LCDR Michelle Sandoval-Rosario, MPH, CPH CDC Epidemiology Assignee - - PowerPoint PPT Presentation

Hiding in Plain Sight: Identifying Patients with Undiagnosed Hypertension Using Electronic Health Records LCDR Michelle Sandoval-Rosario, MPH, CPH CDC Epidemiology Assignee Arizona Department of Health Services

Overview

• Background
• Electronic Health Records
• CDC Grant
• Clinical Definitions
• Results
• Challenges
• Lessons Learned

Hypertension

• 75 million US adults have hypertension (HTN)
• Every 44 seconds, someone in the US has a heart attack
• Every 4 minutes, someone dies of a stroke
• 1 out of every 3 adults dies from cardiovascular disease

National Health and Nutrition Examination Survey, 2013-2014 CDC Million Hearts

Uncontrolled Hypertension

16.1 M 7 M 11.5 M

Aware and treated Aware and untreated "Unaware"

34.6 M US Adults have uncontrolled HTN

National Health and Nutrition Examination Survey, 2013-2014 CDC Million Hearts

Unaware of Hypertension – A Closer Look

81.8% 82.5% 61.7%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Have Health Insurance Have a Usual Source of Care Have Received Care 2+ Times in Past Year

National Health and Nutrition Examination Survey, 2013-2014 CDC Million Hearts

Hypertension Control

How do you manage an Undiagnosed HTN patient you don’t know about?

Identify potential undx HTN Engage patient in care Diagnosed HTN Manage HTN BP Control

Identifying undiagnosed HTN

Million Hearts

Steps for Finding and Addressing Undiagnosed Hypertension

Establish Clinical criteria for potential undiagnosed HTN Leverage EHR to find patients who meet clinical criteria Implement a plan for addressing the identified population Calculate the hypertension prevalence in your practice

Million Hearts

Purpose and Aim

Improve detection and diagnosis of hypertensive patients at health centers Obtain the true hypertension population denominator at health center Improve awareness and control of HTN

Project Phase

• Pre Five Year CDC Grant:

– 2012 Meaningful Use Analysis of FQHC’s HIT Capacity

• First started evaluating clinic’s capacity to track NQF measures
• Included NQF 13 (HTN x2 Visits per year)
• Multiple vendors; wide range of capacity and training
• Partnerships

– Collaborative relationship established with FQHCs, non-FQHC clinics, State QIO

• Leveraging five Year CDC Grant Activities

– Integrated the reporting of NQF 18 and 59 into most projects that occur in the healthcare setting

• CHW projects
• Team based care projects
• Reinforced what was learned in the 2012 capacity analysis – some are

ready, some are not

Year 3 Pilot and Year 4

• Year 3 Pilot

– Selected non-FQHC community health center to pilot an EHR enhancement

• Yuma, AZ. Creation of a virtual “portal” to create easy, chronic care

management dashboards by patient or by specified patient population. Sorted by provider, condition, etc. – Results were very good. Clinic optimized information to target high risk patients. – Selected clinic to run reports on undiagnosed HTN after providing definitions and parameters.

• Year 4

– Mirrored EHR portal development with additional clinics – Challenged five other health centers to report on undiagnosed HTN through inclusion of “required” performance measure reporting, in addition to their contractually obligated reports on NQF18, self management, etc.

Clinical Definitions

• Proportion of adults in the state aware they have

high blood pressure:

– Numerator: the number of adults who have been diagnosed with HTN – Denominator: Total number of adult patients with HTN (diagnosed and undiagnosed)

• Embedded algorithms into EHR to identify patients

greater than 18 years old at risk for undiagnosed HTN

– Definition: two or more non-consecutive blood pressure readings of >140/90 mm HG who did not have documentation of HTN

Year 3 Pilot Findings

• Between 09/01/2015 – 07/31/2016

– 966 patients identified with HTN (diagnosed and undiagnosed) – 14% (138) undiagnosed – 51% Females and 93% Hispanic – 52% with controlled HTN

Year 4 Findings

Five additional health systems throughout Arizona

CHC Location # of patients with 2 or more blood pressure readings ≥ 140/90 (undiagnosed) # diagnosed and undiagnosed with High blood pressure Percent Undiagnosed Controlled blood pressure 1 Urban 77 256 30% 58% 2 Urban 92 386 24% 67% 3 Rural 159 2218 7% 80% 4 Urban 84 1773 5% 79% 5 Rural 46 4305 1% 86%

Challenges

• Multiple definitions and algorithms
• Health System’s EHR capacity or IT support
• Lack of awareness/resources
• Buy-in regarding methods/algorithm used
• Time
• Clinical criteria

– Undiagnosed HTN – HTN Self Management Program

Lessons Learned

Partnerships

Identify EHR capabilities Establish definition and clinical criteria Provide on-going technical assistance and guidance Develop a plan to address patients with high blood pressure

Identifying Patients with Undiagnosed HTN

ADHS Ongoing Efforts

• Ongoing technical assistance/guidance to health systems
• Developing clinical protocols to address undiagnosed

hypertension

• Collaborating with the American Heart Association

Multicultural Office

• Partnership with the Health Information Network of

Arizona (HINaz)

• Partnerships with safety net health systems (e.g.

Paramedics, Emergency Medical Trauma professionals, Associations, FQHCs, other health centers)

• Utilization of Community Health Workers to address

undiagnosed hypertension

Electronic Health Records

• Identifying individuals with undiagnosed and/or

uncontrolled hypertension to target for outreach, follow up, or clinical management efforts

• Identifying priority populations or geographic areas to

target for intervention

• Monitoring individuals to help them manage their blood

pressure

• Informing clinical quality improvement (QI) efforts
• Monitoring population-level trends and measures over

time

• Reporting on clinical quality measures

Acknowledgements/Co-Authors

Arizona Department of Health Services Anna Alonzo Omar Contreras, MPH David Heath, MA Teresa Manygoats, MPA Reginal Center for Border Health Amanda Aguirre, MPH Marisol Penuelas Centers For Disease Control and Prevention CDR Timothy Cunningham, ScD, SM, FACE

Thank you! Questions/ Comments?

Michelle.Sandoval-Rosario@azdhs.gov