An opportunity to gain market share”, which explained how QHP issuers can gain market share in the individual space. In that blog I mentioned that, as part of the Quality Rating System, plans offered on the Marketplace will receive a “Star” rating based on a 5 star rating system. Over the next few posts, I would like to take a look at what this means from a health plan’s perspective.
As background, there are 43 measures that will need to be tracked. Out of the 43 measures, 31 are derived from data and 12 are derived from the survey. In addition, the draft QRS scoring specifications published by CMS organizes the 43 required measures into composites that roll up into eight domains. These domains are as follows:

• Clinical Effectiveness
• Patient Safety
• Care Coordination
• Prevention
• Access
• Doctor and Care
• Efficiency and Affordability
• Plan Services

The eight domains are then rolled up in to three summary indicators: 1) Clinical Quality Management; 2) Member Experience; and 3) Plan Efficiency, Affordability and Management. And of course, the final result is a star rating.

The most important unknown at this time is the calculations and weighting that will be used when creating the composites, domains, summary indicators and final star rating. This will ultimately affect which areas a plan will need to focus on the most; however, there are some areas to look at while waiting for the final scoring rules.

The two main areas to focus on when evaluating where a plan might rank are current NCQA HEDIS Accreditation rankings and current CAHPS scores. Why? Because almost all of the QRS data measures are existing NCQA HEDIS measures, and almost all of the Enrollee Satisfaction Survey questions are taken from existing CAHPS surveys.

Of course there are a couple of items one must keep in mind when looking at current HEDIS Accreditation and CAHPS scores: 1) the plans being measured; 2) the population being used for reporting; and 3) the differences in measurement scoring for health plans that chose another accreditation entity such as URAC for HEDIS Accreditation.

In the next couple of posts I will outline some factors to consider for both the data and survey measurement requirements.

Starting in 2015 all issuers of Qualified Health Plans (QHPs) on the Healthcare Marketplace will need to provide Quality Rating System (QRS) measurements that will be aggregated and scored to provide consumers with a star rating for each product offered.

How many stars will you have?

Although there are still details to be worked out by CMS, the required measures for the 2015 beta test are in place. All issuers that wish to continue providing QHPs on the Marketplace will need to provide the required measures. There are two different sets of measures included in the beta specifications.

The first is a set of clinical quality measurements that are mostly taken from the current NCQA HEDIS accreditation process. Many issuers already collect the data for these measures; especially, if they are meeting the requirement to be accredited for the Marketplace today and are using NCQA for that process.

The second is set of measures derived from an enrollee satisfaction survey (ESS) that needs to be performed by an accredited third party survey vendor. Most of the questions in the ESS are drawn from CAHPS. The survey processes requires that a sample of data is drawn, audited by a third party and provided to the survey vendor. The vendor then performs the survey and reports the results to CMS. Questions focus on rating an enrollee’s satisfaction with a plan over a six month period.

While the QRS initiative driven by the ACA attempts to provide transparency, it also creates a competitive market that will force issuers to look at ways to increase the quality of care and enrollee satisfaction to deliver better scores. The prize? For consumers, better products. For issuers, a larger share of the market.

Want to participate and win? Then you need a solution that not only provides the required measures, but also provides insight and the ability to drive quality improvements. This can be accomplished with a well thought out solution architecture that provides processes for delivering the measures and the means for analyzing data to drive improvements.

This morning a colleague forwarded a Fast Company article entitled “The Mayo Clinic’s New Doctor is an iPhone.” The article describes a new Mayo Clinic concierge medicine via mobile device that is subscription based. For $50 per month (per household) the Mayo Clinic basically offers unlimited access to their nurse’s line powered by iPhone virtual visits. The service includes:

• Real-time video chats with Mayo Clinic nurses
• Personally-tailored health information culled from Mayo Clinic databases
• A “symptom checker” that incorporate’s individual user’s health histories
• Access to a personal medical concierge who can provide more information or schedule patients’ doctor appointments

Programs like this are becoming increasingly popular. As I mentioned in the Connected Health trends series, Time Warner Business Class announced it was venturing into the world of virtual medicine through a partnership with the Cleveland Clinic. The program is part of Time Warner Cable’s Home Health Monitoring network that was designed to connect healthcare providers to patients in their homes. It will provide secure, encrypted, two-way video conferencing between patients and Cleveland Clinic providers on a subscription basis.

