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Analytics & Research

No Lack of Attention to ADHD

Attention deficit-hyperactivity disorder (ADHD) continues to draw public attention, with articles appearing in the November New England Journal of Medicine and most recently in the New York Times. The Times article emphasized the rising use of ADHD drugs by both adults and children in 2012, based on a recent report issued by Express Scripts about ADHD medication trends. The Express Scripts study showed a steady growth in the number of children taking ADHD medication through 2012. Recently, athenaResearch examined diagnostic data coming in from physicians on the athenahealth network to see whether 2013 data indicate any slackening of growth in ADHD diagnoses.

The ADHD Diagnosis Debate
The public attention to ADHD includes intense debate about whether the large numbers of ADHD diagnoses and prescriptions are appropriate. Proponents of ADHD medication believe that drug treatment has conferred substantial benefits on numerous children and adults. In contrast, skeptics believe the increase in ADHD diagnosis and treatment is unnecessary, citing several factors that may have contributed to the increase. Among the skeptics’ contentions is that greater academic performance pressures on students may lead parents to push pediatricians for a medical solution to behavior that in past years would have been tolerated. Those questioning the current level of ADHD diagnosis also suggest that some pediatricians may lack the time for careful clinical interviews or the training for neuropsychological testing – both needed to make reliable ADHD diagnoses. As a result, some cases are possibly misdiagnosed as ADHD, rather than anxiety, mood or conduct disorders. Finally, some believe that because behavioral therapy for ADHD is fairly time consuming and expensive, parents and physicians may prefer medication (page 9 of Express Scripts report).

We are not in a position to judge the relative merits of arguments for and against current levels of medical treatment of ADHD. However, given the public focus on the issue, we thought it would be useful to examine recent practice patterns to determine whether pediatricians have become more conservative in their diagnosis and treatment of ADHD over the last year or so.

2013 ADHD Diagnosis Patterns
To shed light on more recent patterns, we examined a sample of 538 pediatricians across 31 states that have used athenahealth services between January 2010 and the end of 2013. Our sample consisted of roughly 3.5 million office visits over this three-year span.

Our Findings
Concerns about ADHD have not stemmed from the long-standing increase in ADHD diagnosis. For every subcategory we considered, the proportion of pediatrician visits resulting in an ADHD diagnosis increased at roughly the same rate as was evident between 2010 and 2012.

For girls, the proportion of visits with a diagnosis of ADHD increased from 3.6% in 2010 to 4.2% in 2012, and then to 4.6% in 2013. For boys, ADHD diagnoses increased from 9.1% in 2010 to 10% of all visits in 2012 and then to 10.5% in 2013. The same pattern was evident in all subgroups.

In short, at least for pediatricians within the athenahealth network, we have not yet seen an inflection point in which concerns about ADHD over-diagnosis and overtreatment have translated into a more conservative approach in clinical practice.

For those interested in scrutinizing the data more closely, figures are provided in the following table.

Check out Matt Nix’s Google+ Profile.

Analytics & Research

ACAView: Measuring the Impact of Health Care Reform on Day-to-Day Physician Practice

Iyue Sung, Director of Core AnalyticsWith this post, we are pleased to introduce ACAView, a joint initiative between the Robert Wood Johnson Foundation (RWJF) and athenahealth. 2014 marks the launch of the Affordable Care Act’s (ACA) most important coverage expansion provisions, designed to dramatically reduce the number of uninsured Americans. Between now and the end of 2016, millions of individuals are expected to sign up for subsidized insurance coverage through newly established health care exchanges, or marketplaces. Other tracking initiatives are closely monitoring the number of individuals that sign up for this coverage as well as those that take advantage of expanding Medicaid coverage in some states.

With ACAView, we will take a different approach. We will focus on the provider perspective; more specifically, how the ACA affects the practice patterns and economics of physicians and other care team members around the country. This is also part of a wider effort, Reform by the Numbers, RWJF’s rich source of timely and unique data about the impact of health reform.

