on the move: applying for public programs using mobile ......tering, applying, shopping, shipping,...

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Key Findings

Application assistors partici-pating in the pilot found the One-e-App mobile applica-tion fast and client-friendly. Key benefits cited were effi-ciency, accessibility, and comprehensiveness.

Launching a mobile applica-tion is not as simple as just flipping a switch and expect-ing assistors and applicants to start using it. There are design, training, and equip-ment issues that must be considered.

Safety net providers do not typically have dedicated IT staff to configure and sup-port mobile equipment. Training on these topics is therefore critical.

Mobile technology raises unique security and privacy matters, including oversight against loss and theft of mo-bile devices and use of the devices in public environ-ments such as waiting rooms.

On the Move: Applying for Public Programs Using Mobile Technology

November 2012

This issue brief describes findings from a pilot of the mobile application of One-e-App, a web-based tool developed and operated by Social Interest Solutions (SIS) that screens and enrolls low-income consumers in a wide range of health, social services, income support and other public programs. At the forefront of the automated enrollment industry, SIS has long used smartphones as an assistive technology, supporting text messaging and al-lowing for the upload of photographed documents from smartphone cam-eras. However, recognizing the need to push the technology to the next level and support the “consumer first” aspirations of federal health care reform, SIS, with support from The California Endowment, developed and tested a mobile version of One-e-App. Lessons from this California pilot with application assistors in a safety net setting have important national relevance.

Introduction Consumers increasingly manage their lives online – banking, buying, regis-tering, applying, shopping, shipping, tracking, blogging – all without leaving their own chairs. The proliferation of mobile devices, such as smartphones and tablets, has accelerated this movement, making most services available at the touch of a fingertip, wherever and whenever is most convenient for the consumer. Mobile applications are being utilized in every industry imaginable, from looking up directions to purchasing airline tickets to apply-ing for loans. Even private health insurance has gotten in on the action, with mobile applications available from brokers and individual health plans. Public health and human services programs should be no different. We as a nation now have the opportunity to bring such efficiencies and convenience into the realm of healthcare. In fact, federal healthcare reform requires it. The Affordable Care Act (ACA) calls for a “first-class” consumer experience including establishment of enrollment channels which allow individuals to apply for health programs and manage their ongoing coverage online. Modernizing the enrollment process for these programs will now enable low-income families, struggling in a relentless economic crisis, to find help when they need it.

© 2012 Social Interest Solutions www.socialinterest.org

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Considerations for Healthcare Reform

Interoperability is a key component of ACA, and interfaces are critical to usability of a mobile de-vice. The ability to ex-change data electronically across systems is key to a user-friendly client experi-ence.

Mobile applications are a convenient and valuable tool, but some consumers may not want to complete the entire application on their mobile device. Therefore, careful consid-eration must be given to the ability to move seam-lessly between desktop and mobile versions of an online Exchange applica-tion.

For mobile enrollment in multiple benefit programs to be effective, electronic signatures must be consis-tently accepted by all of the agencies that deter-mine program eligibility.

Whether or not states intend to launch a mobile application immediately in 2014 to support their Ex-change, they should be working now to determine how they can leverage mobile technology to maximize enrollment.

As smartphones and tablets become more affordable and more prevalent, particularly among low-income consumers who might not otherwise have access to broadband, their value as an enrollment tool will multiply. As de-scribed in a recent issue brief on mobile technology from Kaiser Family Foun-dation and The Children’s Partnership, “the potential of mobile technology to help individuals and families learn about, apply for, and manage their health coverage options is particularly great for those with low incomes, who are less likely to have broadband access to the Internet at home and who use mo-bile devices at high rates.”1 Nearly 85 percent of U.S. adults own cell phones, and 42 percent of those are smartphones.2 Although smartphone adoption is most prevalent among higher-earning households, nearly a quarter of households with incomes be-low $30,000/year now have smartphones.3 For one in four smartphone users, their phone is their primary source of Internet access.4 For this population, mobile technology offers the opportunity to increase access to health cover-age and options for managing that coverage.