One of the first widely noted technology based concierge practices to pick up speed was Hello Health. I wrote about them in a white paper back in 2011. Hello Health developed a healthcare business model that meets non-traditional patient demands (i.e. uninsured and under-insured patients). Hello Health was a paperless primary care practice, based in Brooklyn, that used social media-like capabilities to communicate with patients. Hello Health touted “healthcare freedom” through the use of their web-based patient communication, practice management, and electronic health records. Access to these tools were provided in exchange for a small monthly fee lower than health insurance premiums and co-pays. Patients could send an instant message to a doctor via a secure, HIPAA certified messaging tool, for example. An email response from the doctor were free, and patients were charged an additional fee for a “virtual visit”, office visit, or an actual house call. Hello Health has since been acquired by a firm in Canada that has turned the technology around Hello Health into a concierge EHR option for healthcare providers.

It seems appropriate on Valentine’s Day to write love letters. This is my letter of adoration to Meaningful Use. In the past, I have written about how much time and productivity is wasted in the average physician’s office handling phone calls about prescription refills. My physician’s office has successfully implemented their EMR software, and the patient portal is very, very handy for all of the right reasons. I could wax poetic about the ease of checking on appointments and reviewing lab results. The source of my real happiness is the ease of asking for refills and having the ability to route the request to the right pharmacy. It was love at first click.

Instead of calling the doctor, waiting on hold to talk to the nurse, fretting about getting the medication name and dosage right for the refill, it was magic. I signed into the patient portal in a secure fashion, clicked on medication refills, and there was a correct list of my medications! I selected the ones I needed refilled including a suggested number of days like 30 or 90, selected the pharmacy of my choice and Voila! Several hours later, I received an email confirmation from the pharmacy that they were processing my order. Now honestly, I didn’t have to see what went on behind the curtain in the doctor’s office to review my request, but I’m sure they like the elimination of potential communication errors on medications, too.

My doctor has shared with me about the financial burden of casting out his first EMR investment and starting over with a better EMR software. I have to say that from my point of view, he clearly chose the right one and it actually fulfills the basic tenets of Meaningful Use, particularly from the patient’s point of view. I plan to share my enthusiasm for the patient portal with him including the secure messaging that allowed me tell him that his changes in my medications worked and improved my quality of life. This secure messaging was another plus for productivity, and patient satisfaction, because those positive responses got lost in the challenges of telephone communication in the past.

Like a lot of relationships, alas, things are not perfect. The EMR and patient portal have a mobile application that is still very basic. It gets high marks for security, but lacks the medication refill capability of the patient portal. I would venture a guess that it will be there eventually, but it brings to mind the challenges of screen real estate on a typical web browser on a laptop versus a mobile phone. Nevertheless, love can overlook some imperfections.

In a period when our government is making these big investments in electronic medical records and expecting Meaningful Use to be demonstrated in return, it’s time to send out some positive news: keep the faith and push forward because the healthcare consumer will benefit. I know that simplifying the ordering of refills seems like a small thing in the course of things, but if it saves time, productivity and especially errors, then it is a big deal. Thanks to my physician, who re-invested and made the commitment to real Meaningful Use. Here’s your love letter!

P.S. — No personal healthcare information (PHI) was harmed in the making of this blog. If you are curious about which EMR software is so terrific, stop by our booth #2035 at HIMSS, and I will whisper it in your ear. HIMSS 2014 is going to be a great event!

Our Countdown of the Top Connected Health Trends of 2014 brings us to:

#8: Sharing Notes with Patients

The more obvious driver of this trend is Meaningful Use. However, there is a separate market push for patient record access, which is being driven by consumer engagement. As luck would have it, there was a Healthcare IT News article on this very topic that surfaced yesterday entitled “Consumers now calling for Meaningful Use” by Eric Wicklund.

Where the general trends of the marketplace are concerned, the participatory care movement has been a big catalyst of this trend. For those not in the know, this movement is being driven by patient advocates through the Society for Participatory Medicine. This group is driven towards an industry where:

“networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners”.

Quite an admirable cause, indeed.

The Results are In

Back in October, the Journal of Participatory Medicine published a study documenting patient perception of increased data access. This study surveyed Kaiser Permanente members who had viewed at least one test result online in the last year. There were a total of 1,546 respondents. The findings showed:

• Patients that were able to view their lab results online overwhelmingly reacted positively to being able to do so
• Survey participants reported high levels of satisfaction, appreciation, calm, happiness, and relief
• Few were confused, upset, or angry at being able to see lab results online
• After reviewing results online, the most common actions were discussing results with family and friends, looking up information online, or making a graph of results over time

What provider wouldn’t want to own survey results like these?

