Sick Obamacare website affects millions as White House scrambles for a cure
The botched rollout of the website built to allow Americans to enroll in a health insurance plan under the Patient Protection and Affordable Care Act—also known as Obamacare—will go down in history as one of the biggest technology debacles ever.
Since its launch Oct. 1, millions of people who used www.healthcare.gov to find a health plan have encountered error messages, delays, crashes and stalled accounts.1
The snarls didn’t end there. The reports generated from the federal exchange on new enrollees and sent to insurance providers were riddled with errors—such as syntax mistakes and transposed and duplicate data. Insurers also reported receiving multiple enrollments and cancellations without time stamps from the same people. Insurers resorted to contacting enrollees directly to follow up.2
Just six people successfully enrolled on the first day it opened. Of the 9.47 million people who visited the site the first week, only 36,000 were able to complete the enrollment process, according to an analysis by the consulting firm Kantar US Insights.3
"Nobody is madder than me," President Barak Obama said as he spoke about the problem-ridden website—technology that’s at the very heart of his plan to bring health coverage to millions of Americans.
The online marketplace is central to the 2010 law to reform the U.S. healthcare system. Every American will be legally required to have health insurance after Jan. 1 or face a penalty.4 The federal exchange and similar state websites are meant to be one-stop shops for health insurance for Americans who can’t afford coverage and don’t get it through employers.
The federal exchange is a huge system that’s composed of multiple systems with hundreds of integration points, making it innately difficult to manage, said Robert Charette, president of ITABHI Corp., a business and technology risk management consultancy.5 The website must fuse with disparate platforms of other large government agencies in addition to the systems of state exchanges and insurance providers.6
The federal exchange website also must do many things: verify a person’s identity, legal residence and income; record his or her personal information; match the enrollee with health insurance plans; calculate subsidy eligibility; provide comparison shopping features and, finally, enroll the person in a plan.
Initially, Obama blamed the website meltdowns on an overwhelming number of visitors.7 Software engineering experts identified fundamental issues with the website’s design and function, however.
Some software engineers have suggested the website’s consumer end, designed by one contractor, is not "talking to" the website’s back end, which was created by a different contractor.8
"Anyone in software engineering will tell you that cross-group coordination is one of the hardest things to get right, and also one of the most crucial, because while programmers are great at testing their own code, testing that their code works with everybody else’s code is much more difficult," wrote software engineer David Auerbach in a recent Slate column.9
Many of the problems also stem from a design element that requires users to create accounts before shopping for insurance. Making all users go through the registration process created logjams that blocked most other users from the marketplace.10
Project management missteps
Building a system takes more than good programming. It also requires sound project management. The Centers for Medicare and Medicaid Services (CMS) oversaw the entire project while also monitoring the development of the state exchanges.11
The flop isn’t that surprising, considering the CMS and most of the government has no experience running a project this large, wrote Steve Bellian, a professor of computer science at Columbia University, in a CNN column.12
"There are standard approaches, standard tools and standard software for building large-scale websites. Using them correctly takes good planning and management. That was in short supply here," Bellian wrote.
Representatives from private contractors charged with building www.healthcare.gov told members of the House Energy and Commerce Committee at a hearing in late October that full testing of the website didn’t begin until two weeks before it went live instead of months earlier.13
"You must create and emulate the customer experience as closely as possible," said Tim Moynihan, VP of marketing at Empirix, a network performance company that provides testing and monitoring services for web systems. "You must understand how it works and appears from the customer side of the equation, not the inside, IT side of the equation."14
While CGI Federal, a primary contractor, was awarded its $94 million contract to design the website’s back end in December 2011, the government was so slow to issue specifications that the firm did not start writing software code until spring 2013. As late as the last week of September, features were in flux because officials kept making changes.15
"That becomes a real problem if you’re using a waterfall method where you begin with the requirement process, then move to coding, then move to testing, then release an entire system," said Kev Coleman, head of research and data at HealthPocket, a site that compares and ranks health insurance plans.16
According to expectations
Major IT projects fail in the private sector, too, but without the entire nation watching.
