Who is in charge here?

 

The other day I had a couple of very interesting and unusual office visits. My first patient of the afternoon was a simple hypertension follow-up, or so I thought as I was walking into the room. She was a healthy 50-year-old woman with no medical problems other than her blood pressure, which was measured at 130/76 in the office. Her heart and lungs were normal, she had no chest pain or shortness of breath, and she was taking her medications without any problem. All simple enough. I complimented her on how she was doing, told her to continue her medications, and return in 6 months.

She put up her hand and said, “Wait a minute.”

Then she pulled out her smartphone. She tapped open an app, and handed it to me so I could look at a graph of her home blood pressures. The graph had all of her readings from the last 4 months, taken 2-3 times a day. It had automatically labeled each blood pressure in green, yellow, or red to indicate whether they were normal, higher than normal, or elevated, respectively.

Of course, the app creators had determined that a ‘green’ (normal) systolic pressure was less than 120 mm Hg. Values above that were yellow (higher than normal), until a systolic pressure of 130, at which point they became red (elevated). This is consistent with the most recent American Heart Association guidelines, but these guidelines have been the subject of a lot of controversy. There are many, including myself, who believe that the correct systolic pressure to define hypertension should be 140 for many patients, rather than 130. The app disagrees, and patients using the app see the app’s definition of hypertension every time they enter a blood pressure. In the case of my patient, since normal was indicated only by a systolic of less than 120 (which is a relatively rare event), I had to explain the difference between normal blood pressure and her blood pressure goal, and why the two were not the same.

Later that afternoon I was seeing a 60-year-old male who had electrical cardioversion of his atrial fibrillation 2 weeks prior to the visit. He had been sent home, as is usually the case, on an antiarrhythmic and an oral anticoagulant. He was feeling fine and had not noticed any palpitations, chest discomfort, or shortness of breath. I listened to his heart and lungs, which sounded normal, and I told him it sounded like he was doing well. Then he said, “I have an Apple watch.” I had a feeling I knew what was coming next.

He handed me his iPhone and asked me if I could review his rhythm strips. For those unacquainted with the new Apple watch, all he had to do to obtain those strips was open an EKG app and touch the crown of his watch with a finger from his other hand. This essentially made an electrical connection from his left to right arm, allowing the watch to generate a one-lead EKG tracing. The device then provides a computer-generated rhythm strip and sends that image and an interpretation of it to an iPhone, which is connected to the watch via Bluetooth. These results can then be shared or printed out as a pdf document.

 

The patient wanted to know if the smartphone’s interpretation of those rhythm strips was correct, and if he was really having frequent asymptomatic recurrence of his atrial fibrillation. Unsurprising to me or anyone who has used one of these (or other) phone-based EKG devices, the watch-generated rhythm strips looked clean and clear and the interpretation was spot on. It correctly identified his frequent asymptomatic episodes of atrial fibrillation. This was important information, which markedly affected his medical care.

These two very different examples are early indications that the way that we will be collecting information will rapidly and radically change over the next few years. It has always been clear that making long-term decisions about the treatment of hypertension based on a single reading in the office setting is not optimal. It has been equally clear that a single office EKG provides a limited snapshot into the frequency of intermittent atrial fibrillation. Deciding how to treat patients has never been easy and many decisions are plagued with ambiguity. Having limited information is a blessing and a curse; it’s quick and easy to review a small amount of data, but there is a nagging recognition that those data are only a distant representation of a patient’s real health outside of the office.

As we move forward we will increasingly have the ability to see a patient’s physiologic parameters where and when those values are most important: during the countless hours when they are not in our offices. The new American Heart Association hypertension guideline, issued in late 2017, has placed increased emphasis on ambulatory blood pressure monitoring. Determining how to use all this new information will be a challenge. It will take time to become comfortable with interpreting and making sense of an incredible number of data points. For example, if a patient checks his blood pressure twice a day for 3 months, his efforts will generate 180 separate blood pressure readings! You can bet there is going to be a good deal of inconsistency in those readings, making interpretation challenging. There will also probably be a few high readings, such as the occasional 190/110, which are likely to cause concern and anxiety in patients. There is little question that the availability of such detailed information holds the potential to allow us to make better decisions. The challenge will be in deciding how to use it to actually improve – not just complicate – patient care.

What are your thoughts on this? Feel free to email us at [email protected].

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on twitter (@doctornotte).

