healthy4u: begging the question

I used to have great respect for the New England Journal of Medicine.<br /><br />No more. <br /><br />That respect was reduced significantly in 2010 when I saw the following passage (as I wrote in my July 2010 post "<a href="http://hcrenewal.blogspot.com/2010/07/new-england-journal-on-meaningful-use.html" target="_blank">Science or Politics?  The New England Journal and The 'Meaningful Use Regulation for Electronic Health Records</a>"):<br /><br /> <br /><blockquote class="tr_bq"><div class="MsoNormal"><b><span style="font-family: Arial;">... </span></b><span style="font-family: Arial;">In the NEJM article "<b>The 'Meaningful Use' Regulation for Electronic Health Records</b>", David Blumenthal, M.D., M.P.P. (ONC Chair) and Marilyn Tavenner, R.N., M.H.A. (10.1056/NEJMp1006114, July 13, 2010) available <a href="http://healthcarereform.nejm.org/?p=3732&query=home">at this link</a>, the opening statement is (emphases mine):</span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><br /></div><div class="MsoNormal" style="margin-left: .5in;"><span style="font-family: Arial;">The widespread use of electronic health records (EHRs) in the United States <b>is inevitable</b>. EHRs <b><span style="font-family: Arial;">will</span></b> improve caregivers’ decisions and patients’ outcomes. Once patients experience the benefits of this technology, they <b><span style="font-family: Arial;">will demand</span></b> nothing less from their providers. Hundreds of thousands of physicians have <b><span style="font-family: Arial;">already seen these benefits</span></b> in their clinical practice.</span></div><div class="MsoNormal"><span style="font-family: Arial;"><br style="mso-special-character: line-break;" /><br style="mso-special-character: line-break;" /></span></div><div class="MsoNormal"><span style="font-family: Arial;">I think it fair to say those are grandiose statements and predictions presented with a tone of utmost certainty in one of the world's most respected scientific medical journals.</span></div><div class="MsoNormal"><span style="font-family: Arial;"><br />Even though it is a "perspectives" article, I once long ago learned that in writing in esteemed scientific journals of worldwide impact, statements of certainty were at best avoided, or if made should be exceptionally well referenced. I note the lack of footnotes showing the source(s) of these statements.</span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: Arial;">I also note the lack of mention of literature refuting or potentially refuting these statements of certainty. I can think of more than a few examples of the latter just off the top of my head [ref. 1-15 below, certainly not a comprehensive list but merely skimming the surface].</span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: Arial;">... So, did the NEJM publish fact, or political platitude?</span></div><div class="MsoNormal"><br /></div><div class="MsoNormal"><b><span style="font-family: Arial;">Can someone provide a list of peer reviewed, rigorous studies that back the assertions of certainty in 10.1056/NEJMp1006114, and override the body of literature that could cast doubt on these assertions of certainty?</span></b></div></blockquote><br />The negative if not bitter reader comments to yesterday's New York Times article on the health IT lobby (<a href="http://hcrenewal.blogspot.com/2013/02/nyt-digital-shift-on-health-data-swells.html" target="_blank">link</a>) certainly cast some doubt.<br /><br />My respect has dropped several more notches in 2013.<br /><br />The NEJM has served as a PR journal for health IT once again.<br /><br />In a correspondence piece "<b><a href="http://www.nejm.org/doi/full/10.1056/NEJMc1213481" target="_blank">Early Results of the Meaningful Use Program for Electronic Health Records</a>"</b>, N Engl J Med 2013; 368:779-780,  February 21, 2013 by Adam Wright, Ph.D., Stanislav Henkin, B.A., Joshua Feblowitz, M.S., Allison B. McCoy, Ph.D., David W. Bates, M.D. and Dean F. Sittig, Ph.D., the following statement is published (emphases mine):<br /><br /><blockquote class="tr_bq">... The downstream effects of meaningful use on  quality, safety, and efficiency <b>are not yet known</b>,  and <b>further increases in EHR adoption, functionality for clinical  decision support systems, and research are needed to <u>ensure the  effectiveness</u> </b>of the meaningful use program </blockquote><br /><span style="font-family: inherit;"><span style="font-size: small;">I note that <a href="http://www.nizkor.org/features/fallacies/begging-the-question.html" target="_blank">B</a><a href="http://www.nizkor.org/features/fallacies/begging-the-question.html" target="_blank">egging the Question</a> is a fallacy in which the premises include the claim that the conclusion is true or (directly or indirectly) assume that the conclusion is true. </span></span><br /><br />Further, I made the following points in my Jan. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/01/meaningfully-experimental-protocols-and.html" target="_blank">Meaningfully Experimental Protocols and Interfaces to Nowhere?  