• Questions Are the Answer - AHRQ - Agency for Healthcare Research and Quality - supporting reduction of medical errors and accuracy - through patient involvement. Now the health system can meet patients half way by providing this information as part of every encounter.

Pickering, Thomas G., Nancy Houston Miller, Gbenga Ogedegbe, Lawrence R. Krakoff, Nancy T. Artinian, and David Goff. “Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring. A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association.” Hypertension (May 22, 2008).

As we have been planning a multi-stakeholder pilot to demonstrate improved management of chronic conditions by Californians, this paper was just published, which adds compelling information to the discussion. Talk about interesting timing.

The paper is a compendium of research and information to date on the value of home blood pressure monitoring, which has not been previously integrated into the clinical practice of improving blood pressure control. The impact of poor control is reiterated: high blood pressure as accountable for 27% of total CVD events in women and 37% in men.

Useful Facts

• 35% of hypertensive patients check their BP once a week, 64% of patients own a monitor.
• Arm monitors appear to still be the best choice through validation studies.
• There is often “poor” agreement between patient reported readings and readings stored in the monitors’ memory, with one study showing up to a 20% error rate.
• Patients are at risk for over-diagnosis (”white coat hypertension”) up to 20% of the time, and under-diagnosis (”masked hypertension”) up to 10 % of the time, resulting in over/unnecessary treatment, or undertreatment.
• Blood pressures measured outside of the doctor’s office in many cases is superior in predicting which patients are at risk for organ damage.
• It appears that more study is needed regarding the effectiveness of home blood pressure monitoring to guide treatment and ultimately support better control. As far as I can tell, none of the studies mentioned here assess the impact of coupling improved patient-health system communication (eg secure messaging with physicians or health system) with home blood pressure monitoring.*
• Medicare currently reimburses ambulatory (24 hour) blood pressure monitoring for patients with suspected white coat hypertension, and this monitoring has been shown to be cost-effective in reducing unnecessary treatment.
• Of extreme interest in our planning, this paper refers to studies assessing patient attitudes toward home monitoring, which appear favorable, but maybe less so when out of pocket expense is required - this is a follow-up/countermeasure item.

*A helpful study is under way at Group Health Cooperative that is going to add very useful information to this part of the discussion.

Conclusion

Beyond information about the value of home blood pressure monitoring, there are suggested protocols for integrating this monitoring into practice. This seems like a great springboard to integrate this into patient access to their own clinical information, along with potential connections to the health system and other patients.

Based on the information presented, there seems to be a case for employing “connected” blood pressure monitoring for accurate diagnosis of blood pressure and response to treatment. Given that Medicare already reimburses ambulatory blood pressure monitoring for white coat hypertension, there may also be a case to extend, as a pilot, reimbursement for home monitoring for diagnosis and initial management of blood pressure outside of physician visits. This ties well to the data that most patients with high blood pressure are insured and seeing physicians, with only 35% control, making this approach a worthy alternative.

From a biological plausibility perspective, it makes sense that measuring an ongoing physiological state (average blood pressure throughout the day) in its native environment, over time, has a likelihood of being more accurate than a few point measurements done outside of the environment where people live and work (the doctor’s office).

The opportunity for the proposed project here is to integrate the benefits of home monitoring with a sustainable workflow inside and outside of the health system, using technology available today, to improve patient and family involvement in their care. Of interest, the Agency for Healthcare Quality and Research is promoting the idea of patient involvement in care as a quality and safety improvement strategy for patients. This work could extend the strategy to more stakeholders, including employers and the health system itself.

Conflict of Interest Analysis

I think this should be part of a review of any paper, given the information being published about sponsored research (here’s some examples).

The lead author has a significant relationship with device maker Omron, and has received speakers fees from pharmaceutical manufacturer Boerhinger-Ingelheim and Omron. Another author has received speaker’s fees from Merck and serves in a consultant/advisory board capacity for Pfizer and CV Therapeutics.

There was discussion previously about support to the American Heart Association by device makers.

