Rickerby, J, and J Woodward. “Patients’ experiences and opinions of home blood pressure measurement.” J Hum Hypertens 17, no. 7 (0): 495-503.

Pare, Guy, Mirou Jaana, and Claude Sicotte. “Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base.” J Am Med Inform Assoc 14, no. 3 (May 1, 2007): 269-277

Little, Paul, Jane Barnett, Lucy Barnsley, Jean Marjoram, Alex Fitzgerald-Barron, and David Mant. “Comparison of acceptability of and preferences for different methods of measuring blood pressure in primary care.” BMJ 325, no. 7358 (August 3, 2002): 258-259.

Not pictured: Port, Kristjan, Kairit Palm, and Margus Viigimaa. “Daily usage and efficiency of remote home monitoring in hypertensive patients over a one-year period.” J Telemed Telecare 11, no. suppl_1 (July 1, 2005): 34-36.

There’s a potentially serious gap in the Connectivity for Californians initiative that we are addressing. Here’s a quote that illustrates it:

It is very clear from the interview data that patients have their own ideas, and spend a lot more time thinking about their BP than is apparent in the average 10-min consultation in general practice.

The gap is patient involvement in the design and planning of this initiative, or any healthcare initiative for that matter. Patients have many more ideas about what the problems are to be solved than can be gleaned even from articles like this - the articles simply show that the ideas are out there. Fortunately, we are committing ourselves to have a patient representative involved from the beginning, and that is coming together before any work is started.

The quote above is from the first paper by Rickerby, et. al (click on the images to the right to review any of the papers yourself), which described a qualitative study to look at a small number of patients’ attitudes toward monitoring their own blood pressure, in a practice that routinely recommends this.

The question (#1)

The reason I have reviewed these particular papers is because of the commonly posed question to me over the past several months, in the form of, “Ted, will/are patients really motivated to check their own blood pressure?” with the implication that they are not and they won’t. It’s a fair question that deserves an informed response. Several of the readers on this blog have given me some information from their own lives. These papers add to that knowledge.

The answer (#1)

They are and they will.

The question (#2)

This came up during reading of the papers. Does patient engagement come from having knowledge? Or does knowledge come from being engaged? This came up because patients in the first study who did not have knowledge about why they should monitor their blood pressure or how to do it seemed less engaged.

The answer (#2)

Unclear, with the implication being about whether to work to engage patients with more knowledge or use knowledge as a means test for engagement. I think regardless of the answer, there’s no reason not to provide information to patients. That answer is good enough in this case.

Read on for more conclusions….

Read the rest of this entry »

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….

• Participatory Medicine - Nice summary by Gilles Frydman

• Essay - Fed Up With the Frustrations, More Doctors Change Course - NYTimes.com - I am sympathetic, and this is the reason I champion LEAN wherever I go - the processes we use in health care can be changed, and we can involve patients and our families so that everyone works together to be healthy. The challenge for physicians is that we are not trained at all in process improvement, so we usually enter environments with broken processes, and manage these situations with the training we have been given, which doesn’t lend to collaboration. See this blog entry for examples of extreme challenges in our medical education system today. I sometimes say that we’re all actors in a play that has a script we didn’t write. Let’s rewrite the script (patients and their families included).

  If anyone wants to collaborate on a medical student rotation looking at LEAN concepts / process improvement / patient centered care / respect for staff and customer, let me know. This presumes that there’s a medical school either teaching this or interested in this. Is there?

• Pew Internet : Participatory Medicine - The latest data from the Pew Internet & American Life Project about participation on the Internet. Participatory medicine may become a more common idea thanks to the Web2 revolution.