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VA Electronic Health RecordClinical Improvement in
Hypertension
Ross Fletcher, MD
VHA Doctor. 1
Demo Patient 1
000-00-0001 001/01/1901 (00)
ProgressNote Text
Updatesfor PCE
1. SelectReminder
2. Select fromDialogs to Resolve
the Reminder
Reminders
How VA Care Compares: Quality Measures
Clinical Indictor VA 2010 VA 2009 Commercial 2009*
Medicare2009*
Medicaid 2009*
Breast cancer screening 88% 87% 71% 69% 52%
Cervical cancer screening 93% 92% 77% n/a 66%
Colorectal cancer screening 82% 80% 61% 55% n/aLDL-Cholesterol < 100 mg/dLafter AMI, PTCA, CABG 69% 67% 59% 56% 41%
Diabetes: DM control HbA1c <9.0% 98% 98% 89% 90% 81%
Diabetes : LDL-C < 100 mg/dL 70% 69% 47% 50% 34%
Diabetes: Eye Exams 90% 88% 57% 64% 53%
Diabetes : Renal Exam 96% 95% 83% 89% 77%
Diabetes: BP <140/90) 82% 80% 65% 61% 60%
Smoking Cessation Counseling 97% 96% 80% 78% 74%
Smoking: Medications offered 94% 90% 53% n/a 43%
Smoking: Referral / Strategies 97% 96% 50% n/a 39%
Immunizations: Influenza 81% 83% 66% n/a n/a
Immunizations: Pneumococcal 94% 95% 61% n/a n/a
* Healthcare Effectiveness Data and Information Set (HEDIS)
Hypertension Treatment
< 140, < 90 > 160, > 100
Perc
ent
Patie
nts
n = 3,173 6,535 8,360 9,403 10,748 12,626 13,198 12,781 13,653 13,485 13,256 13,636 13,618
0
10
20
30
40
50
60
70
80
90
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Washington, DC VAMC
Analysis at 4 month IntervalBal
timore
Mar
tinsb
urgW
ashin
gton
Baltim
oreM
artin
sburg
Was
hingto
n
0
20
40
60
80
100
Per
cen
t o
f P
atie
nts
September 20, 2001 January 3, 2002
0
20
40
60
80
100
High(> 160 / 100 )
Moderate(140 - 159 / 90 - 99 )
Normal(< 140 / 90 )
Hypertensive Patients Returning to < 140 / < 90
Months
0.3
0.35
0.4
0.45
0.5
0.55
0.6
Per
cen
t P
atie
nts
Jan 9
9
Jul 9
9
Jan 0
0
Jul 0
0
Jan 0
1
Jul 0
2
Jan 0
3
Jul 0
3
Jan 0
4
Jul 0
1
Jan 0
2
Anchorage, AK
Honolulu, HI
Boston, MS
Washington, DCBaltimore, MD
Miami, FL
Los Angeles, CA
Houston, TX
Fargo, ND
Chicago, IL
San Juan, PR
Philadelphia, PA New York, NY
Minneapolis, MNPortland, OR
Hypertension Study – 15 Cities
Hypertensives Returned to Normal
40
45
50
55
60
65
70
75
80
Month
Perc
ent
Nor
mal Control rate 2000-2007
3.7%, 95% CI 3.1 – 4.3P < 0.0001
Control rate 2007-20102.0%, 95% CI 1.9 – 2.2P < 0.0001
Summer – WinterSeasonal Variation6.8 %
20
00
-09
20
00
-12
20
01
-03
20
01
-06
20
01
-09
20
01
-12
20
02
-03
20
02
-06
20
02
-09
20
02
-12
20
03
-03
20
03
-06
20
03
-09
20
03
-12
20
04
-03
20
04
-06
20
04
-09
20
04
-12
20
05
-03
20
05
-06
20
05
-09
20
05
-12
20
06
-03
20
06
-06
20
06
-09
20
06
-12
20
07
-03
20
07
-06
20
07
-09
20
07
-12
20
08
-03
20
08
-06
20
08
-09
20
08
-12
20
09
-03
20
09
-06
20
09
-09
20
09
-12
20
10
-03
20
10
-06
582,881 Hypertensive Patients
Hypertensives vs. Normotensives
50
60
70
80
100
110
120
130
140
150
Bloo
d Pr
essu
re
Month
20
00
-09
20
00
-12
20
01
-03
20
01
-06
20
01
-09
20
01
-12
20
02
-03
20
02
-06
20
02
-09
20
02
-12
20
03
-03
20
03
-06
20
03
-09
20
03
-12
20
04
-03
20
04
-06
20
04
-09
20
04
-12
20
05
-03
20
05
-06
20
05
-09
20
05
-12
20
06
-03
20
06
-06
20
06
-09
20
06
-12
20
07
-03
20
07
-06
20
07
-09
20
07
-12
20
08
-03
20
08
-06
20
08
-09
20
08
-12
20
09
-03
20
09
-06
20
09
-09
20
09
-12
20
10
-03
20
10
-06
90
Systolic – Patients with Hypertension
Diastolic – Patients with Hypertension
Systolic – Patients with Normal Blood Pressure
Diastolic – Patients with Normal Blood Pressure
Percent Hypertensives Controlled by Race
Month
30
40
50
60
70
80
90
Perc
ent
Nor
mal
Black
Hispanic
Caucasian
