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Service Delivery Innovation Profile

Information Technology-Facilitated Identification of At-Risk Primary Care Patients Combined With In-Office Automated Measurement Significantly Reduces Undiagnosed Hypertension


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Snapshot

Summary

Leveraging existing information technology, operational workflows, and reporting processes, NorthShore University HealthSystem provides clinicians in 40 primary care practices with a monthly list of patients at risk of undiagnosed hypertension. Practice-based staff proactively contact these patients to schedule a standardized visit for blood pressure measurement and primary care evaluation. In addition, a decision support tool within the electronic health record generates an automatic alert whenever an at-risk patient comes to the office for any reason and whenever any patient has an elevated manual blood pressure reading during a visit. For these patients (whether identified through the monthly list or while at the office), a medical assistant initiates automated office blood pressure measurement, a series of readings taken while the patient sits alone in the examination room (to mimic the more accurate results normally seen with ambulatory blood pressure monitoring). The primary care clinician (a family physician or internist) then uses these measurements to make diagnostic decisions. The program has reduced the proportion of at-risk patients remaining undiagnosed for hypertension by approximately 70 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation comparison of the proportion of patients at risk of undiagnosed hypertension, along with a post-implementation breakdown of the type of diagnosis received (e.g., hypertension, white-coat hypertension, prehypertension, not hypertensive).
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Developing Organizations

NorthShore University HealthSystem
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Use By Other Organizations

Primary care practices affiliated with Mayo Clinic and Cleveland Clinic routinely use a similar automated office blood pressure device to monitor blood pressure in patients. In addition, GE Centricity has tested the algorithms developed by NorthShore, finding them to be feasible for use with other electronic health record systems and data repositories.

Date First Implemented

2011
The program began on January 1, 2011.

Problem Addressed

Roughly a third of adults in the United States have hypertension, yet almost one in five of these individuals remains unaware of the condition. Most patients with undiagnosed hypertension regularly use health care services, but many are not diagnosed or treated due in part to concerns about the reliability of office-based blood pressure (BP) measurement and underuse of ambulatory-based monitoring.
  • Many undiagnosed cases of hypertension: Approximately one-third (33 percent) of adults age 20 and older have hypertension,1 which is the leading modifiable risk factor for coronary artery disease, congestive heart failure, stroke, and chronic kidney disease.2 Almost one in five (18.5 percent) hypertensive individuals remains unaware of the condition.1
  • Variability in office-based measurements: Most undiagnosed individuals with hypertension regularly use health care services.3 However, variability in office-based BP measurement often prevents these individuals from being properly diagnosed and treated, in part because physicians have concerns about the reliability and accuracy of these readings.4,5,6
  • Underuse of ambulatory-based BP monitoring: Because 24-hour ambulatory BP monitoring more accurately reflects true BP and better predicts cardiovascular morbidity and mortality than office-based monitoring, some guidelines recommend its use to confirm a diagnosis of hypertension.7,8,9,10,11 However, many patients do not tolerate this type of monitoring, since it typically requires wearing a cuff for 24 consecutive hours and having it inflate and deflate repeatedly throughout the day. Consequently, relatively few patients are referred for ambulatory BP monitoring.12,13

What They Did

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Description of the Innovative Activity

