HIX, A Disaster Foretold, Needs Time

It would be easy to focus on the price of the federal government's health insurance marketplace and expect it to work better than some Web startup launched by a couple of heavily-caffeinated kids. But it wouldn't be fair.

No one ever said information technology was foolproof. Even the most advanced systems today have their glitches. Now we can add healthcare.gov to the list.

Last week, at the CHIME conference, my informal poll of healthcare CIOs found broad agreement that it's no surprise the federal health insurance exchange Web site, healthcare.gov, has been overwhelmed by the number of unexpected visitors and other basic flaws.

Here's one example of how bad it is: A New York Times researcher successfully registered, but despite "more than 40 attempts over the next 11 days," was reportedly unable to log into healthcare.gov.

"I know the government spends a lot of money on their contractors and Web sites, and I also know that it's very difficult for them to make changes because of the process the government may go through," said Pam McNutt, senior vice president and CIO of Methodist Health System in Dallas, TX.

McNutt thought back to when CMS rolled out software that providers use to achieve Meaningful Use attestation, and how long it took the government to remediate problems in that software. "It does not surprise me," she says, that an IT project of healthcare.gov's scope and scale started out on the wrong foot.

A System Almost Predisposed to Failure
It's easy to focus on the price tag, $643 million or so, and expect it to work better than some Web startup here in Silicon Valley that say started on a shoestring a few weeks ago and yet is serving millions today. While tech's most darling sites have all had their outages, healthcare.gov last week is one for the books, resembling one long running outage.

But remember that the users of those Silicon Valley sites are usually tech-savvy types who have low expectations of a new site's capabilities, and are often attracted by a few glitzy features. In contrast, the nation's health insurance exchanges were defined by Congress—a body not known for designing things of beauty—and implemented by a raft of government contractors who got the job of plodding through an incomprehensible set of rules and regulations while purporting to be the lowest bidder.

It's a system almost predisposed to failure, and I've already received more than one email urging me to point out that the fact that the mere fact that the system is working at all is something of a coding triumph, or, as I put it back in July, something of a miracle.

But returning to CHIME, CIOs in attendance also pointed out that the public, which is so annoyed by healthcare.gov's shaky start, also requires a whole lot of educating about the kaleidoscope of choices the Web site presents them. And all of them are aware of the ticking clock—they must be signed up for coverage by the end of December to avoid a penalty.

Remember that healthcare CIOs aren't exactly sitting around waiting for things to do. They are up to their armpits in Meaningful Use, ICD-10, HIPAA Omnibus, accountable care organizations and a raft of other mandates and transformations that won't wait.

One CIO who I won't name even confided to me that he had received an email about the new health information exchanges from the CEO of his hospital's health plan, but he had not bothered to open it yet. "If I see anything exciting, I'll send it to you," he said to me.

As my colleague John Commins pointed out recently, hospitals are becoming default advisors on health insurance exchanges. CIOs I talked to at CHIME confirmed that this is happening, to lesser or greater degrees depending on the hospital.

It's Not Like Amazon
A hospital cannot and will not be expected to provide the same analysis that the federal data hub will, processing a prospective health plan member's income and producing expected tax credits. That will still require the federal and state HIX systems which have performed poorly so far.

A few pundits last week took issue with the way healthcare.gov requires all visitors to create accounts before they can receive such information, but I don't see any way around it. It's true that you can anonymously price-compare on Amazon and lots of other popular Web sites, but those sites do not require your tax information to calculate a price. By statute, healthcare.gov has to work this way.

So while everyone is throwing bricks at the Beltway Bandits who now scramble madly to fix and scale up the federal and state sites, let's not forget that the master architect of this information system was Congress, and the people who elected its members.

Technology is usually best designed by some megalomaniac who gets a good idea and pushes it through over the objections of investors and even the public because of some overarching vision of what it can be. Technology is not usually designed well by committees of any kind.

Give it Time
But we are not designing an iPad here, more like a set of incredibly boring plumbing that, like the plumbing in our houses, simply has to work, all the while adhering to an ocean of FIPS (Federal Information Processing Standards) designed by other committees and acts of Congress.

Could the Federal and state procurement processes that produced healthcare.gov be reformed? Sure, there is always room for improvement. But at the federal level, agencies have to deal with 435 cranky investors, each of which has way too much authority over the process without the requisite qualifications to design systems. I don't see a procurement process around that.

Let's all take a breath or two and give this some time. That was my takeaway from CHIME on this whole health insurance exchange mess. The CIOs gathered in Scottsdale, Arizona were indeed far from idle – serving up passionate ideas about how to fix electronic health records, how to move to value-based care, how to align IT goals with business goals.

I don't expect them, or healthcare systems, or even Silicon Valley, to fix the health insurance exchange rollout, and neither should anyone else.