For Clinicians
MyCare Hypertension
MyCare Hypertension is a digital program in Connect/MyChart that expedites the management of BP using home BP data.
For general questions about the program, contact Ian Kronish at ik2293@columbia.edu
Patients can log onto MyCareHypertension.org for more information.
How Does It Work
Clinicians order MyCare Hypertension in Epic.
Patients use their own home BP devices. (Help your patients obtain validated home BP devices)
Patients get prompted to review short articles and videos that teach them how to self-manage hypertension.
Patients get prompted to enter BP readings into Connect/MyChart through Track My Health.
Clinicians get weekly Epic in-basket messages with a list of their patients’ BP readings. Clinicians also get in-basket messages when BP readings exceed thresholds. Settings can be customized.
Clinicians get access to the average of home BP readings in last 1 week/1 month/3 months as well as BP trends in Snapshot
You can bill for time teaching patients to use home BP devices and for reviewing home BP data between visits using CPT codes.
Why MyCare Hypertension
Benefits
In the usual approach to home BP monitoring, clinicians rarely get detailed home BP data, and when they do, it can be overwhelming to manage. With MyCare Hypertension, clinicians get access to structured home BP readings in-between and during patients visits. Results in better BP control, higher patient satisfaction.
Reasons
Patients get to use their own home BP device
Patients receive education in how to self-manage hypertension
Home BP data is integrated into Epic
Average BP is calculated for you
Patients get reminders to track their home BP
No fees for patients
Using digital tools to support home BP monitoring is an evidence-based way to lower BP*
Get reliable access to home BP data during or in-between visits
*McManus et al. Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial. BMJ. 2021; 372: m4858.
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Good candidates:
Patients who already have a valid home BP device or who can easily get one
Patients who find it easy to navigate the Connect/MyChart app (e.g., patients who message you through the app)
Patients who are motivated to share their home BP readings with you. Patients may also have family members who wish to enter their BP readings for them
Who to Refer
Clinicians choose who to refer.
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Think twice before referring:
Patients who have trouble navigating Connect/MyChart and don’t have anyone to help them
Patients who have trouble getting their own home BP device
Patients that find it anxiety-provoking to self-monitor their BP at home
Patient does not know how to read English or Spanish
Ordering
⏵ Order in Epic
Orders must be placed from Office Visit or Documentation encounters
Type “MyCare” in order box to find the order “MYC241: Enroll patient in MyCare Companion Hypertension”
The MyCare order is actually a combination of 2 orders: Connect Blood Pressure Flowsheet and My Care Hypertension Care Plan educational modules
⏵ Customize Connect Blood Pressure Flowsheet
You can customize how frequently you want to receive in-basket messages listing home BP readings
You can also modify or discontinue these flowsheets anytime (see below)
Caution: We do not recommend customizing the BP thresholds. These indicate when a BP reading will be flagged as an extreme reading. The term “normal range” is a misnomer.
⏵ Review Educational Tasks (Optional)
Educational tasks assigned to patients can be viewed on a To Do List accessible through an icon near the patient’s name
You can remove one or all tasks if preferred by patients. This can include removing daily reminders to take a blood pressure reading
⏵ Explain the Program to Patients
Key points to convey to patients:
“You will receive a notification on your smartphone/tablet saying that their provider has enrolled them in a Hypertension Monitoring Program.”
“You will be reminded to check your blood pressure at home and asked to enter your BP readings into Connect/MyChart via Track My Health.”
“If you have a wireless home BP device, you may be able to share your BP readings with Track My Health so that you do not need to type in the BP readings.”
“You will be prompted to read articles and watch videos to learn more about how to control their BP.”
“You can contact the Epic help desk for technical support: 646-962-4200 or log onto www.mycarehypertension.org.”
Patient Experience with MyChart Hypertension
Patients can go to mycarehypertension.org to learn more
Ordering a Valid Home BP Device
NY state Medicaid covers the cost of home BP devices. To increase the chance that your patient’s device will be covered by Medicaid, order it on Parachute. It takes seconds to do so, and the device will be delivered within days. Ask your DME Social Worker for help if you need it.
Steps to order on Parachute
Launch Parachute and Create New Order.
2. Select Supplier (Landauer at NYP).
Please note that your practice’s preferred vendor may differ from the one shown below. Ask your social worker or practice manager if you are unsure which is the best one for your practice.
3. Search for '“blood pressure” and select “Automatic Blood Pressure Monitor”.
4. Choose the correct size and provide any additional information needed. Ensure that I10 Hypertension is one of the ICD-10 codes listed. If not, then delete one of the other codes and add I10. This is required for Medicaid coverage.