ACAView will monitor the impact of coverage expansion on a monthly basis, mining insights from athenahealth’s cloud-based network of more than 50,000 providers and 50 million patients. Our cloud-based, centrally hosted software platform provides us with near real-time visibility into practice patterns of physicians around the country.

Our goal is to inform, exchange ideas, and provide a timely, front-row view of how this landmark legislation affects a robust cross-section of providers across the nation. In subsequent reports, we will examine an evolving set of metrics that address a broad range of topics. We will also share our analyses on the extent to which our providers represent all providers in the US. For more about our data on practices and patients, as well as our preliminary list of metrics, please read our Methodology report.

No Meaningful Change to Date in New Patient Volumes
Among the many unknown questions surrounding coverage expansion is the number of new patients physicians will accommodate. This is a critical issue because one of the goals of health care reform is to allow individuals to form stable physician relationships, rather than seek care in high-acuity settings or forgo care altogether. If the ACA is working, we would expect physicians to see a higher percentage of new patients over the course of the year. Over the long term, this number should eventually return to historical levels as these new patients become established.

Figure 1 shows the percentage of provider visits accounted for by new patients, for the first two months of 2013 and 2014. These percentages are based on physician practices active on athenahealth’s network before 2011. In January through March of 2014, new patients accounted for 17% of visits to primary care practices, down slightly from the 17.9% for the same period in 2013. Other specialties, with the exception of pediatrics, also showed a slight decline in the proportion of new patient visits. In general, we view these differences as too small, or the timeframe too early, to indicate a meaningful change.

The absence of an increase in new patient visits in the first two months of the year does not surprise us. As of April 1, 7.1 million individuals had enrolled in private insurance plans, through either state or federal marketplaces. This represents approximately 2% of the population (estimates for Medicaid enrollment were not yet available at the time of this report). Of that 2%, an unknown proportion of these individuals had some form of previous coverage, so they are not necessarily “newly insured.” It will take some time for newly insured patients to locate new physicians, make appointments with them, and receive care. We look forward to monitoring this metric to identify meaningful changes when and if they occur.

Will there be Noticeable Differences in the Health Status of New Patients?
Another question is whether the new patients that physicians see are sicker than they were in the past. We will examine this issue in greater detail in our next blog post, but provide an early example here. Figure 2 shows the percentage of new patients with a diagnosis of diabetes from January through March 2014 compared to January through March 2013. The chart also shows the same statistics for established patients (patients who have visited in the last two years), who have a higher rate of diabetes. For both groups, we see no change to date, but will continue to monitor this and other chronic disease indicators.

The questions of whether the ACA will cause physicians to devote a higher share of their case mix to seeing new patients, or whether new patients will be more likely to have chronic disease (compared to new patients from previous years, or established patients) are just two issues we will consider over the course of the year.

Other questions we will examine include the following:

  • How much will new patients owe for their care?
  • How will reimbursement levels change for new patients relative to historical patterns?
  • How long will new patients have to wait for care from the time an appointment is made?

Our objective with this joint initiative is to answer a broad set of questions as the year progresses, and we welcome your commentary and suggestions along the way. For continued updates, follow Reform by the Numbers, as well as the ACAView tag on the athenahealth CloudView Blog.

You can connect with our researchers through email at We also invite you to follow Josh Gray, VP of athenaResearch, on Twitter @JoshGray_hit on Twitter.

Matt Nix and Chris Jones of athenahealth conducted the analysis used in this post.

Analytics & Research | Cloud Services

This Week’s Flu Report and the Case for Cloud-Based Disease Surveillance

The latest data from our athenaResearch team shows a nationwide decline in the flu for a fourth consecutive week and a 25% decline from this season’s peak rate, which occurred the week ending December 28, 2013 (see Figure 1). If this trend continues, this week’s update may serve as our last flu report for the 2013-2014 season.

While the national rate declined, there are some states where our data showed an increase (or no decline) in flu, including the New
England region, particularly Connecticut, Massachusetts and Vermont. Our data shows modest increases each week in those states, but with flu levels far below last season’s peak (week 4 rates of 0.6%, 0.4% and 0.7% rates respectively for the three states, compared to national rate of 0.7% for week 4 and 1.1% three weeks earlier).

