At the end of 2012, 2.8 million patients worldwide were using a home monitoring system, according to a Research and Markets report. Mobile health has the opportunity to transform management of many chronic diseases, particularly those that require patients to carefully and consistently monitor and report clinical data on their health status, such as hypertension (high blood pressure).
Home blood pressure monitoring (also referred to as self-measured blood pressure monitoring) has long been viewed as effective, even without a technology component. Consider:
• 95% of physicians agree that home blood pressure measurements are useful in making treatment decisions to manage the condition of patients with hypertension
• Risk of blood pressure above target is lower in people with home monitoring
• Home monitoring can reduce healthcare costs―for instance, one study found that it reduced the medication needed for blood pressure control, saving $1,198 per 100 patients per month3
The ability to incorporate mobile health into home blood pressure monitoring can better engage patients and motivate proactive behaviors, cut healthcare costs, track treatment effects between visits, and help providers confirm diagnoses earlier, according to the Mayo Clinic.
The American Medical Group Foundation and its national Measure Up/Pressure Down® hypertension campaign recently concluded a home blood pressure monitoring project with four members of the American Medical Group Association: Billings Clinic (Billings, MT), Community Physician Network (Indianapolis, IN), Cornerstone Health Care (High Point, NC), and Wilmington Health (Wilmington, NC). The 18-month project, sponsored by Withings, aimed to identify best practices for mobile health home blood pressure monitoring programs and improve blood pressure control.
During the project, 150 patients connected the Withings Wireless Blood Pressure Monitor with their compatible iOS or Android device using Bluetooth technology. Patients took their blood pressure on a regular basis, with the frequency of readings recommended by the care team. The measurements were then transmitted in real-time via a dedicated web portal to their medical group, which then scheduled follow-up office visits and/or recommended necessary therapy changes for those with blood pressures of 140/90 mmHg or greater.
Tips for Mobile Health and Chronic Disease Management
The following four tips were identified based on best practices and lessons learned:
1. Start by recruiting tech-savvy patients.
A 2014 Harris Poll found that nearly half of American adults report being “extremely” or “very interested” in being able to check their own blood pressure using smartphones or tablets. These patients will likely be willing to sign up for a home blood pressure monitoring program at your organization and be familiar with the technology needed to participate effectively.
This familiarity with technology can ease the burden on your care team and the time that it takes to recruit and enroll patients. For instance, by starting with tech-savvy patients, your care team may not need to spend significant time working with a patient who does not know their smartphone password and therefore could not download the required app that collects and aggregates readings, as was the case with our pilot project.
As your program expands to patients less comfortable with such technology, consider offering step-by-step instructions for home monitoring – from turning on the device to taking and viewing a reading. Medical groups and health systems can also become more efficient by developing guides to verify the compatibility of the device with the patient’s smartphone or tablet operating system and address other technological questions. Device companies, including Withings, are generally willing to provide direct customer support services to answer questions about the technology.
2. Leverage direct referrals by providers during recruitment and enrollment.
The many moving pieces of recruitment and enrollment can be an obstacle during such a program. Identifying patients with uncontrolled hypertension, explaining benefits of participation, scheduling a training session to learn about and connect the device and having the patient actually attend this session proved challenging at times.
The most successful medical groups found that leveraging direct referrals from the healthcare team was the most important factor in gaining patients’ trust―and interest. Once patients learned that participation in a home blood pressure monitoring pilot project was recommended by their provider, they were much more willing to partake. As one group noted, “Once we told patients that this program was recommended by their provider, that made all the difference. If the doctor tells you to do something and you trust them, you’ll do it.”
3. Create a clear workflow that involves the entire care team.
Project implementation required changes in care processes―including patient engagement and treatment modifications―due to the integration of home monitoring. Understanding the complexity of the changing practice pattern and the many steps involved, the most successful medical group participants created and documented an effective care process early on and assigned specific tasks to members of the care teams.
The typical workflow at participating groups consisted of the following steps:
1. Blood pressure taken by patient using the Withings Wireless Blood Pressure Monitor
2. Blood pressure readings in Withings portal reviewed by participating group
3. Data manually entered into EHR by participating group
4. Group follows up with the provider for patients with elevated blood pressures and determines appropriate treatment changes (as appropriate)
5. Group follows up with the patients without recorded readings (as appropriate)
These responsibilities were assigned to different care team members, depending on the site. One group, for instance, relied on a clinical pharmacist to review readings, add or discontinue medications on behalf of a provider within the parameters of a collaborative agreement and physician-approved protocols to expedite control, and schedule a follow-up appointment for in-office blood pressure measurement and lifestyle coaching. Another utilized a quality department leader and health coach to access the readings on a daily basis and flagged any escalated readings immediately for the provider.
4. Integrate mobile health monitoring into your EHR.
EHR integration is critical to the success of any mobile health monitoring initiative, particularly those on a large scale.
During the project, EHR integration was not implemented because of the short-term nature and relatively limited size of the pilot, along with the barrier of coordinating integration. Instead, the four medical groups utilized Withings’ secure web-based portal to review the systolic blood pressure, diastolic blood pressure and heart rate taken with the Withings device.
All four participating groups noted that automated integration of the blood pressure readings directly into the EHR is necessary to increase the number of participants. Without this integration, project teams spend substantial time reviewing readings, entering data into the EHR, and alerting providers and care teams of results.
Project Outcomes
Beyond identifying the best practices above, the project also sought to improve patient control rates. Findings showed that blood pressure control rates improved from 38.6% to 70.0% when comparing the first and last blood pressures recorded with the Withings Wireless Blood Pressure Monitor during the 18-month project. Median blood pressure control rates improved for patients across the time period of the project, from 44.1% to 64.7%.
According to patient and provider/staff surveys, both groups generally enjoyed using the Withings Wireless Blood Pressure Monitor and expressed that they felt it was useful in controlling hypertension.
Integration of remote monitoring and mobile health have tremendous potential to improve outcomes and engage patients, as evidenced by the successes of this pilot project. For healthcare providers considering implementation in their own practices, these best practices can help organization avoid common pitfalls and use lessons learned from others to deliver care in more efficient and effective ways.
Note: These findings were developed from data in an observational study. By nature, observational studies cannot be used as a reliable source to make statements of fact about the safety, efficacy, or effectiveness of a practice or device. As AMGF and Withings did not collect and analyze all factors that can potentially contribute to hypertension control, there is no means of verifying that the improvements occurred because of enrollment in this project or use of the Withings Wireless Blood Pressure Monitor.
1 Soghikian, K. et al. “Home Blood Pressure Monitoring: Effect on Use of Medical Services and Medical Care Costs.” Medical Care. 30(9). 1992: 855-865.
2 Verberk, W.J., et al. “Self-Measurement of Blood Pressure at Home Reduces the Need for Antihypertensive Drugs: A Randomized Controlled Trial. Hypertension. 50. 2007: 1019-1025
In his role as the Chief Medical and Quality Officer of the American Medical Group Association (AMGA) and the President of the American Medical Group Foundation (AMGF), Jerry Penso, MD, MBA works to design, develop, and implement initiatives related to quality management and research. Prior to joining AMGA and AMGF, Dr. Penso served as Medical Director, Continuum of Care for Sharp Rees-Stealy Medical Group in San Diego. He previously practiced as a family physician with Sharp Mission Park Medical Group in north San Diego County for over 14 years.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker’s Hospital Review/Becker’s Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.