"Anyone who has written a line of code or built a system from the ground up cannot be surprised or even mildly concerned that www.healthcare.gov did not work out of the gate," said Jim Johnson, chair of the Standish Group International, an IT company. "The real news would have been if [www.healthcare.gov] actually did work."17
Still, government IT has a notorious reputation for poor project management and an overreliance on contractors. A 2008 report showed 48% of federal IT projects were restructured because of cost overages or goal changes. Another 2008 report said 43% of the Department of Health and Human Services’ major projects were being monitored by the Office of Management and Budget because of poor performance and other concerns.
After improvements trickled in and outages occurred in the first few weeks following the rocky launch, the White House enlisted some of the best and brightest from Google, Oracle and RedHat to fix the problems that were still rampant and crippling the website in early November.18,19
But the clock is ticking, and some officials worry the troubled website may start to directly affect the success of the healthcare law.20 The White House hopes to enroll 7 million people in Obamacare by the end of 2014.
"Obama says the product is good. You can have the best product in the world, but if no one can buy it, it really doesn’t matter," said David Lloyd, CEO of IntelliResponse, a customer service technology provider.21
—Megan Schmidt, contributing editor
- Tim Carmody, "Inside the Failure of Healthcare.gov," Newsweek, Oct. 31, 2013, www.newsweek.com/inside-healthcaregovs-failure-1449.
- Michael Scherer, "Traffic Didn’t Crash the Obamacare Site Alone. Bad Coding Did Too," Time, Oct. 24, 2013, http://swampland.time.com/2013/10/24/traffic-didnt-crash-the-obamacare-site-alone-bad-coding-did-too.
- Elise Viebeck, "Analysis: Less Than 1 Percent of Visitors to ObamaCare Exchange Enrolled," The Hill, Oct. 16, 2013, http://thehill.com/blogs/healthwatch/health-reform-implementation/328797-analysis-less-than-1-percent-of-users-initially-enrolled-at-healthcaregov.
- Scherer, "Traffic Didn’t Crash the Obamacare Site Alone. Bad Coding Did Too," see reference 2.
- Willie Jones, "The Obamacare Rollout: What Really Happened?" IEEE Spectrum, Nov. 4, 2013, http://spectrum.ieee.org/riskfactor/computing/it/the-obamacare-rollout-what-really-happened.
- Carmody, "Inside the Failure of Healthcare.gov," see reference 1.
- Scherer, "Traffic Didn’t Crash the Obamacare Site Alone. Bad Coding Did Too," see reference 2.
- David Auerbach, "Err Engine Down," Slate, Oct. 8, 2013,
- Christopher Weaver and Louise Radnofsky, "Healthcare.Gov’s Flaws Found, Fixes Eyed," Wall Street Journal, Oct. 10, 2013, http://online.wsj.com/news/articles/SB10001424052702304500404579127783931191264
- Steven Bellovin, "Why Healthcare.gov Has So Many Problems," CNN, Oct. 15, 2013, www.cnn.com/2013/10/14/opinion/bellovin-obamacare-glitches.
- Sandhya Somashekhar and Amy Goldstein, "Full Testing of HealthCare.gov Began Too Late, Contractors Say," Washington Post, Oct. 24, 2013, www.washingtonpost.com/politics/house-panel-grills-contractors-on-troubled-health-insurance-web-site/2013/10/24/8f42c748-3ca7-11e3-b7ba-503fb5822c3e_story.html.
- Alex Kane Rudansky, "Why Healthcare.gov Failed," InformationWeek Healthcare, Oct. 25, 2013, www.informationweek.com/healthcare/policy/why-healthcaregov-failed/240163089.
- Robert Pear, Sharon LaFraniere and Ian Austen, "From the Start, Signs of Trouble at Health Portal," New York Times, Oct. 12, 2013, www.nytimes.com/2013/10/13/us/politics/from-the-start-signs-of-trouble-at-health-portal.html?_r=0.
- Chris Nerney, "Bad Code, Bureaucracy Prove a Toxic Combo for Healthcare.Gov," HealthcareIT News, Oct. 25, 2013, www.healthcareitnews.com/news/bad-code-bureaucracy-prove-toxic-combo-healthcaregov.
- Sean Gallagher, "The Seven Deadly Sins of HealthCare.gov," Ars Technia, Oct. 29, 2013, http://arstechnica.com/information-technology/2013/10/the-seven-deadly-sins-of-healthcare-gov.