In general, the flu is running at levels roughly 30% lower than last year’s national level, with some states seeing extremely benign flu seasons relative to last year. Centers for Disease Control spokesman Erin Burns said last week, “I don’t think we can say yet that the flu season has peaked,” but our team here at athenahealth is encouraged by the sustained decline.

The athenaResearch Perspective
Now that my team is at the tail end of our first disease surveillance – the 2013-2014 influenza season – I wanted to share some of our experiences using a cloud-based IT infrastructure as we have to track health-related data and report findings.

Using the Cloud to Monitor Disease
As described in previous posts, athenahealth operates from a single instance, cloud-based infrastructure. This means that all of our clients access the same software platform and use common clinical, operational, and business definitions. All documented care is immediately added to a secure, hosted database that our research team can access for analytic purposes. This gives us highly granular, real-time visibility into clinical practice patterns and patient treatment for our more-than 47,000 providers across the country. These are the data assets our team has applied to monitoring flu diagnoses over the past 13 months, and that we’ve looked to for other recent studies, such as behavioral health in pediatrician visits.

athenaResearch and the CDC
Our approach to disease surveillance differs from that of the CDC. The CDC measures flu based on weekly reports from roughly 1,800 outpatient providers across the country who report on the frequency of influenza type illness (ILI) in their population. They also report on flu lab results, strains and deaths.
In contrast, athenaResearch reports on the percentage of patient visits that included a diagnosis of flu, documented as an ICD-9 code on a claim. Each week, we collect data from visits to over 16,000 primary care physicians (PCP), nationwide. Although our methods differ from those at the CDC, our trends have generally mirrored theirs with high consistency.

Cloud-based Surveillance Provides a Safety Net for Public Disease Surveillance
During last fall’s 16-day federal government shutdown, the CDC was forced to furlough 68% of its work force, cutting their flu monitoring efforts. Because a flu outbreak in October is not unheard of, we saw an opportunity to help during this period of exposure, and published flu trend reports for the duration of the furlough. Fortunately, flu incidence during this period was very low; but, had a flu outbreak occurred during the government shutdown, we would have detected it and reported on it, both here on our athenahealth blog, directly to athenahealth providers, and throughout the Epocrates network via alerts. The larger lesson: Private sector, cloud-based disease surveillance activities provides a degree of valuable redundancy to public sector approaches. A safety net, of sorts.

In addition, cloud-based EHRs allow for situational awareness, where physicians can be alerted to pathogens circulating in their communities and can educate patients accordingly. Part of our roadmap at athenahealth calls for us to alert physicians when flu or other communicable diseases start presenting in their communities. Imagine a PCP alerting an at-risk patient who has not received a vaccination that the flu is projected to hit their area in three weeks based on neighboring states – still enough time to receive a vaccine and be protected.

A More Timely Source of Data
At athenahealth, our technology platform enables us to report on claims submissions or clinical documentation in real time, and generate daily data with a one-day lag, when appropriate. That is the power of cloud technology. Comparatively, many public health reports provide weekly data with a seven-day lag — and depending on the day of the week, public health reports may provide data from7-13 days prior. (For diseases with large public health implications, that time frame can be compressed, but data may be incomplete.) Cloud-based disease surveillance can “fill in the blanks” between regular weekly reports and reportable event systems, and can also provide data on diseases that aren’t included in regular reporting.

A More Robust Database for Projections
A cloud-based database contains a multitude of patient characteristics — address, location of diagnosis, demographics, clinical characteristics, lab values — that may be particularly useful in tracking the flu. When combined with other data streams (like flu look-up data online or flu mentions on Twitter), projections of flu incidence are likely to be more robust. We are currently speaking with several research groups about providing them data feeds that will help them refine and segment available flu incidence projections.

Supporting Local Public Health Agencies
In cases where athenahealth serves more PCPs in a particular region than an existing disease monitoring network, we may be able to provide useful supplemental information to local public health authorities.

