Identifying and treating hypertension is an elusive goal that exposes millions of people in the country to the risk of heart attack and stroke. According to the Centers of Disease Control and Prevention, nearly one in three U.S. adults—about 68 million people—have high blood pressure, which is undiagnosed in 7 to 8 percent of the population.
An interdisciplinary team of clinicians, informaticists, and quality experts at NorthShore University HealthSystem, Evanston, Ill., has taken a major step in controlling this disease in its outpatient population, by harnessing its electronic health record (EHR) to screen for and evaluate individuals with previously undetected hypertension in its multi-specialty medical group. The system, which went live in January 2011, has helped the integrated health system make significant progress in eliminating undiagnosed hypertension among its patients receiving care within its primary care network.
The Undiagnosed Hypertension Project grew out of NorthShore’s Quality Mini-Fellowship, part of the health system’s Practice-Based Research Network, whose goal is to link practicing physicians with research and quality improvement that produce outcomes that can be incorporated into daily practice.
The idea to identify people with undiagnosed hypertension came from Michael Rakotz, M.D., the lead physician at the NorthShore Medical Group Primary Care office in Highland Park, Ill., who was in the first group of four family physicians to participate in the fellowship program. Halfway through the six-month program, each participant was given the opportunity to choose a project. This was in 2010, and NorthShore’s enterprise-wide data warehouse had just come on line and was available for clinicians to start using it, Rakotz recalls.
“I had first crack at asking a question,” he says; and he chose to ask this one: “How many undiagnosed patients were in our system, based on the criteria of having hypertension that was not documented in the electronic medical record?” Rakotz says he has always been fascinated by the fact that hypertension is easy to diagnose, yet it is often missed in clinical practice. He notes that traditional manual blood pressure readings taken in doctors’ offices have long been recognized as problematic for a variety of reasons, including so-called “white coat syndrome” and poor technique for taking in-office pressures. The bottom line is that manual office blood pressures correlates poorly with cardiovascular disease, especially when compared to 24-hour ambulatory blood monitoring, the gold standard around the world for accurately determining if a patient has hypertension, he says.
The initial query as to who had undiagnosed hypertension was limited to ambulatory settings of primary care offices and specialist offices across the NorthShore enterprise. Rakotz worked with the clinical informatics team, led by Ari Robicsek, M.D., vice president of clinical and quality informatics, and Chad Konchak, director of clinical analytics. Their first step was to examine records back to 2006 to identify all of the patients who met Joint National Committee (JNC) 7 criteria for hypertension of multiple blood pressure readings of greater than 140/90. They found over 6,000 patients who had three elevated blood pressure readings and had not been diagnosed. (When they followed the patients forward to the present, they found that most of them were eventually diagnosed, suggesting that NorthShore physicians did a good job of diagnosing hypertensive patients in the long run, Rakotz says.)
Michael Rakotz, M.D.; Steve Smith, Chief Information Officer; Ari Robicsek, M.D., Vice President, Clinical & Quality Informatics; Chad Konchak, MBA, Director, Clinical Analytics; Jonathan Silverstein, M.D., Vice President, Clinical Research Informatics Photo by Jon Hillenbrand, NorthShore University HealthSystem
According to Robicsek, the team was able to identify the cohort of patients in specialist offices; after pulling data on the patients, they observed that primary care offices accounted for the majority of the patients with undiagnosed hypertension. He says this illustrated the difficulty of “connecting the dots. Electronic health records, unless you ask for it, don’t show you the whole sequence of a patient’s blood pressure results. All you have in front of you are today’s blood pressure readings,” he says.
A Quest for Actionable Information
Rakotz and his informatics colleagues set their next task: to employ actionable information that can be used to inform physicians that their patients might be at risk of hypertension. Blood pressures taken in the traditional way with a blood pressure cuff tend to be inaccurate and an overestimate; and they realized that just because a patient had three high readings did not necessarily mean they were truly hypertensive.
Rakotz notes that much of the research on blood pressure so far has been done in a research setting, not an office setting. “We’re doing it wrong; we’re using inaccurate blood pressures that correlate poorly with predicting disease, and we’re using them every day,” he says.