The barriers, at least at our site, are very challenging. A great deal of money has been paid to the EMR provider, yet they have delivered an extremely inflexible system and we cannot add any value adds without paying more money. I'm sure this is a common problem. They are reticent to work with others. In terms of the advantages, the major one is that the patient can be managed remotely. This is the way healthcare needs to be delivered and is the very definition of patient centered care

I think EVERY physician needs to know how to properly measure BP - it's a skill that is used for more than just managing high blood pressure. That said, I think the future should automated measurements and out-of-office measurements - lots of measurements to ensure an accurate assessment of BP.

Medical students need to master BP measurement skills in while in medical school because they will likely not be retrained or retested after medical school. Too often the only training takes place in the first year Unlike other healthcare professionals who are retested every six months (per guideline recommendations) this doesn't happen with residents, fellows, and physicians in practice. While physicians may believe they have attained competency, when tested, this does not seem to be the case for the majority. I am always being told that this skill isn't necessary for physicians because medical assistants or RNs take BP measurements in the real world, yet most physicians we ask tell us they won't make a diagnosis of hypertension or uncontrolled BP without checking the BP themselves. Often in the exam room on aneroid devices that are not always checked for accuracy as often as they should be. Given that these are often the BPs used to make treatment decisions, the physicians mastery of the skills needed to estimate BP are critical. If they are only taught in medical school, then they need to be masted at that time - and preferably retested periodically as recommended with all other healthcare professionals.

I agree completely with Raj that the future will involve more education and training of patients to measure their own BP out of the office. This will yield more BPs over longer periods of time giving us a more accurate assessment of what someone's BP is. Automated devices has made this easier, allowing people to focus on proper positioning, rest, and environment. Hopefully with better technology we will see more accurate devices that can more easily transmit BPs directly to clinicians to remove another layer of possible errors.

One thing we all need to keep in mind: no matter how well a device did in its ANSI/AAMI/ISO validation study the device will have varying accuracy on individual patients........there are too many variables such as vessel stiffness, arm shape, arm circumference, etc to be able to design an algorithm accurate for all. We would all benefit from a mechanism to assess accuracy for each patient.

....or maybe automated auscultation would have been a better choice given the vagaries of oscillometry....

In the new paradigm of the Patient-Centered Medical Home, the physician is to be the "captain of the healthcare team" supporting the patient's journey to health. The captain is ultimately responsible, and should have a working knowledge of the roles and responsibilities of each member of the team, as well as be able to step in and validate the results obtained by others. Thus although the physician will likely not take routine BPs any longer in the office (if/when in-office automated BPs take over), it is often reassuring to patients that the physician repeats and validates an abnormal measurement before intensifying therapy.

As I don’t work in an outpatient setting, I can only base my opinion off of what I recommend to family and friends. I advocate for them to buy a reputable home BP monitor with the ability to upload this data to their phone or other electronic device. I then emphasize the importance of frequent measurements which can then to self-reported to the physician for correlation between OBP and HBP.

It depends on the accuracy of the reading, the setting (pain, fear, volume overload, &) and the patient. Don't forget about the patient! If there is only slight elevation, the BP should be repeated in a week or two. All of the rest is clinical judgment based on target organ damage, other risk factor and the reliability of the patient. If the patient has been referred, a telephone call to the referring practitioner should be mandatory.
Many of my patients acquired home BP devices. I would have them bring the device to the clinic and have the patient take his or her own BP with it. I touched nothing--just observed. No one ever did it correctly. The most common errors were body position, cuff placement (even upside down!) and watching the digital numbers as they flashed by. I convinced them to look at the numbers only after the cuff deflated. In summary, it ain't simple.

It depends on how high the BP reading is and the context in which it was measured. In general one high BP reading warrants a dedicated BP visit. Then a 24 hour ambulatory BP monitor or a home blood pressure series can provide further information. Depending on how high the BP is on those measurements, a sequential trial of lifestyle modification and antihypertensives or both simultaneously could be undertaken.

Many challenges exist, so I will tackle just one. Time pressures are a major issue and I think the major barrier to proper BP measurement. This leads to sloppy technique, dispensing with a rest period, rapid deflation (in the case of auscultation), and terminal digit preference.... I think, because out-of-office measurements are more accurate, they should be used more in clinical practice. The best way to achieve this is to teletransmit the measurements to the EMR, so that the provider has all of the information before the patient arrives (or so that the visit can be conducted virtually). Telemonitoring has been done in many trials but implementing it in clinical practice appears to be elusive because cooperation and coordination is required.

I agree with Raj, the importance of out-of-office/Home BP monitoring gives the best trend. Parati et al. (2008) In the Journal of Hypertension identify that the increased use of home BP (HBP) measurements were of equal or potentially more prognostic value. These correlations were even higher if the patient had other comorbidities.

