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Hypertension management in the digital era

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REVIEW

CURRENT
OPINION Hypertension management in the digital era
Richard V. Milani a,b, Robert M. Bober a,b, and Alexander R. Milani a,b

Purpose of review
Hypertension (HTN) is the most common chronic disease in the United States, and the standard model of
office-based care delivery continues to yield suboptimal outcomes, with approximately 50% of affected
patients not achieving blood pressure (BP) control. Poor population-level BP control has been primarily
attributed to therapeutic inertia and low patient engagement resulting in significant and preventable
morbidity and mortality. This review will highlight the rationale for a reengineered model of care delivery
for populations with HTN.
Recent findings
New technologies now enable patients to generate accurate home-based BP readings that are transmitted
directly into the electronic medical record. Using more frequent BP measurements in conjunction with
assessment of social health determinants, computerized algorithms can be generated that provide tailored
interventions and communications that can transform HTN control.
Summary
New capabilities enable healthcare providers the means to measure larger volumes of BP data directly
from home and provide near real-time interventions that can dramatically improve HTN control.
Keywords
chronic disease, digital, hypertension

INTRODUCTION of the population, and suggested that our health

Hypertension (HTN) remains the most common
chronic condition, affecting 30% of U.S. adults
and is the leading diagnosis made during a primary
care office visit [1]. In the United States alone, the
estimated annual cost of HTN exceeds $50 billion,
and across the globe, HTN is responsible for approxi-
mately 10% of healthcare spending [2,3]. Roughly
half of individuals with HTN have not achieved
guideline-recommended blood pressure (BP) targets;
as a result, HTN remains one of the nation’s leading
causes of death, responsible for one in six deaths
among adults annually. In fact, since the year 2000,
HTN-related deaths in the United States have risen
by 23%, whereas all other causes of death combined
have fallen by 21% [4]. In addition to its impact on
mortality, uncontrolled HTN increases rates of non-
fatal myocardial infarction and stroke, and remains
the second leading cause of renal failure. Therefore,
achieving BP control remains a primary objective of
public health policy and healthcare financing
organizations across the globe, yet interventions
have been limited to minor adjustments in the
current model of office-based care delivery [5,6].
In 2001, the National Academy of Medicine
concluded that our office-based model of care deliv-
ery is inadequate to meet the chronic disease needs
delivery system must be reengineered to better adapt
to the real needs of the 21st century [7]. This review
will highlight specific issues in our current delivery
model, and will introduce a new model of care
delivery for patients with HTN encompassing
digital medicine.
Failure of office-based care delivery
Physician adherence to the current evidence base in
the management of chronic disease including HTN
is poor, and patients diagnosed with chronic dis-
eases such as HTN typically receive only half of the
recommended process of care [8–13]. In the case of
a
Department of Cardiovascular Diseases, John Ochsner Heart and
Vascular Institute, Ochsner Clinical School – University of Queensland
School of Medicine, Brisbane, Queensland, Australia and bCenter for
Healthcare Innovation, Ochsner Health System, New Orleans, Louisiana,
USA
Correspondence to Richard V. Milani, MD, Center for Healthcare Inno-
vation, Ochsner Health System 1514 Jefferson Highway, New Orleans,
LA 70121, USA. Tel: +1 504 842 5874; fax: +1 504 842 5875;
e-mail: rmilani@ochsner.org
Curr Opin Cardiol 2017, 32:373–380
DOI:10.1097/HCO.0000000000000405