Opening the Book on Doctor’s Notes

What do you think would happen if doctors handed their notes over to patients in an effort towards patient engagement? The great thing is, we already know. OpenNotes is a program that gives patients online access to the notes of their doctors, nurses and other clinicians. The notes may contain:

• History of present illness (what the patient told the clinician)
• Physical exam findings (blood pressure, heartbeat, lung sounds)
• Lab, radiology, pathology, or other results
• Assessment or “impressions” (the clinician’s diagnosis or documentation of symptoms
• The treatment plan

Patients who read their notes have reported many benefits, which include:

• Better understanding of health and medical conditions
• Improved recall of the care plan
• Feeling more in control of care,
• Taking better care of themselves
• Doing better at taking medications as prescribed
• Strengthening the partnership between patient and physician

Health Plans & the Shared Medical Record

Another, oftentimes unconsidered, source in the drive for demand of record sharing is actually the health plan. Having a storied history of largely ignoring the B2C relationship, Affordable Care and the drive towards the management of chronic conditions has brought us a health plan that is very interested in helping members gain access to their records. Understanding that patients typically don’t want their health plan involved in their care, health plans are finding consumer engagement tactics that involve providing members with tools that the provider has been slow in implementing. Access to medical records is one of those tactics.

The Truly Open Book

Driving towards a world where the patient can gain easy access to their medical records is an important trend. However, what I am most interested in seeing would have to take us another big step forward (don’t blame me, I was born that way).

We will truly have a foundation towards participatory medicine when sharing notes is a two-way street. Patients have a lot of data to share as well. The true power of consumer engagement will surface when both the patient and the clinician are able to collaborate over their shared open book.

Figure 2: Updated Systematic Review of Effects of Meaningful Use Functionalities on Quality, Safety and Efficiency, By Study Outcome Result (% of Studies)
Health IT evaluation studies, 2007-2013 (n=493). Number of studies by meaningful use functionality in parentheses. Positive defined as health IT improved key aspects of care but none worse off; Mixed-positive defined as positive effects of health IT outweighed the negative effects; Neutral defined as health IT not associated with change in outcome; Negative defined as negative effects of health IT on outcome.
Citation: Jones SS, Rudin RS, Perry T, Shekelle PG. “Health Information Technology: An Updated Systematic Review with a Focus on Meaningful Use,” Ann Int Med 2014;160:48-54.

This is a fascinating report on a study by RAND researchers about meaningful use. It shows strong evidence that Health IT improves patient outcomes, specifically quality, safety, and efficiency outcomes.

Michael Furukawa Director at the ONC , and Meghan Gabriel, Economist at the ONC, presented the results from this study in a blog post on HealthIT Buzz. They asked RAND to:

…examine recent evidence on the effects of meaningful use functionalities on quality, safety, and efficiency outcomes. The study was the largest and most comprehensive assessment of the health IT literature to date.

The healthcare IT field is rapidly developing and changing. Emerging technology and updated regulations put pressure on healthcare providers and health plans to stay ahead of the curve. Perficient creates a monthly list that explores some of the current topics and issues in health IT. This list examines the most talked about issues and technologies that are currently affecting the industry.

Consolidation and Mergers

Healthcare entities, both payers and providers, have been making an increased effort to capture market share and dominate their geography. Smaller players are being picked up by larger players, consolidating physician practices and health plans. These mergers have driven digital strategy projects and paperless environments, with an increased interest in advertising and public facing websites to try to attract market share.

• Changes in Hospital Finance Drives Flurry of Mergers
• Partners-South Shore merger review grows
• Cadence Health plans to merge with Rockford Health System
• Blue Cross of NEPA, Highmark exploring ‘stronger’ partnership
• Area hospitals promise transparent merger

Extending Your EMR

Healthcare professionals have been very vocal about the challenges that come along with electronic medical record systems. The workflow in many EMR systems was created by a programmer and works the way it was programmed, not the way healthcare professionals work. Several technology tools were made to extend or approve upon EMRs without ripping the code apart, often by putting it into a browser or allowing it to be mobile.

• EHRs can’t do everything
• 9 Reasons Doctors Hate Their EMR
• Docs blame EHRs for lost productivity
• So much data-gathering, so little doctoring
• How connected is EHR user satisfaction to vendor choice?

Security and Privacy of PHI

The further we develop our technology, the more security risks we’re introducing at the same time. BYOD and wireless networks increase the mobility and sharing of data, which is helpful for diagnosis and storage but risky for protecting PHI. There is a delicate balance between how much security is enough and when security will make it impossible for us to manage the system.

