Talk a bit about how health information technology became such a big "pillar" of the stimulus bill. You call it a "no-brainer that appealed to Obama's hyper-rational side."

There was a lot of money in this bill for healthcare. The biggest chunk was aid to states to prevent huge Medicaid cuts. And there's some other stuff in there, but health IT – Rahm Emanuel had that famous line about how you never want to waste a crisis. And health IT had been something that had real bipartisan support: Hillary Clinton and Newt Gingrich ... I recently did Mike Huckabee's radio show, and he was talking about how he loved health IT when he was governor. Because it really is a no-brainer, right? We've got online banking, we've got online dating. It's preposterous that you have to fill out the same 20 forms every time you go to the doctor's office. And that two doctors who aren't in the same room can't look at the same file. And that if you show up at a hospital on the weekend they have no way of seeing the test that you took on Wednesday and you have to retake it. And that your doctor could kill you with his chicken-scratch handwriting. It's just crazy.

So I do think it sort of appealed to Obama, who really is this sort of rationalist, pragmatist, sort of policy guy. It's not like he had a new idea, this was one of the old ideas. Something that members of Congress had been working on in a bipartisan way. And here was this opportunity to spend $800 billion dollars, well, why don't we just do it? People had been squabbling over the details for several years; the prospect of $27 billion really did focus the mind.

Do you think the administration saw this as sort of a way of laying the groundwork a bit for broader health policy reform – what eventually became Obamacare?

Absolutely. In fact, Secretary Sebelius specifically said that to me. She said she considered the stimulus, and especially health IT, as the foundation for Obamacare.

One thing I often point out is that one thing that did set Obama apart from the other Democrats during the primary when it came to healthcare was that he really was focused on cost. That his analysis of the healthcare problem was that it was too expensive. He wanted to do universal care too, but his analysis of why there wasn't universal coverage was that it was too expensive. Anything you could do to make healthcare cheaper was the way to expand coverage. And health IT really has the potential – when you think about all the crazy stuff we do when this is not online, the way you have to see multiple doctors or take multiple tests – to reduce costs. And not just in money, but the personal tragedies that happen because of these mistakes that happen because who the hell can read the handwriting on these clipboards?

For Obama, this was the sort of thing of, "Well yeah, obviously we should do it. Figure out the details and then let's do it." And they did sort of work out the details. And my sense – I'm definitely not as in the weeds as you are – but my sense is, I'm aware of some of the decisions they had to make, and it sounds like they basically came out in the right place and it's already changing healthcare.

It was a big deal in this industry seven or eight years ago when President Bush just gave health IT  passing mention in the State of the Union address. He may have given the industry a boost, but as you point out in the book he spent comparatively little: $100 million or so. Obama earmarked $27 billion. Talk about the challenges of doing something effective with that much money – addressing all the concerns of privacy and interoperability and incentives while still getting the most bang for the buck. What was the process?

Putting the bill together there were all kinds of disputes that had to be worked out. Privacy is one of them. How hard are you going to make it to share this information? If you make it too hard then it's kind of useless. By putting this stuff online, not only are you making the act of providing healthcare easier and more efficient, but you're also providing data. There are really important potential uses for this stuff. And you're also allowing the possibility of having the interaction with the doctor and the patient where, if there are protocols, there are recommended protocols where your computer can say, y'know ... the obvious one is when there are dangerous drug interactions. David Blumenthal describes how he almost once prescribed a drug that a patient was allergic to, but his computer alerted him to the allergy.

But there were all kinds of details that had to be worked out. One I remember is there was a fight when [Democratic California Rep.] Pete Stark basically wanted to force everybody to adopt the VistA system.

Which is a great electronic health record…

Yeah, in Jonathan Alter's book [The Promise: President Obama, Year One (Simon & Schuster)], which I really admire, he took a shot at how ridiculous it was that they didn't all just adopt VistA. And I think there are going to be some real challenges in making sure these things can all talk to each other. But the thinking was, as I recall, "Why be prescriptive? Maybe somebody will come up with something better than VistA. We want NIST to create these standards, so there will be these interoperability requirements, but let's not lock ourselves into VistA. This could be an industry of the future, let's see what the great American innovators come up with."

When I wrote the book, the Bureau of Labor Statistics said [health IT] was the fastest-growing industry, and the money had just started going out the door, so there is the sense that this has created a burst of innovation.

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