Welcome to the Heart 360 Innovation Video Series prepared by the
Agency for Healthcare Research and Quality Health Care Innovations Exchange.
These videos are part of Million Hearts, a Department of Health and Human Services
national initiative aimed at preventing 1 million heart attacks and strokes
over the next five years.
This is one of two videos that focus on the Heart360 innovation,
a program involving home blood pressure monitoring,
that uses the Heart 360 online reporting system developed by the
American Heart Association.
Dr. David Magid developed and implemented the Heart 360 innovation
in Kaiser Permanente Colorado.
Dr. Magid is the Director of Research for the Colorado Permanente Medical Group
and an Associate Professor of Emergency Medicine and Preventative Medicine
at the University of Colorado Health Sciences Center.
The Heart 360 Innovation was one of several programs featured in a
Million Hearts event in April 2012.
The Million Hearts initiative invited prominent health care thought leaders
and stakeholders to Washington DC, to inspire creative thinking about scaling and spreading
cardiovascular prevention activities throughout the United States.
Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality
and Dr. Thomas Frieden, Director of the Centers for Disease Control and Prevention,
inspired and motivated attendees to achieve the Million Hearts goal.
Throughout the day the attendees shared real-world success stories
about service delivery innovations shown to improve blood pressure and cholesterol control.
Attendees also brainstormed ideas to scale and spread these and other
innovative approaches to better heart health.
At the meeting, Dr. Magid provided an overview of the Heart 360 program,
addressed issues central to scaling, including implementation challenges,
and then forecasted the return on investment.
A reactor panel of experts representing different stakeholder perspectives
then commented on the feasibility of the program spread.
This Reactor Panel included: Nancy Artinian,
Associate Dean for Research and Director of the Center for Health Research at Wayne State University,
speaking from the perspective of a Cardiovascular Disease Provider and Specialist.
MaryAnne Elma, Director of Quality Innovation and Implementation at the
American College of Cardiology, commenting from the perspective of a spread agent.
Veronica Goff, the Vice President at the National Business Group on Health,
commenting from the perspective of a health care purchaser.
Bruce Siegel, President and Chief Executive Officer of the National Association of Public Hospitals
and Health Systems, speaking from the perspective of a purchaser and potential adopting organization.
And Lisa Simpson, the President and Chief Executive Officer of Academy Health,
reacting from a policy perspective.
Let's begin with a brief overview of this presentation.
The Heart360 program offers medication therapy management to patients
who record their home blood pressure measurements,
3 to 4 times each week in the American Heart Association's Heart360 system.
Pharmacists monitor and review these measurements,
modify medication therapy, and consult with the patient on lifestyle changes as needed.
The Heart360 program improved blood pressure control for Heart360 participants.
Participants were more satisfied with their care when compared to patients
not in the program.
The program has the potential to save millions of dollars each year.
A 10-year forecast demonstrates a savings of 20 million dollars annually.
Let's take a look as our innovator and experts talk about scaling and spreading the
Heart360 innovation.
Part one of this video series focuses on the core elements of the
innovation, evidence for the innovation's effectiveness,
its potential for adaptation to other settings,
and facilitators and barriers that must be considered when spreading this innovation.
We were led to think about what are the really essential elements of this.
I think when you think about spreading something an intervention
in a complex system, if you can break it down into what's called
simple rules or minimum specifications,
what are the four or five or three or six basic principles that if you
put these principles in place, it works.
Local modifications to fit those principles are then okay.
And so I really believe when you're asking me about the
components that are important, it is marrying the home blood pressure
with the system to get their blood pressure readings to someone who can
look and act on it and make sure that the blood pressure readings are
stored in that cuff and all transmitted to you so that you don't have selective readings.
We know that if you just give people a blood pressure cuff that that will
not lead to either any or much improvement in care,
so we know that and also we know that you need to figure out a system
whereby that can be done easily with the patient.
Certainly we know that the weight of the evidence is an important tool
and adopter, and positive outcomes certainly lead the way for spread.
We have no knowledge about the duration of effects of the intervention beyond six months.
