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Three Ways Your Workflow Can Hinder Hypertension Management

With a growing number of patients being monitored for hypertension, it seems logical that practice workflows should be optimized to enhance management of this disease.

Here are three common situations in busy primary care practices that could potentially impact how you diagnose and treat your patients relative to blood pressure, and how you can address them.

1. The “white coat” effect

Many practice workflows still depend on manual single-reading methods for blood pressure—but evidence suggests this may not be sufficient for identifying and diagnosing hypertension. Mitigating factors may include white coat hypertension, among others.1

When the “white coat” effect is in play, a patient’s blood pressure is uncharacteristically high in the office, potentially leading to a false hypertension diagnosis and unnecessary medication.

“Addressing this effect may require a device that takes blood pressure automatically when the patient is in the room alone. It may require averaging or just discarding the first two readings we take,” said John Bisognano, MD, PhD.

Blood pressure averaging has, in fact, been shown to reduce misdiagnosis of hypertension by up to 56%.2 Monitors classified for unattended use are also available, helping to reduce the risk of white coat hypertension without impacting accuracy. Clinicians should, of course, be mindful that automated readings can have some limitations in patients with certain arrhythmias.

Even when white coat hypertension is not a factor, Dr. Bisognano is in favor of using digital technology for blood pressure readings. “I don’t see any advantage in manual devices. The technology for digital devices has been well tested, and it’s probably more accurate than most people reading blood pressure on their own,” he said.

“We also do our patients a disservice if we don’t get a reading we like digitally, and we tell the patient, ‘I’m going to take it manually,’’’ said Dr. Bisognano. “It suggests that since the digital method didn’t give me the numbers I want, now I’m going to do it ‘right.’ And that’s not the message we really want to be giving a patient because the automated readings are accurate.”

2. Errors due to rushing, rounding and transcription

“In most offices, we’re committed to take a blood pressure very quickly, as we’re bringing the patient into the clinic room. But to take a reading appropriately, you can’t rush through it,” said Dr. Bisognano.

The consequences of rushing and not following guidelines for appropriate measurement can be critical. Under- or overestimating blood pressure by as little as 5 mmHg can lead clinicians to incorrectly rule hypertension in or out. The ramifications of this may include improper medication, unnecessary costs and negative psychological reactions.3

“I’ve seen people let the air out of the cuff like they’re letting air out of a balloon. When they do this … they’re accepting inaccuracy because they’re in a hurry,” said Dr.Bisognano. “With an automated device, you can’t rush it. It insists on giving you an accurate reading.”In addition, manual transcription can easily lead to data entry errors and omissions in the EMR, which can negatively impact treatment decisions and patient outcomes.

“It’s not uncommon to see an outlying blood pressure as a result,” said Dr. Bisognano. “If the patient’s blood pressure is always 139 and the record shows 169, did the person entering the data hit the wrong key? If it goes from 139 to 193, did they reverse the keys?”

Monitors with EMR connectivity can send accurate, timely vital signs data to your EMR with the tap of a button. No manual data entry is required. “Anything that can go directly into the medical record is a big plus, because it improves accuracy tremendously,” said Dr. Bisognano.

3. Hearing loss and environmental factors

Hearing levels and other environmental factors also need to be considered, as they can impact the accuracy of manual readings.1 Hearing loss, for example, may lead to misreading the Korotkoff sounds at systolic blood pressure and diastolic blood pressure.4

“An automated cuff will take the appropriate amount of time to get you a good reading, so the only variable is the patient’s variability—are they nervous? Do they have ‘white coat?’ If you take it manually, the variables are the patient’s variability, as well as the reader’s variability—does the reader have hearing loss, or is their hearing compromised in some way? Even people with normal hearing have occasional sinusitis, stuffy ears and allergies,” said Dr. Bisognano.

Digital blood pressure readings can help standardize technique across clinicians and circumstances.

Are there other things to consider?

“Patients who have hypertension tend to be rich in other cardiovascular disease, so it’s not uncommon to find a patient with hypertension who has had arrhythmia, such as atrial fibrillation, or evidence of an old heart attack on their ECG,” said Dr. Bisognano.

Connectivity can help with ECGs as well. If the ECG device is connected to the EMR, transcription errors are eliminated. Some of these devices also offer automated technology designed to capture data with the least amount of noise. “People move during an ECG, no matter how many times you tell them not to. So, having a device that captures the best ten seconds is a great advantage,” said Dr. Bisognano.

When it comes to diagnosing hypertension, accurate blood pressure readings are non-negotiable. Automated vital signs devices can mitigate common factors that can impact readings—and put clinicians’ minds at ease.


1. Pickering, Thomas G., MD, D Phil, et al. Recommendations for Blood Pressure Measurement in Humans and Experimental Animals. Circulation. 2005; 111:697-716.

2. Smith, R. Blood pressure averaging methodology: Decreasing the risk of misdiagnosing hypertension. 2014.

3. Handler J. The Importance of Accurate Blood Pressure Measurement. The Permanente Journal. 2009;13(3):51-54.

4. Song S, Lee J, Chee Y, Jang DP, Kim IY. Does the accuracy of blood pressure measurement correlate with hearing loss of the observer? Blood Press Monit. 2014 Feb; 19(1):14-8.