Implementing a "Hiding in Plain Sight" Protocol

Steps:

• Generate a patient list from your EHR

• Using existing EHR reporting options, run a report of your “total patient population”, flagging patients with 2 or more elevated blood pressure readings over the prior 3 years and no diagnosis of hypertension. Consider implementing these steps:

  • Open the reporting module or dashboard within your EHR system where custom reports can be created. Select patient population criteria and choose the conditions for your report (e.g., primary care visit in the last three years and two or more elevated blood pressure readings). These criteria will identify the target population.
  • Specify the time range for the report. Set it to capture patients who had a primary care visit within the last three years.
  • Determine the specific data elements you want to include in the report, including patient demographics, visit details, diagnoses, and blood pressure readings.
  • Define the threshold for elevated blood pressure readings in your report. This will establish that patients with two or more high blood pressure readings are included in the criteria you selected. (e.g., Systolic blood pressure >140, Diastolic blood pressure >90)
  • Run the report based on the defined criteria and data elements. The EHR will analyze existing patient data and generate the report according to your specifications.
  • Once generated, filter out patients with an existing hypertension diagnosis.
  • With these steps complete, you will have a list of active patients with existing EHR data that suggests possible hypertension but no such diagnosis.

  

  Links:

  Undiagnosed Hypertension Partner Toolkit

  Patients with Undiagnosed Hypertension (Hiding in Plain Sight)

• Use the report from your EHR to contact patients who need to be evaluated for potential hypertension. The following steps can be taken:
• • Examining the list, determine which patients need further evaluation under the lens of potential hypertension and invite them to schedule a health maintenance visit if one is not already scheduled. During the health maintenance visit to the clinic, using clinical protocols, mentioned below, evaluate whether the patient should have a diagnosis of hypertension.
  • Begin by reviewing the patient’s medical history, including previous blood pressure measurements, reported symptoms, and risk factors for hypertension (e.g., family history, lifestyle, and comorbidities).
  • Apply the Hypertension Screening Algorithm:
    • All patients whose 3 most recent encounters yield a mean SBP > 140 or a mean DBP > 90
    • All patients who had 3 encounters with a SBP > 140 or a DBP > 90 within the 12 months prior to their most recent encounter.
    • Patients who had a single encounter with SBP > 180 or a DBP > 100 within the 12 months prior to their most recent encounter.
  • Depending on the patient’s clinical presentation and risk factors, additional diagnostic tests may be warranted to confirm the diagnosis and assess the extent of hypertension. These tests may include blood tests, cholesterol levels, electrocardiograms, or other imaging studies.
  • Review the patient’s screening results to ensure they meet the criteria for a positive hypertension screening.

  

  Links:

  Improving Identification and Diagnosis of Hypertensive Patients Hiding in Plain Sight (HIPS)

• If a patient is “Hiding in Plain Sight” and screens positive for hypertension, it means they have been unknowingly living with high blood pressure.

• If hypertension is strongly suspected but further confirmation is required, it is advisable to follow up relatively soon to obtain another blood pressure reading. The recommended timeframe for a follow up reading may vary depending on the specific clinical situation, the severity of suspected hypertension, and the presence of any associated risk factors or symptoms. A general guideline, a follow up blood pressure measurement within a few weeks is appropriate. It is important to note that a diagnosis of Hypertension is not typically based on a single blood pressure reading but rather multiple measurements taken on different occasions. This approach helps to account for potential fluctuations in blood pressure throughout the day and minimizes the influence of transient factors. Ensure the patient’s blood pressure readings always meet the diagnostic criteria for hypertension. This involves multiple elevated readings on separate occasions. These steps can be taken to address their condition:

  • Call the patient back into the medical office to check their blood pressure.
  • Clearly explain to the patient they have been diagnosed with hypertension, emphasizing the significance of early detection and the importance of managing blood pressure for their overall health.
  • Educate the patient about hypertension, its risk factors, potential complications, and the importance of blood pressure control. Explain the importance of lifestyle modifications and, if necessary, how medications can help manage the condition effectively.
  • Conduct a thorough assessment of the patient’s current lifestyle habits, including diet, physical activity, alcohol consumption, smoking, and stress levels. Identify areas for improvement and provide personalized recommendations for positive changes.
  • Instruct the patient to monitor their blood pressure regularly at home using a reliable blood pressure monitor. This is called Self-Measured Blood Pressure or SMBP. Provide education/instructions on proper self-measurement techniques (e.g., correct posture and cuff placement). Teach them how to properly measure blood pressure, keep a record of their readings, and instruct them to bring them to their next visit.
  • If feasible, provide the patient with a reliable home blood pressure monitor or assist the patient with where to obtain a blood pressure monitor. Ensure the monitor is validated and acceptable for accurate measurements.
  • Determine the duration and frequency of SMBP monitoring. Advise the patient to measure their blood pressure at specific times of the day (per office protocol) for a defined period (e.g., several days or several weeks).
  • Ask the patient to submit their SMBP readings to the clinic. Have the patient include the date, time, and blood pressure reading. Indicate the importance of consistency and adherence to the monitoring schedule.
  • Assess the need for pharmacological intervention based on the patient’s blood pressure readings, overall risk profile, and response to lifestyle modifications. If necessary, prescribe appropriate antihypertensive medications, taking into consideration any comorbidities or contraindications.
  • Schedule regular follow-up visits to monitor the patient’s blood pressure, evaluate the effectiveness of lifestyle modifications and medications, and make any necessary adjustments. Ensure the patient adheres to the recommended treatment plan and address any concerns or questions the patient may have.
  • Provide ongoing support to the patient, addressing any barriers or challenges they may face in managing their hypertension. Offer resources, educational materials, and referrals to dieticians or support groups to aid in their journey toward blood pressure control.

  

• If, after further evaluation, hypertension is not confirmed, these steps should be considered
• • Conduct multiple blood pressure measurements with a lower detection threshold (based on those enumerated in ACC/AHA guidelines) which refers to the level at which hypertension is considered to be detectable or clinically significant. It indicates the point at which medical professionals should initiate diagnostic testing or interventions for hypertension on separate occasions to rule out any isolated or temporary spikes in blood pressure. Explore alternative explanations for the initial positive screening. Consider conditions that can lead to elevated blood pressure readings, such as white coat hypertension (elevated blood pressure in a clinical setting), anxiety, pain, caffeine intake, or certain medications.
  • If hypertension is ruled out, establish a suitable follow-up plan to monitor the patient’s blood pressure periodically and assess their overall health. Determine the appropriate frequency of follow-up visits (repeat Self-Measured Blood Pressure (SMBP)/Automated Office Blood Pressure (AOBP) in 3-6 months) based on the patient's specific circumstances and risk factors.
  • Even if hypertension is not confirmed, it is important to encourage the patient to maintain a healthy lifestyle. Emphasize the benefits of regular physical activity, a balanced diet, weight management, stress reduction, and smoking cessation (if applicable) to promote overall well-being and cardiovascular health. Use this opportunity to address any other health concerns identified during the evaluation, and provide guidance, educational resources, and interventions as needed.

  

  Links:

  Million Hearts Hiding in Plain Sight Partner Toolkit