Hypertension EffortsMercy Medical Group, Inc

September 29, 2016Alan R. Ertle, MD, MPH, MBAChief Medical Officer

• Introduction of Mercy Medical Group

• Burning Platform

• Impetus and question

• Initial survey of primary care physicians

• Second survey of medical assistants

• Steps we are taking

Topics

• 420+ provider multi-specialty group in the Sacramento metro area

– 86 hospitalists serving the four Sacramento-area Dignity Hospitals

– 75 APCs in almost all specialties

– Other physicians are split between primary care, medical specialties, and surgical specialties

• 36 specialties (and many subspecialties) represented

• Under Dignity Health Medical Foundation

Mercy Medical Group, Inc.

Burning Platform

Burning Platform

• Sacramento Right Care Initiative/University of Best Practices

– Should we develop a hypertension guideline an disseminate it to providers in our region?

Fall 2014

Alan’s Default Strategy:

• Questions based broadly on JNC8

• 29 of 65 primary care physicians responded

Assess Primary Care Physicians’ HTN Knowledge

Q1: For adults younger than the age of 60 years old, what is the appropriate target for HTN control?

Q2: For patients 60 to 79 years old, what is the treatment goal for HTN control?

Consistent answer for all age groups was 50-75%

Q4: What percentage of your patients in each age group do you estimate have appropriate blood pressure control?

Q5: What lifestyle changes do you recommend for your hypertensive patients?

Q6: What proportion of patients are able to control their hypertension to recommended levels with lifestyle changes alone?

• First line therapy for non-African Americans

• First line therapy for African Americans

• Second line

• Third line

• Combinations

• Home BP monitoring devices (~50% and of those ~50% use them)

Additional Questions

• Are you aware of Measure Up/Pressure Down?

– 85% no

• Are you aware of the Million Hearts campaign?

– 94% no

Additional Questions

Q18: What are the biggest impediments to achieving blood pressure control in those patients who are not controlled?

Q19: Do you feel the medical assistants at MMG have the training and

experience to consistently measure blood pressure accurately?

Q21: Do you feel you have enough knowledge and training to care of the majority of your hypertensive patients?

Q24: On a day-to-day basis in the care of your hypertensive patients, for what percentage of patients do you refer to the hypertension guideline or protocol?

• Probably didn’t need to develop another guideline

• Definite gaps in knowledge

• They needed information on the most up-to-date guideline—JNC8

Conclusions and Follow Up

• Summary of Survey Findings

• Summary of JNC8

• Treatment Goals <60 years of age

• Treatment Goals >=60 years of age

• First Line Therapy for Non-African Americans

• First Line Therapy for African-Americans

• Second Line Therapies

• Third Line Therapies

E-mail to MMG PCPs—January 2015

• Contacted Lead Analyst, Kelly Miller, at IHA

– JNC8 recommendations were updated in September 2014 (150/90 target for age >= 60

• Updated our Internal Query and Goals

– Ensure this is flowing into our Point of Care Reminders

– Ensure this is reflected into our Physician Dashboard—how physicians are doing on 32 ambulatory quality metrics, including HTN

– Ensure this is flowing into our Chart Preparation sheet that highlight metrics out of range or due/overdue

Additional Follow-up

• CMO and VP, Health Policy @ Quality Measurement, Health Services Advisory Group

– “Alan, we’re thinking about putting together a survey for back office staff regarding blood pressure measurement.”

Mary Fermazin, MD, MPA

Alan’s Default Strategy:

• Broadly based on Plank 1 from Measure Up/Pressure Down

• Three medical assistant sub-groups:

– Primary care

– Medical specialties

– Surgical specialties

Back-office (Medical Assistant) Survey

• Primary care 45

• Medical specialties 32

• Surgical specialties 24

– Total 101 responses (just under 40%)

Medical Assistant Responses

1. On a regular work day in the clinic, about how many times a day do you take a patient's blood pressure?

0.0%

10.0%

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60.0%

70.0%

80.0%

90.0%

100.0%

0-1 2-5 6-10 11-15 >15 Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses were more than 15 (e.g., 15-25 or 30)

2. On what percentage of patients that you check in and room do you take their blood pressure?

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0-10% 11-25% 26-50% 51-75% 76-90% >90% Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses were all “100%”

3. When you are taking a patient's blood pressure, do you ask them about consuming caffeinated beverages or smoking prior to

taking their blood pressure?