Beyond providing an additional, highly-convenient and less-expensive online channel of access, mobile devices offer advantages over desktop computers for online applications. Supporting documentation can be uploaded through built-in cameras, tools such as live chat and voice call back support the user’s interaction with assisters and call centers, and text messaging can facilitate user support and follow-up reminders. Some of this mobile device functional-ity was explored by Enroll UX 2014, a project that worked with eleven states and the federal government to develop a design reference for state and fed-eral health insurance exchanges.5 Mobile applications also offer benefits to safety net clinics and community-based organizations helping clients apply for public programs. The ability to travel to clients with disabilities, to assist with applications in unwired loca-tions like waiting rooms or health fairs when computer stations aren’t avail-able, and the opportunity to more seamlessly support clients in rural areas are all enhanced by mobile technology. With this promise in mind, Social Interest Solutions built and pilot tested a mobile application version of its enrollment tool – One-e-App. This issue brief describes the findings from a pilot test of the mobile application of One-e-App by certified application assistors, and captures the lessons and implications for mobile device usage by consumers themselves.


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Background

One-e-App is a web-based tool that screens and enrolls low-income families and individuals in a large range of health, social services, income support and other public programs including Medicaid, CHIP, SNAP (formerly called Food Stamps and referred to as CalFresh in Cali-fornia), Earned Income Tax Credit, energy assistance, and local health coverage programs. One-e-App is used statewide in Arizona and in communities in California, Florida, Indiana and Maryland. People seeking services can complete an application in One-e-App with help from an application assistor at a hospital, clinic or com-munity center or – in some regions – can log onto the system from home or from any location where they have access to a computer and the internet. One-e-App is developed and maintained by Social Interest Solutions (SIS). SIS, at the forefront of the automated enrollment indus-try, has long used smartphones as an assistive technol-ogy, supporting text messaging for alerts and reminders and allowing for the upload of photographed docu-ments from smartphone cameras. However, recogniz-ing the need to push the technology to the next level and support the “consumer first” aspirations of ACA, SIS developed a mobile version of One-e-App for use on smartphones and tablets. The first version of this mo-bile application was designed for use by trained applica-tion assistors at clinics and other safety net organiza-tions, and includes applications for five programs: Medi-Cal for adults, Medi-Cal for pregnant women and chil-dren, Healthy Families (CHIP), CalFresh (Food Stamps), and CalWORKs (cash assistance). In order to field test the One-e-App mobile application and evaluate its success, SIS received funding from The California Endowment (TCE) to conduct a One-e-App mobile application pilot. SIS identified as its partner the Redwood Community Health Coalition (RCHC), a net-work of safety net clinics and community health centers serving clients in four Northern California counties. Cer-tified application assistors (CAAs) at RCHC clinics in two of those counties – Sonoma and Napa – have been us-ing One-e-App since 2010 to facilitate patient enroll-ment in public health and social services programs.

This pilot focused on the assisted One-e-App environ-ment, where trained assistors help clients complete their applications using tablets. In subsequent pilot studies, SIS will test the mobile One-e-App application with pub-lic users, who will access the application directly using their own smartphones or tablets.

Pilot Study SIS and RCHC identified a group of CAAs in seven clinics to participate in the pilot. These CAAs were selected based on the high volume of applications they were gen-erating in One-e-App each month. Each CAA was pro-vided a tablet (iPad 3) and a wireless Lexmark Office Edge Pro 4000 MFP printer for use during the pilot study, and participated in one half-day, in-person training ses-sion to become familiar with the mobile application, the hardware, and the evaluation process. The equivalent of 8 full-time CAAs participated in the full 6-week pilot. Following training, the pilot spanned six weeks, during which the participating CAAs completed all of their One-e-App applications in the mobile version. Findings were compiled based on observations during the pilot as well as surveys and interviews. Every week, each CAA completed a short survey designed to collect information about their experience, their clients’ per-spectives, and their suggestions for improvement. RCHC project managers were also interviewed to solicit feed-back on the training process and user support issues.