Parati, G. et al. (2008). European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring, Journal of Hypertension. (26), 1505-1530.

This is a really complex question. At our clinic, we focus primarily on out-of-office BP measurement. 24 hour ambulatory BP is used for initial diagnosis and home BP is used to follow patients. We don't have home BP telemonitoring as yet, but this needs to be implemented in order to maximize the effectiveness of home BP use. For patients who don't have home BP devices, we either give a loaner or, if that's not possible, we use the automated office BP device (a device that takes serial BP measurements while the patient is left unattended in an empty clinic room). However, we have concerns that the automated office BP method is too variable and also that it tends to systematically under-read ambulatory BP.

In Canada, we have decided to advice against use of auscultation. Auscultation is a fine method in theory - I actually believe it's a fundamentally stronger method than oscillometry (which is the method used in nearly all of the automated devices). In fact, simultaneous blinded two-observer auscultation using a mercury sphygmomanometer is considered the gold standard method in BP device validation studies. However, auscultation is poorly performed in clinical practice and use of anaeroid devices is widespread. These devices require frequent calibration and this is often not done. Time pressures in clinical practice are the major reason auscultation is not done well. It takes about 8-10 min to do a proper set of auscultatory measurements, which is difficult to do. A final problem with auscultation is that it requires the provider to be next to the patients (very very few automated devices use the auscultatory method). This prohibits the ability to do out-of-office measurements and is a major limitation (because out-of-office measurements are more accurate as they eliminate white coat and masked hypertension).

I believe that SPRINT has set the standard for BP measurement. Unfortunately, almost no one does this in practice. It is critical to have the patient seated, rested, back and arm supported, feet flat on the floor and to use a proper sized cuff. I agree that the auscultory method is obsolete. AHA and JNC 7 spell this out. In a busy practice, BP tends to be determined poorly and the practitioner may make decisions based on erroneous data. Despite efforts to teach students, PAs and ARNPs the correct technique, I see little evidence of success.

While there are standards, there is also what is pragmatic in a busy clinical practice and with patients who may not have or understand how to use a home BP cuff (or how to document/transmit the data from them). Even if the proper technique is known, the flow of the clinic may not allow for it to occur. Interested to hear if clinics have solved this at the point of care, rather than trying for home measurement.

I wish that I could use our clinics as an example, but I cannot. Our research personnel are well trained and retrained. The clinical people are not. If one or two persons in a clinic (even a non-clinician) were trained to determine BP in a quiet room (HAH!) with the patient properly positioned and rested, the practitioner just might get results on which valid decisions could be made. Otherwise, it is up to the practitioner to detect what might be spurious data. When I have a personal routine appointment (and I hate being a patient), I determine my weight and BP at home and present those data to my clinician. The method of "sit down, slap the cuff on, push the button, shove a thermometer under one's tongue and never stop talking" does not meet anyone's guidelines. The SPRINT method has merit, but costs money.

The clinic in which I formerly worked did research-quality BPs manually until we validated the instrument most often used in SPRINT. When we learned how good it was, we changed paradigms and let the nurse hook up patients to the automated device, and record BPs that way. It was a big change, but our terminal digit preference disappeared, and the standard deviation of triplicate measurements decreased significantly. We also did fewer ABPMs after switching BP measurement techniques, but this may have been confounded by reimbursement issues.

Bravo! I doubt if we can get funding and I have tired of the fight. I agree that this is the way to do it.

Each of the questions requires an hour long seminar. BP in the clinical office is typically measured by the lowest-paid, least-experienced nursing aide. The curse of BP accuracy is the “check-in chair,” the bottle neck of the office flow system. No office manager or MD is willing to have the patient wait 5 minutes without talking or being talked to. The solution can be placing the patient in the exam room, hooking up the BPM, and having the patient alone for 4-5 minutes, then return to estimate BP.

All automated devices, of course, do not measure BP; that can only be done by intra-arterial catheter, or (possibly) manual auscultation done using a research-grade protocol. Currently there are devices available which can cycle independently, without any medical personnel in the room. This will also tend to solve the white coat effect commonly present.

Another solution, of course, is to do 24 hours ABPM. As described by Dr. Padwal, the Canadian Guidelines now call for automated P use, not manual auscultation. The abandonment of auscultation was done because, despite training and re-training, office personnel will NOT perform BP protocols consistently or correctly.
Even if a BPM has been properly validated by using the ANSI/AAMI/ISO protocol using ≥ 85 subjects, the device can be certified as accurate only for populations, not individual patients. I recommend that each patient bring his/her self-measurement device to the MD office/clinic so that its readings can be compared to what is thought to be the “reference device” in use for clinical decision-making.

