Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers

Achieving BP control requires multiple supportive evidence-based strategies, including SMBP. Before the pandemic, 43.5% of US adults with hypertension engaged in home BP monitoring but only 6.9% shared their BP measurements with their clinical provider using remote data transmission methods [18]. Certain CHCs in this study belonged to an HCCN that had implemented SMBP among a limited number of its patients prior to March 2020. This implementation included the development of custom configurations to capture SMBP measurements in structured/reportable EHR fields, which facilitates documentation of BP measurement and corresponding hypertension management. CHCs have focused on the implementation of SMBP since 2017; with the support of HRSA’s National Hypertension Control Initiative, 500 additional CHCs nationwide received $90,000 to implement SMBP since January 2021.²

Despite the growing evidence and endorsement of SMBP’s value in diagnosing and managing hypertension [18‐20], potential cost savings [21], and potential in reducing hypertension-related care and outcome disparities [22], there are well-known patient and clinician barriers for implementation. One such barrier is limited insurance coverage. As of December 2021, only 34 state Medicaid programs provided some level of coverage for automatic upper arm devices and 26 provided some level of coverage for the separate cuffs [21]. For CHCs, which receive reimbursement through Medicaid through prospective payment rates, monitors are not included, although in general, some CHCs had acquired a limited number of SMBP monitors before the pandemic through grant funding.

Although SMBP is an evidence-based strategy that, when used in conjunction with co-interventions, including medication titration, therapeutic lifestyle changes, and education and counseling, leads to clinically significant BP reduction in patients with hypertension, there is still much to be done to effect widespread implementation, particularly around data transmission [19, 23‐25]. Most EHRs cannot automatically process out-of-office BP data, in part due to the lack of standards-based interfaces between home BP devices and EHRs and because of the lack of structured data fields in which to store the data. Currently, average BP is not required by the most recent version (3) of the United States Core Data for Interoperability [26], which means EHR vendors are not required to include average BP in their EHR software as a standard data field. Moreover, virtual health platforms relying on smartphones, computers, and high-speed internet may not be equally available to all patients and communities, and therefore, patients without access to or who are not literate in using the technology needed for SMBP may not benefit from this strategy.

It is also important to note that the SMBP model does not fully align with the eCQM model, which is based on assessing a single BP measurement from the most recent visit. SMBP guidelines typically ask patients to take multiple readings per day over 3–7 days and average the results, so asking the patient to take their BP again during a telehealth visit to comply with CMS 165v8 specifications may feel repetitive and not as meaningful. Further, the CMS 165v8 measure only allows for BP measurement data to be electronically transmitted from SMBP devices directly to the care team for numerator compliance; patient-reported data are not accepted [13]. This limitation precludes patients seen through telehealth encounters without the ability to show their device memory via video; it also may preclude patients without access to a Bluetooth home BP device and fast internet that enables them to share their BP measurements electronically with their health care providers. The next iteration of the UDS Controlling High Blood Pressure measure criteria to be implemented in 2023 is expected to align with the National Committee on Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS), a tool used by > 90% of US community health centers to measure performance on different dimensions of care and service, which accepts patient-reported BP measurements. Nonetheless, the issue of where to document out-of-office BP measurements in the EHR will still be a barrier, as will the incongruency of the eCQM approach of using a single BP measurement to gauge BP control vs. SMBP, which uses an average of BP readings over time to assess BP control.

There is an opportunity to use technology to redefine BP control by developing standards to facilitate remote data exchange between patients and health care providers and enable clinical decision making. Additionally, EHR vital signs interfaces should be improved to prompt for and allow the capture of out-of-office BP measurements and averages during a patient encounter. Collective efforts could modernize data transfer and processing, improve broadband access, expand device coverage, and increase affordability [18]. Further, an essential component to SMBP implementation involves education and training for health care providers (e.g., billing for SMBP services using current procedural terminology codes, reimbursing for SMBP training and data management), and patients (e.g., improving digital health literacy, appropriate device selection, fitting and usage, behavioral health changes). Finally, the telehealth policies that enabled broader and flexible telehealth coverage during the Public Health Emergency, especially around the originating site and audio/telephone only visits [27], could be made permanent.

An additional limitation is that data were quickly extracted in the midst of the pandemic and were only available as aggregates of three HCCNs whose health centers were participating in the NACHC Million Hearts^® project, thus not allowing for more granular analyses. For this reason, one non-SMBP implementing CHC was analyzed as part of the SMBP implementing group, which might have underestimated the BP control rate in this group. We also did not determine the number or characteristics of patients with no encounters during the study period, nor the characteristics of patients with BP measurements and whether they differed from those who had an encounter but no documented BP. Lastly, the sample size used for the determination of encounter type was small.