Evaluation of a Computerized Clinical Decision Support System and Electronic Health Record (EHR)-linked Registry to Improve Management of Hypertension in Community-based Health Centers

Hypertension affects millions of adults in the United States (US) and is the most prevalent modifiable risk factor for cardiovascular disease. While effective medications and guidelines exist for the treatment of hypertension, half of US adults diagnosed with hypertension are poorly controlled. This project analyzed the efficacy of using clinical decision support (CDS) and performance feedback to improve the control of hypertension in patients treated in community health centers (CHCs).

The components of the CDS implemented included: highlighting in red elevated blood pressures; a hypertension template that lists the information a provider should obtain during visits; medication adherence forms that prompt clinical staff to ask patients about how they are taking their medications; a hypertension order set; and clinical reminders to prompt providers to screen for tobacco use or to order tests that need to be updated.

The main objectives of this project were to:

• Test whether an office-based electronic health record (EHR) with decision support and registry-linked provider performance feedback is more effective in improving hypertension control than a standard EHR alone.
• Assess the implementation process, and delineate factors that influence adoption of the EHR-supported quality improvement intervention.

The project was conducted at the Open Door Family Health Center, a four-site Federally Qualified Community Health Center in New York. The intervention involved a combination of both quantitative and qualitative methods. A pre- and post- study was done to evaluate changes in hypertension control over the 36-month study period. During the 15-month “EHR-only” pre-intervention period, hypertension data in the EHR was collected and analyzed, the providers and staff were surveyed and interviewed, and the intervention was developed. After 15 months, the CDS and provider feedback intervention was simultaneously implemented at all sites. A 4-month acceptance period allowed for refinement and full adoption by providers before post-intervention EHR data was collected. In addition, surveys and structured interviews with providers were conducted before and after the intervention.

This study showed improved adherence to guidelines and more aggressive, systematic, and focused attention on a priority condition – hypertension – on the part of providers using CDS. Control of hypertension was found to be significantly greater post-intervention and process measures improved significantly. Patients were 1.5 times more likely to have their blood pressure controlled after the intervention than before. The project team found six facilitators of change that were important for their implementation: leadership, organizational culture, provider engagement, rigorous implementation process, framing of intervention as quality improvement, and health center capacity to process data. The implication is that health information technology (IT) can play a central role in improving adherence to care standards and clinical outcomes when guided by organizational and cultural environments that value health IT.