1. Underdiagnosis of Pediatric Hypertension – An Example of the Potential of Electronic Medical Record Research for Clinical Pediatricians
David C Kaelber, MD, PhD
Internal Medicine and Pediatrics Physician
National Library of Medicine Medical Informatics Fellow
Center for Information Technology Leadership (CITL)
Staff Physician
Children's Hospital Boston, Brigham and Women’s Hospital, Massachusetts General Hospital, and Massachusetts General Hospital for Children

2. Disclosures
I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity.
I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3. Background

4. 2-5% of all children have hypertension.
Background
Adult
Children
Blood Pressure
Stage II HTN
Stage I HTN
Pre-hypertensive
Normal
SBP >159 and/or DBP >99
SBP >139 and ≤159 and/or DBP >89 and ≤99
SBP >120 and ≤139 and/or DBP >80 and ≤89
SBP ≤120 and/or DBP ≤80
SBP and/or DBP > 99% +5mmHg for gender, age, and height
SBP and/or DBP ≥ 95% and ≤ 99% +5mmHg for gender, age, and height
SBP and/or DBP ≥ 90% and < 95% for gender, age, and height
SBP and/or DBP < 90% for gender, age, and height
Need 3 measurements for diagnosis of hypertension (HTN) or prehypertension (preHTN).
2-5% of all children have hypertension.

5. Study Design Design: Cohort study.
Setting: Outpatient clinics in a large, academic, urban medical system in Northeast Ohio.
Patients: children and adolescents age 3-18 years who were seen at least three times for well-child care between June 1999 and September 2006.
Main Outcome Measures: Diagnosis of hypertension or prehypertension documented in the electronic medical record (EMR). Logistic regression analysis was performed to identify factors associated with a correct diagnosis.

6. EMR Data Collection Basic Information MR# birth date gender race
primary care physician
past medical history
past surgical history
family history
Visit information
visit date
visit site
BP reading(s)
height reading
weight reading
diagnosis code(s) (ICD9)
problem list code(s) (ICD9)
order(s)
billing code(s)

7. Study Results

8. Study Results

9. Study Results – HTN factors
Logistic regression analysis of factors associated with having a correct diagnosis of HTN
Variable OR
95%CI
Age (1 year increase)
1.09
Height-for-Age Percentile (1% increase)
1.02
Weight-for-Age Percentile (1% increase)
1.00
Obesity-related diagnosis
2.61
Male Sex
1.15
African American Race
1.04
Hispanic/Latino Race
1.31
Family History of HTN
1.21
Number of Elevated Blood Pressures over 3 required
1.77
Stage 2 HTN
1.68

10. EMR Study1 Paper Chart Study2
Task
# of hours
EMR Study Paper Chart Study2
Planning Meetings 30
IRB Preparation 10
Data Collection 5
5764
Data Processing 15
Data Analysis
Abstract
Manuscript 40
TOTAL
145
5909
Distribution of Task and # of hours to complete tasks.
1 – actual time for this EMR study
2 – estimated time for equivalent paper chart study (assumes 1 minute for initial screen and 5 minutes to find and extract data)

11. Study Timeline
April June August October December August
Clinical
Observation
IRB Approved
PAS Abstract Submitted
Data Obtained and Analyzed
Study Design and Team
ML Hanson, PW Gunn, and DC Kaelber. Underdiagnosis of Hypertension in Children and Adolescents. Journal of the American Medical Association. 298(8):
1 3rd year medical school student, 1 4th year medical school student,
1 medical informatics fellow, ~150 hours, ~17 months, $0

12. Clinical Research Implications (retrospective clinical research)
Characteristic
Old Paradigm
New Paradigm
Data
Separate Research Database
Shared Research and Clinic Database (EMR)
Time
1000+ hours
100+ hours
Money
100,000-1,000,000+
0-10,000+
People
Many
Few
Order of magnitude less time and money with electronic medical records.

13. Conclusions
Electronic medical records have the potential to create a paradigm shift in retrospective clinical research.
This paradigm shift can make clinical research much for accessible for clinical pediatricians.

14. dkaelber@partners.org or david.kaelber@case.edu
Questions?? Comments?? or