And more importantly, I wondered if there's other evidence that you
might have in terms of other outcomes,
are there important modifiers to the effects of this intervention,
does this intervention differ by race, sex, gender, socioeconomic status?
Also might there be other outcomes to take a look at like decreased
number of healthcare visits or increased medication adherence,
so can you talk a little bit more about the evidence. So I think in terms of the weight
of the evidence, this is not the only study that's been done in home blood pressure monitoring.
The first thing we know is that if you just give someone a home blood pressure cuff,
and see what happens, we know that the effect of that is either negative or very small,
so we know multiple studies that have done that.
Our studies falls into a second group of studies where patients were
given a home blood pressure cuff but it was part of a more coordinated
system where there was kind of a provider who reviewed those,
and there have been multiple studies like that and almost everyone of
them are positive and positive to the same degree,
so I think the weight of evidence of the benefits of blood pressure,
of home blood pressure monitoring where it's with support of a provider
are strongly positive and very clear, so I think we could put that aside,
the weight of the evidence is plenty good.
Most of those studies though are of short duration,
ours was six months, the longest ones are really about most of them
are 12 months, I think they may be one that's at two years.
But we certainly don't have any studies that go out to like five or ten years
or something like that, and I'm not sure we ever will.
So that was the first question.
I think the second question within our study and in most studies the results
have been positive within subgroups. I think in terms of the sort of mediators of the effect,
the mediators appear to be two-fold, one is treatment intensification so
recognition that people have elevated blood pressure and taking
actions on behalf increasing medications or diet and exercise and
the other effect is through improved adherence to therapy,
so both of those, both in our study and other studies have been shown to be important mediators.
Most of the studies are good as the AHRQ review says,
but it hasn't gone from studies context to sort of large spread of creating an
evidence-base on multiple settings and whether it's pharmacist led, HPBM or provider led, etc.,
so Medicare is increasingly using its coverage with evidence development policy
and this is a policy that says okay, we'll pay for the service as long as you collect X, Y, Z
extra data to create a broader evidence base for us because we determine that
we'll actually pay for this long term. So I wondered if that had come up at all
because while I believe the evidence base is robust as you've said,
it's still in limited settings and now widespread.
The same kind of model could be in a patient center,
medical home, with some kind of global payment or some other,
some different payment than fee-for-service, or an ACO using other people.
And Henry Ford for example uses panel managers.
Panel managers could review blood pressures if they're abnormal,
they pass along to the nurse practitioner or PA, that's the way it's done.
So I would look at this model as being no,
not just the way you did it, but lots of different variations with
the key things of using home a blood pressure measurement,
having rapid response and intensification where needed,
and a payment system that rewards that kind of behavior.
Yeah, I would totally agree with that,
I mean obviously we use pharmacists, other people,
I mean one of the reasons why we use pharmacists is because in the State of Colorado,
pharmacists can actually make medication changes that don't need to be signed off by a physician,
and that's one of the reasons why we did it,
but people have used other types of providers and I couldn't agree with you more
as well as your suggestion about the payment.
Until we've changed that, I don't think it's going to work on a fee-for-service system.
And it's the Clayton Christianson idea of trying to move down on the
breakthrough innovation curve of finding someone less expensive,
more accessible, so you're always looking for other ways of doing
things in a less expensive and more accessible and whatever that is,
a pharmacist, a nurse, a train volunteer even perhaps in some cases.
And one, just real quick one thing that there was a study in Great Britain
where they actually had patients making changes themselves.
Yeah.
Sort of like setting out a plan and saying if your blood pressure
continues to be elevated, we want you to double the dose,
or we want you to, here's a prescription I want you to fill this new medicine,
so this is not rocket science, and you don't need to be a physician to do this stuff.
When I look at your model, I see a huge potential for low income populations who are in working families,
who can't take off a day or half a day to go to the doctor,
and perhaps wait longer than they'd like to actually see the physician.
And so the impact of your model could be really big for people with
low income, for ethnic and racial minorities who have very high rates
of hypertension and heart disease and everything else,
so my question, have you thought about that explicitly and have you
started to look at the impact on populations in your practice?
The regular cuffs that we sell in our pharmacy costs about $30 to $35.
