Web-based Team Care to Improve Hypertension Control

the e-BP study and beyond

Bev Green MD, MPHGroup Health Research Institute

No disclosures

AHRQ Innovations Web-siteElectronic Communications and Home Blood Pressure Monitoring

to Improve Hypertension Control http://www.innovations.ahrq.gov/content.aspx?id=2318

National Heart, Lung, and Blood Institute: R01HL075263-04

Special thanks to the e-BP, e-Care for Heart Wellness, and e-CHIP Teams

BP Remains Uncontrolled Even Though it is the Most Common Diagnosis in Primary Care

• Hypertension is the most common diagnosis made in primary care.*

• In primary care practices only ½ of patients with a hypertension diagnosis have a blood pressure (BP) below target**

• 90% of patients with hypertension have health insurance***

•* Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. 2010(27):1-32

** Belletti DA, Zacker C, Wogen J. Hypertension treatment and control among 28 physician practices across the United States: results of the Hypertension: Assessment of Treatment to Target (HATT) Study. J Clin Hypertens (Greenwich). 2010;12(8):603-12

•*** Morbidity and Mortality Weekly Report 2/4/11. Vital Signs Prevalence, Treatment, and Control of Hypertension.

Why is blood pressure control so low in primary care?

Physician Issues: Is it therapeutic inertia?

Tyranny of the urgent The omnipresence of the complex A desire to provide patient-centered care Ability to recognize contextual alerts Evidence takes a long time to get to the front lines

Patient Factors: Is it adherence?

Costs of medications, fear of medications, so many medications Lifestyle is hard Priorities (pay now for something in the future) Going to the doctor takes time (and a co-pay) Co-factors depression, substance abuse

The Electronic Communications and Home Blood Pressure Monitoring Trial (e-BP).

We wanted to know whether a new model of care that engages patients more in there own care, by taking it out of the office and into their homes led to improved BP.

Home BP monitor and use of an existing patient Web site

This plus pharmacist care management (delivered via the

patient Web site)

The e-BP Intervention Components were Based on the Chronic Care Model

Ed Wagner

The External and Internal Context and Individuals (and adoption)

• Setting = Group Health Cooperative Integrated Healthcare Delivery System Provides healthcare insurance to over 700,000 patients in Washington and both

healthcare insurance and comprehensive care to the over 375,000 patients that receive their care within its 26 owned primary care medical centers.

• These clinics all have an integrated comprehensive electronic health record (EHR) and patients have access to this and other services via a secure patient Web portal (MyGroupHealth)

• Each clinic also has its own clinical pharmacists – that were already used to do population based care for chronic conditions (and were enthusiastic about doing more)

• 10 clinics were asked to participate in the e-BP study and all agreed.

Patient Web Portal

Secure messaging

Medication refills

Viewing portions of their medical record

Health information

Links to Group Health and community resources

Patient Adoption Has Been Rapid

The secure patient Web portal (myGroupHealth) was “turned on” November 2002

1/3 of Group Health clinic visits are now “virtual” (secure e-mail).

Group Health has1.4 million e-mail encounters per year

Adult patients (age 18 and over)

Registered(Has used member ID

to navigate site)

Verified (Secure Password)

June 1, 2005 (beginning of e-BP study)

44.0% 28.3%

November 1, 2010 73.4% 63.7%

Patients are Very Satisfied with MyGroupHealth

Finding Patients with Uncontrolled Blood Pressure

Automated databases: Diagnosis of hypertension and were on anti-hypertensive medications

No exclusionary health conditions (serious illnesses, heart disease,

diabetes)

Telephone Survey:

Access to a computer, the Internet, and an e-mail address

Screening Visits (2):

Uncontrolled HTN at both visits (BP >140 mm Hg systolic or >90 mm

Hg diastolic at both visits)

Recruitment: (reach)

• 22% did not have Web access (2005-6), those without access were*:

• Had lower levels of education (< high school degree RR = 3.22 [2.67-3.87])

• Were older (age 65-75 adjusted RR = 2.27 [1.92-2.67] )

• Were more likely to be from a racial minority group (African American compared adjusted RR= 1.38 [1.22 -1.66])

