Better blood pressure, no added burden: One practice's story


A Chicago-area physician has achieved a 90 percent control rate for his hypertension patients in the past year by working with his medical assistant, nurse and other staff members to execute standardized blood pressure protocols in the practice.


Family medicine physician Michael K. Rakotz, MD (pictured right), is using a team-based care approach to improve hypertension control in his office. Dr. Rakotz is part of a pilot program of the AMA’s Improving Health Outcomes initiative, which involves physicians and their teams at multiple clinic sites in two states. Participating practices are incorporating evidence-based principles into their workflows to control hypertension.

Since the start of the pilot, Dr. Rakotz’s practice has seen a double-digit leap in the number of hypertensive patients who have their blood pressure controlled, moving from 78 percent to 90 percent in 12 months. He attributes the practice’s success to the work of his practice staff, who have been trained in a standardized checklist approach to measuring blood pressure.

Dr. Rakotz’s medical assistant (MA) follows a procedure to measure accurately. If an initial automated reading shows that blood pressure is elevated, she follows a specified protocol using an automated machine that takes multiple readings over six minutes, with no staff in the room to reduce the “white coat” effect on the patient’s blood pressure. If these readings indicate the patient has high blood pressure, the MA flags this information for Dr. Rakotz.

“All of this occurs before the physician enters the room, so the system is very efficient,” Dr. Rakotz said. “It does not add any burden to the physician.”

The practice also has a strong home-monitoring program for patients whose blood pressure management requires more clinical data. Practice staff give these patients a special checklist that explains how to properly position themselves for measurement as well as when and how often they should be measuring their blood pressure. Staff can validate and check the accuracy of patients’ personal blood pressure machines or lend patients machines that record a week’s worth of blood pressure readings.

Practice staff enters all data from patients’ home monitoring into the practice’s electronic health record system.

“This brings actionable information to the physician before the physician even walks into the exam room,” Dr. Rakotz said. “Those kinds of little innovations, little empowerments of the staff, make the system function really well.”

He also employs a nurse to take charge of patient outreach.

The challenge up front is training staff to understand and appropriately implement checklists and protocols. After that, “it’s autopilot,” Dr. Rakotz said.

“Physicians are so overwhelmed with meaningful use criteria, insurance authorizations, paperwork and forms—all this nonclinical care,” he said. “Anything our staff can do to help us is huge. The more time I have to care for patients, the better. I want [my staff] to be smart and follow protocols using common sense. If someone has high blood pressure, I want my staff to know what to do. I want them to follow a set of guidelines.”

The AMA pilot is working with researchers at Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities to develop test protocols, including the one Dr. Rakotz uses. The tools are being refined before being made available to physicians across the country.

“Even if you’re in a more rural, smaller practice, the more time you invest in training your staff up front, the more dividends you’re going to get on the back end in quality of care,” Dr. Rakotz said.