EHRs can improve recognition, management of abnormal blood pressures in children
David C.Kaelber, M.D., Ph.D., M.P.H., FAAP and MatthewTien, M.D., FAAP
Health IT Trends
An 11-year-old boy presents to his pediatrician’s office with a blood pressure of
117/77 mmHg. Is the blood pressure normal or high? Does the child have hypertension?
More than 70% of pediatric patients with hypertension are undiagnosed and 90% of these
patients are untreated. More pediatric patients are expected to be diagnosed with
abnormal blood pressures under the 2017 Clinical Practice Guidelinefor the Screening and Management of High Blood Pressure in Children and Adolescents (http://bit.ly/2wbdQsO).
An electronic health record (EHR) can be a useful tool to identify and support care
for pediatric patients with abnormal blood pressure:
Hundreds of normal and abnormal values exist across the pediatric age spectrum. These
values can be programmed into an EHR to save pediatricians the labor of looking up
every blood pressure on reference tables to determine whether they are normal or abnormal.
Pediatric blood pressure definitions rely on more than one abnormal blood pressure
measurement at a given visit and multiple visits over time. Averaging blood pressures
in a given visit and assessing blood pressures over time (especially when the child’s
age and/or height percentile may have changed, shifting the reference cut-offs) is
easy for an EHR if programmed correctly.
A common concern about blood pressure measurements made by clinical staff is whether
the measurements were obtained using methods consistent with the pediatric hypertension
guidelines. If staff are notified immediately when an abnormal blood pressure is entered
into the EHR, they can be prompted to recheck in accordance with guidelines methodology.
Advanced clinical decision support can embed the guidelines to make them easy to follow,
suggesting appropriate actions such as when to follow up for another blood pressure
measurement, diagnostic testing and/or referral orders. A typical general pediatrician
may have only a handful of patients with abnormal blood pressures and may not be knowledgeable
about pediatric high blood pressure guidelines.
The 2017 pediatric hypertension clinical practice guideline is the first AAP guideline
to include a key action statement specifically regarding EHRs. Key action statement
number four indicates that organizations with EHRs used in an office setting should
consider flagging of abnormal blood pressure values, both when the values are being
entered and when they are being viewed.
The 2018 technical report Diagnosis, Evaluation, and Management of High Blood Pressure in Children and Adolescents (http://bit.ly/2MWPV7J) provides information and details for any EHR to implement clinical decision support
for abnormal blood pressures. Clinicians can check with their EHR vendor to see how
it has implemented hypertension-related functionalities and how to use them. Clinical
decision support is most effective when it is embedded directly in the EHR.
What about the 11-year-old boy? Because the health system implemented a suite of pediatric
blood pressure tools in its EHR, the following actions occurred:
1. The medical assistant was flagged that the first blood pressure (taken by oscillometric
measurement) was high.
2. The assistant was prompted to recheck the blood pressure and did so by auscultation.
3. When the repeat measurement by auscultation was entered, the assistant was flagged
that this was still high and knew that a second measurement by auscultation would
be needed so today’s measurements could be averaged.
4. On entering the patient’s EHR chart, the pediatrician was provided with:
a) A flag that this visit’s blood pressures were higher than normal.
b) A display of blood pressures from past visits, which made it easy to see this had
been the case multiple times before.
c) A refreshable link in the progress note showed the cutoffs for elevated BP, Stage
1 and Stage 2 hypertension, for this specific patient to help categorize today’s measurements.
5. The pediatrician received a summary of AAP guidelines with:
a) a hyperlink to the full guidelines and
b) several potential orders that could be signed to follow management recommendations
for this patient.
In this health care system, EHR alerts have increased recognition of abnormal blood
pressures by over 100%. If all pediatricians implement similar strategies through
their EHRs, many more children with abnormal blood pressure will be identified and
hopefully will be managed appropriately based on the new guidelines.
Dr. Kaelber is a member of the AAP Council on Clinical Information Technology (COCIT)
and the Child Health Informatics Center Project Advisory Committee. He is a co-author
of the 2017 clinical practice guideline and the 2018 technical report on pediatric
hypertension. Dr. Tien is a member of COCIT.