Findings During the six week pilot, the partici-pating RCHC CAAs initiated 386 appli-cations for house-holds (including 658 individuals) in the One-e-App mo-bile environment. This volume repre-sented approximately one-third of the entire One-e-App volume for those CAAs during this time period.

With today’s technology, we can assist the public with faster and more accu-rate ways to process an application. Mobile tech-nology means no long lines and no waiting.

Annette Rowland, CAA


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This section outlines the pilot findings in five areas: de-sign and development, training, user experience, secu-rity/privacy and equipment. Design and Development The One-e-App mobile application pilot revealed a num-ber of key findings related to the user-interface and un-derlying technology design and development of a mo-bile application. One of the biggest development chal-lenges was to build a mobile solution that could handle all of the major mobile technologies in the market (Apple, Android, Blackberry, and Windows Mobile). The RCHC pilot tested the One-e-App mobile application on iPads, and a subsequent San Diego pilot is testing it on Samsung Galaxies. However, the application was de-signed to support the wide range of mobile devices on the market. These devices use separate technology platforms and programming languages. Further, an Ap-ple native mobile application has to be developed using a Mac, not a Windows operating system. This reality makes it challenging to develop a universal application that can support all these devices. HTML 5 promises to handle this issue with a single coding standard, but it has yet to be proven. With regards to the user interface, mobile applications must consider the limited real estate on small device screens as compared to desktop or laptop computers. Each screen must be designed to minimize the amount of words, graphics and other information, while still be-ing intuitive and easy-to-navigate for users. This effort requires careful design considerations for each applica-tion screen, and is much more complex than simply tak-ing an application that has been designed for a com-puter and accessing it from a small device. Finally, testing of the mobile application proved to be a challenge. Although there are several simulation tools available that can be used to test mobile applications across different devices, these tools are not foolproof. SIS found significant discrepancies between how the application worked on the simulation tool and how it worked on actual devices. Simulation tools, therefore, can be a useful preliminary testing platform, but mobile applications must be tested using actual devices before

being put into the field. Training The CAAs who participated in the pilot were all sea-soned computer users with a thorough understanding of the desktop One-e-App application. However, they needed to be trained in two areas: the new mobile application version, and the mobile devices and sup-porting equipment they would be using during the pilot. As described above, SIS provided a half-day, in-person training session for the CAAs to orient them to their new equipment and to the features and user interface of the mobile application. Because the CAAs were already so familiar with One-e-App’s user interface, training on the mobile applica-tion version – which utilizes the same look and feel, application ques-tions, and many of the features and functionalities of the desktop ver-sion – was fairly straightforward. The training high-lighted the screens and functionality that had been pared down and simplified in re-sponse to the bandwidth constraints of the mobile environment (for example, automatic tabbing be-tween fields, numbers of questions per screen, and use of images and icons). In addition, trainers fo-cused on two particular pieces of the application process: signature collection, and uploading of docu-ments, both of which are functionally different in the mobile environment. CAAs were trained on how to create an electronic signature using a checkbox and typed name, and were taught how to take and upload photographs of supporting documents into One-e-App using the iPad’s camera. Signatures and docu-mentation are discussed further below in the

It is rewarding to help families apply for public benefits, and it is so much easier to do this using mobile technology. I am now able to com-plete an application faster than before and accommodate those who are disabled.

Viridiana Perez, CAA


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“Equipment” and “Considerations” sections. CAAs were also trained on the tablets and wireless printers they’d be using during the pilot. Most of the participating CAAs had never used a tablet before and needed to be oriented to the touch screen interface and walked through the process for setting up their iPads. In subsequent training sessions, they were taught how to set up an Apple ID and account that would allow them to download and install free software needed to support the mobile application (such as Adobe Acro-bat). However, by far the biggest training challenge was printing. During the training CAAs were shown how to print from their iPads to a wireless printer. When they returned to their sites and tried to set up their printers, however, it became clear that more assistance was needed in installing the printers and establishing the required wireless networks (see “Equipment” below for more information). We learned that many of the clinic sites did not have dedicated IT staff to help them with these types of tasks, and that more training and equip-ment set-up time was needed at the outset of the pro-ject. Incorporating the lessons learned from the RCHC mobile application training process, SIS subsequently developed a remote training protocol, and is testing that protocol in San Diego.