Leveraging existing information technology (IT), operational workflows, and reporting processes, NorthShore University HealthSystem provides clinicians in 40 primary care practices with a monthly list of patients at risk of undiagnosed hypertension. Practice staff proactively contact these patients to schedule a standard visit for BP measurement and primary care evaluation. In addition, a decision support tool within the electronic health record (EHR) generates an automatic alert whenever an at-risk patient comes to the office for any reason and whenever any patient has an elevated manual BP reading during a visit. For these patients (whether identified through the monthly list or while at the office), a medical assistant initiates automated office blood pressure (AOBP) measurement, and the primary care physician (a family physician or internist) subsequently uses the AOBP values to make diagnostic decisions. Key program elements are detailed below:
  • Algorithm-based screening to identify those at risk: Using guideline-based algorithms, an electronic data warehouse queries the EHR charts of active primary care patients to identify those at risk of undiagnosed hypertension, based on BP values recorded in the EHR. The algorithm excludes patients with an existing diagnosis coded in the EHR of primary/secondary hypertension, "white coat" hypertension (elevated BP due to the anxiety of a medical office visit), or prehypertension. It also excludes BP values from the inpatient, emergency department, and ambulatory surgery center settings to reduce the risk of including those with temporarily elevated levels stemming from acute medical conditions.
  • Monthly list of at-risk patients: Each month, primary care physicians within the 40 practices receive a list of their patients who, based on the query, meet the criteria for being at risk of undiagnosed hypertension.
  • Proactive outreach to schedule appointment: The physicians evaluate their lists and exclude any patient who has died or left the practice, along with anyone judged to be unsuitable for the program due to lack of mobility, mental illness, or multiple comorbidities. For patients who remain on the list, staff mail a personal letter signed by the physician explaining the potential risk of undiagnosed hypertension and inviting them to schedule an office visit for an evaluation. A week later, staff call each patient on the list to answer any questions and schedule the visit; they typically make up to three attempts to reach a patient.
  • Automated alerts when at-risk patients have visits or when others have elevated readings: A best-practice advisory alert automatically appears on the EHR screen whenever an at-risk patient comes to the office and whenever any patient has an elevated manual BP measurement during a visit. This alert, which appears regardless of the reason for the visit, notifies the medical assistant and the physician of the need for AOBP measurement.
  • In-office measurement using automated device: Whenever an at-risk patient arrives for a standard visit or an automated alert appears for a given patient, the medical assistant uses an AOBP device to obtain multiple measurements in the examination room, in an environment similar to what the patient might experience at home. The measurement typically takes place at the beginning of the visit, after the medical assistant orients the patient to the examination room. The assistant initiates the measurement, stays in the room until the first measurement has been completed (to make sure the device is working properly), and then leaves the patient alone in the room. The device obtains five additional measurements at 1-minute intervals.
  • Calculation of reading used for diagnosis: Because the medical assistant's presence in the room might cause some anxiety that could temporarily elevate the patient's BP, the first reading is discarded. The remaining five are averaged to produce a mean systolic and diastolic BP that the physician can use to make the appropriate diagnosis.

Context of the Innovation

NorthShore University HealthSystem is an integrated delivery system serving patients throughout the northern Chicago metropolitan area, including the northern suburbs. The system has four hospitals and a medical group that employs over 800 primary care physicians and specialists who work in more than 70 offices. NorthShore has a teaching affiliation with the University of Chicago Pritzker School of Medicine and operates a practice-based research network (PBRN) known as the Ambulatory Primary Care Innovations Group.

The impetus for this program came from Michael Rakotz, MD, a full-time practicing family physician in the NorthShore Medical Group and one of three family physicians who participated in the first year of the NorthShore Quality & Safety Fellowship (2010–2011), organized by Bernard Ewigman, MD, Chair of the Department of Family Medicine and founding director of the PBRN, and Ken Anderson, DO, Chief Medical Quality Officer for the system. Dr. Rakotz thought that NorthShore needed to do a better job of detecting and diagnosing hypertension. During and after his participation in this fellowship, he led the research and quality improvement work related to this program.

Did It Work?

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Results

During the program's first 2 years of operation in an initial set of 23 primary care practices, the proportion of at-risk patients remaining undiagnosed for hypertension fell by more than 70 percent.
  • Significant reduction in risk of remaining undiagnosed: Over a 2-year period, the rate of undiagnosed hypertension in the first 23 practices to implement the program fell by more than 70 percent, from 1.1 to 0.3 out of every 100 patients. Prior to implementation of the program, 1,586 out of 91,844 primary care patients were at risk of having undiagnosed hypertension (as determined by the previously described algorithm). A total of 1,033 patients were followed prospectively for 2 years. By the end of this followup period, 740 patients had received a diagnosis or classification related to hypertension (e.g., hypertension, white-coat hypertension, prehypertension, or not hypertensive) and only 293 at-risk patients remained undiagnosed. Of the 740 who received a diagnosis, 520 completed the AOBP measurement protocol and 220 received a diagnosis from the physician by some other means, often through review of information already in the medical record.14
  • Vast majority found to have abnormal BP: Of the 740 patients receiving a diagnosis, the vast majority (roughly 88 percent) were found to have a BP-related condition, including 361 (48.8 percent) with hypertension and 290 (39.2 percent) with white-coat hypertension or prehypertension.14

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation comparison of the proportion of patients at risk of undiagnosed hypertension, along with a post-implementation breakdown of the type of diagnosis received (e.g., hypertension, white-coat hypertension, prehypertension, not hypertensive).