Nagging Questions On Healthcare IT Remain</a>":<br /><br /><blockquote class="tr_bq">... there is a major problem with the term "<span style="font-weight: bold;">meaningful use</span>" itself:<br /><blockquote><br />This  [term "meaningful use"] is an example of putting the cart before the  horse, and is a semantically-based, self contained logical fallacy of  sorts. If a health IT system is harmful, the term "meaningful use" is  itself Orwellian. If we don't know if HIT is beneficial, or have doubts,  then such as term presupposes that health IT is inherently beneficial. A  better term would have been <span style="font-style: italic; font-weight: bold;">"good faith use"</span> - use based on the faith or hope that health IT will have an overall  positive effect. The term "meaningful use" jumps the gun and is more a  political slogan than a "meaningful term."</blockquote><br />I go further. Use of a term that <span style="font-style: italic;">a priori</span> assumes some outcome reflects the antithesis of science.  The term  "meaningful use" in the domain of technology implies that those  following the recipe for use of some technology, as well as their  subjects, <span style="font-weight: bold;">will experience meaningful outcomes.</span>  A parallel is in the logical fallacy of <a href="http://www.logicalfallacies.info/presumption/begging-the-question/">begging the question or circular argument</a>, where the conclusion of an argument is among its premises.</blockquote><br />In this current NEJM passage, the "question" of MU effectiveness is shamelessly begged like a hungry puppy begging for a <a href="http://snausages.com/" target="_blank">Snausage doggie snack</a>. <br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPmkXt5cm0oa6UEcuITsYQ0L1LBsHyz_Vk6_adzOsPcKEDK0ycg56RxordM-mcHKEyeuWFUabhhYvKD8xgrsURwRH48HHquDOG2J9_Yhx9RJlX9licuN8HOxhgEvOcXK5Q3dtt7_ze5hTo/s1600/Snausages-.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgPmkXt5cm0oa6UEcuITsYQ0L1LBsHyz_Vk6_adzOsPcKEDK0ycg56RxordM-mcHKEyeuWFUabhhYvKD8xgrsURwRH48HHquDOG2J9_Yhx9RJlX9licuN8HOxhgEvOcXK5Q3dtt7_ze5hTo/s200/Snausages-.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><br /></td></tr></tbody></table><br /><b>"Ensure the effectiveness?"</b>  The inherent assumption is that MU (developed by consensus committee without supporting rigorous evidence of effectiveness), whose 'downstream effects' are admittedly unknown,<b> WILL</b> be effective -<b> if only</b> we spend MORE billions of dollars on the technology.<br /><br />At best, the appropriate statement to have been made is this:<br /><br /><blockquote class="tr_bq">... The downstream effects of meaningful use on  quality, safety, and efficiency <b>are not yet known</b>,  and <b>further increases in EHR adoption, functionality for clinical  decision support systems, and research are needed <span style="color: red;"><i><u>to determine </u><u>if</u></i></span> meaningful use <span style="color: red;"><i><u>will have any positive impact on healthcare quality, safety and efficiency</u>."</i></span></b></blockquote><br /><div style="right: auto;"><span style="right: auto;">From a physician commenter overseas who excels in demolishing health IT propaganda: </span><br /><br /><blockquote class="tr_bq"><span style="right: auto;">Seriously, did they proof read the last paragraph? How did the NEJM editors let that get printed?  <br /><br />Given the recent food scandal in the UK, it is like the PM saying we are not quite sure that there's horsemeat in the Burgers and Lasagna so we are going to need to import a lot more of this muck from France, Poland & Romania before drawing any conclusions... </span></blockquote></div><div style="right: auto;"></div><br />Shame on the New England Journal.  My respect for them is even lower than after the 2010 health IT advert as above.  This current letter's conclusion is a high school-level <a href="http://www.thefreedictionary.com/faux+pas" target="_blank"><i>faux pas</i></a> and, in my opinion, should not have been published in its present form.<br /><br />-- SS<br /><br /><b>Addendum:</b>  Let's see if they publish my Letter to the Editor on this matter, submitted today.<br /><br /><b>Second addendum:  </b>a reader opined that MU could have a <i>negative </i>impact on quality, safety and efficiency (cf. yesterday's NYT article and reader comments, <a href="http://hcrenewal.blogspot.com/2013/02/nyt-digital-shift-on-health-data-swells.html" target="_blank">link</a>).  While less likely, we just don't know.<br /><br /><b>Addendum Mar. 18, 2013</b>. <br /><br />I received this today from the NEJM:<br /><br /><blockquote class="tr_bq"><span style="font-size: small;"><span>Your letter referring to  the Wright article of 21-Feb-2013  has been received.  Because of the  limited availability of space, we can publish only a fraction of the  letters we receive.  Although we will not be able to print yours, we  have forwarded a copy to the authors in case they wish to reply directly  to you.</span></span><br /><span style="font-size: x-small;"><span style="font-size: 10pt;"></span></span></blockquote><span style="font-size: x-small;"><span style="font-size: 10pt;">  </span></span><br />This is why I blog.<br /><br />-- SS

EHRs and "Meaningful Use": Begging the Question in the New England Journal of Medicine

I used to have great respect for the New England Journal of Medicine. No more. That respect was reduced significantly in 2010 when I saw the...

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