Open AccessLeveraging the Electronic Health Records for Population Health: A Case Study of Patients With Markedly Elevated Blood Pressure
Author(s) -
Lu Yuan,
Huang Chenxi,
Mahajan Shiwani,
Schulz Wade L.,
Nasir Khurram,
Spatz Erica S.,
Krumholz Harlan M.
Publication year - 2020
Publication title -
journal of the american heart association
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.494
H-Index - 85
ISSN - 2047-9980
DOI - 10.1161/jaha.119.015033
Subject(s) - medicine , blood pressure , population , electronic health record , medical record , electronic medical record , health records , health care , emergency medicine , environmental health , economics , economic growth
Background The digital transformation of medical data provides opportunities to perform digital population health surveillance and identify people inadequately managed in usual care. We leveraged the electronic health records of a large health system to identify patients with markedly elevated blood pressure and characterize their follow‐up care pattern. Methods and Results We included 373 861 patients aged 18 to 85 years, who had at least 1 outpatient encounter in the Yale New Haven Health System between January 2013 and December 2017. We described the prevalence and follow‐up pattern of patients with at least 1 systolic blood pressure ( SBP ) ≥160 mm Hg or diastolic blood pressure ( DBP ) ≥100 mm Hg and patients with at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Of 373 861 patients included, 56 909 (15.2%) had at least 1 SBP ≥160 mm Hg or DBP ≥100 mm Hg, and 10 476 (2.8%) had at least 1 SBP ≥180 mm Hg or DBP ≥120 mm Hg. Among patients with SBP ≥160 mm Hg or DBP ≥100 mm Hg, only 28.3% had a follow visit within 1 month (time window of follow‐up recommended by the guideline) and 19.9% subsequently achieved control targets ( SBP <130 mm Hg and DBP <80 mm Hg) within 6 months. Follow‐up rate at 1 month and control rate at 6 months for patients with SBP ≥180 mm Hg or DBP ≥120 mm Hg was 31.9% and 17.2%. Conclusions Digital population health surveillance with an electronic health record identified a large number of patients with markedly elevated blood pressure and inadequate follow‐up. Many of these patients subsequently failed to achieve control targets.