How They Did It

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Planning and Development Process

Key steps included the following:
  • Securing buy-in from practice leaders: Dr. Rakotz met personally with physician leaders at 23 practices in the PBRN to explain the program and the rationale for it. As part of this process, he highlighted key findings from literature on undiagnosed hypertension and provided copies of the referenced articles. Additionally, he asked physician leaders to discuss the study with their colleagues and provide copies of the articles to those requesting them. Dr. Rakotz also presented information about the program at a regular meeting of primary care physician leaders and, together with Dr. Ewigman, Dr. Anderson, and Dr. Robiscek (then director of informatics for the PBRN and now director of quality analytics for the health system), presented program-related information at grand rounds and during routine meetings of clinical department chairs, the system board, and system leaders over a period of 2 years.
  • Researching, choosing, and purchasing device for office-based measurement: Aware of concerns among physicians about the reliability of routine office-based measurement, Dr. Rakotz and Dr. Ewigman reviewed the literature on ambulatory BP measurement devices. After identifying and reviewing evidence related to several AOBP products, they chose one (BpTRU BPM-200) for use by the practices. Studies of this device suggested that it correlates well with the daytime readings achieved from ambulatory BP monitoring, without the associated barriers to use. NorthShore initially purchased eight AOBP devices and ultimately purchased at least one device for each of the participating practices.
  • Developing IT infrastructure: Building on the existing electronic data warehouse, Dr. Robiscek (who led development of the warehouse) oversaw IT-related aspects of the program, including creation of the search functions to identify at-risk patients and the electronic alerts.
  • Training practice-based clinicians: During the research phase, Dr. Rakotz visited each practice to provide brief training on the device to the medical assistants, nurses, and physicians, including how to use it and interpret its results. Since that time, training and orientation have been built into existing workflows. 
  • Continuing and expanding program after successful trial: Based on the successful results achieved in the initial trial, physician and administrative leaders at the health system and the PBRN (including Joe Golbus, MD; Kathy Gaffney, RN; and John Revis, MD) led efforts to make the program an ongoing part of operations, including expanding it to 17 additional practices.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing employees within the health system (primarily IT staff) and physicians and staff at the primary care practices perform program-related activities as part of their regular duties.
  • Costs: For the initial research trial, NorthShore's PBRN purchased eight AOBP devices that were rotated among the 23 practices that participated, at a cost of approximately $1,160 per device. The PBRN also purchased eight carts to hold the devices, at a cost of $250 each. When the decision was made to continue and expand the program, the NorthShore Medical Group purchased additional AOBP devices and carts so that all 40 participating practices would have one of each. 
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Funding Sources

NorthShore University HealthSystem
The PBRN provided partial salary support, part-time research staff, and analytical support to Dr. Rakotz and Dr. Robiscek during the initial research trial, as part of a partnership with The University of Chicago Institute for Translational Medicine, using funds from a National Institutes of Health Clinical Translational Science Award. The Department of Family Medicine at NorthShore University HealthSystem funded the aforementioned Quality & Safety Fellowship. The NorthShore Medical Group paid for the previously described equipment purchases and provided physician, administrative, and informatics staff to support development and implementation of the program.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Educate leaders on benefits of tackling undiagnosed hypertension: Programs are much more successful when high-level administrative and clinical leaders support them. To garner such support, program developers should share information on the significant prevalence of undiagnosed hypertension and the medical problems it can cause when left untreated, such as heart attack, stroke, and kidney disease. In addition, developers should share data on the program’s potential to reduce downstream health care costs by preventing these problems and to generate fee-for-service revenues due to increases in primary care visits. As the transition from fee-for-service to shared-risk payment systems accelerates, leaders of health plans and provider organizations will increasingly be attracted to this type of program, which can simultaneously improve quality and reduce utilization and costs.
  • Use reliable measurement process: As noted, physicians often mistrust traditional office-based BP measurements, which tend to be variable and inaccurate. While NorthShore chose to address this issue by using a validated AOBP device, other strategies are available, such as instituting a rigorous training program among medical assistants and nurses on how to consistently take manual or electronic readings in compliance with established guidelines.
  • Use data repository in EHR: The ability to query the data repository within the EHR proved to be very important to the success of this program. In particular, the electronic data warehouse facilitated the routine development of lists of at-risk patients. 
  • Make system credible and easy to use: The system's built-in decision support, algorithms, and report-generating capabilities have made the system very easy to use. In addition, all of these features are based on reliable, credible sources of information that physicians readily accept, including use of algorithms with acceptable sensitivity and positive predictive values.

Sustaining This Innovation

  • Maintain program even as number of undiagnosed patients dwindles: The program should remain in place as an ongoing quality improvement initiative even after it succeeds in significantly reducing the risk of undiagnosed hypertension. Primary care practices constantly attract new patients (some of whom will likely be at risk), existing patients may move into the at-risk category over time, and new practices may be added to the organization.
  • Consider addition of program to promote guideline-based treatment: Identifying and assessing those at risk of undiagnosed hypertension is only half the battle. Once diagnosed, hypertensive patients need appropriate treatment. To that end, under the leadership of Dr. Masi (internal medicine director for the PBRN), a team of NorthShore primary care and administrative leaders recently launched a program offering decision support to primary care physicians in 23 PBRN practices to help them provide guideline-based care. As with the program focused on diagnosing hypertension, this initiative features regular feedback to physicians. Each month, physicians receive data on the proportion of their hypertensive patients whose BP is under control and a list of the names of those not at goal who may need an adjustment in their treatment regimen.

