Using an EMR to assess pediatric blood pressure: Challenges and opportunities in a nephrology cohort

Background: Hypertension is a prevalent condition in the pediatric population. Diagnosis and management can be challenging due to difficulties with accurate measurement techniques and complex diagnostic criteria. The widespread adoption of electronic medical records (EMRs) has revealed their potential for improving patient care and research. This study aims to assess the clinical utility of using EMR data to enhance the identification and evaluation of children with hypertension. Objectives: The primary objectives of this research project were to utilize the EMR to extract anthropometric, demographic, and blood pressure related data from patients seen in the nephrology clinic as well as describe and evaluate trends in hypertension assessment and treatment while also identifying areas for improvement. Design: We performed a single center, retrospective cohort study using EMR data. Setting: Children who had their initial visit at the nephrology clinic between January 1st, 2018, and January 1st, 2022, were included in the cohort. Methods: Outpatients were identified using ICD 10 codes related to nephrology diseases. The EMR was reviewed to extract anthropometric, biochemical, and blood pressure data. A blood pressure (BP) index was calculated using systolic and diastolic BP values and the 2017 American Academy of Pediatrics (AAP) hypertension guidelines. The primary analysis categorized BP phenotypes. A secondary analysis using EMR and chart review, assessed whether elevated BP was appropriately managed, including scheduling follow up visits, diagnosing white coat hypertension, or initiating pharmacological or nonpharmacological interventions. Results: A total of 1,469 children aged 1 to 18 (median age 9.8 years) were newly referred to the nephrology clinic with complete data for BP index calculation. Many children were initially diagnosed as hypertensive, but across multiple visits were normotensive. Despite being hypertensive across multiple visits, we observed that many children had missing data following EMR extraction (~20%). Furthermore, despite meeting criteria at visit one for hypertension, many children did not have follow up visits (~20 to 30%). We identified that those children presenting with isolated elevated diastolic blood pressure elevations were more likely to have fewer BP measurements and were less likely to have BP related follow up, likely reflecting the perceived benign nature of this phenomenon. Limitations: This study's retrospective, nonrandomized design limits generalizability. Conclusions: This study underscores the challenges in studying pediatric hypertension using an EMR, particularly highlighting missing values and decreased measurements as problematic.