Hypertension (HT) during adolescence tracks into adulthood, contributing to adult cardiovascular morbidity and mortality. National guidelines for the diagnosis and treatment of hypertension in children and adolescents were developed by the National High Blood Pressure Education Program (NHBPEP);their Fourth Report was published in 2004. Despite heightened awareness of hypertension in pediatric populations, most adolescents with elevated blood pressure remain clinically unrecognized. Factors that contribute to this gap in care include: the need to translate adolescent blood pressure (BP) measures into BP percentiles on the basis of age, gender, and height, lack of familiarity with NHBPEP clinical guidelines, and competing demands at clinical encounters. Electronic health record (EHR)-based clinical decision support (CDS) can be used to address these barriers and support better care of elevated BP and HT in adolescents. In this project, we integrate EHR-extracted data with sophisticated Web-based CDS algorithms to provide patient-specific point-of-care clinical recommendations, in accordance with NHBPEP guidelines. To evaluate the impact of this innovation on quality and cost of care, we randomize 18 clinics with their 130 pediatric care providers (PCP) and their estimated 17,000 adolescent patients to receive or not receive this EHR-based CDS intervention. We hypothesize that the intervention will improve recognition and early management of elevated BP and that short-term increases in outpatient care costs will be offset by longer-term clinical benefits, estimated using established econometric models. This innovative project (a) addresses the under-recognized high-risk patient population of adolescents, (b) integrates EHR and Web-based CDS technology to provide sophisticated patient-specific point-of-care CDS, (c) develops and implements novel and intuitive visual interfaces to communicate CDS recommendations to PCPs, and (d) provides both clinical and cost outcome data useful to clinicians and policymakers. If the EHR- based CDS intervention improves adherence to NHBPEP recommendations, it will provide a much-needed tool to combat the burgeoning problem of rising cardiovascular risk factors in children and adolescents. Further, regardless of outcome, the technology that is developed and tested will provide many useful insights to advance the science of EHR-based CDS. This will, in turn, help translate the massive public and private investments in EHR technology into improved adolescent health outcomes.

Public Health Relevance

Over the past few decades, rates of hypertension have increased substantially among adolescents, yet diagnosis and care of hypertension in this age group continues to be suboptimal. This project (a) uses electronic health record (EHR) technology to deliver patient-specific clinical decision support (CDS) to adolescent providers at the point of care, (b) assesses the impact of this intervention on identification and clinical careof hypertension in adolescents, and (c) assesses the impact of the intervention on costs of care. The innovative intervention provides a useful template for extending EHR-based clinical decision support to other domains of adolescent care, in order to translate massive public and private investments in EHR technology into improved adolescent health outcomes.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project (R01)
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Health Services Organization and Delivery Study Section (HSOD)
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Larkin, Jennie E
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Healthpartners Institute
United States
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Kharbanda, Elyse O; Asche, Steve E; Sinaiko, Alan R et al. (2018) Clinical Decision Support for Recognition and Management of Hypertension: A Randomized Trial. Pediatrics 141:
Kharbanda, Elyse Olshen; Asche, Stephen E; Sinaiko, Alan et al. (2018) Evaluation of an Electronic Clinical Decision Support Tool for Incident Elevated BP in Adolescents. Acad Pediatr 18:43-50
O'Connor, P J; Sperl-Hillen, J M; Fazio, C J et al. (2016) Outpatient diabetes clinical decision support: current status and future directions. Diabet Med 33:734-41
Parker, Emily D; Sinaiko, Alan R; O'Connor, Patrick J et al. (2016) Potential Misclassification of Blood Pressure Status in Children and Adolescents With Short or Tall Stature. Am J Epidemiol 183:79-83
Kharbanda, Elyse O; Nordin, James D; Sinaiko, Alan R et al. (2015) TeenBP: Development and Piloting of an EHR-Linked Clinical Decision Support System to Improve Recognition of Hypertension in Adolescents. EGEMS (Wash DC) 3:1142