Back to meaningful use for a moment. This is a long process. The rules were devised in 2009, Stage 2 was just published this past month and Stage 3 is still to come. Did other parts of the stimulus, that had all this money thrown at them, have anything like that? Any similarly stringent frameworks outlining how they could receive or spend this cash?

That's a good question. Yeah, there were lots of things like this. Another example – a part of the bill that actually has a lot in common with health IT, although it had a more ambitious timetable, because with health IT everybody knew it was going to take several years before it got started – was the Smart Grid. Which also, actually, has the same sort of NIST-doing-interoperability stuff. Merging the Internet with the electric grid: digitalizing the grid with sensors and routers. It's another thing where it's going to be providing all this information about electrons, sending it to utilities through these networks. These networks all over the country are going to have to learn how to talk to each other.

And so there I know there's a similar process going on at NIST. And so with the Smart Grid it was similar to how it was with health IT: There had been $100 million spent on it, and then suddenly it was $27 billion. That's just a lot of money going into a system that wasn't up yet. For the Smart Grid, the deadlines were a lot tighter. And at first it created some issues: The money wasn't moving, there were fights over whether the recipients to the Smart Grid grants would be taxed, people who had done Smart Grid work stopped, because they thought maybe they could get the government to pay for it, and I think there's probably some of that going on with health IT was well.

Yes, some providers wanted stimulus money who had implemented EHRs years before HITECH.

Exactly. The Smart Grid was even farther behind than health IT, but certainly people who had been doing some planning and had maybe been thinking of starting their implementation, put it off for a year. There's a scene in the book where Rahm hauls in all the Smart Grid people and asked them what was going on, and tried to hammer them to do, I guess what would be the equivalent of the VistA approach: just do what's easiest and get it done. But the energy guys stood up and said, 'Well, actually, Rahm, that doesn't make sense. At the risk of a lot more F-bombs, we've got to do it the right way." And they have, and now it is starting to show some results – in the same way the adoption rates for health IT are starting to take off.

It is, for sure. You have that quote from former Senator Judd Gregg (R-NH) who referred to the stimulus as: "A bunch of hospitals wanted money." But it wasn't just cash thrown willy nilly at a problem, without any thought about how to make it effective and lasting.

I remember I visited Mayo Clinic for another story. I think it came out around the same time as Atul Gawande's [New Yorker] story about McAllen, Texas and the high healthcare costs there, so no one really noticed it. But I did sort of an opposite story about the Mayo Clinic and how its costs were so low. I remember talking to them, and at the time they had like five different computer systems at Mayo. And they were spending a few hundred million dollars to reduce it to three. So the complexity of this stuff is really something. That's why I know Zeke Emanuel was initially annoyed that if we wimped out on meaningful use – if we took our foot off the gas – there was no way we were going to get everyone on an electronic health record by 2015. We won't get all the way across the finish line.

And now he's at peace with it. He realizes, "OK, so maybe it will be 2017. It's fine." I'm often asked when I give talks about the book, "What could happen? How much of this is permanent legacy and how much could be overturned tomorrow?" Health IT, I think is one example of, "There's no turning back," I think. Different public policies and different economic settings will change the rate at which this stuff becomes adopted, and how it becomes adopted, but we're not going back to pen and paper.

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