Average Blood Pressure

Physiologic measurements of a patient that indicate the status of the body’s life sustaining functions.

Data Element

Description (*Please confirm or update this field for the new USCDI version*)

Arithmetic average of systolic and diastolic components of two of more blood pressure readings in a specified time period or according to a specified algorithm or protocol.

Examples include but are not limited to 3-day morning and evening home monitoring, clinical encounter repeat average, and 24-hour ambulatory measurement.

Applicable Vocabulary Standard(s)

Applicable Standards (*Please confirm or update this field for the new USCDI version*)

Both standards are required.

Logical Observation Identifiers Names and Codes (LOINC®) version 2.74
The Unified Code of Units for Measure, Revision 2.1

Submitted By: Matt Reid / American Medical Association
Data Element Information
Rationale for Separate Consideration	USCDI has Diastolic Blood Pressure and Systolic Blood Pressure, but it does not have average (computed) blood pressures for each.
Use Case Description(s)
Use Case Description	Use Case #1 Submitted by AMA Over 85 million adults in the United States have high blood pressure. Average blood pressure readings can guide the diagnosis and treatment of hypertension. The M.A.P. (Measure Accurately, Act Rapidly and Partner with Patients) BP Improvement Program is an integral part of Target: BPTM, a national initiative formed by the American Heart Association and the American Medical Association in response to the rising incidence of uncontrolled BP. Guidance in the M.A.P. Program includes: • For those with an initial screening blood pressure reading above the cut-off threshold, the average of two or more BP readings is recommended. • For those doing self-measured blood pressure (SMBP) monitoring the M.A.P. Program also provides a protocol for measuring an average blood pressure over the course of a week. Use Case #2 Submitted by CDC: The CDC Division for Heart Disease and Stroke Prevention and the Million Hearts® 2022 Hearts national initiative (co-led by the Centers for Medicare & Medicaid Services) uses this data as it is available for monitoring and evaluation to prevent 1 million heart attacks and strokes in 5 years. Furthermore, the CDC plans to leverage this data further in the future for surveillance and epidemiology studies if advanced through policy and available from EHRs. The Multi-state EHR-based Network for Disease Surveillance (MENDS) pilot will use electronic health record (EHR) data collected in clinical settings leading to a real-time, chronic disease surveillance model to plan and evaluate short-term outcomes of policies and program interventions.
Estimate the breadth of applicability of the use case(s) for this data element	Use Case #1 Over 85 million adults in the United States have high blood pressure. Average BP measurements can be used by thousands of physicians to better diagnose and manage hypertension.
Link to use case project page	https://targetbp.org/patient-measured-bp/how-it-works/ https://targetbp.org/wp-content/uploads/2017/08/Target-BP-Participant-Webinar-Measure-Accurately-8-10-2017.pdf
Healthcare Aims	Improving patient experience of care (quality and/or satisfaction) Improving the health of populations Reducing the cost of care Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s)	SNOMED CT has: 723232008 \|Average blood pressure (observable entity)\| 314453003 \|Average diastolic blood pressure (observable entity)\| 314440001 \|Average systolic blood pressure (observable entity)\| LOINC (version 2.69): 96607-7 Blood pressure panel unspecified time mean 96608-5 Systolic blood pressure unspecified time mean 96609-3 Diastolic blood pressure unspecified time mean
Additional Specifications	The data element is included in the HL7 FHIR® Implementation Guide: Vital Signs, Release 1- US Realm (1st Standard for Trial Use Ballot) which went through the ballot cycle in September 2020. After this submission was accepted by USCDI in October 2020 as Level 2, the Vital Signs Implementation Guide has completed the ballot process and anticipates reaching STU1 in 2021.
Current Use	In limited use in production environments
Supporting Artifacts	Cerner, Epic and Higi use Average Blood Pressures (systolic and diastolic). Submission of this data element is also rooted in the information cited in: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines For example, the cited document states, “BP is categorized into 4 levels on the basis of average BP measured in a healthcare setting (office pressures): normal, elevated, and stage 1 or 2 hypertension.” https://pubmed.ncbi.nlm.nih.gov/29133354/
Extent of exchange	2-3
Supporting Artifacts	To our knowledge, there are production implementations that exchange Average Blood Pressure information using FHIR. Specifically, we are aware that at least Higi and Cerner exchange this data through a SMART Application.
Potential Challenges
Restrictions on Standardization (e.g. proprietary code)	N/A
Restrictions on Use (e.g. licensing, user fees)	N/A
Privacy and Security Concerns	We support expanding the USCDI and the overall goal of getting meaningful information into the hands of clinicians and patients. However, we stress that the USCDI coupled with increased access to this information (both inside and outside HIPAA), could create a conduit for bad actors to syphon sensitive data from patients. We believe there should always be a balance between more information and strengthening patients’ trust in how the information is used. As with any personal information, there is a need to ensure patients are comfortable sharing such data with their physicians. Thus, we encourage ONC to expand the USCDI to include average blood pressure data elements while concurrently coordinating with standards development organizations working to ensure data is shared with appropriate protections, including when it is accessed by third parties outside of the health care system.
Estimate of Overall Burden	Unknown

