VISN Collaborative for Improving Hypertension Management With ATHENA-HTN

Background / Rationale:

Despite the existence of evidence-based guidelines, there is a gap between evidence-based
recommended best medical practice and actual practice. In previous work, we used hypertension
as a model to study the translation of research regarding clinical blood pressure targets and
drug choice into primary care practice through computer-based implementation of clinical
practice guidelines. In collaboration with experts in guideline-automation at Stanford Center
for Biomedical Informatics Research (BMIR) (formerly known as Stanford Medical Informatics,
SMI), we developed an innovative clinical decision support system: ATHENA-CDS-HTN
(hypertension) also known as ATHENA-HTN. ATHENA-HTN is a knowledge-based CDS that uses
knowledge bases (KBs) of clinical knowledge of hypertension encoded into computable formats.
Clinical data from an electronic health records system is processed with the knowledge in the
KB by an execution engine (also known as a guideline interpreter) that generates
patient-specific outputs with conclusions about the current state of the patient with respect
to the guidelines as shown in the patient's electronic health record data and also generates
detailed recommendations for next steps in clinical management of the patient's hypertension.
The system is designed to take account of multiple data elements in the patients' clinical
data including co-morbid diagnoses that are relevant to hypertension and its treatment, other
medications currently prescribed, history of adverse drug reactions/events, and selected
laboratory values relevant to hypertension and its management. In previous work, we had
demonstrated that deploying this CDS system in VA primary care clinics was feasible and that
clinicians found the system usable and useful, as shown by their actual extensive use of the
system and their response to a questionnaire survey. The current project was funded by the
Department of Veterans Affairs Health Services Research and Development (HSR&D), under a
special funding initiative for Quality Enhancement Initiative (QUERI) projects designed to
improve care for hypertension by collaboration with a Veterans Integrated Service Network
(VISN) to implement programs to encourage use of established best-practices for managing
hypertension according to evidence-based guidelines available at the time of the study. These
studies were known as "VISN Collaboratives". The studies did not involve any new drugs or new
uses of established drugs, but rather encouraging use of established drugs recommended in
standard evidence-based guidelines for care. The focus of the study was implementation of
existing known best practices in managing hypertension, using the CDS as a vehicle to bring
information to the point-of-care, with detailed individualized recommendations about patients
presented to the primary care provider at the time the provider sees patients in scheduled
outpatient primary care clinic visits.

Objective(s):

Our objectives in this VISN Implementation Collaborative included: (1) implement
evidence-based guidelines for hypertension in a CDS system by upgrading the ATHENA-HTN
knowledge-base (KB) to the most recent guidelines; (2) deploy the CDS system in 5 medical
centers within VISN 1 to generate individualized recommendations to primary care clinicians
caring for patients in outpatient clinics; (3) evaluate the implementation including the
organizational aspects.

Methods:

In Phase 1 we plan to update the KB and conduct offline testing; to revise the M (formerly
known as MUMPS) program that extracts patient data daily from VistA to extract additional
data elements; to streamline the system architecture to make it easier to implement in
multiple sites; to work with the site-PIs to obtain IRB approval at 5 implementation sites in
VISN 1 plus the coordinating site at VA Palo Alto; to improve the user interface design; to
identify and resolve issues in implementing new information technology in multiple different
VA medical centers (VAMC) with different Computerized Patient Record System (CPRS)
implementations and different methods of distributing computer access to clinicians; to train
the site PIs in use of the system; and perform baseline data analysis to inform the
randomization. In Phase 2 we plan to recruit primary care providers from the participating 5
medical centers in VISN 1; randomize clinics to ATHENA-HTN intervention or usual care; deploy
the system for intervention providers; train intervention providers in use of the system; and
conduct a 12-month clinical trial of the system.

Status:

The project has been completed. We completed Institutional Review Board (IRB) approvals at
all five medical centers. We updated the knowledge base of computable knowledge regarding
hypertension and conducted offline testing. Our system was deployed to all five medical
centers. While we were preparing for deployment of the CDS, one site changed from a
rich-client environment to a thin-client environment for the medical center computers; we
developed new code to run the system in a thin client environment. The previous programming
computed recommendations of the CDS based on clinical data available the night before the
clinic visit (in order to pre-compute advisories for faster display during clinic); in this
project we developed software code to obtain automatic blood pressure updates for the day of
visit if these were entered by clinical staff at the time of the visit. VA Palo Alto staff
worked with staff at each VAMC to validate clinical data extraction at each site. We
developed code for a clinician to select, optionally, for blood pressure write-back to VA
VistA so that if clinicians entered to our CDS a blood pressure measurement that they had
just taken so they could view updated recommendations based on the repeat blood pressure they
would not also have to enter that blood pressure separately to electronic health record. We
recruited primary care providers (clinicians) at each of 5 medical centers to participate in
the project. One of the 5 medical centers completed the installation of the ATHENA-HTN
system, but did not continue with the intervention period, so the intervention included 4
rather than 5 medical centers. Our site-principal investigators and project coordinator
trained intervention providers on use of the system by offering short phone calls for
training or in-person introduction, and by making the system available for a short period of
time for familiarity. Records of patients seen by the clinicians in this training period were
excluded from analyses. We completed a 6-8 month intervention period for the clinical trial
at the 4 participating medical centers. Our random allocation was at clinic level, where a
clinic is a substation of a medical center (station). Before initiating data analyses, we
prepared a detailed data analysis plan.

Inclusion Criteria:

- Must be primary care clinicians (for example, physician or nurse practitioner) at one
of the participating VA medical centers. This study is NOT recruiting patients.

- The primary care clinician must have a panel of patients for whom he or she provides
direct care.

Exclusion Criteria:

- Anyone who does not meet inclusion criteria.