5. Sign your order.
Don’t forget to ask your patient to bring their home BP device to an upcoming appointment so that you or a team member can check that the patient follows the correct measurement protocol and has the correct cuff size.
If your patient is using a device not on the validated device listing (see www.validatebp.org), also check to see if the BP reading measured by the device is concordant with readings from your office device.
There are several ways to view Home BP readings in Epic. These are the most convenient ways:
Patient Clinical Update. This is where you will get weekly updates of your patients’ home BP readings
Health Trends (found within Patient Snapshot - scroll down to find it). This is the best way to view trends and average BP. Consider changing your layout of Patient Snapshot so that Health Trends is re-positioned to come on top.
Episodes and RPM Synopsis provide two other ways to access home BP data.
Viewing BP Data
Managing Home BP Data
Clinicians manage home BP data how they think best.
To keep track of patients in MyCare, don’t click “Done” for a given patient’s message in Patient Clinical Update until you get another message a week later. Then click “Done” on the prior week’s message. This way you will have one message for each patient.
We recommend giving patients feedback on their home BP data every 1-2 weeks, if possible.
For patients with home BP at or close to goal, click on “Msg to Pt” to send a quick “congratulations” message through Connect.
For patients with home BP above goal and no upcoming appointments, here are some options:
Schedule patient for an in-person or virtual visit. This way you can bill for your time and not add to your unscheduled time
Send your patient a Connect message with treatment recommendations, especially if you had discussed them in advance.
Call your patient, and use billing codes to get reimbursed for your effort
Clinicians can turn off home BP flowsheets anytime if they no longer want to receive home BP readings in Epic
Doctors are not expected to respond to very high or very low readings right away.
MyCareHypertension provides automated triage support.
Patients will be asked to indicate if they are having any symptoms as a way to triage them (See screenshots below)
Extreme BP Readings
BP readings that trigger automated triage support*
SBP < 90 mmHg or > 210 mmHg
DBP > 130 mmHg
Pulse <40 bpm or >130 bpm
*You can customize these settings
Billing
Self-measured BP monitoring is billable under Medicare/Medicaid and some commercial insurers (CPT 94744). If you are interested in billing, discuss how to bill with your practice manager.
CPT 99473 can be applied once for the time spent teaching patients how to use a home BP device correctly.
CPT 99474 can be applied on a monthly basis to bill for the time spent managing patients using home BP data. A minimum of 12 BP readings per month (on any number of days) are required in order for patients to be eligible.
Charges cannot be dropped at the same time as an E&M bill.
Members of the clinician’s team can be the person communicating with patients on behalf of the billing clinician.
Clinicians can drop the bill using a Telephone or Patient Engagement Encounter to document the discussion.
Reimbursement Amount:
Medicare/Medicaid: ~ $15/mo (0.5 RVU)
Commercial insurer: ~ $45/mo (1.5 RVU)
If bills are placed, patients with Medicare or commercial insurance may be charged a co-pay, typically up to 20% or $3 for Medicare and $9 for commercial insurer
Note: You do not need to consent patients before applying SMBP billing codes
Timeline & Program Length
How long does the MyCare Hypertension program last?
Patients get notifications to review articles and videos and to track their home BP readings for 12 weeks. Patients can continue sharing their home BP readings with you after 12 weeks, but will not receive any further reminders to do so.
You or your patient can end the program anytime.
You can re-order the program for your patient at any time. You may need to re-order BP Connect Flowsheets separately to cancel the old Flowsheet and create a new Flowsheet.
If you no longer want to be responsible for viewing the home BP readings, you can turn off the BP Connect Flowsheets at any time.
Customizing Patient Reminders to Track BP
At any time, clinicians can turn off, turn on, or change the frequency of patient reminders to track BP in MyChart. In our experience, most patients stop tracking their BP once reminders expire. It may be appropriate to decrease the frequency of reminders to once or twice a week or even once per month after their home BP is well controlled.
To do any of these, go to the Patient To Do List by clicking the To Do List icon.
To remove individual patient reminders, scroll down the Patient To Do List to where it says “Track Your Blood Pressure” and “Track Your Heart Rate,” then click the X for each one. If you want to remove all To Do List items, click on “Remove All”.
To add patient reminders, go to the Search box at the top of the Patient To Do List, and type “Track Blood Pressure”. Select the option in English or Spanish. The default is English. Note that some options (e.g., “Recheck”, “2x/week” do not allow you to customize the frequency), but the other options do. You can similarly create a reminder to do the same for “Track Heart Rate”.