0268-4705 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-cardiology.com
Hypertension
KEY POINTS
 Regular BP measurements collected from home that are
directly transmitted to the electronic medical record is
now feasible.
 Presenting this information to an IPU dedicated to HTN
management along with key social determinants leads
to marked improvement in HTN control compared with
traditional office-based care.
 Management of chronic diseases such as HTN requires
reengineering of our healthcare delivery system to meet
the real-time needs of the population.
the two most common chronic diseases, fewer than
one in three patients with HTN and hypercholester-
olemia attain control of both disorders, which has
led to higher clinical events and added healthcare
costs [9,14,15]. The causes of these care deficiencies
are multifactorial, but are primarily because of four
factors impacting quality healthcare delivery for
patients with chronic conditions: physician time
demands, rapidly expanding medical database,
therapeutic inertia and lack of supporting infrastruc-
ture.
The majority of care for the HTN patient typi-
cally rests on the shoulders of the primary care
physician, whose time for face-to-face patient care
has become progressively constrained; it is esti-
mated that direct patient care accounts for only
55% of the average workday [16,17]. Studies evalu-
ating the time necessary to achieve the recommen-
dations of national practice guidelines for just 10
chronic diseases estimate that this alone would
require 10.6 h a day, more time than primary care
physicians have available for patient care overall
[18].
Second, the rapidly evolving medical database
has grown exponentially in the last 4 decades. In the
mid-1960s, there were approximately 100,000 peer-
reviewed articles published in the medical literature
per year. By 2012, there were 28,100 active scholarly
peer-reviewed journals collectively publishing
about 1.8–1.9 million articles a year [19–21]. Fur-
ther, confounding the widening breadth of medical
information is that a significant percentage of pub-
lished studies contradict current medical practice, or
what has been labeled a medical reversal [22–25].
The ability therefore to keep up with the current and
accepted evidence base across the broad range of
medical conditions comprising chronic disease is
clearly a major challenge for any busy practicing
clinican [26].
When comparing patients with controlled ver-
sus uncontrolled HTN, routine characteristics such
374 www.co-cardiology.com
as age, sex, health insurance and visit frequency are
remarkably similar. In National Health and Nutri-
tion Examination Survey III, 92% of patients with
uncontrolled HTN possessed health insurance, and
86% reported a regular source of healthcare [27].
Moreover, patients with uncontrolled HTN saw
their physician an average of 4.3 times per year, a
frequency similar to that of patients with controlled
HTN. Most importantly however, is that in only 22–
38% of these visits was pharmacologic therapy
either started or intensified. The failure to augment
therapy in order to achieve disease-specific treat-
ment goals has been coined ‘therapeutic inertia’,
and has been reported to be as high as 87% of
provider interactions in patients with uncontrolled
HTN. The reasons underlying therapeutic inertia are
multiple, but can be categorized into three domains
of responsibility: the clinician, the patient and the
&
healthcare system [28 ,29] (Table 1).
The fourth factor impacting care delivery is the
lack of adequate infrastructure supporting the
patient and physician. Multiple studies covering a
variety of medical conditions consistently show that
providing the physician with a team-based infra-
structure of specialized, nonphysician caregivers
improves adherence to quality measures and yields
superior outcomes, cost and patient satisfaction
[30]. Moreover, nonphysician caregivers following
evidence-based guidelines are less likely to be
impeded by therapeutic inertia [1,17,31]. Manage-
ment of warfarin is an excellent case in point. When
compared with physician-management, pharma-
cist-directed care results in the highest attainment
of quality indicators and patient satisfaction while
yielding the lowest adverse clinical events and cost
[32,33]. In addition, an information technology
infrastructure that supports patient-generated
health data including analysis and data visualiza-
tion tools will be essential to effectively manage
populations of HTN patients in real time.
Office-based care delivery, therefore, can be
reengineered through the use of guideline-based
protocols executed by nonphysician providers
working in a ‘focused-factory’ model of disease man-
&
agement [28 ]. This care model utilizes specialized
integrated practice units (IPU), which has now been
demonstrated to be highly effective in HTN manage-
&
ment [34 ].
An IPU utilizes nonphysician personnel dedi-
cated to a specific disease condition for the full cycle
of care [35,36]. Members of the care team may
include pharmacists, advanced practice clinicians,
nurses, health educators, dieticians, social workers,
counselors and therapists, all organized around the
patient’s medical condition. In this model, patients
can be more frequently and effectively connected to
Volume 32  Number 4  July 2017
 Hypertension management in the digital era Milani et al.