Recently an inexpensive cellphone app has been developed which can be used to validate automated BPM readings by use of automated auscultation. This new product may easily solve the dilemma of whether a particular BPM is accurate on a specific patient.

The question as to why the medical students all failed the testing organized by Dr. Rakotz and several of his colleagues (including me!!) is relatively easy. BP is not treated with the respect it deserves. BP is the only one of the routine vital signs which predicts long-term morbidity and mortality. Medical school curriculum change is needed urgently. Students should be instructed and given practical experience in every one of the 4 years of medical school. Every resident, with the possible exception of psychiatry, should be required to do retraining during every year of residency. MDs in practice should be encouraged, perhaps even required, to do the same on a yearly basis.

Until then, we will not be able to trust that there is a “gold standard” MD who can measure BP by auscultation using strict AHA guidelines. I would venture to say that almost no current resident or clinician (who is not a hypertension expert) could describe how to choose the correct BP cuff to use.

Bruce, I completely agree. The lack of interest in what residents see as “non-important” can be seen in their regard for mastery of blood pressure measurements. These measurements are seen as “below” them, and a task that should be delegated to others. Yet this measurement may have more importance than almost any other noninvasive monitoring technique. I have been a nurse for almost 8 years and was in prehospital areas for 9 years before that and I can only remember a handful of times when a physician performed the measurement himself/herself without delegating it to others.

I agree with all of the above. When I ran a consultative practice in an academic setting, I could spend 60-90 min with a patient and take the BP myself with the patient seated and standing and in both arms. The "bean counters" eventually got to me and demanded that I see 5 patients per hour. Reluctantly, I closed the practice. In the real world few if any physicians can afford to do this. They have to pay rent, the light bill and the salaries of their employees.
In a study of a special protocol for diuresing cirrhotics with massive ascites, weight was a critical measure of fluid balance. The house staff wouldn't do it. I and two professors involved in the study came to the ward early each morning and weighed the patients ourselves. The house staff was not interested. They do view BP estimation (it is an estimate) as something to be done by others. And then there is the funduscopic exam in patients with severe hypertension. Lots of luck! End of rant.

AMEN to Barry. So how do we FIX this? What can we do in protest to the bean counters to make sure residents in training UNDERSTAND that they are the gold standard for all levels of medical personnel. Without MD's who know the proper technique and will demand it in their patient Dx and Rx we are hopelessly doomed to bad medicine. "Modern Medical Care" is far worse that a century ago, when Korotkoff was the guru and everyone cared. Why isn't anyone except us listening?

Hi, I am an internist, epidemiologist and pharmacologist based at the University of Alberta in Edmonton, Canada. I also am the past Chair of the Hypertension Canada Clinical Practice Guidelines and Director of the Hypertension Clinic at the University of Alberta.

I am a general internist and Associate CMIO at Boston Medical Center in Boston, MA. As an internist this is an issue of importance to me and my patients. As a health IT leader, I think about BP measurement as it relates to information reliability, retrieval, decision support, and reporting.

I am a nephrologist/hypertension specialist who worked with Ed Freis on many VA Cooperative studies. I was on JNC 7 where we coined the term "prehypertension" and have a paper in press advocating a lower deffinition of hypertension. AHA/ACC has just done exactly that.

I am a clinical pharmacologist, internist, and hypertension specialist with a lot of experience teaching medical students. I have strong opinions about why so few students measured BP correctly. Accurate measurements in routine clinical practice require a lot of attention to detail, whereas technology has much to offer that takes much of the variability out of the equation. Given today's students' reliance on all things technical, I am not surprised that few if any would devote the time and attention to proper BP measurement, when research (especially SPRINT) shows the benefit of integrating technology into clinical practice, absolving many physicians from spending time and effort to perform the mundane task of measuring BP accurately in the office.

I am a family physician and work full time at the American Medical Associations Improving Health Outcomes group, working on national quality improvement programs to improve blood pressure control nationally. I also work part time at Northwestern as an assistant clinical professor in the Department of Family and Community Medicine in the Feinberg School of Medicine.

I am a General Internal Medicine Specialist and an Associate Professor at the University of Alberta. My research interest is Blood Pressure Measurement and I have a clinical interest in hypertension.

Sepsis Program Coordinator at SUNY Upstate Medical University Hospital, working on my Masters in Health Informatics at University of Illinois at Chicago.

I'm at a new medical school in San Antonio, University of the Incarnate Word School of Osteopathic Medicine, and am boarded in Public Health and Preventive Medicine, Clinical Informatics, and Lifestyle Medicine.