As an example, we serve a large number of physicians in the Columbus, Ohio region, and supply the Columbus Department of Public Health with weekly data that goes beyond what they’re receiving through other sources. Although these activities have been just for the flu, we envision other valuable opportunities for cloud-based IT companies to supplement the information available to public health authorities. Monitoring Lyme disease, pertussis, respiratory syncytial virus, chickenpox, and GI infections could all be valuable.

If you work with a public health organization and would be interested in a proprietary data feed from athenahealth, we would love to speak with you. Please email our Director of athenaResearch, Iyue Sung, for details:

Agile Analytics
In a mature cloud-based environment, identifying disease surges or declines is just the first step. Well-curated data sets and reporting tools can provide a platform for answering a series of questions: Once flu is diagnosed, how do physicians behave? How often do they prescribe antivirals or antibiotics, and to what type of patients? For patients with neurological disabilities, what are the differences in flu rates for vaccinated and unvaccinated patients? We are working to build a system that effectively identifies disease surges, and then drills down to distill useful insights.

Check out Josh Gray’s Google+ Profile. Follow @JoshGray_HCIT on Twitter.

Analytics & Research

Survey Finds Pediatricians Experiencing Heavy Burden and Stress

Iyue Sung, Director of Core AnalyticsIn numerous conversations with our pediatrician clients over the last year, individual clinicians report increased complexity in their practices and, in many cases, decreased fulfillment in their work. To get a closer read on the “State of Pediatrics,” Epocrates and athenaResearch recently surveyed more than 700 pediatricians on the Epocrates network. Here are a few of the more prominent findings:

Declining Morale
The survey results paint a troubling picture of declining job satisfaction. Only 15% of pediatricians say they are happier than they were five years ago; 47% are less satisfied over that period of time.

Not surprisingly, these overall figures obscure a fair degree of nuance and variation in how pediatricians feel about their work. We certainly found many pediatricians that were deeply fulfilled in their practice, but also encountered a distressing number who were burned out and disillusioned.

Most common were those pediatricians trying to balance the immense meaning and satisfaction they derive from caring for children with the drudgery of the administrative and business aspects of their practices. As one respondent remarked, “The acuity of my practice and the increased requirements for documentation and Meaningful Use greatly add to my frustration. I still love what I do. But some days I wonder if it is worth it.”

Stress from Growing Complexity
As shown in Figure 2 below, a substantial majority of pediatricians report that administrative and clinical complexity have increased their workload while reimbursement has stagnated, adding economic stress to the mix.

Interestingly, these trends are generally similar for both academic and community practitioners. While a somewhat larger proportion of academic-based providers report a greater case mix complexity, percentages for increased workload and insufficient reimbursement were nearly identical for both groups.

Seeing More Patients with Chronic Disease
Even before taking administrative hassles into account, pediatricians report that the very nature of their practice is shifting. Academic and community practitioners alike are seeing more patients with asthma, depression, diabetes, and hypertension. And roughly 80% report seeing more cases of obesity.

As we reported in a previous post, mental health diagnoses are particularly challenging in pediatrics, having increased steadily for the five years we at athenaResearch have been tracking this trend. One pediatrician reported, “I feel like a primary mental health provider without adequate training.”

Even for those physicians feeling comfortable with the growing behavioral health needs, there is a widespread sense that reimbursement levels have not kept pace with the increased complexity of these patients’ needs, as well as the growing demands from parents.

Particular Dissatisfaction with Administrative and Documentation Complexity
Problematic reimbursement combined with growing complexity would be challenging enough; but the incremental pressures of administrative and documentation requirements are proving to be particularly stressful for pediatricians. They complain about the growing burden of complying with Meaningful Use, more demanding pre-authorization requirements, and other administrative hassles. Among these issues, struggles with electronic health records (EHRs) stand out as being particularly frustrating for pediatricians. The following response from a community pediatrician is representative of multiple comments we received about EHRs:

“The requirements of EHRs and all the stipulations… has to be recorded each time even if not pertinent to the visit that day… more work vs. doing paper… I spend twice as long clicking and documenting the information on the computer than I would paper. This leads to either patients waiting longer to be seen so I can document or leaving the documentation till after clinic hours to give patients the time they deserve.

