How Digital Services Can Change Health Care

Digital services are showing great promise for enabling technology teams to solve complex challenges quickly and with human-centered design principles front and center. Andrea Fletcher, chief digital strategy officer at the Centers for Medicare and Medicaid Services, has a passion for helping solve problems for some of health care’s biggest challenges.

From a technology standpoint, a critical component of that is building the right tools for the right contexts. Even more importantly, she said, is recruiting the necessary workforce that government technology desperately needs.

GovCIO Media & Research spoke with Fletcher about her start in digital services and where she sees it growing at the agency as it strategizes how to make health care more equitable and accessible for the 88 million beneficiaries and 34 million people who sign up for healthcare.gov each year.

What is your background in health and what brought you to CMS in digital services?

Fletcher: I have a background in public health. My first job out of graduate school was at a startup called Dimagi, one of the first companies to build apps for frontline health care workers in India and sub-Saharan Africa. I ran around sub-Saharan Africa for a few years, living mostly out of a backpack. I would show up to help build an app and I would get a strange look: “This is the techie — a 25-year-old woman?” Very early on I learned to have the attitude of, “That’s me! I’m here to build you an app!” I would just roll up my sleeves and figure it out.

I learned a lot from that experience, particularly because it was a low-resource setting. We never had enough of anything — money, staff, time, but you still had to learn how to get stuff done. I worked with governments that had no laws on the books for collecting people’s health information on mobile technology; so we’d have to work with them to make sure that what we were doing was safe and trustworthy. Sometimes that meant writing the policy or processes to help ensure that the data collection was safe, sometimes that meant re-working processes or helping hire staff. I was fortunate enough to work in over 20 countries, mostly in Southern and Eastern Africa. In 2014, I also got to support some of the first contact-tracing apps to roll out during the 2014 West Africa Ebola Outbreak.  It was an incredible opportunity to see how technology can impact a crisis.

I came into CMS in early 2021. My call to service, watching America and how we were handling COVID and realizing that our public health system needed help. I kind of looked around and realized that I might have the right skills to step into the U.S. health care system and be a part of the change. I remember thinking, “Put me in, coach!” My coach ended up being the U.S. Digital Service, and after applying I landed at CMS to join the team working on health care.

How have these experiences influenced how you view your priorities now?

Fletcher: When I think about early times in my career, what was interesting is how quickly countries could leap ahead. They didn’t have the legacy systems that we have in the U.S. — it was mostly paper-based. We were building stuff on tablets and mobile phones and end-to-end technology systems for national health systems with very modern approaches. We built open-source software and designed with users because it helped us de-risk the technology and build better products. I also learned how to design with users, and the importance of including them in the process.

I spent a lot of days walking around villages with community health workers, getting an understanding of how difficult their jobs are and how much they care about the people they see. I needed to make their jobs easier with technology, not become an additional burden. The apps were always the easy part. But it’s all the other things that have to happen in order to put that piece of technology in somebody’s hand that is the difficult part of delivering great digital services.

At CMS, the scale is just unfathomable. We process 4.5% of the U.S. GDP through Medicare part A and B claims. Taxpayers pay into the Medicare trust, so it’s an immense responsibility to ensure that we are paying claims on time and accurately. It can be easy to get lost in the scale of it all and forget that real people are using these services. Part of how my previous experiences have influenced me to always bring it back to the users — stay focused on their needs and design with them.

How do you see digital services impacting the health care system? What problems are you trying to solve?

Fletcher: I’ve been thinking about the meaning of the word service lately. Our team comes in for a tour of service, meaning they sign up to serve their country for a period. When I think about how digital service impacts an organization like CMS, we’re bringing in the next generation of talent. It is very hard to get high-level technical talent hired into the federal government. One way of doing that is to use a tour-of-service model. I have people on my team who came from big tech companies, startups and across the federal government because they have a passion for health care, technology and solving tough problems. Bringing in talent is the number one thing that we can do right now in the federal government.

The other way I think about the word service is service delivery — delivering services to the American people. I often think about how my grandparents signed up for Medicare — it was most likely a paper form at a physical Social Security location. That is very different than what the expectations are now. People want to go to a website or download an app. They want the information to be understandable, they want it to be fast and user friendly. Expectations of the American people on what their experiences are for interacting with the federal government are the same that they have for any online service, and it’s our job to help these services live up to those expectations.

Our team partnered with SAMHSA to deliver a new website for issues with mental, drugs and alcohol. Findsupport.gov launched in May and is an incredible resource for navigating the health care space. Another example of things our team has been working on in the digital services space is surprise medical billing. We recently led the collaboration on building out new content for people who get an unexpected medical bill, https://www.cms.gov/medical-bill-rights. Both of these websites were developed from hundreds of hours of user research, many versions of wire frames and mock-ups, and continual user testing to ensure that we are helping people navigating the complexities of the health care system.

What does the ideal health care system look like to you?

Fletcher: Equitable, affordable and high quality. I’m really excited about CMS’ focus on health equity. It is imperative that we give people information they can find quickly and in accessible plain language. For health care, that also means that our services are easy to use for people using screen readers and with low vision, cognitive disabilities, low bandwidth and non-English speakers.

What do you think is still needed to get there, and where do digital services fit in?

Fletcher: I am constantly asking the question at CMS “How can we help?” A digital service team like the one we have at CMS are the team of helpers. Most of the time we end up helping defining the problem, building a prototype and demoing it, mapping out the processes, and talking with users and stakeholders.

You can’t do this without having really good people. Hiring is everything, and making sure we bring in the best talent in the country into public service to tackle big problems is critical to ensuring that we deliver the best digital services that we can. Federal government service is both an honor and an opportunity. If you’re waiting for the call to service, this is it!