- Sam Baker, "Obamacare ‘Tech Surge’ Draws From Google, Oracle," National Journal, Oct. 31, 2013, www.nationaljournal.com/health-care/obamacare-tech-surge-draws-from-google-oracle-20131031.
- Robert Pear, "Troubleshooter Reports Progress and Barriers in Bid to Repair Health Portal," New York Times, Nov. 1, 2013, www.nytimes.com/2013/11/02/us/politics/day-1-on-healthcaregov-fewer-than-a-dozen-signed-up.html.
- Scherer, "Traffic Didn’t Crash the Obamacare Site Alone. Bad Coding Did Too," see reference 2.
- Rudansky, "Why Healthcare.gov Failed," see reference 14.
Who’s Who in Q
NAME: Rob Herhold.
RESIDENCE: Dardenne Prairie, MO.
EDUCATION: Bachelor’s degree in business management from Washington University in St. Louis.
CURRENT JOB: Former president of the Institute for Strategic Management Practices. Herhold is currently disabled with Lou Gehrig’s disease, or amyotrophic lateral sclerosis (ALS), but he continues to volunteer his expertise in quality to companies and nonprofit organizations.
INTRODUCTION TO QUALITY: During the late 1970s, Herhold worked for TRW Inc., considered one of the first Fortune 500 companies to use the Toyota Production System. He met Shigeo Shingo and has been hooked on quality ever since.
PREVIOUS EXPERIENCE: During his days with McDonnell Douglas (Boeing), Herhold and others formed its first quality processes division. The division was on the cutting edge with total quality management and helped establish the Baldrige Foundation. Herhold is also a former executive with the Excellence in Missouri Foundation, which administers the Missouri Quality Award, one of the most successful state quality award programs in the country.
ASQ ACTIVITIES: Malcolm Baldrige National Quality Award alumni examiner; past chair and board member emeritus of Epworth Children & Family Services; member of the state advisory board of the Missouri Small Business and Technology Development Centers; and member of the steering committee of the Center for Supply Chain Management Studies at St. Louis University.
RECENT AWARDS: Herhold received the Ambassador Award from Epworth Children & Family Services. He has also received the ASQ Volunteer Excellence Award and the Waldo Vezeau Technical Achievement Award, as well as other plaques and citations from ASQ and other organizations, including the Human Resource Management Association of St. Louis, March of Dimes, Muscular Dystrophy Association, American Red Cross, University of Missouri, Defense Contract Management Command and the Finnish Government.
PERSONAL: Married 17 years to Jan. Three grown children and two grandchildren.
FAVORITE WAYS TO RELAX: Reading and staying in touch with the happenings in the quality profession.
QUALITY QUOTE: There are two phrases that most people define as Herhold’s signature quotes: "Trust the process," and "You can’t make this stuff up."
Hospital Errors the Third-Leading Cause of Deaths in the U.S.
New research estimates that up to 440,000 Americans are dying each year from preventable hospital errors, which would make medical errors the third-leading cause of death in the United States.
The research, prepared by the Leapfrog Group, a patient safety advocacy group, underscores the need for patients to protect themselves and their families from harm, and for hospitals to make patient safety a priority, group representatives said.
"During this time of rapid healthcare transformation, it’s vital that we work together to arm patients with the information they need and tell doctors and hospitals that the time for change is now," said Leah Binder, president and CEO of Leapfrog.
The research also grades general hospitals in the United States. Leapfrog reports that many of these hospitals are making headway in addressing errors, accidents, injuries and infections that kill or hurt patients, but overall progress is slow.
For more information about the research and how the hospital safety scores were calculated, visit www.hospitalsafetyscore.org.
Three Honored as 2013 Award Recipients
Three organizations from two different categories have been name recipients of the 2013 Malcolm Baldrige National Award.
The recipients, announced Nov. 13, include:
- Pewaukee School District, WI (education category).
- Baylor Regional Medical Center at Plano, TX (healthcare category).
- Sutter Davis Hospital, Davis, CA (healthcare category).
"The Baldrige program has had a tangible impact on the success of thousands of organizations worldwide and our nation’s economy, and the winners will undoubtedly continue that legacy and serve as role models for their peers in the health care and education sectors," U.S. Commerce Secretary Penny Pritzker said during the announcement of this year’s award recipients.
