This is a longer-ish piece that was commissioned by the California Healthcare Foundation earlier this year. It never made it into publication, so through the magic of Web2.0, I’m publishing it here.
I’ve re-reviewed the data below and feel it is still accurate, with the exception that I have found newer information that indicates that the rate of “masked hypertension” discussed below may be as high as 50%, rather than the 10% quoted.
Enjoy and see what you think.
In June, 2008, I was asked by the California Healthcare Foundation to investigate the chronic conditions that might benefit from patient-centered health information technology applications in employed populations.
I assumed that we would likely target the 5% of the population that accounts for 50% of health care costs – the so-called “high concentration (of expenditures)” patients. Conditions accounting for these costs include mood disorders, diabetes, heart disease, asthma, and hypertension. High-concentration patients have several of these at the same time.
After I reviewed the data, spoke with national experts, shadowed physician visits, and spoke to patients, my colleagues at the California Healthcare Foundation and I physically stepped a group of California high-tech, employer, and health care stakeholders through to the conclusion that shocked me. It isn’t the smaller number of patients with multiple chronic conditions where the impact for patient centered health information technology is greatest. It is the enormous number of patients with one chronic condition where the greatest difference can be made. In the case of blood pressure, I believe the data points to the idea that the management of blood pressure in a doctor’s office without the use of telehealth may be unsafe. I learned that with telehealth, we have the opportunity to improve the quality, safety, and cost of a condition that affects one-third of the US population, as well as to rethink a paradigm to really put the patient at the center of care.
The opportunities to improve blood pressure control have been well characterized by the expert community interested in hypertension. In 2008, however, two significant pieces of work emerged to make the case for widespread telehealth implementation.
The first was the joint American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association Scientific Statement, “Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring,” which introduced me to the work of Nancy Houston-Miller, RN, BSN, FAHA, a national expert in hypertension management and cardiac rehabilitation. The second was the publication of a multi-million-dollar randomized controlled trial of blood pressure management through a secure web portal at Group Health Cooperative in Washington State. The first piece consolodated the science and major issues around changing the way we manage blood pressure. The second piece provided definitive proof of the value of online interactions with patients in improving chronic condition management. In the study, there was a marked and significant improvement in blood pressure control when patients were coached and supported outside of the doctor’s office their community.
We know that today’s standard of care for managing blood pressure doesn’t set a very high bar for quality. The national rate of control of blood pressure (for most people, below 140 mm Hg systolic, 90 mm Hg diastolic, lower for some people such as those with diabetes) is 37%. In 2004, it was determined that the percent of patients leaving their doctor’s office with their blood pressure under control was 45%, or less than the odds of flipping a coin. Most patients with high blood pressure in the US are insured and have access to care – less than 10 % of uncontrolled hypertension is due to lack of health care use, so this is not a problem of lack of coverage. In fact, hypertension is the #1 reason for a visit to the doctor in the United States.
Within the in-person doctor visit, the numbers become even more concerning – about 20% of the time, a patient is diagnosed with high blood pressure in the office when they are really not hypertensive. This is known as “white-coat hypertension” and results in these patients being placed on medications, sometimes for life, unnecessarily.
About 10% of the time, a patient is not diagnosed with hypertension in the office when they do have high blood pressure. This is known as “masked hypertension.” According to Huston-Miller, this number may be even higher. Just as some people are thought to remember to floss their teeth a week before their dental appointment, the same happens with people and blood pressure medicine before the doctor visit. It’s therefore possible that many more patients are really not under control, with potentially devastating results.
An important issue I discovered is with the paradigm of today’s blood pressure management – the “data” needed to make decisions is localized to the doctor rather than the patient. Doctors say things like, “Come back in 2 weeks and I will check your blood pressure,” which gives the impression that the doctor’s role is to tell you, the patient, what is happening with your body. If this is how we frame the condition, is it any wonder that some patients think about medication as the kind of thing to take to make their doctor happy rather than themselves? When I put the data about errors in diagnosis, errors in treatment, and the fact that high blood pressure may account for 27% of cardiovascular disease events in women and 37% in men, I began to think that blood pressure management localized to the doctor’s office may not only be inadequate, it may be harmful.
Unfortunately, the cost for this level of quality is high – $51 billion per year in direct health care costs, and dwarfed by the indirect cost – around $300 billion per year. Why $300 billion? Studies have shown that for an individual person, the loss of productivity is not as great due to hypertension compared to other conditions. However, the number of people affected – over 65 million – takes a huge overall toll on employers, families, and patients themselves. The indirect cost is borne by all of society rather than the health care system, which may explain why health-system supported telehealth applications tend to focus on high direct-cost conditions, such as congestive heart failure.
Interestingly, the Center for Medicare and Medicaid Services and most major health plans understand the cost of misdiagnosis. They pay for a type of home-based diagnosis called because they have determined that enough patients can avoid unnecessary treatment this way. There’s even a CPT code (93784) that covers the following:
“Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report.”
This CPT code is rarely billed for, because the technology involved in “Ambulatory Monitoring” isn’t practical – it involves wearing an inflatable cuff on your arm for 24 hours straight.
A comparable CPT code for modern home-based monitors that are as accurate at predicting heart damage from high blood pressure with just two measurements a day could dramatically change this current state. Consumer purchased blood pressure cuffs are now able to store readings digitally and transmit them electronically for review against targets set by physicians.
Electronic transmission is important – 20% of readings written down by patients can be significanlty inaccurate. The detailed algorithm for diagnosing and treating is beyond the scope of this piece; however, one exists and few patients and physicians know about it, most likely because our system continues to emphasize the physician-visit so strongly.
The final hurdle I have considered is the one around patient engagement. This is the statment made to me so many times in the past year: “But Ted, patients really aren’t interested in monitoring their blood pressure/taking responsibility for their health.” Again, a review of the literature explodes this myth. Studies show patients actually perceive home measurement of blood pressure as the most preferred method compared to checks by their doctor, their nurse, or by themselves in the doctor’s office. Patients also have greater interest in their conditions that we give them credit for:
“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.” (From: http://www.nature.com/jhh/journal/v17/n7/abs/1001582a.html – Rickerby, J, and J Woodward. “Patients’ experiences and opinions of home blood pressure measurement.” J Hum Hypertens 17, no. 7 (0): 495-503. )
The story of the opportunity our nation has through the use of telehealth is illustrated well in the example of blood pressure management. With a comprehensive approach to use telehealth, the use of the physician-office blood pressure check should significantly decrease, and the use of the home-based blood pressure check should significantly increase. Less patients would require medication. A change in paradigm will occur, from one of the patient asking their doctor for their blood pressure reading to one of the doctor asking the patient. In this way the talent and interest of patients and their families in managing their own health can be leveraged. With conversion of an existing CPT code that reimburses for legacy technology to one that reimburses for modern techology, physicians can be reimbursed for the congitive services they provide in coaching and guiding patients to better health.
The most important potential outcome we can achieve is the one all patients and their physicians want most – to be diagnosed correctly, managed accurately, and to leave every interaction with the health system more healthy than when they arrived.