User Experience Overall, the pilot testers reported a very positive user experience with the One-e-App mobile application. One CAA succinctly summed up the benefits of the mo-bile application as follows:

Efficiency: more applications in less time Mobility: helping people anywhere Multifunctional: everything you need to complete the process in the iPad

At the end of the first week of the pilot, nearly 60% of the CAAs reported that the mobile application was eas-ier to use than the standard version of One-e-App, and an additional 15% said that its ease of use was equiva-lent. Even after only one week’s worth of experience

on the mobile application, nearly three quarters of the pilot testers reported that it took the same amount of time or less to complete the mobile appli-cation as compared to the standard version of One-e-App. By the end of week six, 46% of the CAAs re-ported that the mobile application took less time to complete than the standard application, and an addi-tional 36% reported it took about the same amount of time.

One reason for the shorter completion time is the mobile application contains fewer programs than the standard version. However, CAAs reported the mobile application interface was more streamlined and eas-ier to navigate. As described above under “Design and Development”, the streamlined navigation of the mo-bile tool was deliberately designed to take into ac-count the smaller screen size and more limited func-tionality of a mobile device as compared to a desktop computer. Throughout the pilot, CAAs would often move be-tween the mobile and desktop environments in One-e-App. For example, they might start an application in the mobile version, and transition to the desktop later to complete the application or to utilize the more ro-bust case management functions available there. This highlighted the benefit of having a lighter, faster, more streamlined application on the mobile device that synched with a more robust desktop version. The mobility also provided the RCHC CAAs with op-tions to better coordinate application assistance ser-vices with staff at other community agencies, which is particularly helpful in rural communities. For exam-ple, a receptionist at a homeless shelter could input a client’s demographic data into the One-e-App mobile application, complete with signatures and photo-graphs of documents. A trained CAA could then pick up the application in the desktop version to complete and submit.

CAAs reported the vast majority of their clients were comfortable with the mobile application process, and many were enthusiastic about the technology. One CAA estimated that 60 percent of her clients had


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smartphones and were already familiar with mobile technology. As one client reported, “It’s great that you can do the application on the iPad. You finished with the application a lot faster than before.” Several CAAs said that the mobile application made it easier to inter-act with their clients while helping them with the appli-cation: “They are able to see me selecting or entering their responses to the questions, which I think makes them feel comfortable and builds trust.” Another CAA reported that the small size of the tablet made it less obtrusive and allowed her to have more eye contact and personal communication with the applicants, mak-ing the experience much more intimate: “I didn’t have to constantly apologize because I couldn’t look them in the eye.” Finally, the CAAs indicated the mobile applica-tion was particularly beneficial to their clients with dis-abilities, allowing them to travel to their clients.

While most aspects of the mobile application were well received, the pilot testers did encounter some chal-lenges, most notably problems uploading documents and issued with printer compatibility. Their feedback helped SIS identify areas where upfront training could be improved, and SIS was able to troubleshoot and re-solve many of the issues prior to the end of the pilot. The CAAs also offered design improvement suggestions, including workload functionality and improved search capability. Finally, the RCHC CAAs – many of whom sup-port clients in multiple counties – reported that the county-by-county differences in enrollment policies and procedures remain a challenge. Security/Privacy The One-e-App mobile application includes all of the privacy and security features that are part of One-e-App, including secured data transmission, firewall pro-tection, user account management, application authen-tication, enforcement of a strong password policy, ses-sion time outs, encrypted data storage, and auditing. It also adheres to the security standards required by Sec-tion 1561 of ACA.6

However, the mobile environment raises some privacy and security concerns that are different from those in the in-house enrollment world. The mobile application

proved most useful in places like clinic waiting rooms, where lack of access to a computer workstation had previously made application assistance difficult. Thus, it quickly became evident that privacy screens were needed to block the view of the iPad screen from oth-ers who might be seated nearby.

