Overview

The intent of this implementation guide is to describe the AHRQ-funded, patient facing clinical decision support logic and value set encompassed in the Collaboration Oriented Application to Control High blood pressure. It uses the CPG-on-FHIR framework to implement standard recommendations relevant to patients; it is intended for use in conjunction with outpatient health care practice with a focus on primary care.

Clinical Relevance & Role

This tool is designed for use in the treatment of high blood pressure in adult patients between the ages of 18 and 80. It incorporates agreed-upon recommendations from multiple clinical practice guidelines. The recommendations provided are not intended for use in high blood pressure treatment for patients who are currently pregnant, have hypertension secondary to other causes, or have end-stage renal disease.

Substantial effort has been made to ensure the logic and data will be adequate from most EHR systems. These include a data adequacy assessment, surveys of patients and providers, and the use of health information technology for managing multiple conditions. These results are integrated into the tool and our approach.

The tool is intended to assist in high blood pressure treatment by (1) providing effective blood pressure monitoring, by (2) engaging patients in shared decision making practices, and by (3) assisting patients in communicating urgent updates to their care team.

1. The tool uses patient blood pressure readings to provide recommendations. It can retrieve office blood pressure measurements from the EHR and allows home blood pressure entry. For home blood pressure monitoring, it provides a protocol and records the date and time of the entry as well as allowing the patient to indicate if they followed the protocol. The tool provides recommendations based on the average of the most recent set of blood pressures, defined as 4 office readings or 6 out of office readings. It also alerts patients to very high blood pressure readings that may indicate a hypertensive emergency.
2. The tool provides recommendations to patients and prompts them to set goals to help control their blood pressure. It draws current antihypertensive medication information from the EHR to allow patients to refer to their current prescriptions. Additionally, it provides patients with information about classes of antihypertensive medications that may be prescribed to them so that they can be better informed when discussing treatment options with their care team.
3. The tool provides messages that patients can copy into MyChart to alert their care team to changes in their blood pressure or updated treatment needs. These alerts include messages about potential hypertensive emergencies and adverse events, with the goal of hastening adjustments to treatment to promote better health outcomes.

Prevalence of HTN

High blood pressure (hypertension) is a common condition in the United States, affecting roughly 47% of adults. It is a primary predictive factor for heart disease and stroke, which are among the most common causes of death in the U.S. Despite its prevalence, hypertension often goes underdiagnosed and undertreated.

Challenges to controlling high blood pressure include (1) detection, (2) measurement quality, (3) the need for precise treatment, and (4) patient engagement.

1. Hypertension can be challenging to detect, as elevated blood pressures may not be noticeable to patients, leading to a lack of recognition from care teams and action and engagement from patients.
2. Measuring blood pressure requires careful attention to protocol to avoid error in measurements; monitoring blood pressure at home is frequently recommended yet rarely followed, leading to uncertainty about control and increased risk of adverse events from overtreatment.
3. The therapeutic index in controlling blood pressure can be narrow; the largest recent blood pressure trial, the SPRINT study, showed a 25% relative reduction in cardiovascular events in the tightly controlled blood pressure group (<120/80 vs 140/90 for less intensive), but a substantial increase in adverse events such as dizziness, falls, electrolyte disturbances and acute kidney injury.
4. The role of the patient is crucial in blood pressure control: behavioral and lifestyle changes can reduce blood pressure by > 15 mmHg in most patients; self-monitoring requires time and resources; and most people treated for hypertension require multiple medications. Given the lack of symptoms for most people with high blood pressure, engagement and motivation remains a substantial issue.

Behavioral Science

A major goal of this application is to engage patients in setting goals, changing behaviors, and achieving healthier outcomes. To that end, the choice architecture has been arranged so that priority actions patients are recommended to take are indicated as such, while allowing users the freedom to set goals that fit their own lifestyle by treating their high blood pressure as aggressively as they choose.

Goal setting is optimized to allow patients to set their own lifestyle change goals using a mad-libs approach, with a free text option available. Each goal requires a patient to set a date by which they would like to achieve that goal. The system allows patients to track current goals and prompts them to check in on goals on the selected completion date to mark the goals as completed or incomplete, prompting them to set a new goal if their blood pressure readings remain above their blood pressure target. The goal of this is to encourage patients to set actionable, short-duration goals that can be achieved and iterated upon to encourage patients to successfully make lifestyle and behavioral changes that will help reduce their blood pressure.

Use of FHIR standards

This tool was developed using HL7 FHIR (Health Level 7 Fast Healthcare Interoperability Resources) standards to pull blood pressure, diagnostic, and medication data from the EPIC EHR (Electronic Health Record) system. Initial CQL (Clinical Quality Language) artifacts were created using the CDS Authoring Tool developed by AHRQ (Agency for Healthcare Research and Quality), with subsequent CQL code written by hand. Recommendation text and logic were designed to be compatible with the CDS Hooks infrastructure for connectivity and functionality.

Links

• HL7 FHIR Website
• AHRQ CDS Authoring Tool
• CDS Hooks

License

This software is published by OHSU under an Apache 2.0 License. Click here for details.