Provider Perspectives on Patient- and Provider-Facing High Blood Pressure Clinical Decision Support.

BACKGROUND: Hypertension, persistent high blood pressures (HBP) leading to chronic physiologic changes, is a common condition that is a major predictor of heart attacks, strokes, and other conditions. Despite strong evidence, care teams and patients are inconsistently adherent to HBP guideline recommendations. Patient-facing clinical decision support (CDS) could help improve recommendation adherence but must also be acceptable to clinicians and patients. OBJECTIVE: This study aimed to partly address the challenge of developing a patient-facing CDS application, we sought to understand provider variations and rationales related to HBP guideline recommendations and perceptions regarding patient role and use of digital tools. METHODS: We engaged hypertension experts and primary care respondents to iteratively develop and implement a pilot survey and a final survey which presented five clinical cases that queried clinicians' attitudes related to actions; variations; prioritization; patient input; importance; and barriers for HBP diagnosis, monitoring, and treatment. Analysis of Likert's scale scores was descriptive with content analysis for free-text answers. RESULTS: Fifteen hypertension experts and 14 providers took the pilot and final version of the surveys, respectively. The majority (>80%) of providers felt the recommendations were important, yet found them difficult to follow-up to 90% of the time. Perceptions of relative amounts of patient input and patient work for effective HBP management ranged from 22 to 100%. Stated reasons for variation included adverse effects of treatment, patient comorbidities, shared decision-making, and health care cost and access issues. Providers were generally positive toward patient use of electronic CDS applications but worried about access to health care, nuance of recommendations, and patient understanding of the tools. CONCLUSION: At baseline, provider management of HBP is heterogeneous. Providers were accepting of patient-facing CDS but reported preferences for that CDS to capture the complexity and nuance of guideline recommendations.

Assessing Data Adequacy for High Blood Pressure Clinical Decision Support: A Quantitative Analysis.

OBJECTIVE: This study examines guideline-based high blood pressure (HBP) and hypertension recommendations and evaluates the suitability and adequacy of the data and logic required for a Fast Healthcare Interoperable Resources (FHIR)-based, patient-facing clinical decision support (CDS) HBP application. HBP is a major predictor of adverse health events, including stroke, myocardial infarction, and kidney disease. Multiple guidelines recommend interventions to lower blood pressure, but implementation requires patient-centered approaches, including patient-facing CDS tools. METHODS: We defined concept sets needed to measure adherence to 71 recommendations drawn from eight HBP guidelines. We measured data quality for these concepts for two cohorts (HBP screening and HBP diagnosed) from electronic health record (EHR) data, including four use cases (screening, nonpharmacologic interventions, pharmacologic interventions, and adverse events) for CDS. RESULTS: We identified 102,443 people with diagnosed and 58,990 with undiagnosed HBP. We found that 21/35 (60%) of required concept sets were unused or inaccurate, with only 259 (25.3%) of 1,101 codes used. Use cases showed high inclusion (0.9-11.2%), low exclusion (0-0.1%), and missing patient-specific context (up to 65.6%), leading to data in 2/4 use cases being insufficient for accurate alerting. DISCUSSION: Data quality from the EHR required to implement recommendations for HBP is highly inconsistent, reflecting a fragmented health care system and incomplete implementation of standard terminologies and workflows. Although imperfect, data were deemed adequate for two test use cases. CONCLUSION: Current data quality allows for further development of patient-facing FHIR HBP tools, but extensive validation and testing is required to assure precision and avoid unintended consequences.