Green, Beverly B., Andrea J. Cook, James D. Ralston, Paul A. Fishman, Sheryl L. Catz, James Carlson, et al. “Effectiveness of Home Blood Pressure Monitoring, Web Communication, and Pharmacist Care on Hypertension Control: A Randomized Controlled Trial.” JAMA 299, no. 24 (June 25, 2008): 2857-2867.

Our findings demonstrate the effectiveness of using home blood pressure monitoring combined with pharmacy care over the Web to improve BP control for patients with essential hypertension

This is a significant study in the world of health care and e-health - the first randomized controlled trial to test the use of care management over the Web. It was performed at Group Health Cooperative, using the Web services that I helped implement as part of our electronic health record system.

Looking at the data, it appears that patients with uncontrolled hypertension without access to supportive pharmacists over the Web were much less likely to have their blood pressure controlled compared to patients that did. In other words, patients were not able to achieve as sufficient control through doctor visits alone.

This study further supports the idea that we have a great opportunity to support non-visit-based, participatory health care as a modality to manage chronic illness.

For a health system already paying for physician visits that have less than a 1 out of 2 chance at recording a controlled blood pressure in them, maybe there’s an opportunity to change the way high blood pressure is managed, for example, in California.

I was able to speak with Nancy Houston-Miller, RN, BSN, FAHA, about the future of blood pressure management today. She’s a national expert in the field, and has a research career spanning 30 years which has supported innovative ways to improve health. In the 1970’s her team established that patients could exercise to rehabilitate their hearts at home, rather than spending 6 weeks in the hospital.

I wanted to talk to Nancy about blood pressure, and specifically home monitoring, as a co-author and lead of the recent Call to Action by the American Heart Association, the American Society of Hypertension, and the Preventive Cardiovascular Nurses Association.

Her research has shown that the gold standard for blood pressure control should be the home, rather than office measurement, which is still where most blood pressure is managed (and with less then favorable results for most patients - about a third have adequate control, despite being well insured and with access to care). Nancy told me that control can be achieved using non-office based approaches, and her research has shown this. This is refreshing to hear especially in light of data indicating that it may becoming more difficult to control blood pressure. Could this be because of the “how” (office-visit-based) it’s being treated today?

What was the purpose of this conversation and where do we go from here? We think there is a good case for planting the seed for patient and family involvement in care for all chronic illnesses, using patient-centered technology, by starting here. As Nancy told me on the phone:

72 million Americans have high blood pressure, only a third have it under control, and they are at huge risk for kidney disease, heart disease, and stroke

High blood pressure may account for 27% of total CVD events in women, and 37% in men, 14% of heart attacks in men, 30% of heart attacks in women. We know the science of managing blood pressure, and the ways it can be managed best (by patients), why not empower them to do it, and empower them to help us design the ways to do it (see next post)

Stay tuned….

This is the data we have today, can we do better? From the well-done Deloitte 2008 Consumer Survey

Ideas requested….

In the patient-centered technology world, there are a lot of different measures that various organizations use to show the size / accessibility of their online services. The challenge of all these numbers is that when someone tries to figure out who the leader in this space is, or where they are more likely to have access and involvement, it’s unclear. Everyone uses the numbers that capture the data they have (and by extension that are the most optimistic sounding - it’s human nature).

Some measures use number of patients on a provider’s web site (”We have 86,000 patients verified for use of our portal”), some use percent penetration (37 % of adults enrolled or that receive care here are online - that’s the one I used). These numbers can be confused by different denominators (adults only? all enrollees?) and services offered (access to what? claims data? e-mailing doctors? lab results?). One metric we began using at Group Health was, “% lab results reviewed online by patients” - this crosses primary care and specialty care practices, and since the assumption is that most patients want the results of their tests, may be a good measure of how much a provider promotes access to clinical data, other things being equal.

Why is it useful to figure out?

As I mentioned in a previous post, we currently measure penetration of electronic health records in practices (it’s scarily low still); however, this doesn’t say very much about the value to the patient, the customer. So:

1. If a patient can compare organization x / provider y in terms of the accessibility of the data - through whatever channel - there may be better incentive to compete on something that matters a lot - involvement in care and partnership.
2. If a supporting organization is working to promote patient access across a constituency, they can understand which organizations need more assistance quickly.

Agree? Disagree?

Throw out some ideas for a measure - is it a combination of what is offered (scope of content), how many people are actually using what’s offered (satisfaction with content, priority of the organization in supporting services), and service measures (messages responded to in a timely manner, test results shared)?

Kaiser Permanente provides one example that I am using with permission. As the probable largest personal health record in the world currently, there were 2,140,017 members with access to secure features as of the end of Q1-2008, out of 8.7 million members, and 63.6 % of registered members signed on two or more times in the past 12 months. There are a suite of services on kp.org that include messaging your doctor, access to lab test results, after visit summaries, and a comprehensive health encyclopedia.

This does matter to patients today, like me, as Jen McCabe Gorman pointed out in this post on her blog. She also pointed to a comment on my twitterfeed as well: I am, and I won’t.