Table 1. Factors leading to therapeutic inertia and methods to enhance therapeutic activation

Therapeutic inertia Therapeutic activation

Clinician
Failure to initiate treatment Guideline-based therapy using nonphysician providers
Failure to titrate to goal Guideline-based therapy using nonphysician providers
Failure to set clear goals Cocreation of treatment plan with patient
Underestimation of patient need Needs assessment upon enrolment
Failure to identify and manage comorbidities Screen for related comorbidities
Insufficient time IPU-model of care delivery
Insufficient focus on goal attainment IPU-model of care delivery
Reactive rather than proactive Weekly patient-generated health data
Patient
Medication side-effects Screening and close follow-up by care team
Too many medications Medication simplification by clinical pharmacist
Cost of medications Screening for medication affordability, use of generic
alternatives and patient-assistance programmes
Denial of disease Disease-focused education and patient engagement
Denial of disease severity Disease-focused education and patient engagement
Forgetfulness Medication reminders (apps, pill boxes and so on)
Perception of low susceptibility Develop concept of total CV risk
Absence of disease symptoms Develop concept of total CV risk and patient education
Poor communication with MD Monthly reports to patient and routine calls
Mistrust of clinician Work toward building trust and regular communication
Depression, mental illness and substance abuse Screening for depression and substance abuse
Low health literacy Screening for health literacy; the use of modified
education and Rx. labeling
Health system
Lack of clinical guideline The use of current evidence-based guidelines
Lack of care coordination IPU creates single point of contact
No visit planning Calls and outreach built into EMR
Lack of decision support CDS tools guide which patients need what help and when
Poor communication between MD and staff Monthly reports to patients and providers, and routine calls
No disease registry Registry created in EMR
No active outreach IPU creates active outreach to patient’s home

CDS, clinical decision support; CV, cardiovascular; EMR, electronic medical record; IPU, integrated practice unit.
Reproduced with permission from [29].

the health delivery system utilizing apps as well as
home-based and wearable devices, and communi-
cation can be consistent and at regular intervals
&
between the care team and the patient [28 ].
Patients can achieve a higher level of engagement
in the care process via enhanced education, real-
time feedback via wearable and home-based devices
and enriched communication with both the care
team and other patients via social networks, thus
achieving high satisfaction and improved out-
comes within the healthcare system (Fig. 1) [37].
Finally, the IPU can assess and address many of the
social determinants that directly impact successful
HTN control.
Social determinants in hypertension
management
Managing patients with HTN requires more than
identifying the correct treatment plan. It necessi-
tates understanding the various components that
determine health status (Fig. 2) [37] and what
measures are needed to positively influence them
[38,39]. These typically include social determinants
that are not routinely assessed, as they often lie
outside the domain of the traditional physician–
&
patient interaction [29,40,41,42 ] (Table 2).
To examine the impact of these social determi-
nants in HTN management, we created a ‘health
capability’ score encompassing several components

0268-4705 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-cardiology.com 375
Hypertension

Better or worse?
Analytics Need intervention?
Self monitoring and
Engine Need encouragement? Tools
Need advice? Integrated
home monitoring tailored
Frequent Data Practice for each
Points Unit patient

“Continuous measurement”
Specialized IPU
Reports
Patient activated

Exercise Rx Diet Planning Medication

Patient with
Adjustment
Chronic Disease(s)
PCP in Data Treatment initiated
Network and referral to IPU

Education Health Apps Social Development

Regular feedback; reinforcement; appropriate level intervention Network

Social Strengthen
Social Support Active
Network Educate

FIGURE 1. The use of patient-generated health data in conjunction with an integrated practice unit in the management of
hypertension. Reproduced with permission from [37].