Early in the pilot, SIS also identified concerns about the documentation that was being photographed and uploaded onto the iPads for submission with the ap-plication. Because iPads are more portable – and therefore more vulnerable to theft – than desktop computers, there were concerns about the security of documents that were saved onto these devices. In response, CAAs were instructed to delete all image files at the end of each day, and SIS is currently re-searching software that could sweep the devices automatically on a regular basis.

Equipment As discussed above, RCHC pilot testers utilized iPad 3 tablets and Lexmark wireless printers. Overall the pilot testers were very pleased with the iPads, report-ing that they were much lighter than laptops, easy to transport, had good battery life, and were easy to use (even for those formerly unfamiliar with touchscreen technology).

There were a number of challenges related to the equipment. The pilot highlighted the fact that many clinics and community-based organizations do not always have dedicated IT staff, and if they do they are often focused on competing priorities. Even within a single clinic consortium, network rules and policies can be different across individual clinic sites, and mak-ing changes to those can be a challenging process.

As described above, this pilot utilized Apple iPads. As the pilot proceeded, it became evident that identify-ing internal IT support for Apple software was a chal-lenge in the heavily PC-based environment. SIS also identified several limitations to the Apple Safar i browser, the biggest of which is that it would not al-low users to view pre-populated forms on the iPad. Pre-populated forms are used frequently in One-e-App,


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allowing users to upload data they’ve provided in the One-e-App application into a paper application in in-stances where electronic submission is not permissible by the receiving agency. As a workaround, CAAs were instructed to download Adobe Acrobat onto their iPads, and to switch to the Adobe browser to view forms when needed. However, the biggest equipment issues were related to printer compatibility. Many of the clinic sites participat-ing in the pilot faced challenges in getting the printers connected and working properly. In order to print from the tablet, users were required to establish a wireless network, and then configure both the tablet and the printer to that network. This raised security concerns, as some agencies are not comfortable transmitting cli-ent data over a wireless network. One option is to use a MiFi device as the wireless network. In a pilot currently underway in San Diego, SIS is testing Samsung Galaxy tablets to assess whether these same types of issues persist and to identify any potential additional chal-lenges.

Considerations for Healthcare Reform

As mentioned above, ACA calls for the establishment of multiple enrollment channels for healthcare and human services programs. The mobile environment, the wave of the future, must be one of those channels. But, meeting mobile demand is not as simple as taking an already-developed application and assuming it will work on a mobile device. Nor is it simple to just flip a switch and expect clinics and community-based organizations to start using it. There are training, equipment, and functional issues that must be considered. The One-e-App mobile application pilot raised a number of these considerations related to the implementation and pro-liferation of mobile applications in the Exchange appli-cation process:

User needs are paramount. Mobile applications provide a valuable online enrollment channel for many people who already have smartphones, and who may not otherwise be connected to the Inter-net. They are also a useful tool for Navigators who may travel to see their clients and can take advan-