ASTP Evaluation Details Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1 Maturity - Current Standards	Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2 Maturity - Current Use	Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3 Maturity - Current Exchange	Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4 Use Case(s) - Breadth of Applicability	Level 2 - Use cases apply to most care settings or specialties.

Comment

Submitted by RUy on 2023-09-21

Vital Signs – Date and Time is a crucial for Average BP

We applaud the inclusion of Average Blood Pressure on USCDIv4.

Vital Signs – Date and Time is a crucial metadata that is currently not included in USCDIv4.

See attached letter of support for details and additional comments on multiple data elements.

2023-09-20 NACHC USCDIv5 Letter of Support_16.pdf

Submitted by marti.velezis on 2023-04-18

Include additional data for ABP

An average blood pressure should include the following information whether it is self-measured or in a clinical setting: Device identification (e.g., identifier for the device or manufacturer/device name), Method, and BP Body Position (i.e., the body position of the patient while measuring the blood pressure).

Submitted by yale-coredQMRoadmap on 2023-04-17

CMS-CCSQ/CDC Joint USCDIv4 Priority: ABP

CDC and CMS agree that Average Blood Pressure should move forward as part of USCDI V4. However, in the draft final USCDIv4 ABP data element description, ONC has defined ABP as “Mean value of two or more blood pressure readings in a specified time period.” CDC and CMS strongly recommend clarifying the language to say either “average” to eliminate any confusion end-users could have with using mean arterial pressure or “arithmetic mean” to differentiate between other types of means (e.g., geometric, harmonic).

Submitted by mattreid on 2023-04-17

Support Average Blood Pressure for USCDI v4

The American Medical Association (AMA) appreciates the opportunity to provide public comment in support of adding the Average Blood Pressure (ABP) Level 2 data element to the final USCDI v4.

High blood pressure impacts more than 120 million people in the United States. It is the leading modifiable risk factor for preventing cardiovascular disease and premature death. The accurate measurement and interpretation of blood pressure for diagnosing and assessing the effectiveness of treatment is imperative to improving the health of the nation.

The value and improved accuracy of an average blood pressure compared to a single blood pressure reading has been demonstrated repeatedly through clinical evidence over the last 30 years (Chen et al., 2018). Due to physiologic variability, single blood pressure readings are suboptimal for clinical decision making. It is clear and affirmed in clinical practice guidelines (Whelton et al., 2018; Williams et al., 2018), scientific statements (Muntner et al., 2019), and policy statements (Shimbo et al., 2020) that obtaining two or more BP readings and calculating the average is a more accurate and representative measurement of an individual’s blood pressure compared to a single BP reading.

Although there are several different methods of measuring BP, the individual readings from each method should be averaged to make them clinically useful. Due to this, the definition of the average blood pressure data element purposely does not define requirements for a protocol that must be used to calculate an average.

Physicians need health IT systems that can store and exchange Average Blood Pressure separately from individual readings. This will lay the groundwork for consistent communication of needed patient information by facilitating documentation and enabling physicians to use this specific information in their clinical decision making.

We support the Health Information Technology Advisory Committee and subsequent Interoperability Standards Workgroup recommendation to include Average Blood Pressure in the USCDI v4. AMA strongly urge ONC to adopt Average Blood Pressure data element into the final USCDI v4 as it is critical for the accurate measurement of blood pressure and essential in driving clinical decisions.

Submitted by gc_vreyes on 2023-04-12

Average Blood Pressure for USCDI v4

Guideline Central supports inclusion of Average Blood Pressure for USCDI v4 as it further aids in implementation and adoption of clinical practice guidelines.

