Remote Monitoring and Digital Patient Engagement Improves Blood Pressure Control

CLINICAL PRIORITY

Family Doctors and Ashley Clinic wanted to improve performance with CMS’ electronic clinical quality measure (eCQM) 165v9, controlling high blood pressure (BP), by increasing the number of hypertensive patients with a BP of <140/90 mmHg.

The organizations sought to comply with the 2017 recommendations of the American College of Cardiology (ACC) and the American Heart Association (AHA) by achieving BPs of <130/80, reducing the incidence of heart attack, stroke, heart failure, kidney disease or failure, peripheral artery disease (legs, arms, head), vision loss, and sexual dysfunction.

Family Doctors and Ashley Clinic pursued at-home, remote monitoring of BP and supplemental support between visits to properly diagnose and treat hypertension, understanding that high blood pressure is often misdiagnosed in the clinic, leading to unnecessary or ineffective treatment. Up to 75 percent of patients with hypertension do not have their condition well controlled.

APPROACH

Ashley Clinic and Family Doctors partnered with Twistle® Patient Engagement by Health Catalyst to implement its Controlling Blood Pressure Pathway (CBPP) to improve clinical quality measure performance and outcomes for patients with an elevated in-office blood pressure reading.

每日发送短信提醒患者检查他们的血压。患者既可以手动输入家庭血压监测仪读数，也可以使用蓝牙连接设备自动上传。

The pathway automatically delivers real-time BP interpretation and guidance, coupled with periodic education about how to lower blood pressure through lifestyle modifications. Upon completion of a 14- or 28-day cycle, the daily home BP readings are automatically sent to the providers’ EHR, along with calculated average systolic and diastolic BP results, reducing the time required for clinical review and decision-making during a telehealth or in-person follow-up visit.

IMPLEMENTATION APPROACH

Phase 1 of the pilot study included patients over 18 years of age with an average SBP/DBP of >140/90 mmHg. The provider and staff were notified about each patient’s automatic enrollment in the Twistle CBPP so they could answer questions and encourage participation.

In Phase 2, the age range was modified to include patients 18-80 years old. Patients could opt out themselves or be opted out for reasons such as illness or injury. Patients also received encouragement to obtain a home BP monitor.

第三阶段在入组时为所有高危患者提供家庭BP监测仪，并为希望使用蓝牙或蜂窝连接设备的患者提供更大的技术支持。

The Twistle pathway has enabled us to deliver comprehensive care even when patients aren’t in the clinic, and that’s been essential to helping us properly diagnose and treat hypertensive patients.

Dr. Peter Barker, Family Doctors

RESULTS

The combination of remote monitoring and digital patient engagement software to accurately diagnose hypertension and provide support to patients between in-person visits has meaningfully impacted the diagnosis and management of high blood pressure. More than 1,250 patients were enrolled in the CBPP and 465 patients opted out.

• 22 percentage point increasein the number of patients with blood pressure control.
• For patients completing just one cycle of the CBPP:
  • 80 percentachieved a mean SBP/DBP of <140/90.
  • 36 percentachieved a mean SBP/DBP of <130/80.

• $7K return on investment per provider per year通过对3级或4级后续办公室或远程保健访问进行计费，获得所有相关费用后的额外收入。

ADDITIONAL READING

• Digital Care Technology Enables COVID-19 Care at Scale
• Simplifying Recovery from Total Joint Replacement with Digital Care
• Digital Patient Engagement: Best Practices to Drive an Optimal Patient Experience and Outcomes
• How Proactive Patient Communication Solves Medication Non-Adherence
• Twistle by Health Catalyst