The Baldrige judges also recognized two organizations that excelled in one or more of the Baldrige criteria categories. They are:
- Duke University Hospital, Durham, NC.
- Hill Country Memorial, Fredericksburg, TX.
A ceremony honoring the organizations will take place during the 26th Quest for Excellence Conference April 7-9, 2014, in Baltimore.
To read more about the recipients, visit www.nist.gov/baldrige/baldrige_recipients2013.cfm.
Certification Organizations Change Name
The ASQ entity RABQSA International and iNARTE last month changed their names to Exemplar Global.
The organization, which develops personnel and training certification products for professionals and training providers, wanted "to recalibrate itself so that we can demonstrate that we now serve a broader community of professionals and organizations in their pursuit of recognition of their abilities," Peter Holtmann, CEO and president of Exemplar Global, said in a statement.
The rebranded RABQSA International Inc. and iNARTE brands are represented in 190 countries and offer certifications to 15,000 industry professionals and more than 100 training organizations. For more information about the name change, visit Exemplar Global at www.exemplarglobal.org.
GLOBAL STATE OF QUALITY RESEARCH
Report Puts the Spotlight Squarely on the ‘Qustomer’
A balance between quality and customer engagement is needed to increase the value of products and services organizations provide to both internal and external customers, according to the first of four reports that complement ASQ’s Global State of Quality Research.
The five-page "spotlight" report highlights an ASQ-coined term—Qustomer—and says 67.4% of respondents share some quality performance information with customers, but a delicate balance is critical to success: Too much interaction with customers can be costly, but too little won’t yield adequate information to improve quality.
In addition to striking a balance, the report concludes there are other challenges to incorporating the customer into the quality process, including cultural differences, intellectual property issues and regulatory standards.
The report also describes how organizations such as Airbus, ABF Freight and Booz Allen Hamilton share information within their organizations about the role of customers.
"These spotlight reports take a close look at the data presented in the Global State of Quality Research, providing real-world examples of the impact of quality," said ASQ Chair John Timmerman. "The Qustomer spotlight offers examples of how organizations are engaging customers to improve product performance and services, and offers approaches that all companies can use and benefit from."
To download the Qustomer spotlight report, visit http://asq.org/global-state-of-quality/index.aspx. The report is free to ASQ members and $29 for nonmembers.
SECOND KEYNOTE ANNOUNCED Tony Kern, the founding partner and CEO of Convergent Performance LLC, a think tank based in Colorado Springs, CO. has been announced as the second keynote speaker for ASQ’s 14th annual Lean and Six Sigma Conference—to be held Feb. 24-25 in Phoenix. Kern has authored seven books on human performance, including the Plane of Excellence trilogy (Redefining Airmanship, Flight Discipline and Darker Shades of Blue). He is also a featured columnist for Canadian Skies, Vertical and Vertical 911 magazines. Kern joins Shane A. Yount, the previously announced keynote speaker for the lean and Six Sigma event. Yount is a nationally recognized author, speaker and principal of Competitive Solutions Inc., an international business transformation consulting firm. Watch for more updates on the conference at http://asq.org/conferences/six-sigma. Early-bird registration pricing runs through Jan. 13.
PITTSBURGH SECTION HONORED ASQ’s Pittsburgh Section has received the Keystone Alliance for Performance Excellence (KAPE) Award. KAPE helps Pennsylvania organizations achieve performance excellence using the Baldrige criteria as a framework for improvement. Five other award recipients were recognized along with the ASQ section at a banquet and conference in November in Harrisburg, PA.
STUDENT MEMBERSHIP UPGRADE Student members of ASQ can now select to participate in one of ASQ’s 25 forums and divisions as a way to further network with those in the quality community and learn best practices. The upgrade is one way to enhance this level of membership and improve the experience of student members. For more information about membership levels, visit http://asq.org/membership/members/your-benefits.html.
NEW CASE STUDIES Two new healthcare-related case studies have recently been published on ASQ’s website. The first case study describes a Philadelphia hospital’s use of value stream mapping and kaizen events to improve how patients moved through its operating room. The second case study covers how a Phoenix healthcare provider overcame cultural difficulties to identify and implement multiple process improvements within its emergency departments. Find these stories and more by clicking on the Case Studies tab at ASQ’s Knowledge Center at http://asq.org/knowledge-center/index.html.