• 53% of patients with HTN remaining eligible agreed to a screening visit

• 63% had controlled BP (average BP < 140/90 at 2 visits)

Final sample (computer able - uncontrolled BP)

• 778 patients randomized (12% of those sampled and 64% remaining eligible)

*Green BB, Anderson ML, Ralston JD, Catz S, Fishman PA, Cook AJ. Patient Ability and Willingness to Participate in a Web-based Intervention to Improve Hypertension Control. J Med Internet Res 2011; 13 (1):e1

Recruitment:

• 22% did not have Web access (2005-6), those without access *:

• Had lower levels of education (< high school degree compared to college graduate, (adjusted RR = 3.22 [2.67-3.87])

• Were older (age 65-75 years compared to 40-54, adjusted RR = 2.27 [1.92-2.67] )

• Were more likely to be from a racial minority group (African American compared too Caucasian, adjusted RR= 1.38 [1.22 -1.66])

• 53% of hypertensive patients still eligible agreed to a screening visit

• 63% had controlled BP (average BP < 140/90 at 2 visits) (risk factors for lack of BP control African American race, overweight or obese)

Final sample (computer able - uncontrolled BP)• 778 patients randomized (11% of those sampled and 64% of those remaining

eligible)

*Green BB, Anderson ML, Ralston JD, Catz S, Fishman PA, Cook AJ. Patient Ability and Willingness to Participate in a Web-based Intervention to Improve Hypertension Control. J Med Internet Res 2011; 13 (1):e1

Group 1: Usual Care

Registered to use the existing patient Website

Received Group Health Pamphlets (“High BP Basics” and “The No Waiting Room”)

Told BP not in control and to work with their physician to improve control

Group 2: Home BP and Web Only (self-care management support only)

Usual Care plus BP monitor and training Web training

Group 3: Web Pharmacist Care (included all the components of the Chronic Care Model)

Clinical Pharmacists: experience with care management, registry database work, and electronic medical record in day to day work (apart from front line work)

Pharmacist Training:

Evidence based hypertension guidelines and stepped medication protocols

Information Systems: registry database and EMR documentation

Patient-centered communication styles

Ongoing meetings with me, the pharmacist lead, and a behavioral psychologist (every 2 weeks initially, then every month)

Web communications – Action Plan

Smart Phrase: eBP1stActPlan

HI .NAME

Here is your current action plan:

1. BP monitoring: Measure your BP at least 2 times each week (with two BP measurements each time). Choose two days of the week that are easy

to remember, like Saturday and Thursday or Monday and Friday and a time that is convenient, by making a regular time it will be easier to remember.

Remember to: (refer to your e-BP notebook for more detailed instructionAvoid exercise, caffeine, and tobacco for at least 30 minutes before you take your measurement. Remove tight fitting clothing from your upper arm.Sit in a comfortable position with your legs and back supported.Rest quietly for at least two minutes. Wait at least two minutes between BP measurements.Place your arm on a table or desk so that your arm is at the level of your heart.I will be sending you a secure message asking you for your BP measurements.

2. Medications:Your current medications are on ***If these are not correct please let me know.

3. Lifestyle Changes:You decided to work on *** You might want to check out some Group Health Resources such *** 4. Assessment Your average BP was 148/84. The next step would be to increase your dose of xxLet me know if you have any concern about this plan

5. Follow-up Plan:Please go to a Group Health Lab to have: ***I will send you a reminder to send me more BP readings in 2 weeks.

.Me

Ongoing Pharmacist Care-Management

• Web communications every 2 weeks for the first 3 months or until the BP is in control

• Stepped medication changes per protocol

• Continuing web communications about medication adherence and lifestyle goals, linked patients to information, Group Health and community programs

• Clinical concerns and deviations from the medication protocol pharmacist transferred to patient’s primary care physician

BP control at 12 months

Control BPM-Web Only BPM-Web-Pharm

All 31% 36% 56%*

Systolic BP at baseline >160

20% 26% 54%*

*P < 0.001 compared to UC and BPM-Web

Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson J, Carrell D, Tyll L, Larson EB, Thompson, RS. Effectiveness of Home Blood Pressure Monitoring, Web Communicatin, and Pharmacist Care on Hypertension Control. JAMA 2008; 299:2857-67.