tage of the lightweight equipment and wireless con-nectivity. But both of these populations are likely to need some training and support. On this front, SIS has begun testing the use of remote training in a pi-lot in San Diego with the goal of providing learnings about the design of online training tools. It is also important to consider that some users may not want to complete the entire application process (e.g. health plan selection) on their mobile device, and therefore the ability to seamlessly move between desktop and mobile Exchange applications must be carefully architected. Electronic interfaces and system integration are criti-cal to usability on a mobile device. In the desktop ver-sion of One-e-App, interfaces are used wherever per-missible to allow for the electronic submission of ap-plication data. In cases where the receiving agency does not allow for an electronic interface, a pre-populated paper application can be generated, and mailed or faxed to the agency of record. In the mobile environment, it is not efficient or practical to print paper applications, making the availability of elec-tronic interfaces critical to success. But even beyond the mobile environment, interoperability is a critical issue, especially in California where Medicaid eligibility is determined on a county-by-county basis by systems that don’t interface with one another. With decisions underway now about the role of the county IT systems within the larger State Health Benefit Exchange, stake-holders need to consider how a two step process will be supported by mobile devices. Electronic signatures must be the accepted standard. An electronic signature is a process used to authenti-cate the identity of the signer of a document, and can include everything from a scanned written signature to an audio voice verification to a checkbox establish-ing the signer’s agreement to let their typed name serve as their signature. Industry is rapidly moving away from requiring an electronic replica of a written signature, and instead is moving to secure account establishment processes that create electronic “fingerprints” that support data integrity and signer authenticity. In order for a mobile application to be feasible, electronic signatures must be consistently accepted by the agencies that determine enrollment for Medicaid and other federal, state and local pro-


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Social Interest Solutions is a non-

profit technology and policy solution

provider dedicated to improving low-

income families’ quality of life by

leveraging innovation to connect

them to needed programs and ser-

vices.

www.socialinterest.org

The Redwood Community Health

Coalition is a coalition of community

health centers in Northern California

that supports its members' mission to

provide high-quality cost-efficient

care to all, regardless of ability to

pay.

www.rchc.net

The California Endowment, a private,

statewide health foundation, was es-

tablished in 1996 to expand access to

affordable, quality health care for

underserved individuals and commu-

nities, and to promote fundamental

improvements in the health status of

all Californians.

www.calendow.org


accepted by the agencies that determine enrollment for Medicaid and other federal, state and local programs. In California there are inconsistent policies across and within counties about what kinds of signatures are ac-ceptable. Due in part to this challenge, this pilot was not able to explore the full complement of electronic signature possibilities, but SIS is continu-ing to look at signatures in a subsequent pilot in San Diego where we will test the use of telephonic signatures in the mobile environment. Security remains a top priority. The electronic environment allows for a heightened level of security over the old paper application process, requir-ing the creation of user accounts and strict password policies, and elimi-nating the risk of paper being left on a desk or in a fax machine. However, stringent precautions must be taken to ensure that image files are secure and cleaned out regularly, and to protect electronic transmissions. IT support for mobile devices and supporting software and hardware is critical. The existing IT support infrastructure of community-based organi-zations and Navigators must be considered when determining what type of mobile devices will be used. If organizations have traditionally been PC-based, then they will need to carefully consider their ability to support Ap-ple products should they decide to focus mobile application efforts on iPhones or iPads.

Several key issues still need to be examined, and SIS plans to test them in sub-sequent pilots, including a study already underway in San Diego. The San Diego pilot is exploring the use of telephonic signatures in the mobile environ-ment, and will test the use of PC-based devices to compare with the Apple-based findings in this study. An important next step will be to look beyond use of the mobile application by CAAs and examine the use of this technology directly by applicants themselves, as well as the translation of the mobile ap-plication into additional languages and related cultural competency issues. Whether or not states intend to make a mobile application for their Exchange programs available immediately in 2014, they should be working now to de-termine how they can most effectively leverage the mobile environment and the exponential proliferation of personal mobile devices to maximize enroll-ment opportunities in health and human services programs. Only by doing so can states meet ACA’s “first-class” consumer requirement, and fully enable low-income families to find the help they need, when they need it. In this age of technology, mobile enrollment is not an option - it is a requirement.

1. Kaiser Family Foundation Commission on Medicaid and the Uninsured, “Mobile Technology: Smart Tools to Increase Participation in Health Coverage,” March 2011. 2. Pew Internet & American Life Project, “Smartphone Adoption and Usage,” July 11, 2011 (http://pewinternet.org/Reports/2011/Smartphones). 3 and 4. Ibid. 5. www.ux2014.org/about-ux-2014 6. http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3161

http://www.socialinterest.org

http://www.rchc.net

http://www.calendow.org

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