These associations could result in over-exhuberant promotion of home blood pressure monitoring devices and treatment (i.e. it’s unlikely that a device manufacturer would have an interest in less devices being sold), and need to be taken into account when reviewing this piece. This might be reflected especially in areas where the data is/was equivocal about benefits, yet conclusions are framed in the positive or hopeful.

One of the issues in the discussion of device/medication promotion is that new treatments are compared to placebo instead of to current practice. The information presented here compares the treatment of interest to current practice, which has room for improvement. With that in mind, I think the information here is contributory to the work we’re considering and will be used to update the A3 accordingly.

A Disclosure of My Own

I should point out that I assisted in the planning of the Group Health blood pressure study mentioned above from an operations/informatics perspective, and was not funded under the grant and am not a co-author of that study, which is not connected to this work. I am currently funded by the California Healthcare Foundation.

Comments welcome, of course.

Just Looking: Consumer Use of the Internet to Manage Care - CHCF.org - Report from California Healthcare Foundation on consumer use of the internet. Note use by the uninsured, which tracks other data, showing that this population is online in respectable numbers. In addition, 54 % of those with high school education or less use the Internet to find information about specific medical conditions/prescription drugs. I think a nice proxy for Internet use is the use of online banking, since there’s a component of “convenience” and “confidence” in using these services. A recent analysis of online banking use shows similar results. As the CHCF report says:

These segments of the public likely have the greatest need for information that can help them manage their health, particularly in the case of the uninsured, who many not have regular access to health care.

In my work studying LEAN, I used to put “I see many correlations to clinical practice” on every blog post about another industry’s success in being customer centric in ways that we could learn from, kind of skipped-CD like. For this issue, I’d like to say, “the data demonstrates that every patient in every care system deserves to have this access.” To not provide patient access in HIT installations that serve these populations is the same as reducing access of 40 % of those patients to useful information for them (and their families) to be involved in their care.

• Wireless Messaging System Has No Impact on Blood Glucose Levels, but Patients Believe It Improves Quality of Care - From the AHRQ Innovations Exchange. I thought the title of the Exchange article was interestingly different than the actual title of the study that it references, so I pulled the actual paper and read it. There was not a significant drop in HbA1c (a long term measure of diabetic control) after 3 months of the study, but half of the intervention patients who were hypertensive before the study were not after the study, a significant difference. I think that’s interesting, especially among patients with diabetes.

• Beyond Blogs : Businessweek - A refresh of Businessweek's landmark 2005 story about Social Media and businessweek. Interesting update: prediction of mass firings of employees who blog (being "Dooced") has not happened, with the exception of a few well publicized cases, like this one. Perhaps Web2.0 is subtly changing the expectation of transparency on the part of organizations and their customers - participation is becoming more of a norm.

• Bioethics Forum - Google Health: Organizing Your Medical Information - Comment on this blog about a method to display drug/device ads to physicians reviewing a patient's medical record. Is this sort of thing different than a physician reviewing a medical record while writing with a branded pen on branded paper that sits in their office in front of their computer, next to their drug sample cabinet (if they allow these things in their practice). Shouldn’t the conversation be about being an unbranded doctor instead of Google’s implementation?

• McCain Makes Health Records Public - Could he do it using CCR? - Without commenting on the content of Senator McCain's health care record, wouldn't it be cool (if he approves) to release it in CCR format to show the promise of the standard? Same for all the candidates?

• Monitors urged for all with high blood pressure - Yahoo! News - American Heart Association urges patients to monitor their blood pressure - nice coincidence for the work we're doing in California. Note the concern about conflict of interest, however - it comes up multiple times in the article. People are interested in information free of bias - another nod to Information Therapy and patient and family involvement, in my opinion.

This weeks’s photographs come from San Francisco’s Legion of Honor, which is currently hosting and exhibition of Annie Leibovitz’s photographs. I came here because this was the suggested venue for a walking meeting with Sophia Chang, MD, MPH, one of my advisors at California Healthcare Foundation.