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10.0%

20.0%

30.0%

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50.0%

60.0%

70.0%

80.0%

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100.0%

Rarely Sometimes Often Almost Always Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses primarily “never” or “when it is high”

4. When taking the patient's blood pressure, do you or the patient talk to each other?

0.0%

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70.0%

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100.0%

Rarely Sometimes Often Almost Always Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses were never or no

5. Do you round the systolic and diastolic blood pressures to the nearest 10? (e.g., round 144 to 140 or round 78 to 80)

0.0%

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40.0%

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70.0%

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Rarely Sometimes Often Almost Always Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses were never or no

• Their perception is accurate:

– The proportion of each last digit 0, 2, 4, 6, 8 is roughly 20% each by query of the systolic and diastolic fields in the EMR

Rounding

7. Where do you usually take the patient's blood pressure during the check-in process?

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In the hallway In the exam room Other

Primary Care

Med Specialties

Surg Specialties

8. How is the patient normally positioned when their blood pressure is measured?

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100.0%

Standing inHallway

Seated in Chair inHallway

Seated on theExam Table

Lying down onthe Exam Table

Seated in Chair inExam Room

Other

Primary Care

Med Specialties

Surg Specialties

9. Where are the patient's feet/legs when you normally take their blood pressure?

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Dangling Crossed legs Both feet onexam step

Legs on examtable

Both feet onthe floor

Other

Primary Care

Med Specialties

Surg Specialties

11. If you take the patient's blood pressure on their arm, what is your preference as far as the position of the patient's arm during

the blood pressure reading?

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Arm hanging Shoulder level Support arm Arm on exam table(lying)

Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses were “arm supported at heart level”

12. How long do you usually wait before the patient sits down before you take their blood pressure?

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Right away Wait 30 sec. Wait 1-2 min. Wait 3-4 min. Wait > 5 min. Other

Primary Care

Med Specialties

Surg Specialties

13. What percentage of the time does the patient roll up their sleeve to get their blood pressure measured, as opposed to having

a bare arm?

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100% 76-99% 51-75% 26-50% 0-25% Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses include “only if not in short sleeves” and “do it over the sleeve”

14. Do you use a manual (e.g., mercury manometer with stethoscope) or an automated blood pressure cuff when taking

patient's blood pressure?

0.0%

10.0%

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100.0%

Manual Automated Other

Primary Care

Med Specialties

Surg Specialties

“Other” responses “50-50” or “depends” or “both”

15. How many different blood pressure cuff sizes do you have ready access to at your site or in your hallway? Check all that apply.

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Normaladult

Large adult Thin adult Thigh Child Infant Newborn Other

Primary Care

Med Specialties

Surg Specialties

18. What percentage of your patients do you think have a blood pressure cuff at home to monitor their own blood pressure?

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100.0%

0-10% 11-25% 26-50% 51-75% 76-90% >90% Other

Primary Care

Med Specialties

Surg Specialties

• Blood pressure is checked very often by the back office staff.

• We are not doing it on 100% of patient visits (14% of the visits [e.g., derm, ophthalmology] do not have a recorded BP from a follow-up query)

• There are a number of knowledge gaps

– Asking about smoking and caffeine use

– Talking during measurement

– Rounding measurements up or down for some

– Seated in exam room with feet flat on the floor

– Arm supported

– Wait five minutes

– Rolling up sleeve (unless not constricted)

Tentative Observations

• Multiple devices to contend with

• All cuff sizes are not available in all hallways

• The stethoscopes the MAs use have no bell

• Direct observation shows that they lower the BP cuff much to quickly when using the manual devices

• Training has been a long time ago for some

Tentative Observations

• Perhaps 40-50% of patients have home BP devices

– Unclear if used regularly

– Unclear if using good technique

– Unclear if they are calibrated

Additional Observation

• Quality Improvement and Education Committee (QEIC) May 2015

– ~15 Providers from Mercy Medical Group

– ~15 Leaders from Dignity Health Medical Foundation

– Recommendation was to join Measure Up/Pressure Down and to embrace Planks 1 and 8

• Mercy Medical Group Board of Directors Approval May 2015

Discussed Findings Internally

• Joined Measure Up/Pressure Down—current control 71%

• Embraced Planks 1 and 8

– Direct Care Staff Trained in Accurate BP Measurement

– Take BP at Every Visit (all specialties)

• Commitment to move to 100% automated cuffs (Welch Allen)

We are convinced that our 71% HTN control rate will be markedly improved just by doing Planks 1 and 8 using automated devices

Next Steps

Distribute Hypertension Algorithm Pocket Card to PCPsProduced by the Capitol Region Right Care Initiative

Distribute “What to Do: Abnormal Blood Pressure Reading”to Mercy Medical Group Specialists and their MAs

https://www.youtube.com/watch?v=OIOLDkyIGRQ

Train/Retrain Medical Assistants

Thank you!