 

The other day I had a couple of very interesting and unusual office visits. My first patient of the afternoon was a simple hypertension follow-up, or so I thought as I was walking into the room. She was a healthy 50-year-old woman with no medical problems other than her blood pressure, which was measured at 130/76 in the office. Her heart and lungs were normal, she had no chest pain or shortness of breath, and she was taking her medications without any problem. All simple enough. I complimented her on how she was doing, told her to continue her medications, and return in 6 months.

She put up her hand and said, “Wait a minute.”

Then she pulled out her smartphone. She tapped open an app, and handed it to me so I could look at a graph of her home blood pressures. The graph had all of her readings from the last 4 months, taken 2-3 times a day. It had automatically labeled each blood pressure in green, yellow, or red to indicate whether they were normal, higher than normal, or elevated, respectively.

Of course, the app creators had determined that a ‘green’ (normal) systolic pressure was less than 120 mm Hg. Values above that were yellow (higher than normal), until a systolic pressure of 130, at which point they became red (elevated). This is consistent with the most recent American Heart Association guidelines, but these guidelines have been the subject of a lot of controversy. There are many, including myself, who believe that the correct systolic pressure to define hypertension should be 140 for many patients, rather than 130. The app disagrees, and patients using the app see the app’s definition of hypertension every time they enter a blood pressure. In the case of my patient, since normal was indicated only by a systolic of less than 120 (which is a relatively rare event), I had to explain the difference between normal blood pressure and her blood pressure goal, and why the two were not the same.

Later that afternoon I was seeing a 60-year-old male who had electrical cardioversion of his atrial fibrillation 2 weeks prior to the visit. He had been sent home, as is usually the case, on an antiarrhythmic and an oral anticoagulant. He was feeling fine and had not noticed any palpitations, chest discomfort, or shortness of breath. I listened to his heart and lungs, which sounded normal, and I told him it sounded like he was doing well. Then he said, “I have an Apple watch.” I had a feeling I knew what was coming next.

He handed me his iPhone and asked me if I could review his rhythm strips. For those unacquainted with the new Apple watch, all he had to do to obtain those strips was open an EKG app and touch the crown of his watch with a finger from his other hand. This essentially made an electrical connection from his left to right arm, allowing the watch to generate a one-lead EKG tracing. The device then provides a computer-generated rhythm strip and sends that image and an interpretation of it to an iPhone, which is connected to the watch via Bluetooth. These results can then be shared or printed out as a pdf document.

 

The patient wanted to know if the smartphone’s interpretation of those rhythm strips was correct, and if he was really having frequent asymptomatic recurrence of his atrial fibrillation. Unsurprising to me or anyone who has used one of these (or other) phone-based EKG devices, the watch-generated rhythm strips looked clean and clear and the interpretation was spot on. It correctly identified his frequent asymptomatic episodes of atrial fibrillation. This was important information, which markedly affected his medical care.

These two very different examples are early indications that the way that we will be collecting information will rapidly and radically change over the next few years. It has always been clear that making long-term decisions about the treatment of hypertension based on a single reading in the office setting is not optimal. It has been equally clear that a single office EKG provides a limited snapshot into the frequency of intermittent atrial fibrillation. Deciding how to treat patients has never been easy and many decisions are plagued with ambiguity. Having limited information is a blessing and a curse; it’s quick and easy to review a small amount of data, but there is a nagging recognition that those data are only a distant representation of a patient’s real health outside of the office.

As we move forward we will increasingly have the ability to see a patient’s physiologic parameters where and when those values are most important: during the countless hours when they are not in our offices. The new American Heart Association hypertension guideline, issued in late 2017, has placed increased emphasis on ambulatory blood pressure monitoring. Determining how to use all this new information will be a challenge. It will take time to become comfortable with interpreting and making sense of an incredible number of data points. For example, if a patient checks his blood pressure twice a day for 3 months, his efforts will generate 180 separate blood pressure readings! You can bet there is going to be a good deal of inconsistency in those readings, making interpretation challenging. There will also probably be a few high readings, such as the occasional 190/110, which are likely to cause concern and anxiety in patients. There is little question that the availability of such detailed information holds the potential to allow us to make better decisions. The challenge will be in deciding how to use it to actually improve – not just complicate – patient care.

What are your thoughts on this? Feel free to email us at [email protected].

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on twitter (@doctornotte).