Submitted by nedragarrett_CDC on 2023-04-06

CDC's Consolidated Comment for USCDI v4

“We greatly appreciate ONC’s continued leadership on the USCDI. Interoperability in the clinical space is key to optimizing many processes including the inclusion of self-measured blood pressure monitoring (SMBP) into patient care. SMBP is an evidence-based strategy for reducing blood pressure and improving control among patients with hypertension and has the potential to address hypertension-related equity issues. SMBP and other types of out-of-the-office blood pressure monitoring rely on using average blood pressure (ABP) to provide a representative blood pressure value. A structured field in the EHR that captures ABP (and related metadata) is essential for enabling these technologies to be properly incorporated into care pathways. Blood pressure naturally fluctuates so average values are more representative of a patient’s true blood pressure, regardless of the technology used. Physicians need health IT systems that can store and exchange ABP separately and apart from individual readings. Including ABP in the USCDI v4 will enable interoperability of blood pressure information among sites of care, within care teams, and with patients. It will also improve clinicians’ abilities to use these data for quality reporting, clinical decision support, and quality improvement efforts. Because of the reasons articulated above, CDC requests that ONC include the Average Blood Pressure Level 2 data element in the final USCDIv4. ONC has defined ABP as “value of two or more blood pressure readings in a specified time period.” We respectfully request clarifying the language to say either “average” to eliminate any confusion end-users could have with mean arterial pressure or using or “arithmetic mean” to differentiate between other types of means (e.g., geometric, harmonic). CardX represents a wide cross-section of stakeholders working to improve hypertension control by leveraging FHIR-based interoperability through the Hypertension Management. The Hypertension Management use case team is actively working on leveraging and extending existing standards to represent Average Blood Pressure in accurate, meaningful, and actionable terms for clinical decision making "

Comments from NACCHO: NACCHO supports the inclusion of this data element. We would also encourage an inclusion of a specified time period. This will reduce confusion for providers on what to submit as an average.

Submitted by Callie-phillips on 2023-04-05

Support Average Blood Pressure for USCDI v4

The HL7 CodeX FHIR Accelerator Cardiovascular Health Domain (CardX) enthusiastically supports the addition of Average Blood Pressure to the draft USCDI v4. We strongly urge ONC to adopt the Average Blood Pressure data element into the final USCDI v4 as it is critical in driving evidence-based clinical decisions.

CardX represents a wide cross-section of stakeholders working to improve hypertension control by leveraging FHIR-based interoperability. Our Hypertension Management use case team (https://confluence.hl7.org/display/COD/CardX+-+Hypertension+Management) is actively working on leveraging – and extending – existing standards to represent Average Blood Pressure in accurate, meaningful and actionable terms for clinical decision making.

We note that the concept of Average Blood Pressure is not the same as the concept of Mean Arterial Pressure. We urge ONC to clarify the data element definition to specifically refer to “arithmetic mean”.

Signatory CodeX members participating in CardX’s Hypertension Use Case:

American Heart Association, American Medical Association, eviCore healthcare, Guideline Central, Medtronic, MITRE Corporation, Story Health, and the University of Nebraska Medical Center – Center for Intelligent Health Care

Submitted by litvincb on 2023-03-29

Average blood pressure in USCDI v4

Thank you for recognizing the need for Average Blood Pressure as a data element. This will very much facilitate the appropriate and evidence-based use of home blood pressure monitoring to guide clinical decision making about hypertension. Last year, I wrote an article in Health Affairs Forefront describing the importance of ensuring regulatory policies around blood pressure management including CQMs and remote monitoring codes are consistent with evidence-based guidelines (https://www.healthaffairs.org/do/10.1377/forefront.20220517.440131) . Inclusion of an average blood pressure as a data element is a very big step in this direction. Cara Litvin MD

Submitted by palmcorp on 2023-03-29

Average Blood Pressure as a useful health metric

Thank you for recognizing the key need and vital functionality of the Average Blood Pressure data element and adding it to the draft USCDI v4. PALM Associates, Inc. strongly urge ONC to adopt this data element into the final USCDI v4 as it is critical to the accurate measurement of blood pressure and essential in driving clinical decisions.

PALM Associates, Inc. note that the concept of Average Blood Pressure is not the same as the concept of Mean Arterial Pressure. We urge ONC to clarify the data element definition to specifically refer to “arithmetic mean”.

Submitted by ptilkemeier on 2023-03-25

Thank you for recognizing…

Thank you for recognizing the vital functionality of the Average Blood Pressure data element and adding it to the draft USCDI v4. Prisma Health, a large integrated health delivery system in South Carolina with a clinically integrated network strongly urge ONC to adopt this data element into the final USCDI v4 as it is critical to the accurate measurement of blood pressure and essential in driving clinical decisions. The addition of this variable will allow for better assessment of patient care delivery, risk reduction and improvement of the care of our population.