HIT POLICY a Global comparisons. This problem is hardly unique to health care. It explains why numerous other U.S. IT-related industries limp along behind their counterparts in more highly regulated economies. While U.S. wireless telephone carriers fought for more than a decade over which of two protocols to adopt, leaving all of us to roam"(when we could) across carriers, countries throughout the rest of the world had the luxury of saying: Use this one, and get on with it. The same goes for broad band access, which is why the United States ranks sixteenth in the world for per centage of citizens with broadband access and why that access moves data at only 60 percent of the rate of the broadband installed in the rest of the industrialized world. Most Americans would probably never admit this, especially because most probably are not aware of what they do not have, but U.S. technology markets are years behind those in Asia and several European countries, thanks to our reliance on messy markets to grind their way toward standardized technology platform design rather than rational, orderly design Rational, orderly design of a new HIT infrastructure is precisely what Walker and colleagues described and scored financially 30 Not coincidentally, it is the same strategy that David Brailer and Mark McClellan are attempting to inspire within the fractious health care IT vendor community, with more words than dol lars, from their bully pulpits in Washington. Our recurrent struggles with these problems illustrate why they and dozens of others have converged on a single ide The market has failed to coalesce around health care IT standards on its own. The time has come for rational, orderly design, one that will allow us to get on with the real work of improving the health care system with an IT infrastructure that other industries take for granted. This is hardly an argument for the virtues of com mand-and-control economies or industrial planning. Rather, it is an elucidation( the hidden costs-or"negative externalities"-of relying on markets for IT stan- dardization Railroads Water And Moonrocks As Americans, we have been here before-three times to be exact. By the end of the Civil War, we recognized that railroads were the nervous system of the emerg g industrial economy, the same way we recognize today that it is the nervous system of the postindustrial economy. Railroads ran up and down both coasts and out to the frontier, but none crossed the great empty middle. We fixed that prob lem through a publicly funded and privately built construction project unprece- dented in the history of the world. Fifty years later we recognized that the great empty middle of the country crossed by the new railroad was for the most part un inhabitable without gathering and redirecting its limited supply of water. We also recognized that despite the next industrial revolution that was rationalizing agr culture and freeing up the majority of Americans from subsistence farming where water was readily available, the western United States could make no such prog ress without first controlling its water supply. Finally, in 1957 we watched the So 1256 September/October 2005H I T POLIC Y • Global comparisons. This problem is hardly unique to health care. It explains why numerous other U.S. IT-related industries limp along behind their counterparts in more highly regulated economies. While U.S. wireless telephone carriers fought for more than a decade over which of two protocols to adopt, leaving all of us to "roam" (when we could) across carriers, countries throughout the rest of the world had the luxury of saying: Use this one, and get on with it. The same goes for broad￾band access, which is why the United States ranks sixteenth in the world for per￾centage of citizens with broadband access and why that access moves data at only 60 percent of the rate of the broadband installed in the rest of the industrialized world.-^^ Most Americans would probably never admit this, especially because most probably are not aware of what they do not have, but U.S. technology markets are years behind those in Asia and several Furopean countries, thanks to our rehance on messy markets to grind their way toward standardized technology platform design rather than rational, orderly design. Rational, orderly design of a new HIT infrastructure is precisely what Walker and colleagues described and scored financially^" Not coincidentally, it is the same strategy that David Brailer and Mark McClellan are attempting to inspire within the fractious health care IT vendor community, with more words than dol￾lars, from their bully pulpits in Washington.^' Our recurrent struggles with these problems illustrate why they and dozens of others have converged on a single idea: The market has failed to coalesce around health care IT standards on its own. The time has come for rational, orderly design, one that will allow us to get on with the real work of improving the health care system with an IT infrastructure that other industries take for granted. This is hardly an argument for the virtues of com￾mand-and-control economies or industrial planning. Rather, it is an elucidation of the hidden costs—or "negative externalities"—of relying on markets for IT stan￾dardization. Railroads, Water, And Moonrocks As Americans, we have been here before—three times to be exact. By the end of the Civil War, we recognized that raihoads were the nervous system of the emerg￾ing industrial economy, the same way we recognize today that IT is the nervous system of the postindustrial economy. Railroads ran up and down both coasts and out to the frontier, but none crossed the great empty middle. We fixed that prob￾lem through a publicly funded and privately built construction project unprece￾dented in the history of the world. Fifty years later we recognized that the great empty middle of the country crossed by the new railroad was for the most part un￾inhabitable without gathering and redirecting its limited supply of water. We also recognized that despite the next industrial revolution that was rationalizing agri￾culture and freeing up the majority of Americans from subsistence farming where water was readily available, the western United States could make no such prog￾ress without first controlling its water supply Finally, in 1957 we watched the So- 1256 September/Octobe r 2005