Health-care reform presents conflicting and confounding issues, and none of them is bigger than technology. Health care may be a multibillion-dollar behemoth, but it’s also “the last cottage industry in America,” says Hunt Blair, Vermont’s deputy commissioner of health-care reform. “It’s deeply fragmented, it doesn’t communicate well within itself, and because of that, we aren’t able to manage the business with current data.”

Blair should know. He also holds the title of state coordinator for Health Information Technology (HIT), a federally mandated position charged with bringing all those cottages together and getting them on the same technological page. “We have to make this [technological] shift to actually have the necessary tools to manage this business,” he says. But is making that shift an impossible job?

“I don’t feel it’s impossible, but it is hard,” Blair laughs. “It’s complicated and complex. There are lots of layers of technical stuff and governance and turf wars and vendor desires and entrenched behaviors -- and they all intersect across my desk.”

Blair, though, is fortunate in that he got a head start on most of his HIT colleagues. Vermont passed health-care reform back in 2006, and “HIT has been imbedded in it from the outset,” he says. When the Health Information Technology for Economic and Clinical Health Act, part of the American Recovery and Reinvestment Act of 2009, was signed into law, empowering the creation of the Office of the National Coordinator (ONC) for HIT, which in turn mandated state coordinators, “I wrote a really enthusiastic memo saying, ‘This is what we’ve been waiting for,’” he says. “I have since learned a valuable lesson in enthusiasm.” Joking aside, he says the ONC was smart in demanding that every state create its own HIT-man to navigate its uniquely choppy waters.

How do they do that? By playing politics, mostly. “My job as HIT coordinator is to stitch together the various constituents,” says Blair, who has been intimately involved in his own state’s health-care reform. “I am a policy person, not an IT person. I know just enough about IT to be dangerous.”

The same is true of many of his colleagues, so communication has become essential. “A really important function we all play is talking with colleagues in other states to figure out how this will work. It’s really valuable to learn what other states are doing,” says Blair, who is a member and former co-chair of the HIE Alliance, a 13-state coalition that holds monthly phone calls among its members to discuss health information exchanges.

The alliance is run by the consulting firm Manatt Health Solutions, whose managing director, Jonah Frolich, was previously HIT coordinator in California. “It’s an incredibly interesting job,” Frolich says. “It can be frustrating, because many of the stakeholders have different priorities, resources and agendas. Nothing is impossible, but it is incredibly challenging.”

It’s not just about communication and coordination, however. The feds are doling out a half-billion dollars to states in the form of cooperative agreements (rather than grants) to leverage IT reform in the health-care sector, according to Claudia Williams, director of ONC’s State Health Information Exchange Programs. “It sounds like a lot of money, but when you look at what we need to get IT reform going, it’s not a large amount,” she says.

To make sure both levels of government are on the same page, the ONC calls all the state HIT coordinators together once a year. Williams characterized the fed-state partnership as a “close working relationship.”

But Vermont’s Blair admits that some states are “more leery” of working with the feds than others. “We collaborate with the ONC a lot, because Vermont is a bit ahead of other states,” he says. “I am fortunate in that we are small and cohesive, pretty progressive, with a clear vision of where we want to go. There are more warring factions elsewhere.”

The end game of that war, however, is similar in every state. “We are all trying to do the same thing, which is not just to hook up a bunch of computers but improve health care,” he says. He admits that the 2014 deadline for all their work is “ambitious,” but health-care reform without IT reform is unthinkable. “If we are serious about transforming the health-care system,” Blair says, “it has to get done.”