ABSTRACT: This paper traces the federal legislative history of the drive to accelerate health information technology adoption in the United States. Although technologies such as the electronic health record (EHR), computerized practitioner order-entry (CPOE), and telemedicine have been the subject of research and advocacy since the mid-1970s, the daily practice of medicine remained largely unaffected by computerization well into the 2000s -- a trajectory that stands in stark contrast to other similarly sensitive personal-data domains such as finance and commerce. Somewhat ironically, however, the Clinton and Obama healthcare battles of 1992-1994 and 2008-2010, which polarized so much of American politics, produced a remarkable left-right consensus on the importance of constructing a nationwide “health information infrastructure.” Nonetheless, despite broad bipartisan political support, a devoted epistemic community, and a burgeoning industry of HIT vendors, the legislative process was slow and circuitous, and both the new HIT governance regime and the new HIT systems themselves met substantial resistance on the ground.

The contours of both the elite consensus and the ground-level resistance can be read in the two hallmark legislative enactments of this era, the 1996 Health Insurance Portability and Accountability Act (HIPAA), and in the 2009 Health Information Technology for Economic and Clinical Health Act (HITECH). HIPAA sought to clear a path for expanded electronic data interchange, by coupling support for data standardization with protections for patient privacy and computer security. However, when HIPAA’s primarily governance-oriented efforts proved insufficient to achieve widespread HIT adoption, HITECH intervened more directly, by establishing explicit financial incentives for “meaningful” EHR use, along with explicit regulatory penalties for patient-privacy infractions. In many ways, this booster shot achieved its goal: In the decade since HITECH’s passage, HIT adoption rates have risen dramatically. But the new regime continues to be plagued by governance tensions and implementation challenges, and the emerging landscape continues to fall far short of the early advocates’ utopian visions.

We explore this fraught history in light of the burgeoning literature on “institutional entrepreneurship” (Hardy & Maguire 2008; Battilana et al. 2009). Like many other instances of institutional change, the history of HIT in America has been an unfolding process, driven forward as much by acts of entrepreneurial agency as by macro-historical forces or technological imperatives. And like many other instances of agentic institutional entrepreneurship, the history of HIT in America has played out, in large part, in the interstices and overlaps among prior institutions, through the construction of new social networks, the articulation of new legitimating discourses, and the categorization and framing of new classes of actions and actors. But unlike most prior stories of institutional entrepreneurship, ours is more shambolic than heroic: The HIT field has faced three intersecting governance challenges, which we label the economics of standardization, the sociology of trust, and the politics of accountability. At the same time, the HIT field has been contested by at least five different sets of institutional actors -- clinicians, administrators, technologists, patient advocates, and health policymakers -- each with its own guiding metaphors for conceptualizing health information, and each with its own utopian and dystopian visions of what the field could become.

We build our analysis of this complex terrain around a close reading of academic studies, policy papers, press coverage, and Congressional hearings on the state and the future of the US health-information infrastructure, from the 1980s to the present. By juxtaposing these archival sources, we are able to distill underlying themes, metaphors and debates, and to link different perspectives to different speakers, to different professional communities, and to different time periods. This empirical evidence gives us a window into the impact of HIT -- as a myth, as a project, as a challenge, and increasingly as a reality -- on both the daily practice and the legal governance of the healthcare field.

All legal change is, in effect, institutional change; and much legal change reflects the efforts of agentic institutional entrepreneurs. But not all institutional entrepreneurs have a clear vision of where they are headed, nor are welcomed as conquering heroes when they arrive. Thus, the HIT field offers a valuable window into the often messy dynamics of legal and institutional change -- not as their advocates optimistically imagine them, but as they so often are. It allows us to see failures as well as successes, unintended harms as well as unanticipated benefits, resistance as well as evangelism, and structural rigidity as well as agentic ingenuity. The emerging story simultaneously resonates with the tropes of institutional entrepreneurship and yet also complicates the picture, highlighting: the shifting boundaries of the institutional project in time, participants and purposes; the ambiguities of success and failure; and the massive role of misperceptions and misrecognitions, unintended remote consequences, and unforeseeable exogenous events.