of social determination: social isolation, capabilities individual’s unique circumstance. For instance, edu-
to process and understand health information cation programmes and even prescription labeling
(health literacy), engagement in their disease proc- can be adjusted based on health literacy, and focused
ess (patient activation) and economic barriers interventions toward increasing patient activation
impacting treatment plans (medication affordabil-
ity), and demonstrated its relevance in HTN control.
One point was assigned to any deficiency in each Table 2. Screening attributes necessary to phenotype the
component with a higher score indicating declining patient with hypertension
&
health capability (Table 3) [34 ]. Relative to a health Dietary sodium consumption
capability score of zero, the odds ratio of achieving Medication adherence
BP control with an health capability score of 1 was Social circumstances (number in household, support system, meal
0.58 [confidence interval (CI) 0.26–1.3; P ¼ 0.20] preparation and so on)
and 0.17 (CI 0.06–0.50; P ¼ 0.001) when the health Medication affordability
capability score was at least 2, thus illuminating Depression
the importance of these characteristics in HTN con- Alcohol consumption
trol. Patient engagement/activation
Collection of social determinants is therefore an Physical activity index
important component of HTN management, and
Health literacy
based on these factors, the health delivery team
Sleep apnea screening survey
can create a distinct patient phenotype where
Laboratory assessment (glomerular filtration rate, CO2, sodium and
therapy and interventions are tailored to the
thyroid function)
Comorbid conditions (i.e. diabetes)

5% Cardiovascular risk factors (i.e. smoking, dyslipidemia and so on)

10%
Reproduced with permission from [29].
Healthcare
30% Behavioral paerns Table 3. Social determinants and blood pressure control:
Social circumstances
health capability score and 90-day blood pressure control
Genec predisposion
40% Health capability score 0 1 2þ
Environmental exposure

BP controlled 79% (76) 67% (28)a 39% (7)b

15%
BP uncontrolled 21% (20) 33% (14) 61% (11)

a
OR ¼ 0.58 (CI 0.26–1.3; P ¼ 0.20)
FIGURE 2. Determinants of health and their contribution to b
OR ¼ 0.17 (CI 0.06–0.50; P ¼ 0.001)
premature death. Reproduced with permission from [37]. &
Reproduced with permission from [34 ].

376 www.co-cardiology.com Volume 32  Number 4  July 2017

 Hypertension management in the digital era Milani et al.

can be promoted in patients with reduced medi-
cation adherence. Altering medications to generics
and/or enrolling patients in patient-assistance
programmes can help those with difficulties in pay-
ing for medicine, and inclusion of food preparers in
dietary sodium education can significantly influence
overall sodium consumption. All these efforts can
dramatically assist in achieving BP control, and can
be best achieved using an IPU model where compre-
hensive assessment and focused care delivery impact-
ing lifestyle and pharmacologic management are
available without the constraints of a 15-min
office visit.
Need for real-time management of
hypertension
Home BP collection has been endorsed by many
HTN guidelines, and addresses several limitations
of traditional office-based care, including a larger
sample of biologic data, reducing misclassification
because of white-coat or masked HTN and an ability
to take more timely action and course correct
therapy [43–46]. Home measurements better pre-
dict cardiovascular risk than do office measure-
ments, are more reproducible and show better
correlation with measures of target organ damage
[43]. Current consumer technology is accurate,

FIGURE 3. Monthly patient report in a hypertension digital medicine programme. Reproduced with permission from [29].

0268-4705 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-cardiology.com 377
Hypertension