• Bringing care out of the office and into patients’ homes. More active participation by the patient in their own care. Shared electronic health records Asynchronous communications

• Team care – Collaborative Care Pharmacists (and nurses) We are currently testing a model that uses Web-based

Collaborative Dietitian Care

• Cost-effective, cost saving?• This type of care is now a standard part of Group Health’s

Patient-Centered Medical Home • Can this model work in community practices?

Supports a “New Model of Care”(Maintenance within Group Health)

E-CHIP: electronic communications and improving hypertension in community practices

Will the e-BP model of care will work within typical community practices?

We have been doing preliminary work to present the model, establish relationships, learn from providers, staff, and patients about potential barriers and facilitators for using Web-collaborative care.

What type of provider would be best to provide collaborative care? “I always felt a clinical pharmacist in the building is a good idea to assist with and moving some of the care offsite electronically is a next step”

How best to adapt the clinic’s current EHRs for secure messaging? “that patient portal part wasn't part of our initial funding for the EMR. Part number 1 was the business product, part number 2 was the electronic medical record, part number 3 is actually the patient portal where patients send secured message back and forth

How to sustain Web Pharmacist Care? “I like the idea of using the pharmacist if we could come up with a business model”.

Challenges in Dissemination and Implementation of e-BP:

External Context Fee for Service – only face to face visits physicians are currently

compensated (pharmacist and virtual care are not covered) Patients want this but not everyone can participate

• Internal Context Few primary care clinics, even those with EHR’s have patient

portals Few primary care clinics, have collaborative care teams, very few

have “in-house pharmacists”

• Individuals “Relationship” is a critical for success - between stakeholders and

staff. It takes time to establish these and to understand their structural and social networks

Re-AIM applying it to the e-CHIP community adaptation

• Adoption – will clinics adopt this model? Meaningful use, accountable care might be some incentives. Patient demand another.

• Reach – There will be Web access disparities: will the use of proxies, cell phones, assistance from community health workers fix this. Other adaptations will be necessary. Team care can be also be delivered over the phone, in person, by texting – communications

• Implementation – As e-EP is translated to community setting to what degree will their be fidelity in implementation of its core components. If adaptations are made, are they beneficial or do they decrease the benefits of the intervention

• Effectiveness – does BP control improve in the adapted e-CHIP model?

• Maintenance – to what degree can the adapted model be maintained over time? Reimbursement is likely to be a big factor. GPPo

Glasgow.RE, Magid DJ, Ritzwoller D, Estabrooks PA. Practical Clinical Trials for Translating Research to Practice. Design and Measurement Recommendations. Medical Care 2005; 43:551-557 lasgow.RE, Magid DJ, Ritzwoller D, Estabrooks PA. Practical Clinical Trials for Translating Research to Practice. Design and Measurement Recommendations. Medical Care 2005; 43:551-557

Opportunities and Challenges

Patients want Web access to their healthcare*

Patients are highly satisfied with Web services

Team-based care for hypertension improves treatment outcomes. Long-term outcomes are less certain.

Team care can be delivered in person, in community settings, on the phone, and virtually. Comparative effectiveness and cost-effectiveness are needed.

. Most reimbursement policies do not support team or Web-based

patient. New models are being tested.

. *Disparities need to be addressed.

.

.

Questions for the audience Using population-based approaches to identify people with uncontrolled BP has

been difficult and makes it hard to scale up our intervention. Using elevated BPs in the EMR did not help us. Many had controlled BP when rescreened. In rolling this out to the delivery systems physician referral has been low.

Has anyone in the audience tried other methods for identifying people with uncontrolled hypertension and enrolling them in programs?

Our innovation was performed in an integrated healthcare delivery system, that both provides healthcare insurance and care. This model provides a business care for team-based care. We also already had a patient Web portal with a shared EMR

What types of barriers and solutions have you experienced in delivering team care ?

Have any of you had experience using patient owned electronic health records (PHRs) such as HealthVault? What has been positive or negative about this?

Disparities in access to the Web is an issue. What do you think are some of the best ways for addressing this?