TeenBP: Development and Piloting of an EHR-linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents

Abstract

Context:Blood pressure (BP) is routinely measured in children and adolescents during primary care visits. However, elevated BP or hypertension is frequently not diagnosed or evaluated further by primary care providers. Barriers to recognition include lack of clinician buy-in, competing priorities, and complexity of the standard BP tables.Case Description:We have developed and piloted TeenBP— a web-based, electronic health record (EHR) linked system designed to improve recognition of prehypertension and hypertension in adolescents during primary care visits.Major Themes:Important steps in developing TeenBP included the following: review of national BP guidelines, consideration of clinic workflow, engagement of clinical leaders, and evaluation of the impact on clinical sites. Use of a web-based platform has facilitated updates to the TeenBP algorithm and to the message content. In addition, the web-based platform has allowed for development of a sophisticated display of patient-specific information at the point of care. In the TeenBP pilot, conducted at a single pediatric and family practice site with six clinicians, over a five-month period, more than half of BPs in the hypertensive range were clinically recognized. Furthermore, in this small pilot the TeenBP clinical decision support (CDS) was accepted by providers and clinical staff. Effectiveness of the TeenBP CDS will be determined in a two-year cluster-randomized clinical trial, currently underway at 20 primary care sites.Conclusion:Use of technology to extract and display clinically relevant data stored within the EHR may be a useful tool for improving recognition of adolescent hypertension during busy primary care visits. In the future, the methods developed specifically for TeenBP are likely to be translatable to a wide range of acute and chronic issues affecting children and adolescents.

Predicting Hypertension Among Children With Incident Elevated Blood Pressure

“…In settings with EHRs, a predictive risk model for hypertension could be integrated into clinical decision support tools to improve hypertension recognition. 20–22 However, the relatively poor external validity of our predictive risk model indicates that it is not currently suitable for widespread dissemination, because it may not perform well in different health care environments. 23, 30 Many examples exist of predictive risk models with good internal validity, which were never validated in patients and settings external to the development environment; 28 these risk models may have been implemented in new settings with disappointing results.…”

“…In settings with electronic health records (EHRs), predictive risk models can be integrated into clinical decision support tools for use during routine care, as long as the risk models are based upon data readily available within the EHR. 20–22 …”

Clinical Decision Support for Recognition and Management of Hypertension: A Randomized Trial

“…As previously described, 10,11 the CDS was developed over a 12-month period and piloted at a single clinic within the same health system starting in November 2013. The timing of the best-practice advisories (BPAs), wording and visual display of the CDS, and recommendations were developed to be consistent with the BP guidelines 2 available at the time of the study while accounting for clinic workflow and the preferences of medical group leaders.…”

“…As previously described, our team developed and piloted TeenBP, an EHR-linked clinical decision support (CDS) tool that significantly increased the recognition of a single BP ≥95th percentile. 10 Our goals in the current study were to evaluate the effectiveness of TeenBP in improving clinical recognition and the early management of children and adolescents with incident hypertension.…”

You Can’t Treat a Problem if You Don’t Recognize It

“…The study by Kharbanda et al 10 and management. The TeenBP CDS developed by Kharbanda et al 11 and subsequently studied 10 is the most comprehensive and well-integrated pediatric BP CDS described to date. By applying the CDS Five Rights, the authors have developed a wellthought-out and effective CDS tool that more than doubled the rate of recognition compared with standard practice.…”