reliable, easy to use and relatively inexpensive.
Moreover, home BP readings now have the capa-
bility of directly populating the patient’s electronic
medical record, and no longer necessitate each
patient generating a handwritten diary of readings
to bring to their provider.
Timely communication and feedback can play a
large role in efforts toward achieving HTN control.
Communication can include regular progress reports
focusing on achieving BP goals as well as tips promot-
ing and/or reinforcing lifestyle change (Fig. 3) [29].
Communicating test results is also highly desired
among patients with HTN and is typically mediated
via a password-protected patient portal [47]. Life-
style-focused texts offering advice, motivational
reminders and support have also been shown to be
effective in improving HTN and other chronic dis-
eases [48].
Up to 40% of patients with chronic conditions
desire medication reminders, and today, these
can be easily employed using many user-friendly
free apps available on smartphones and smart-
watches (i.e. Apple Watch) [49,37]. Many of these
apps are interactive, providing a means for pro-
viders to monitor medication adherence and
refill needs.
Large volumes of patient generated health data
including home BP readings can be loaded into
computer algorithms within the electronic medical
record that can highlight which patients need
what type of support and when. This can include
advice, encouragement, lifestyle tips or medication
adjustment; all delivered via the IPU in near real
time. Providing this comprehensive approach to
population HTN management has now been dem-
onstrated to be more effective than routine office-
&
based management [34 ].
Hypertension digital medicine programme
efficacy
In a study comparing patients with uncontrolled
HTN, more patients achieved BP control within 90
days using a digital-IPU model as described, com-
&
pared to those managed conventionally [34 ]. Table
4 describes the changes in BP metrics and other
health metrics at 90 days in the digital-IPU model
and usual care groups. BP, including systolic, dias-
tolic, mean arterial pressure and pulse pressure,
improved significantly in both groups (P < 0.001)
&
[34 ]. However, at 90 days, 71% of patients in the
digital-IPU group achieved BP control compared
with 31% of usual care patients (P < 0.001). Over
the 90-day period, the usual care group had an
average of 3  0.2 BP recordings in the electronic
medical record compared with 161  150 recordings
(averaging 4.2/week) in the digital-IPU group
(P < 0.001), who submitted BP data directly from
home to the electronic medical record.
Patients received monthly reports, text
reminders and frequent interactions with the IPU
care team, made up of clinical pharmacists and health
coaches. Patient activation improved overall, as
reflected by a 60% reduction in the percentage of
patients with low patient activation. It is noteworthy
that the mean age of the digital medicine cohort was
68 years, suggesting that the use of technology from
home was not a deterrent for an elderly population.

Table 4. Efficacy of digital medicine in managing hypertension

Baseline 90 days P

(a) Changes in blood pressure and health metrics in the digital medicine/IPU model group at 90 days (n¼156)
Systolic blood pressure (mmHg) 147  19 133  12 <0.001
Diastolic blood pressure (mmHg) 81  12 76  9 <0.001
Mean arterial pressure (mmHg) 103  12 95  9 <0.001
Pulse pressure (mmHg) 66  16 57  11 <0.001
High dietary sodium intake (%) 32% 8% 0.004
Patient activation score 41.9  6.6 44.1  6.7 0.008
Low patient activation (%) 15% 6% 0.03

(b) Changes in BP metrics in the office-based usual care group at 90 days (n ¼ 400)
Systolic blood pressure (mmHg) 147  5 143  14 <0.001
Diastolic blood pressure (mmHg) 81  8 79  9 <0.001
Mean arterial pressure (mmHg) 103  6 100  7 <0.001
Pulse pressure (mmHg) 65  9 63  9 <0.001

&
Reproduced with permission from [34 ].

378 www.co-cardiology.com Volume 32  Number 4  July 2017


The differences highlighted between office-based
care dispersed several times per year and a more
continual care model are not trivial, and were accom-
panied by improved quality and engagement. In
addition, this model of precision-based, highly inter-
active care is cost-effective and is applicable across
broad populations regardless of geographic distri-
bution. We now have well over 1000 patients receiv-
ing care in our digital medicine programme, with
control rates that continue to improve with time.
CONCLUSION
HTN management using an office-based model of
care delivery has demonstrated suboptimal results
in population-level BP control, patient engagement
and HTN-related clinical outcomes. New models of
care delivery, incorporating patient-generated
health data, high levels of patient connectivity
and communication, tailored interventions incor-
porating individual social determinants, all admin-
istered through an IPU model, have been
demonstrated to yield superior BP control, while
at the same time achieving higher levels of patient
engagement. A digital health programme in the
clinical care setting can be an effective mechanism
of delivering HTN management, outperforming
traditional office-based care, and is well accepted
by patients with the additional value of improving
patient engagement. Social determinants, such as
health literacy, patient activation, social isolation
and medication affordability, play a significant role
in disease control and should be integrated in HTN
management strategies.
Acknowledgements
We would like to thank the pharmacists and health
coaches of the Digital Hypertension Programme for their
tireless work.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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pdf Last assessed 31 August 2016.
Volume 32  Number 4  July 2017