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Obamacare, eHealth skill sets, and questions, questions, questions

By Dominic Covvey

I am sure that many of you have been following the debacle of the Obamacare website. Officially known as the Affordable Care Act, Obamacare is one of the greatest advances in healthcare financing in the United States since the introduction of Medicare. Many Presidents and Congressmen have tried and failed to do something like it. To realize its importance, one must recognize that health care in the U.S. is extremely expensive – though not proportionally effective – and that over 40 million Americans lack any form of health insurance.

I have had the opportunity to work with hospitals in the U.S. and to visit both Medicare clinics and emergency departments during my consulting career in the 1980s and 90s. Even when care can be accessed, facilities are unbelievably crowded and care is often very impersonal. I have often reflected that a dog or cat will be treated better than a human lacking proper insurance.

The demand for affordable insurance guaranteed that Obamacare’s healthcare.gov enrollment portal would need to handle high-volumes of enquiries. You probably heard through CNN or other media that, when registration first started, virtually everyone who signed onto the Obamacare website failed to get access. I believe fewer than several thousand succeeded in the first month.

You may be of the political view that Obamacare is inappropriate. Certainly many Republicans in the United States believe that is the case. There are even Democrats who object to the introduction of yet another socialized system, especially one with financial implications as great as this one. Or, you may recognize the desperate need for health care of a frail sector of humanity living sometimes in third world conditions in a first world country. I will not take a position here as my interest has nothing to do with politics.

My interest is in the domain of eHealth. We all need to recognize that eHealth goes beyond supporting the clinical and operational aspects of the healthcare system, and includes the administrative side of this crucial service on which we all depend.

The first thing I want to assert is that creating the Obamacare website is definitely an eHealth intervention. Further, it is a crucial eHealth intervention! Millions of people need to find some way of getting care that is consistent, high quality, humane and accessible. This website is their primary means of accessing the opportunity to get this kind of care. Well, folks, we purveyors of eHealth blew it! Given the importance of this intervention, I think we need to ask ourselves some serious questions. I’d like very much to get answers from you or just your thoughts about how this could have been done better. But, first, some questions.

What in the name of god caused a bunch of intelligent people to put a website into operation without doing end-to-end testing? Were all of these people simply too busy to recognize this crucial step? Were they all incompetent? What was going on in their minds?

I hope there is a study done of what occurred and that we get to read about what actually happened and learn some very important lessons. However, all we can do now is visit the accident site…and there is no NTSB to help us.

Assuming the team was intelligent, was not incompetent and was of adequate complement, there are other occurrences that could explain things. For example, political pressure: “you’ve got to get it done, no matter what (key a Dilbert scene here)!” Or maybe it was a failure to estimate the likely volume of simultaneous users? Frankly, I find that hard to believe, but I guess it’s possible. Even a quick, back of the envelope calculation with a number of assumptions would convince someone that millions of people would want access and they would likely do it during the daytime or evening hours and modeling could surely be done to determine loads. Was this done? If not, why not?

I don’t think there has been an eHealth event since the Ontario eHealth catastrophe, which set us back several years, that has bothered me as much as this situation.

I have no doubt that political pressure played a part. Let’s explore that one. It would seem that we learned nothing from the Challenger disaster that ended up in extinguishing the life of Christa McAuliffe and six other astronauts. In this case, management put pressure on the engineers asking them to “put on your management hat” and allow the rocket to fly despite freezing temperatures and previous knowledge of the failure of seals to work properly. Then there is the almost daily reality of ‘get-home-itis’, where pilots, particularly in small planes, just can’t wait to get home and blunder into storms or run out of fuel and find themselves at the scene of a crash and their own demise.

Why didn’t someone in the team say: “We aren’t ready; put a hold on this and let’s do it correctly”? Why not? As professional engineers, pilots, eHealth Professionals, or anyone who holds people’s lives to some degree in their hands, we have to be able to say “No!”, “Stop!”, or even” I quit!” Somebody MUST blow the whistle!

Often, in interviews, when I played the role of recruiter, I would ask people how to deal with a certain high-conflict situation, like a project that was going awry. They would first answer with some basic solution. I then asked them what if that didn’t work? They’d usually give me a more detailed and somewhat more resourceful answer. Then I asked them what if that didn’t work? And I’d keep asking them that question: “And what if that didn’t work?” There were only a few who would say, then I’d resign. Man, that takes real courage – heroism even! And the Obamacare website team apparently had no heroes!

While we were fascinated with technology, while we were advancing our careers, while we were building up our curricula vitae, while we were schmoozing with the uppity ups, eHealth became central to life itself. People became dependent on it! They came to need it to make good decisions and to properly care for people. Businesses, like hospitals and providers offices, now can be damaged by eHealth failures, incompetence, and, perhaps most importantly, our inability to say “We are not ready!”, to say “Stop!” and to stand firm (and sometimes alone) on our well-founded convictions.

The Obamacare website is now slowly recovering. It has cost around $1 billion. It has at least begun to be able to carry the load and to address the challenge for which it was created. But, its initial failure has served as a means for politicians who would abolish the entire program [d1]to possibly have their way. For millions of Americans, that is damned serious!

Why the hell can’t we absorb the message that our work is central to the future of health care, is depended on by millions, deserves even better consideration than rockets filled with astronauts or planes with their pilots!

We need to be convinced of eHealth as a life-support system and we need to be heroic in achieving competence, giving ourselves to our work, and making sure that we never put our jobs ahead of our commitment to excellence and our obligations to those for whom we are doing this.

Dominic Covvey is President and Director, National Institutes of Health Informatics, and an Adjunct Professor at the University of Waterloo. He is also an Adjunct Professor at the University of Ontario Institute of Technology.

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