UCSF HIPSTER: Hypertension - Innovating Personalized STrategies for Excellent Results

In-person management of HTN poses a challenge for patients, physicians, the health system, and payers. It causes patients to incur the expense of missed work, parking and inconvenience and poses a barrier to care for a mostly asymptomatic condition.  For physicians, HTN management is often done on My Chart or by phone, as most of our providers do not have timely follow-up appointment access.  For our health system, visits for HTN reduce access for other types of patients who need evaluation and advanced testing.  Kaiser’s lauded HTN management service achieves excellent results, but employs expensive human capital (pharmacists, nurses repeatedly engaging with patients) almost exclusively to achieve their outcomes.  And for payers, office visits for HTN management is costly.  In terms of health care value, time to control and percent of patients controlled remains a challenge.  The new SPRINT trial, which will likely be incorporated into guidelines soon, will also raise the need for aggressive BP management with even greater precision, so as to avoid the complications of hypotension. 

To address these issues, it would make sense to leverage technology.  While apps and consumer medical devices can theoretically make personalized management more realizable, patient motivation to participate in self-care may be less for HTN than for more symptomatic conditions.  There is also a disconnect between smartphone app technology that can capture data and symptoms, the devices that record home BP, processes that would allow patients to communicate this information directly with their physician, and the workflow and incentives that would enable the physician’s office to act on this information.  This exposes a chasm and an opportunity in the current technology landscape to design holistic, patient-centered and physician-centered technology that makes the data actionable, personalized, and appropriate for current clinical workflows. 

We would like to design and pilot a portfolio of remote management programs that meet the needs of our various patients.  One example actively being designed by us will use an app and home blood pressure cuffs with an intelligent platform that engages patients ONLY when necessary, informs the care team ONLY when necessary, SIMPLIFIES communication using our own EMR, and enables SWIFT intervention by a care team. Rather than using technology extant, we are flipping the model and designing a product and workflow to fit UCSF health system and UCSF patient needs.  To do this, we have partnered with Vital Labs, Inc. and the UCSF School of Pharmacy to design a product for our needs.  Our goal is to continuously improve the technology based on our patients’ use patterns, user experience and feedback.  Technology often fails because it uses a heavy-handed approach, inundating patients with messages, texts, and tasks that are burdensome and not acted upon.  Our goal will be to continuously study the best possible prescription for BP measurement to result in the best outcome (BP at goal with minimal side effects using the most convenient medical regimen) without asking any more of our patients than we need. This rigorous evaluation can help us design an IT platform that overcomes, and doesn't create, healthcare disparities. Very preliminary assessment of an early version of the app in our clinic has shown that a diverse section of our population has been interested in adopting this type of management, including underserved populations.  Learning from this pilot, we will develop a HTN management menu to meet the myriad needs and abilities for our patients.  This may include traditional in-person visits, telephone e-visits, MyChart based communication, simple text messaging communication, and apps.  The aim is to devise HTN platforms that will enable us to prescribe technology judiciously, in just the right dose, individualized for each patient, and enabling physicians and clinics to operate with the utmost efficiency to achieve the best results.  We are collaborating with and learning from many divisions and units, including Primary Care, Nephrology, and Population Health, the CPI hub, and the CDHI, are very interested to hear from our colleagues' experiences at the VA and SFGH, and actively seek input from all corners.  We hope that our efforts will be generalizable to the broader UCSF patient community.