It has also changed the focus from personal to tech… I am not a fan. It is taking away one of the best and most important part of the world of pediatrics—the doctor-patient-parent relationship. It is a tragedy.”

As technologists who provide EHR services to thousands of pediatricians, we appreciate the complexity and understand providers’ frustration. But we firmly believe that when good technology is designed with the users in mind (in this case, of course, caregivers), a simple, purposeful user experience can help manage this complexity.

Dr. Stephen Bien, an independent physician in Maine, recently wrote about a similar topic in his blog post, “How the Small Independent Provider’s Role Has Come Full Circle.” In the article, Dr. Bien discusses the role technology plays in helping him tackle the challenges of working as an independent doctor in the 21st century, keeping his focus on the main reason he got into practicing medicine—patient care.

Regardless of where pediatricians practice, their preferred health care software, or their perception of health care reform, change is on the horizon (and in many instances, already here). Understanding and coping with these changes will come not only from technology, but also from reporting on changes experienced in the delivery system. Over 2014, we will monitor trends related to pediatric practices, based on real-time data available from our cloud-based platform. We hope to discover and share meaningful insight, and we look forward to robust conversations.

Follow @IyueSung on Twitter.

1. Response to statement “To what extent would you agree with the following statements about your practice today compared to 5 years ago: My job satisfaction is higher”.
- Better: corresponds to response “Strongly Agree“ or “Agree“
- Neutral: corresponds to response “Neutral”
- Worse: corresponds to response “Disagree” or “Strongly Disagree”

2. Respondents answers “Strongly Agree” or “Agree” to the following questions: “To what extent would you agree with the following statements about your practice today compared to 5 years ago?”
- Economic realities have increased the intensity of my workload
- My caseload has increased in complexity
- Reimbursement from commercial payers have not kept pace with the increased complexity of my caseload
- My job satisfaction is higher

Analytics & Research

athenaResearch Report: Flu Rates Slowing Down in the South

In this report, from our third consecutive week monitoring this season’s flu outbreak, the athenaResearch team tracks trends as the recent CDC summary of flu activity (week ending December 28) reports a continued increase in flu diagnoses, particularly with H1N1. You might know the H1N1 strain best by the name “swine flu,” a virus that reached pandemic status in 2009-2010, and is now receiving increased attention in the media. (See more on the CDC report here.)

Despite that reported increase, the first week of 2014 shows an interruption, at the national level, from steep climbs in preceding weeks. Figure 1 shows that rates1 for Week 1 of 2014 are slightly lower than those for Week 52 of 2013.

It’s worth noting that the flu rate for the last two weeks of 2013 may be slightly overstated; because those were holiday weeks, patients may have been more likely to visit their doctor for acute issues (such as flu systems) rather than routine appointments.

Our athenaResearch team believes this decline in the first week of 2014 may only be temporary, as flu diagnoses are now widespread across the United States for the first time this season, for the two weeks ending on January 6, 2014 (see Figure 2).

It’s difficult to determine whether levels are at, or near, this season’s peak, as previous seasons have exhibited “double peaks,” where the flu spikes twice throughout the season.

When we break out flu rates by key regions (as shown in Figure 3), as we did in last week’s athenaResearch flu report, we can see that a drop in the South drove this week’s national decline.

The Middle Atlantic, New England and Pacific regions of the country did show flu rate increases this past week, though at much lower trajectories than the recent spike experienced in the South. Hopefully, we will continue to see rates decline or, at least, find no sharp rises across regions. In the meantime, we will use weekly updates to report any noteworthy trends that we find.

Acknowledgement: athenaResearch would like to thank John Brownstein, PhD, Associate Professor at Harvard Medical School, and Edward Goldstein, PhD, Senior Scientist at Harvard School of Public Health, for their advice on the interpretation of our flu data.

1 Data is based on claims created for physician encounters. Since claims may not be created until several days after time of service, data for the most recent reporting week (service dates ending on Saturdays) will not include claims created after the report creation date (midnight Sunday).

Check out Matt Nix’s Google+ Profile.

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