Everyone seemed surprised when investigators from the RAND Corp  reported in the January 2013 issue of Health Affairs that the widespread use of the electronic medical record had not resulted in reducing medical care costs  – see the NY Times incredulous reaction. The RAND team of course said if we just tried a little bit harder, say by making these systems easy to use, that their original estimate in 2005 that the electronic record would save at least $81 billion a year would be realized; in fact, medical costs have risen $800 billion since the RAND Report urging the adoption of the electronic medical record was issued. So lets summarize. These guys told us eight years ago that if we spent billions of dollars forcing doctors to use an electronic record that we would save billions and billions (sounds like Carl Sagan) of dollars more. But we didn’t. So the only explanation is that we didn’t do it right. No possibility that their original premise might be wrong. Seems to remind me of something I can’t quite place about hen houses and foxes. Let me summarize the summary. RAND said spend money and we’d save a lot more. We didn’t. RAND says spend more.

Well, perhaps RAND is right. But there is at least an additional explanation for the failure of the electronic record to reduce costs. The electronic record is by its nature inflationary – it increase costs. While doctors hate it – they hate all record keeping and they have since Hippocrates invented it – coders and billers love it. Medicare and the medical insurance companies have devised a system of coding and billing for medical services that makes quantum mechanics appear simple. A patient appears complaining of chest pain and the doctor decides that it’s the result of reflux esophagitis. The coder get a hold of this diagnosis and use the electronic record and his computer to figure out which of the thousands of variations of billing codes for chest pain will result in the biggest bill. The effect on costs needs no further discussion. The hospitals, of course, are following the same process.

So RAND says make the electronic record more friendly. I suspect the friendlier it gets the bigger the bill it generates. RAND doesn’t discuss the whole bureaucratic mess that the medical record has become mainly because of the thousands of permutations that have been forced into the system. If we made medical record keeping simpler doctors would still hate it, but it might not drive costs as rapidly as they are now going. Perhaps I’m wrong about all this, but my view deserves a little attention even if it’s dismissive. Haven’t you noticed that your doctor now touches his computer more than he touches you? I recently had two encounters with a very good doctor and the closest he got to me was to show me an image on his laptop’s screen. Forcing doctors to substitute a computer for a stethoscope is not likely to save money or make medical care better.