To customize the patient reminder to track BP, click on Frequency. The default is set at Daily. Click the magnifying glass if you want to see all the options. You can also customize the Start date and End date of reminders. You can also personalize instructions under Patient-friendly description.
Ensure your patients are using valid home BP devices. Go to www.validateBP.org to check to see if your patient’s home BP device is on the validated device listing. Ask your patient to bring their home BP device to an office visit to confirm they are measuring correctly.
Schedule short-term follow-up visits to review home BP readings with your patients. This will help ensure that the time you spend caring for patients in the program will occur during your billable patient care sessions.
Teach your patient that it’s the average that matters. Patients can be confused by their home BP going up and down. Refer them to the www.mycarehypertension.org website for information on understanding their home BP readings.
Review your BP goal (e.g., <130/80 mmHg) with your patient.
Discuss possible treatment plans with your patient in advance of knowing the home BP data. This way, when the data arrives, you will already have a plan in place.
Best Practices for Success
Case Studies
(all based on true patient cases, though details were altered to ensure patient confidentiality)
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NV is a 41 yo woman with obesity (BMI 32) and headaches. She recently became your patient when her insurance changed. She recalls being told she had high BP by her prior doctor but never started treatment. She acknowledges being anxious at the doctor’s office.
Office BP visit 1: 152/92
Office visit 2: 135/94, EKG normal SR, no LVH; normal Cr; Arm circumference = 16”
You recommend she obtain an Omron-3 home BP device (comes with a cuff that fits arm circumference of 9” to 17”) and refer her to MyCare Hypertension. You ask her to bring her home BP device to her next office visit.
Home BP readings in 1st month:
Average home BP 129/79, 20 readings
You call her after 1 month to tell her she has elevated BP, but not hypertension (as per AHA/ACC guidelines)
You agree together that she will work on increasing walking, decreasing portion size, and speaking with the nutritionist about the DASH diet
You recommend she continue monitoring her BP at home intermittently as she is at increased risk for transitioning to stage 1 hypertension by virtue of having white-coat hypertension.
As your patient met the threshold of 12 BP readings in a month, you bill for SMBP using CPT 99474 along with documenting your telephone call in Epic.
2 years later, she comes for an urgent care walk-in visit after being found to have severely elevated BP in dentist office: (BP 182/112), but no symptoms of headache or chest pain.
At walk-in visit, office BP still elevated 172/108. She does not have any recent home BP readings.
You re-refer her to MyCare Hypertension and ask her to start tracking her home BP readings again in MyChart.
This time, average home BP 144/95, 16 readings
You initiate amlodipine 5mg/HCTZ 12.5 mg
One month later, home BP 127/78, no titrations were necessary
Take Home Points:
MyCare Hypertension is useful for assessing white-coat hypertension (BP elevated in office, but non-elevated at home)
Patients with white-coat hypertension are at increased risk of converting to sustained hypertension and will benefit from periodic home BP monitoring
Lifestyle recommendations are still important for patients with elevated BP
Prescribe validated home BP devices, use ValidateBP.org to find validated devices or become familiar with a commonly available accurate device
Initiate combinations of 2 BP medications in patients with stage 2 hypertension. This leads to less need for multiple titrations to get patients to goal and higher patient satisfaction.
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AZ is a 69 yo M, still works as superintendent of an apartment bldg, has mild OA
Medications: acetaminophen, amlodipine 10, HCTZ 25, lisinopril 40
Office BP 146/94
You refer to MyCare Hypertension to determine if he really needs more BP medications.
Home BP readings in first month:
Average home BP: 142/92, 18 readings
Normal Cr, l, K+4.2; aldo 10, renin 1.4
He misses his follow-up appointment, but you catch him on his cell phone.
He agrees to trialing eplerenone 25mg as a 4th line medication even though his labs were not consistent with primary hyperaldosteronism.
As your patient met the threshold of 12 home BP readings in a month, you bill for SMBP using CPT 99474 along with documenting your telephone call in Epic.
Average home BP 1 month later: 135/88, K+4.3
You call him, and he agrees to uptitrate eplerenone to 50mg
As your patient again met the threshold of 12 BP readings in a month, you bill for SMBP using CPT 99474 along with documenting your telephone call.
You see him in your office 6 weeks later
You review his home BP data and labs in advance of his visit
Office BP 135/88; home BP 128/76; normal renal panel
You congratulate your patient on getting his BP under control, explaining that the home BP average is the most important.