Race not specified
20
00
-09
20
00
-12
20
01
-03
20
01
-06
20
01
-09
20
01
-12
20
02
-03
20
02
-06
20
02
-09
20
02
-12
20
03
-03
20
03
-06
20
03
-09
20
03
-12
20
04
-03
20
04
-06
20
04
-09
20
04
-12
20
05
-03
20
05
-06
20
05
-09
20
05
-12
20
06
-03
20
06
-06
20
06
-09
20
06
-12
20
07
-03
20
07
-06
20
07
-09
20
07
-12
20
08
-03
20
08
-06
20
08
-09
20
08
-12
20
09
-03
20
09
-06
20
09
-09
20
09
-12
20
10
-03
20
10
-06
40
45
50
55
60
65
70
75
80
Perc
ent N
orm
al
20
00
-09
20
00
-12
20
01
-03
20
01
-06
20
01
-09
20
01
-12
20
02
-03
20
02
-06
20
02
-09
20
02
-12
20
03
-03
20
03
-06
20
03
-09
20
03
-12
20
04
-03
20
04
-06
20
04
-09
20
04
-12
20
05
-03
20
05
-06
20
05
-09
20
05
-12
20
06
-03
20
06
-06
20
06
-09
20
06
-12
20
07
-03
20
07
-06
20
07
-09
20
07
-12
20
08
-03
20
08
-06
20
08
-09
20
08
-12
20
09
-03
20
09
-06
20
09
-09
20
09
-12
20
10
-03
20
10
-06
<55 55 < 70 70 < 80> 80
Month
Percent Hypertensives Controlled by Age
Systolic / Diastolic BP by Age Group
135
140
145
150
Sys
toli
c B
P
65
75
85
Dia
sto
lic
BP
Month
<55 55 - <70 70 - < 80 80+2
00
0-0
92
00
0-1
22
00
1-0
32
00
1-0
62
00
1-0
92
00
1-1
22
00
2-0
32
00
2-0
62
00
2-0
92
00
2-1
22
00
3-0
32
00
3-0
62
00
3-0
92
00
3-1
22
00
4-0
32
00
4-0
62
00
4-0
92
00
4-1
22
00
5-0
32
00
5-0
62
00
5-0
92
00
5-1
22
00
6-0
32
00
6-0
62
00
6-0
92
00
6-1
22
00
7-0
32
00
7-0
62
00
7-0
92
00
7-1
22
00
8-0
32
00
8-0
62
00
8-0
92
00
8-1
22
00
9-0
32
00
9-0
62
00
9-0
92
00
9-1
22
01
0-0
32
01
0-0
6
Percent Hypertensives Controlled by Gender
Month
Perc
ent
Nor
mal
40
45
50
55
60
65
70
75
80
female
male
20
00
-09
20
00
-12
20
01
-03
20
01
-06
20
01
-09
20
01
-12
20
02
-03
20
02
-06
20
02
-09
20
02
-12
20
03
-03
20
03
-06
20
03
-09
20
03
-12
20
04
-03
20
04
-06
20
04
-09
20
04
-12
20
05
-03
20
05
-06
20
05
-09
20
05
-12
20
06
-03
20
06
-06
20
06
-09
20
06
-12
20
07
-03
20
07
-06
20
07
-09
20
07
-12
20
08
-03
20
08
-06
20
08
-09
20
08
-12
20
09
-03
20
09
-06
20
09
-09
20
09
-12
20
10
-03
20
10
-06
Percent Hypertensives Controlled by Climate
Month
Perc
ent
Nor
mal
40
45
50
55
60
65
70
75
80
warm
cold
Warm = Sja, Hon, Mia, Hou
Cold = Anc, Frg, Por, Min
20
00
-09
20
00
-12
20
01
-03
20
01
-06
20
01
-09
20
01
-12
20
02
-03
20
02
-06
20
02
-09
20
02
-12
20
03
-03
20
03
-06
20
03
-09
20
03
-12
20
04
-03
20
04
-06
20
04
-09
20
04
-12
20
05
-03
20
05
-06
20
05
-09
20
05
-12
20
06
-03
20
06
-06
20
06
-09
20
06
-12
20
07
-03
20
07
-06
20
07
-09
20
07
-12
20
08
-03
20
08
-06
20
08
-09
20
08
-12
20
09
-03
20
09
-06
20
09
-09
20
09
-12
20
10
-03
20
10
-06
Seasonal Variation in Weight
15 Cities – 582,881 Hypertensive Patients
190
192
194
196
198
200
202
Wei
gh
t (l
bs.
)
92
93
94
95
96
97
98
99
100
Ave
rag
e B
P
Avg WT Avg BP
Month
Jun
-00
Dec
-00
Jun
-01
Dec
-01
Jun
-02
Dec
-02
Jun
-03
Dec
-03
Jun
-04
Dec
-04
Jun
-05
Dec
-05
Jun
-06
Dec
-06
Jun
-07
Dec
-07
Jan
-00
Hypertensive RxP
ati
en
ts R
ece
ivin
g R
x
0
10
20
30
40
50
60
70
BetaBlocker
Calcium Channel
Diuretic AceInhibitor
Central Acting
Sep-03 Sep-05 Sep-07 Sep-09
Mortality
50
55
60
65
70
75
80
85
90
95
100
0 12 24 36 48 60 72 84 96 108 120 132 144
Perc
ent
Surv
ival
Months after 3rd elevated reading
< 70 (75 – 100%)
< 70 (50 – 74%)
< 70 (25 – 49%)
< 70 (0 – 24%)
% Months Controlled
> 70 (75 – 100%)
> 70 (50 – 74%)
> 70 (25 – 49%)
> 70 (0 – 24%)
Patients < 70
Patients > 70
1. Adopt reminders with EHR
2. Assess treatment rapidly – 2 weeks
3. Use diuretic medications
4. Improve compliance – Treat all patients
5. Decrease Winter Dip
6. Improve control in Black Patients
7. Reduce obesity
Control of Hypertension
Recommended