Design and Implementation of an Electronic Health Record-Integrated Hypertension Management Application

Abstract

Background: High blood pressure affects approximately 116 million adults in the United States. It is the leading risk factor for death and disability across the world. Unfortunately, over the past decade, hypertension control rates have decreased across the United States. Prediction models and clinical studies have shown that reducing clinician inertia alone is sufficient to reach the target of ≥80% blood pressure control. Digital health tools containing evidence-based algorithms that are able to reduce clinician inertia are a good fit for turning the tide in blood pressure control, but careful consideration should be taken in the design process to integrate digital health interventions into the clinical workflow.

Methods: We describe the development of a provider-facing hypertension management platform. We enumerate key steps of the development process, including needs finding, clinical workflow analysis, treatment algorithm creation, platform design and electronic health record integration. We interviewed and surveyed 5 Stanford clinicians from primary care, cardiology, and their clinical care team members (including nurses, advanced practice providers, medical assistants) to identify needs and break down the steps of clinician workflow analysis. The application design and development stage were aided by a team of approximately 15 specialists in the fields of primary care, hypertension, bioinformatics, and software development.

Conclusions: Digital monitoring holds immense potential for revolutionizing chronic disease management. Our team developed a hypertension management platform at an academic medical center to address some of the top barriers to adoption and achieving clinical outcomes. The frameworks and processes described in this article may be used for the development of a diverse range of digital health tools in the cardiovascular space.

Keywords: clinician inertia; digital health; hypertension.

Figure 1. Biodesign framework (Denend et al; top panel) and development stages of a physician‐facing EHR‐integrated hypertension management application (bottom panel).

EHR indicates electronic health record; HTN, hypertension; and MVP, minimal viable product.

Figure 2. Needs finding.

The first step in the development process is to identify the unmet needs to solve from the numerous barriers in the hypertension management cycle. (1) Measure blood pressure accurately; (2) treatment intensification, clinic care, and follow‐up; (3) lifestyle adherence; (4) medication prescription and refill; and (5) medication adherence.

Figure 3. Workflow analysis.

Simplified workflow analysis of patient tasks, clinic staff tasks, and HrtEx hypertension management platform tasks starting with BP measurement and finalizing with the intensification of medical therapy. BP indicates blood pressure; EHR, electronic health record; and MA, medical assistant.

Figure 4. Prescription tree templates.

Default prescription trees are available, but clinicians can edit and create default prescription trees for their clinic or edit the sequence for specific patients. ACEI indicates angiotensin‐converting enzyme inhibitor; CCB, calcium‐channel blocker; CKD, chronic kidney disease; HCTZ, hydrochlorothiazide; and MRA, mineralocorticoid receptor antagonist.

Figure 5. EHR integrated data flow.

Data flow: (1) BP data are transferred from a Bluetooth BPM to a smartphone application. (2) The smartphone application then transfers data to the EHR. (3) The hypertension management platform (HrtEx) queries data (medication list, blood work, allergies, vital signs) from the EHR every 24 hours to be analyzed by an algorithm. (5) If the 2‐week average BP is above the patient's predefined goal, a medication recommendation is sent to the EHR to the treating clinician's in‐basket message. With 1 click, the message opens an orders‐only encounter that presents a concise summary of the data used to generate the clinician's preselected medication recommendation and a pending medication order waiting to be signed by the treating clinician. BP indicates blood pressure; BPM, blood pressure monitor; and EHR, electronic health record.