Use By Other Organizations

Primary care practices affiliated with Mayo Clinic and Cleveland Clinic routinely use a similar automated office blood pressure device to monitor blood pressure in patients. In addition, GE Centricity has tested the algorithms developed by NorthShore, finding them to be feasible for use with other electronic health record systems and data repositories.

More Information

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Contact the Innovator

Bernard Ewigman, MD, MSPH, FAAFP
Professor and Chair, Department of Family Medicine
University of Chicago and NorthShore University HealthSystem
Chair, Advisory Board, Ambulatory Primary Care Innovations Group
Glenbrook Hospital, Suite 200
1000 Pfingsten Road
Glenview, IL 60026
University of Chicago Medical Center
5841 S. Maryland Avenue, MC 7100
Chicago, IL 60637
(847) 657-1827 or (773) 834-9852
E-mail: bewigman@northshore.org or bewigman@uchicago.edu

Christopher Masi, MD, PhD, FACP
Internal Medicine Director, Ambulatory Primary Care Innovations Group
Director, Health Services Research, NorthShore University HealthSystem
Clinical Associate Professor, University of Chicago Pritzker School of Medicine
Burch 227
Evanston Hospital
2650 Ridge Avenue
Evanston, IL 60201
(847) 570-1277
E-mail: cmasi@northshore.org

Innovator Disclosures

Dr. Ewigman and Dr. Masi reported having no financial or business/professional relationships related to the work described in this profile, other than the funders listed in the Funding Sources section.

References/Related Articles

Rakotz MK, Ewigman BG, Sarav M, et al. A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients. Ann Fam Med. 2014;12(4):352-8. Available at: http://www.annfammed.org/content/12/4/352.full.

Footnotes

1 Go AS, Mozaffarian D, Roger V, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292. [PubMed]
2 Hypertension Working Group. Working group report on primary prevention of hypertension. Bethesda (MD): National Institutes of Health. 2000.
3 Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United States. N Engl J Med. 2001;345(7):479-86. [PubMed]
4 Powers BJ, Olsen MK, Smith VA, et al. Measuring blood pressure for decision making and quality reporting: where and how many measures. Ann Intern Med. 2011;154:781-8. [PubMed]
5 Kerr EA, Zikmund-Fisher BJ, Klamerus ML, et al. The role of clinical uncertainty in treatment decisions for diabetic patients with uncontrolled blood pressure. Ann Intern Med. 2008;148(10):717-27. [PubMed]
6 Sebo P, Pechère-Bertschi A, Hermann FR, et al. Blood pressure measurements are unreliable to diagnose hypertension in primary care. J Hypertens. 2014;32(3):509-17. [PubMed]
7 Redon J, Campos C, Narciso ML, et al. Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study. Hypertension. 1998;31(2):712-8. [PubMed]
8 Ohkubo T, Imai Y, Tsuji I, et al. Prediction of mortality by ambulatory blood pressure monitoring versus screening blood pressure measurements: a pilot study in Ohasama. J Hypertens. 1997;15(4):357-64. [PubMed]
9 Staessen JA, Thijs L, Fagard R, et al. Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. JAMA. 1999;282(6):539-46. [PubMed]
10 Verdecchia P, Angeli F, Gattobigio R. Clinical usefulness of ambulatory blood pressure monitoring. J Am Soc Nephrol. 2004;15(Suppl1):S30-S3. [PubMed]
11 Krause T, Lovibond K, Caulfield M, et al. Management of hypertension: summary of NICE guidance. BMJ. 2011;343:d4891. [PubMed]
12 Mallion JM, de Gaudemaris R, Baguet JP, et al. Acceptability and tolerance of ambulatory blood pressure measurement in the hypertensive patient. Blood Press Monit. 1996;1(3):197-203. [PubMed]
13 Elliot L, Iqbal P. Factors associated with probability of patient rejecting a repeat 24 h ambulatory blood pressure monitoring, despite recommendation by the physician. Blood Press Monit. 2003;8(5):191-4. [PubMed]
14 Rakotz MK, Ewigman BG, Sarav M, et al. A technology-based quality innovation to identify undiagnosed hypertension among active primary care patients. Ann Fam Med. 2014;12(4):352-8. Available at: http://www.annfammed.org/content/12/4/352.full.
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Original publication: July 30, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.