• Addressing BYOD security at a large medical research center
• Factoring healthcare BYOD policies into network security
• 3 tips for proactively protecting PHI
• Sloppy Handling Of Patient Data Always A Danger
• Data Security Added to Worries About Website

Fragmentation of Health Records

While interoperability is a key trend in healthcare, the cost of care is driving us away from this goal. In order to save money, patients are now going to several different pharmacies and stores to get discounted prescriptions where they can, fragmenting their health records. If the only time these medications are reconciled is when patients visit their primary physician, that’s not often enough to prevent adverse drug reactions.

• Why Healthcare Tech will save your life …and your wallet
• Interoperability: A critical mess
• Connecting a new world of care: why interoperability is vital for the NHS
• Health IT can improve care coordination for complex conditions
• Docs can prevent adverse drug reactions by looking up info on mobile phones

FDA Oversight

In September, the FDA revised its guidelines on what mobile medical applications need to be regulated and what are harmless to consumers. Now the FDA is wading into the issue of what else they need to regulate and what they don’t. This week they decided t to block 23andMe for providing medical advice without a physician involved. The FDA will battle where the concept of ensuring accurate medical information will start and stop.

• Congress delves deeper into FDA mHealth oversight
• U.S. approves drug tracking, compound pharmacy oversight law
• The HIT Group wants input into FDA regulation of health IT
• Here’s why the FDA is targeting 23andMe
• FDA to 23andME: Stop genetic tests

Healthcare reform, ACA, Business Intelligence, Enterprise Portals, predictive analytics, pay for performance, the Triple Aim, total cost of care, patient safety….these, and many more, are the buzzwords in healthcare and medicine these days. Install this system, connect that system, run these reports, use this “intelligent program”… Do you ever wonder if we can solve all of these problems with just technology?

As a clinically oriented physician working in a technology world, I need to take a step back and look at behaviors and workflow. How can we mentor the next generation of physicians, nurses and allied health professionals, teach them skills and foster their curiosity while encouraging them to be technologically savvy? I believe there are two critical keys to success: critical thinking and decision support. Both are crucial and neither should exist without the other. Here’s why.

Critical thinking is an essential tool for physicians. Physicians who have this innate ability are often the most successful at diagnosing and treating their patients well. It is part art and part skill but ultimately, it affects patient safety and wellness. I was pleased to see that medical school curriculums are now focusing on this as a fundamental skill. According to the recent Wall Street Journal article, “The Biggest Mistake Doctors Make,” the program at Dalhousie University “aims to help trainees step back and examine how biases may affect their thinking. Developed by Pat Croskerry, a physician known for his research on the role of cognitive error in diagnosis, it uses a list of 50 different types of bias that may lead to diagnostic error”. Couple this with technology driven decision support at the point of care, which assists but never negates clinical judgment, and you have a winning combination. These basic building blocks allow clinicians to concentrate on their craft: diagnosing and treating patients safely and effectively.

Healthcare reform is necessary but it does not have to undermine the knowledge and experience of our clinicians. Adding technology, such as Natural Language Processing (NLP), real time decision support, predictive analytics, patient entered data via portals, mobile healthcare management apps and yes, even Watson, can only enhance and advance healthcare, streamline treatment and decrease costs. Simple? Let me know your thoughts!

When Healthcare.gov launched, it drew an understandably high number of initial users. Millions poured onto the site, but they weren’t able to sign up for insurance due to technical glitches. As an impartial observer, it was interesting to watch media outlets struggle to find even one person that was able to sign up successfully. The Washington Post even went as far as to illustrate this single newly minted healthcare insurance holder as a mythical unicorn.

Leave it to clashing political tensions to throw the topics of non-functional requirements, project management, and user experience into the limelight. Oh, wait. That’s not what everyone has been talking about since the wake of the Health Insurance Marketplace ribbon cutting…but they should.

There’s lots of finger pointing in the great game of Healthcare.gov Whodunit. However, underneath all of the tensions that bely healthcare reform, there are some key takeaways from the Healthcare.gov case study for anyone looking to build a website as a platform for information dissemination and conversion. Here they are:

Project Management

It was originally thought that there were only two players involved in the creation of Healthcare.gov. In reality, there were more than I have fingers to count with. A project this colossal requires some serious project management, and project management was clearly lacking here. It has been reported that those in charge were aware of the flaws and were told the site was not ready for launch. The Washington Post reported that “people were pulling out their hair” and complaining “loudly” about the problems the site was experiencing before being moved over to the live server. Those in charge still insisted on rolling out the new site on the original timeline.

