Integrating a High Blood Pressure Advisory Across a Primary Care Network

Importance: Leveraging technology to prompt team-based care might improve ambulatory hypertension care. Objective: To assess whether an electronic medical record (EMR) high blood pressure (BP) advisory improves hypertension control. Design, Setting, and Participants: This quality improvement study assessed hypertension control in patients presenting to primary care office visits from March 2018 to February 2020. Data were included from 28 primary care clinics (8 clinics contributed data toward the primary objective and 28 contributed data toward secondary objectives) in a single academic health system in California before and after intervention and concurrent care team observations and interviews assessing implementation. Data were analyzed from November 2019 to October 2020. Intervention: An EMR high BP advisory combined with team training, audit, and feedback. EMR entry of elevated BP (systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg) prompted an interruptive medical assistant-facing advisory to recheck BP. Persistently elevated BP prompted a second interruptive clinician-facing advisory with order panel link. Main Outcomes and Measures: The primary outcome was BP lower than 140 mm Hg systolic and lower than 90 mm Hg diastolic during an office visit within 6 months of an initial primary care visit. Secondary outcomes included BP recheck after initial elevated value, antihypertensive medication change, and new hypertension diagnoses. Qualitative outcomes focused on implementation barriers and facilitators. Results: The primary outcome assessed 2760 control patients and 3018 intervention patients with preexisting hypertension (mean [SD] age, 66.5 [14.4] years; 2847 [49.2%] women, 1746 [30.2%] Asian, 619 [10.7%] Hispanic, and 2407 [41.7%] White). The likelihood of hypertension control increased 18.3% per month on average (odds ratio [OR], 1.18; 95% CI, 1.10-1.27; P < .001) in the intervention vs control groups. Modeled rates of adjusted hypertension control over 6 months increased from 82.3% to 92.3% for the intervention cohort and decreased from 71.5% to 70.3% for the control (preintervention) cohort. BP recheck rate increased (from 37.6% to 77.9%; OR, 4.76; 95% CI, 4.45-5.10; P < .001), while ordered antihypertensive medications was unchanged. New hypertension diagnosis increased from 12.1% to 20.6% (OR, 1.34; 95% CI, 1.13-1.58; P = .01). In interviews of 34 care team members (clinicians, medical assistants, and managers) from 6 clinics, implementation barriers included competing priorities and time for BP rechecks, order panel complexity, and mixed clinician engagement; facilitators included intervention visibility, EMR integration, and team-based approach. Conclusions and Relevance: This quality improvement study of an EMR high BP advisory intervention found significantly improved primary care hypertension control and diagnosis due to the combination of team-based care and technology.