You continue MyCare Hypertension for 6 months total to ensure consistent BP control
Although the office visit only took 15 min (99212), you bill for 20 min of work to encompass the additional time you spent reviewing home BP data in advance of visit (99213)
Take Home Points
MyCare Hypertension is useful for motivating patients to track their BP at home, which can provide you with the BP readings you need to confirm patients have true resistant hypertension and benefit from adding a 4th medication
Time spent reviewing data for home BP monitoring can be incorporated into E&M upcoding if done on same day as the office visit
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DJ is a 49 yo M with a family history of early MI and stroke, He has DM on metformin, and hypertension. He is overweight: BMI 29
He is prescribed lisinopril 40, HCTZ 25, amlodipine 10
Office BP: 141/91; Normal renal panel, K+ 4.8
As he already has his own BP device, you refer patient to MyCare Hypertension
Average home BP 1 month later: 140/92, 18 readings
You call patient to discuss treatment options, including adding carvedilol which would be a twice a day medication. You had consider spironolactone but were concerned by the borderline high K+.
He declines to increase his BP medications. He wishes to test better lifestyle management based on what he is learning through the MyCare Hypertension modules. This includes reducing salt in his diet, controlling his stress with meditation, and using a pillbox to help avoid forgetting his medications.
Average home BP at Month 2: 134/82, 16 readings.
Your nurse calls patient on your behalf to discuss results and treatment options. Patient again declines to initiate more BP medication. He prefers to continue to work on lifestyle changes.
As your patient met the threshold of 12 BP readings in a month, you bill for SMBP using CPT 99474 along with documenting the nurses telephone call.
You see patient in the office again at Month 3
Office BP 134/84, average home BP in Month 3: 129/79, 18 readings.
BMI now 27
You congratulate your patient on achieving controlled BP and weight loss.
You recommend ongoing home BP monitoring with patients self-entering BP readings through 6 months.
Take home points:
MyCare Hypertension can improve BP control through increasing patient adherence to medications and lifestyle
Many patients like monitoring their BP at home to test out their ideas for lowering BP without medication
The time your staff (nurses, assistants) spends communicating your plan to patients engaged in home BP monitoring can be used to apply SMBP billing code 99474 on a monthly basis so long as patients have 12 readings in prior month.
At least some synchronous communication (e.g., telephone or video call) with patients is required to bill for SMBP. MyChart messages, alone, are not sufficient.
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ZZ is a 72 yo M with long standing hypertension, stage 4 CKD, CAD, and IDDM.
His office BP is 162/88.
BP medications include: chlorthalidone 25, nifedipine ER 90, furosemide 20
Renal panel has Cr 2.8, K+ 4.8
You refer patient to MyCare Hypertension.
Average home BP 6 weeks later: 148/95, but home BP readings range from 104/66 to 180/112 and pulse ranges from 60-88.
Patient describes occasional dizziness, but not clearly related to when he has low BP readings.
Patient has good understanding of his BP medications and uses a pillbox.
You review his prescription fill data in Epic and see all his BP medications have recent fill dates
You add carvedilol 6.25 bid.
Average home BP 3 months later: 144/92, home BP readings range from 96/56 to 178/110 and pulse ranges from 48-88.
You order eConsult Hypertension Center for advice on titrating his BP regimen.
You refer patient to nephrology for assistance managing his CKD and uncontrolled, labile BP.
Take Home Points:
MyCare Hypertension can be used to identify challenging patients with true resistant hypertension and labile home BP readings
Epic can be used to determine whether patients are filling their BP medications.
Use a team approach to try to get these challenging, high-risk patients to goal.
E-consult for hypertension can be used for quick advice on challenging hypertension cases.
Consultants that may be helpful for co-managing complex hypertension include:
• pharmacists, especially helpful for medication reconciliation and adherence counseling
• cardiologists or nephrologists if underlying CKD
• Columbia Hypertension Center, includes cardiology and nephrology experts in hypertension management (Epic order, 212-342-1273 or https://www.columbiadoctors.org/specialties/cardiology-cardiac-surgery/our-services/hypertension-center)
Other Hypertension Resources
Ordering home BP devices
Medicaid should cover the cost of home BP devices, but managed plans put barriers to receiving them. Order your device on Parachute or ask your social worker for assistance in obtaining home BP devices for your Medicaid-insured patients
Order validated devices. Check the www.validatebp.org to learn if your patient’s home BP device is on the validated device listing.
Ensure you choose the correct cuff size. BP cuffs that are too small can artificially raise BP by 20 mmHg or more.
Consultants that may be helpful for co-managing complex hypertension include:
Pharmacists, especially helpful for medication reconciliation and adherence counseling
Cardiologists or nephrologists if underlying CKD
Hypertension specialists at the Columbia Hypertension Center, includes cardiology and nephrology experts in hypertension management (Call 212-342-1273 or visit here)