They're simple blood pressure cuffs; they don't have a USB adapter.
The cuff that we use in this study cost $58,
so a health plan like ours would need to think very carefully if we
want patients to use these more expensive cuffs then we're probably going to need to subsidize them.
We're not going to, because if you just ask patients,
they're probably not going to want to spend the extra money for a more expensive cuff.
The issue of patient turnover, and it comes back to that economic
analysis from at least from the perspective of the payer.
If you're my member today and I initiate you on home blood pressure monitoring
and I improve your blood pressure but the benefits accrue down the line,
three, five, eight, ten years from now, well, with turnover rates within health plans today,
some of them reach as high as 30%.
So for those high turnover health plans,
they may say well that person is not going to be in my health plan,
I don't believe that economic analysis,
it's more from the societal perspective and not from mine.
I think the cost argument is just going to be a problem for this and I
think it's in part because of the balkanization right,
so you've got, you're going to have some upfront cost,
paying for more expensive blood pressure cuffs,
the resources of change and so forth,
and the benefits and the long term benefits of like heart attack and
stroke and so forth, while it's clearly very important to the people
here at this meeting, it's hard to argue that the organization that
implements that will really ever see that benefit themselves.
Kaiser's specific challenge was getting this data into our electronic health record.
We have an Epic-based electronic health record that's easy to get data out,
for security reasons, very hard to get data in.
As a result, the pharmacist who did this had to work really in two systems.
We work with our own sort of homegrown tracking system called
Health Track as well as the electronic medical record that's a dissatisfier
for providers to have to use two systems instead of just one.
Well, one of the things that's always concerned me is that the system
as it now exists requires that you have access to a computer with Internet access.
And one of the things that I think I mentioned that could really make in
my mind a big difference is if we could figure out a system that
wouldn't, didn't require having a computer but that you could use your cell phone.
There's no real reason that a system like this couldn't be developed
where you could actually use Bluetooth or other sort of cellular transmission technologies.
And when you look at the proportion of people who have cell phones,
it's much higher and particular in low SES community it's considerably higher,
so that, I mean, and not just in the United States, but if you think about the world,
even in the third world, a lot of people have cell phones and that
technology, but they don't have computer.
So that would be one thing that I think would make a big difference towards addressing the gap.
And you're absolutely right, we know that in a lot of racial groups have
higher rates of hypertension and higher rates of cardiovascular
outcomes and so could probably have even a greater impact there.
When we started the project there was a woman,
Dr. Jennifer Jeans who was the head of hypertension in Colorado and she
was very much our champion and along with us as the researchers in the project and she's very excited.
Unfortunately, for family reason, she had to leave in the middle of
the project and since then we've actually had,
we're not on our fourth head of the hypertension program since she
was there, and so the person now who's in it,
has come in after the project, was never involved in the project at all,
and so not that they're not generally supported but there's a
difference between kind of being generally supportive and sort of
getting on your horse with your sword in your hand and marching into battle.
And we don't have someone like that at this time.
I don't think we did as good a job in bringing together the sponsorship we need.
So in some ways having to do this presentation kind of reignited me a
little bit to sort of go back and kind of figure out the story of what
happened, but also start to bring these things in place,
and I think that at least in terms, I think we've had some meetings
again with senior leadership and I think we're bringing together,
we brought together now the sponsorship that we need to.
When we started this project, blood pressure control in Kaiser Colorado wasn't that good.
We were not at the top in terms of the nation and there were a lot of
initiatives that were done and now we are very much at the top and so
it's not seem as quite the priority that it was when we started the project.
And in an organization in our size which is a little more than half a
million people, we have limited bandwidth to do big projects so the
idea of taking this project and saying we're going to
fundamentally change how we manage hypertension,
and move it from an office based model to a home blood pressure
model, that requires a lot of resources and energy to do that and
with a number of other priorities that we have it's just not on the list at the top.
For more information on this and other innovations please visit
AHRQ's Health Care Innovations Exchange Website at
innovations.ahrq.gov.
To learn more about the Million Hearts Initiative visit: milionhearts.hhs.gov
