It may not be immediately obvious how the problems that vexed the nation's founding fathers apply to the challenge of creating a national health information network. But perhaps because I live in Philadelphia and walk at night past Independence Hall, the words of the founders often strike me as relevant to our times.

For instance, on June 17, 1775, John Adams of Massachusetts wrote: "America is a great, unwieldy body. Its progress must be slow. It is like a large fleet sailing under convoy. The fleetest sailors must wait for the dullest and the slowest. Like a coach and six, the swiftest horses must be slackened, and the slowest quickened, that all may keep an even pace...."

This quote came back to me last week as I attended a webinar put on by Perot Systems' healthcare group about the impact of the Health Information Technology for Economic and Clinical Health Act (HITECH) provisions of ARRA.

Harry Greenspun, M.D., Perot's chief medical officer, noted that David Blumenthal, M.D., the new National Coordinator for Health Information Technology, has quite a challenge ahead of him in crafting the definition of meaningful use. He can't set the bar too low or the healthcare system's progress will be slowed, but he can't set it so high that nobody qualifies.

Like the colonists proposing independence, the health IT execs leading the effort have to find the right pace of change, financial help and encouragement so that the slowest adopters don't get frustrated and give up. Just as Adams needed all the colonies to agree to independence, Blumenthal needs all types of providers, large and small, to participate to make a true national network of interoperable health records. Perhaps this is where the proposed Regional Health IT Extension Centers will be key---in helping clinics and small practices find success with EHRs.

Dr. Greenspun and other Perot executives said their customers are eager to know what it will mean to comply. If they have 75 percent of orders going through CPOE, is that enough, or will it have to be 100 percent? Will they have to be actually exchanging data—or just show the capability to do so?

Also, many sophisticated hospitals in terms of health IT are academic medical centers that have built best-of-breed clinical information systems that are not yet certified. Will these systems that meet all the requirements but fail to get certified be punished? Will CCHIT (or whatever certifying body evolves) develop some way to accommodate certification of these systems?

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