Besides the beautiful scenery, there was significant relevance to health care in the exhibit itself, which included photographs of Ms. Leibovitz’ father and her partner Susan Sontag’s last days. These included a haunting image of her parent’s living room, almost completely taken over by a hospital bed, and photographs that relayed the different ways they died, from the intensity of Susan’s fight to that of her father, who died at home, in the arms of his wife.

A3 (Project Plan). Click here to learn more about what an A3 is

This post contains the A3 Document, or the Project Plan, for Connectivity for California Consumers. I have been posting some of the data that supports this plan on this blog (click here to see them all). In addition, I have been working with staff at California Healthcare Foundation and potential stakeholders to improve the plan.

For those of you unfamiliar with the A3 format, it is designed to (a) tell a story and (b) incrementally improved to the point that the actions are clear at the time a project is launched. It may be revised once a day or even more often. The process of discussing the project and making improvements is called “nemawashi.” I am using this blog for extended nemawashi, so please post your comments.

Since an A3 tells a story, starting on the left, going down, and then on the right, I will summarize the story here. Feel free to print out the A3 and follow along (A3 means “11 x 17″ paper. You may have to shrink to fit on letter size).

Issue & Focus

1. The California Healthcare Foundation is dedicated to the improvement of the lives of Californians managing chronic illnesses.
2. There are many community stakeholders involved in supporting this goal; their work could be improved by making connections to each other that are meaningful for patients.
3. This is part of a broader strategic plan to support the objective of involving patients and families in all aspects of their care. This is the identified gap to be closed through this work.
4. California Healthcare Foundation is seen as catalyst and partner for patient engagement in California

Current Condition

1. There are well known gaps the care of people with high blood pressure
2. The impact of these gaps is distributed across stakeholders differently compared to other chronic illnesses, which includes a strong productivity-loss component, due to the high prevalence of the condition in employed populations (see charts).
3. There are examples of employers and technology companies approaching these gaps in hypertension and other chronic illnesses that can be studied.

Problem Analysis

1. Lack of access to care accounts for only 10% of poor blood pressure control; there is a physician component in setting goals, and a patient component in operationalizing those goals, that may not be accomplished in physician visits alone.
2. Patients who are not seen at least every 12 months are at greater risk for non-adherence
3. The societal costs of inadequate management are spread diffusely; few organizations are able to to see the total harm from this perspective
4. There are few models outside of integrated care systems of using non-visit-based approaches to managing chronic illness.
5. We are just entering an era of interoperability, with many solutions not yet integrated into the value chain of patients and payers

Target Condition

This pilot seeks to create a functioning ecosystem that supports chronic disease management across the lifecycle, with the best candidate being hypertension

Action Plan

We began by interviewing example employers, health care providers, and technology providers to understand which approaches and components appeared most promising. At this time, it seems most reasonable to approach this first from the employer perspective.

Next step will be to convene a group of potential partners in June or July, 2008, at California Healthcare Foundation, to discuss how pieces would fit together.

A presentation would be made to the CHCF Board in the fall, with funding and activity to begin in 2009.

Cost / Cost-Benefit / Waste Recognition

There are recognized wastes, which include unnecessary visits for blood pressure monitoring, inadequate medication therapy, and inadequate use of the health system, for patients who have not been seen in the past 12 months.

There are costs including, technology costs (although the goal is not to build anything new), and realignment of incentives to support non-visit-based care.

Followup / Unresolved Issues

Points of concern and planned countermeasures

1. What is the metric for patient access? (Pacific Business Group on Health is working on an employee engagement survey; metrics for patient access to their health data may need to be developed)
2. How can this complement the launch of both a P4P measure for blood pressure management, and a HEDIS “Relative Resource Use for Uncomplicated Hypertension” measure for 2008?
3. Data for presenteeism and productivity loss does not seem intuitive (I have reviewed this in depth and we can bring in clinical champions to verify)
4. Partners and aligned interests (will do due diligence to support cooperative business models of partners)
5. How to engage patients in things like biometric monitoring and blood pressure control (will look at plan design options, but most importantly will go to the factory floor, and will bring an employee/patient advisor on to the team)

So that’s the script that goes with the story, more or less. Comment away, and keep in mind that each comment will change the A3 a little every time.