Measure Components	The CDU uses an EHR system to obtain data that permit assessment of accurate diagnosis and assessment of HBP control and documentation of ASCVD risk, including:
	The EHR/registry vendor shoul d be able to export SDP and DBP measurements associated with ambulatory clinic visits, including the date of service.
	The CDU should consider a standardized field in which the clinician can document the BP used in decision making and the date of service.
	The CDU should consider a standardized field to record home BP determinations and ASCVD risk assessment.
	The EHR/registry vendors should consider creating structured data elements using established, standardized nomenclature.
Rationale
A growing number of health systems are developing or using registries and EHRs that permit large-scale queries to support population health management strategies to identify undiagnosed or undertreated hypertension. Such innovations are implemented as ongoing quality improvement initiatives in clinical practice. To reduce undiagnosed hypertension and improve hypertension management, a multipronged approach may include 1) application of hypertension screening algorithms to EHR databases to identify at-risk patients, 2) contacting at-risk patients to schedule BP measurements, 3) monthly written feedback to clinicians about at-risk patients who have yet to complete a BP measurement, and 4) electronic prompts for BP measurements whenever at-risk patients visit the clinic.55,57
Since passage of the Hitech Act, the use of EHRs and registries in clinical practice has become nearly ubiquitous. The purpose of this SM is to provide guidance to the CDU to aid in the identification of patients with elevated BP or stage 1 or stage 2 HBP through the EHR and/or registry.
Previous studies have demonstrated that many patients with elevated BP or stage 1 or stage 2 HBP are undiagnosed with conventional administrative data sets (ICD-10). Use of free-text data searches or structured data searches can facilitate the identification of appropriate patients. In particular, we recommend the use of NQF’s denominator exceptions for medical, patient, and system exceptions to improve the accuracy of the data.
The evaluation of structured data will greatly facilitate the accuracy of this hypertension performance measure. The intention of this measure is to promote the accurate collection and analysis of BP and demographics through the EHR by using standards-based tools. Currently, most EHRs and registries do not have a specific mapping of sufficient elements to allow the accurate recording and attribution of BPs.
The intention of this SM is to provide guidance to EHR and registry vendors to support fluid data flow between the EHR and the registry, using existing established structured data elements.
Potential additional benefits and characteristics of using properly configured EHRs and registries include:
1. CDS-based algorithms that support evidence-based guideline recommendations for accurate measurement, risk assessment, diagnosis, classification, and appropriate treatment for patients with or at risk of HBP
2. Properly vetted reminders and alerts for both clinicians and patients to ensure follow-up appointments, patient engagement, and adherence to GDMT.
3. Compliance with current national interoperability standards to facilitate exchange of information, including the timely transmission of digital data from BP measurement and monitoring devices.
4. Easy extraction of data needed for advanced analytic approaches to accurate classification and treatment of populations with or at risk of HBP.
5. Accurate and automated extraction of necessary data elements for construction, benchmarking, auditing, and feedback to providers and external reporting (eg, to CMS, NCQA, commercial payers, quality improvement initiatives, and professional society accrediting bodies) of standardized performance and quality measures.
6. Facilitation of internal and external quality improvement initiatives, such as Target: BP (AHA and AMA) and The Million Hearts campaign (HHS, CDC).
7. Documentation of nonclinical data, such as social determinants of health, health literacy, and shared decision making.
Clinical Recommendations
2017 Hypertension Clinical Practice Guidelines4
Recommendations for EHR and Patient Registries (Guideline Section 12.3)
1. Use of the EHR and patient registries is beneficial for identification of patients with undiagnosed or undertreated hypertension.55–57 (Class 1, Level of Evidence: B-NR)
2. Use of the EHR and patient registries is beneficial for guiding quality improvement efforts designed to improve hypertension control.55–57 (Class 1, Level of Evidence: B-NR)

ACC indicates American College of Cardiology; AHA, American Heart Association; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CDC, Centers for Disease Control and Prevention; CDS, clinical decision support; CDU, care delivery unit; EHR, electronic health record; GDMT, guideline-directed medical therapy/treatment; HBP, high blood pressure; HHS, Health and Human Services; ICD-10, International Classification of Diseases, 10th edition; NCQA, National Committee for Quality Assurance; PCE, pooled cohort equations; and SM, structural measure.