 

The other day I had a couple of very interesting and unusual office visits. My first patient of the afternoon was a simple hypertension follow-up, or so I thought as I was walking into the room. She was a healthy 50-year-old woman with no medical problems other than her blood pressure, which was measured at 130/76 in the office. Her heart and lungs were normal, she had no chest pain or shortness of breath, and she was taking her medications without any problem. All simple enough. I complimented her on how she was doing, told her to continue her medications, and return in 6 months.

She put up her hand and said, “Wait a minute.”

Then she pulled out her smartphone. She tapped open an app, and handed it to me so I could look at a graph of her home blood pressures. The graph had all of her readings from the last 4 months, taken 2-3 times a day. It had automatically labeled each blood pressure in green, yellow, or red to indicate whether they were normal, higher than normal, or elevated, respectively.

Of course, the app creators had determined that a ‘green’ (normal) systolic pressure was less than 120 mm Hg. Values above that were yellow (higher than normal), until a systolic pressure of 130, at which point they became red (elevated). This is consistent with the most recent American Heart Association guidelines, but these guidelines have been the subject of a lot of controversy. There are many, including myself, who believe that the correct systolic pressure to define hypertension should be 140 for many patients, rather than 130. The app disagrees, and patients using the app see the app’s definition of hypertension every time they enter a blood pressure. In the case of my patient, since normal was indicated only by a systolic of less than 120 (which is a relatively rare event), I had to explain the difference between normal blood pressure and her blood pressure goal, and why the two were not the same.

Later that afternoon I was seeing a 60-year-old male who had electrical cardioversion of his atrial fibrillation 2 weeks prior to the visit. He had been sent home, as is usually the case, on an antiarrhythmic and an oral anticoagulant. He was feeling fine and had not noticed any palpitations, chest discomfort, or shortness of breath. I listened to his heart and lungs, which sounded normal, and I told him it sounded like he was doing well. Then he said, “I have an Apple watch.” I had a feeling I knew what was coming next.

He handed me his iPhone and asked me if I could review his rhythm strips. For those unacquainted with the new Apple watch, all he had to do to obtain those strips was open an EKG app and touch the crown of his watch with a finger from his other hand. This essentially made an electrical connection from his left to right arm, allowing the watch to generate a one-lead EKG tracing. The device then provides a computer-generated rhythm strip and sends that image and an interpretation of it to an iPhone, which is connected to the watch via Bluetooth. These results can then be shared or printed out as a pdf document.

 

The patient wanted to know if the smartphone’s interpretation of those rhythm strips was correct, and if he was really having frequent asymptomatic recurrence of his atrial fibrillation. Unsurprising to me or anyone who has used one of these (or other) phone-based EKG devices, the watch-generated rhythm strips looked clean and clear and the interpretation was spot on. It correctly identified his frequent asymptomatic episodes of atrial fibrillation. This was important information, which markedly affected his medical care.

These two very different examples are early indications that the way that we will be collecting information will rapidly and radically change over the next few years. It has always been clear that making long-term decisions about the treatment of hypertension based on a single reading in the office setting is not optimal. It has been equally clear that a single office EKG provides a limited snapshot into the frequency of intermittent atrial fibrillation. Deciding how to treat patients has never been easy and many decisions are plagued with ambiguity. Having limited information is a blessing and a curse; it’s quick and easy to review a small amount of data, but there is a nagging recognition that those data are only a distant representation of a patient’s real health outside of the office.

As we move forward we will increasingly have the ability to see a patient’s physiologic parameters where and when those values are most important: during the countless hours when they are not in our offices. The new American Heart Association hypertension guideline, issued in late 2017, has placed increased emphasis on ambulatory blood pressure monitoring. Determining how to use all this new information will be a challenge. It will take time to become comfortable with interpreting and making sense of an incredible number of data points. For example, if a patient checks his blood pressure twice a day for 3 months, his efforts will generate 180 separate blood pressure readings! You can bet there is going to be a good deal of inconsistency in those readings, making interpretation challenging. There will also probably be a few high readings, such as the occasional 190/110, which are likely to cause concern and anxiety in patients. There is little question that the availability of such detailed information holds the potential to allow us to make better decisions. The challenge will be in deciding how to use it to actually improve – not just complicate – patient care.

What are your thoughts on this? Feel free to email us at [email protected].

Dr. Skolnik is a professor of family and community medicine at Jefferson Medical College, Philadelphia, and an associate director of the family medicine residency program at Abington (Pa.) Jefferson Health. Dr. Notte is a family physician and associate chief medical information officer for Abington (Pa.) Jefferson Health. Follow him on twitter (@doctornotte).