Use of home blood pressure telemonitoring in routine practice: Still many rivers to cross

The use of home blood pressure (BP) monitoring has been established for treatment, diagnosis, and monitoring of hypertension by multiple guidelines.1, 2 The addition of tele-transmission to home BP monitoring has led to a health care consumer market booming with smartphone and Bluetooth-enabled devices that are capable of transmitting BP data to web-based portals. In this context, the paper by Roula Zahr et al3 is a welcomed addition to the home BP telemonitoring (HBPTM) literature.4, 5

In this comparative effectiveness trial, the authors asked whether, among 430 patients with uncontrolled hypertension (BP > 140/90 mm Hg), a custom-built bidirectional-texting platform incorporated into patients’ electronic medical records (EMRs) would lead to greater treatment calibration and improvement in BP management than a control group, in which patients manually recorded their home BP into an Internet-based portal connected to their EMR (MyChart™) or sent the data to their physicians via phone, fax, or snail mail. Patients in both groups were instructed to return 14 BP measurements weekly (7 morning and 7 evening). The outcomes included the number of BP measurements submitted, the number of medication changes, systolic BP reduction, and BP control (extracted from chart review) at 1, 3, and 6 months. By the conclusion of the trial, both groups had significant but similar reductions in systolic BP (14 mm Hg in the intervention group vs 17 mm Hg in the comparator group) and the number of BP medication changes despite the fact that the intervention group had a greater level of compliance with the home BP schedule (72% submitted all 14 BP measurements vs 45% in the control group). These findings are actually not surprising because by now it is widely appreciated that the mere introduction of home BP monitoring into clinical practice, whether tele-transmitted or not, results in an impressive BP lowering.6, 7 Recent data from the TASMINH-4 trial conclusively support the finding that home BP monitoring alone is as efficacious as HBPTM in BP reduction.4

This study has several limitations raised by the authors themselves, but we focus on three important limitations that hinder extrapolating results to the real world. First, it is not clear that physicians in the intervention group had ready access to the generated summary report that was based on texted BP data. The challenge remains in how to accurately integrate home BP data into the EMR in a manner that is readily accessible to the patient's physician, and easily translated in order to effect treatment calibration. Second, unlike the intervention group, the fidelity of data transmission for the control group was superior. Specifically, the majority of participants (55%) in this group entered their home BP data into MyChart™, which is easily accessible to their physicians, and as such may explain the significant reduction in systolic BP noted for this group, thus minimizing the effect of tele-transmission. Finally, the BP outcome data were based on clinic BP that was available for about half of the study sample with 27%-32% loss to follow-up. This limitation reduces enthusiasm for the internal validity of the findings. Despite these limitations, the use of HBPTM has several advantages, the least of which is its potential for significant cost savings in the improvement of hypertension management with relatively cheap technology.8 Patient satisfaction stemming from reduced clinic visits, perhaps replaced by virtual e-visits, is another motivating factor in the uptake of this technology.

Regarding the integration of home BP monitoring into routine practice, we have come a very long way from demonstration of its efficacy9; proof of its effectiveness in pragmatic clinical trials,10 and up to the use of tele-transmission (aka HBPTM) as a way to address some of the obstacles in its implementation.5 Furthermore, home BP monitoring is a standard recommendation in hypertension treatment guidelines, and ubiquity of its use by patients and their providers is well established.1, 2 All that said, we still have many rivers to cross in making home BP telemonitoring a reality for the management of hypertension in primary care practices, similar to the adoption of glucometers for the management of diabetes.

The first river is assurance of patient confidentiality; the second river is the formulation of realistic reimbursement models for providers similar to that use of glucometers in the management of diabetes; and the third, and most important river to cross, is the need to relax restrictions for direct transfer of home BP telemonitoring data to physicians using valid data transfer protocols that protect patients’ health information. Currently, privacy and security concerns prohibit automatic input of data from home BP monitors directly into most EMRs via web-based interfaces. This is a major barrier preventing the full realization of the potential for HBPTM as an effective tool for the management of hypertension. In a busy practice, it is prohibitive to have to log into a separate cloud-based vault to extract home BP data. It is even more difficult to go through the current common practice of reviewing a paper log and figuring out an average BP in order to make therapeutic decisions. There are some financial incentives that may motivate the integration of HBPTM in routine clinical practice. For example, the most widely used health care performance metric recently added the use of home BP data for the assessment of BP control.11 This option is only available if home BP data are directly transmitted electronically to the provider. It is time for relevant federal agencies, such as the Center for Medicare and Medicaid Services, to provide guidance on the realization of automated transmission of home BP data directly into patients’ electronic health records. There is potential for significant cost savings in the improvement of hypertension management with relatively cheap technology. Future studies will do well to develop practice facilitation strategies to address these implementation huddles.

In conclusion, although the use of home BP monitoring and the use of HBPTM are well established and have come of age in the past 20 years, there are still many rivers to cross in the journey to implement home BP monitoring as routine practice for the treatment of hypertension. The good news in crossing these rivers and overcoming the respective implementation huddles is that we have so much to learn from the roadmap that made use of glucometers standard reimbursable practice for the management of diabetes. There is no reason to wait any longer, and as shown by findings from this study, home BP monitoring can improve patient care and treatment calibration whether or not the BP data were transmitted directly into the EMR or otherwise. It is time to embark on this journey similar to that used for the adoption of glucometers as standard treatment for diabetes worldwide.

CONFLICT OF INTEREST

Dr Stephen K. Williams has no conflicts of interest or financial ties to disclose.