This brings us to Lesson 1 in PMP 101: The Project Management Triangle. All projects need to be performed and delivered under certain constraints. These are illustrated as a triangle of “scope” or “quality” vs. “time” vs. “cost”. These three are inextricably tied, and one side of the triangle cannot be changed without impacting the other two sides. In this case the triangle failed, and quality suffered as a result.

Lesson for the Rest of Us: I’ve worked on projects that have had multiple organizations working together towards a common goal. This always requires the requisite oversight and planning according to scale. Sometimes a client may want to forgo a project manager role in order to decrease overall project cost. If you want to save costs, then you do so by having good project management. The reverse does not work.

Testing & QA

The biggest impact the imbalanced Project Management Triangle had on the Healthcare.gov site was that “time” had to be given up since the work stream was not adequately scoped from a quality perspective. This ultimately left no time for the most important task of all: testing and bug fixes.

Let’s bring in an example. There were reports that individuals were having issues during the process of signing up for a username and password. User attempts at this fundamental process have resulted in users that are now committing unintentional polygamy with multiple spouses attributed to them by the federal government. More times than that, the site is just freezing and users are not sure if they should wait, hit the back button, or just hit the submit button again and again and again.

This is fundamental. Nothing else works without being able to sign up. As a result, a team of QA specialists should have gone in and tested the sign up process on multiple versions of Internet Explorer, Firefox, Chrome, etc. They should have made sure it worked for PC and Mac users. They should have tested under different user scenarios (single user, versus married user, versus family). Instead, they didn’t do it at all. I was reading this bit on CBS news on the topic of Healthcare.gov and testing. As stated in an interview with Luke Chung, an online database programmer:

It’s not even close. It’s not even ready for beta testing in my book. I would be ashamed and embarrassed if my organization delivered something like this.

Lesson for the Rest of Us: Testing a site after launch is like ” trying to repair a car while someone is driving it.” I know that the launch deadline always has everyone on the project team on edge. No one wants to be the one that asks for more time. However, if something is worth being done, then it is worth being done right. There’s a reason that carpenters measure twice before cutting.

User Experience

Central to the Healthcare.gov debacle is the importance of user experience. The healthcare insurance buying process is complicated. Much more difficult than, say, buying a book on Amazon. So, why is it that more effort is being put into journey mapping the experience of book buyers than were given to the experience of anxious healthcare insurance consumers going through a federal process for the first time, ever?

While “non-functional requirements” (more on that below) were initially blamed for the Healthcare.gov shortfall, the most significant issues were related to user experience. It was this front end that was reportedly: 1) tested least, 2) not done correctly, or 3) both. My bet is on 3. The fact that millions of insurance consumers that had set up accounts are now being asked to sign up again points to significant changes being made to the fundamental components of the site. From a coding perspective, this is like a complete front end rebuild.

Lesson for the Rest of Us: Don’t let a complete front end rebuild after launch happen to you. As I mentioned in the post “Would you co-design you website with patients?“, users are the reason you are building the site in the first place. As a result, they should be at the table during the site design. Many of the healthcare organizations that I work with already have a patient advisory council of some sort that plays a role in governance. Councils like these are perfect contributors for user experience surveys and usability testing.

Non-Functional Requirements

I end where this whole debacle began. White House officials originally blamed high volume, with more than 8 million hits to the site in the first week, as the reason for the problems with Healthcare.gov. Even if this were the actual reason for the problems, which it wasn’t, building out non-functional requirements would have easily uncovered the hardware needs for a site this massive to ensure it did not collapse.

For the uninitiated, non-functional requirements are the requirements related to the nuts and bolts needed to make a site function behind the scenes. Among other things, it studies site usage and then the hardware needs required to support that usage. Healthcare reform involves multiple government agencies, numerous private insurance companies, all 50 states (the majority without a state health insurance exchange of their own). This site had to hold countless legacy computer networks together with more than duct tape and twisty ties. My original reaction to the number of users was “only 8 million hits?” In the grand scheme of things, that’s not a ton. Even back in 2000, there were 50 million Americans and their dependents who were self-insured. This doesn’t even count the millions more that are uninsured. Non-functional requirements take things like that into account.

Lesson for the Rest of Us: Organizations are, usually, good about building out the functional requirements before developing. Non-functional requirements are often left up to educated guess. “Gut instinct” is the lazy man’s non-functional requirements. Don’t do it.

Anything you think I missed? Please comment below.