A public health/primary care partnership to achieve million hearts, physicians quality reporting initiative, and national quality forum goals

West Virginia ranks among the highest in the nation in prevalence of high blood pressure, contributing to troubling rates of cardiovascular disease, heart attack, kidney disease, and stroke. The West Virginia Cardiovascular Health Program and the West Virginia University Office of Health Services Research responded to this problem through an intervention addressing high blood pressure in the primary care setting. Primary care was chosen as the focus as it allows opportunity to address patient care and health outcomes on a more systematic level; impacting on each center's policies and procedures in the diagnosis and treatment of patients with high blood pressure. This effort is bolstered by analysis of electronic health record data using patient registry software to systematize identification of at-risk/undiagnosed patients, stage patients according to blood pressure control, and increase opportunity for patient-provider engagement. Among three pilot West Virginia primary care organizations, the Chronic Disease Electronic Management System is used as a platform for standardizing disparate electronic health record datasets into a common format to systematically track and intervene with this patient population. The registry software allows sites to benchmark outcomes according to Million Hearts, Physicians Quality Reporting Initiative, and National Quality Forum goals. Cohort analyses of de-identified data reveal improvement in: blood pressure control among patients 18-85 with hypertension; LDL control among patients 18 and older with coronary artery disease; increased tobacco screening among patients 18 and older; increased use of weight management plans among patients 18 and older with cardiovascular disease who are overweight or obese; increased prescription of aspirin therapy among at-risk patients; and increased screening and identification of current smokers . This partnership enhances the abilities of primary care centers to use data for quality improvement, while facilitating public health efforts by allowing for multi-site, longitudinal data tracking, de-identified data sharing, and targeting of resources.