A Comparison of Web Sites Used to Manage and Present Home Blood Pressure Readings

E d i t o r i a l

A Comparison of Web Sites Used toManage and Present Home BloodPressure Readings

Birju Patel, BS;1 Sharon Turban, MD, MHS;2 Cheryl Anderson, PhD, MPH;3,4

Jeanne Charleston, RN;4 Edgar R. Miller, MD, PhD;1,3,4

Lawrence J. Appel, MD, MPH1,3,4

Home blood pressure (HBP) monitoring is nowrecommended as a routine component of bloodpressure management in patients with known orsuspected hypertension. Over the last few years,a large number of Web sites, commonly termedPersonal Health Records, have been developed sothat patients can manage and present HBP read-ings. The objective of this report is to describeand compare these Web sites. A list of 33 desir-able Web site features, organized into 4 catego-ries, was developed. Between June and August of2009, a total of 60 Web sites was identified, ofwhich 20 were free or free to try. Each of the 20Web sites displayed HBP readings in tabular andgraphical formats, most offered an option toprint results in tabular (70%) and graphical(70%) form, and many (47%) could downloadHBP data from Microsoft HealthVault. In con-trast, none of the Web sites directly linked with

common electronic medical records. Overall,Web sites offered between 41% and 77% of the33 features considered desirable. In conclusion,there is considerable variation in available fea-tures on Web sites used to manage HBP data.Information presented in this report should beuseful to physicians and patients in selecting aWeb site for managing and presenting HBP read-ings and ultimately improving blood pressurecontrol. J Clin Hypertens (Greenwich).2010;12:389–395. ª2010 Wiley Periodicals, Inc.

In a recent scientific statement, the AmericanHeart Association concluded that home blood

pressure (HBP) monitoring ‘‘should become aroutine component of blood pressure (BP) mea-surement in the majority of patients with knownor suspected hypertension.’’1 Potential benefitsinclude more accurate assessment of usual BP,rapid titration of antihypertensive therapy, identi-fication of white-coat and masked hypertension,and greater patient involvement in managinghypertension, a condition that is typically asymp-tomatic. HBP readings may also be better predic-tors of cardiovascular and renal outcomes thanoffice readings.2,3

According to a 2006 Harris poll, 55% ofpatients with hypertension monitor their BP athome.4 To date, the medical literature has focusedon the accuracy of devices5,6 and the need forappropriate training of patients.7 Some lay publica-tions have compared available HBP devices.8 A listof validated HBP devices is on the http://www.

From the Division of General Internal Medicine1 andthe Division of Nephrology,2 The Johns HopkinsUniversity School of Medicine; the Welch Center forPrevention, Epidemiology, and Clinical Research,The Johns Hopkins University;3 and the Departmentof Epidemiology, The Johns Hopkins UniversityBloomberg School of Public Health, Baltimore, MD4

Address for correspondence:Lawrence J. Appel, MD, MPH, 2024 East MonumentStreet, Suite 2-618, Baltimore, MD, 21287E-mail: [email protected] received September 9, 2009; revised November5, 2009; accepted November 18, 2009

doi: 10.1111/j.1751-7176.2010.00277.x

VOL. 12 NO. 6 JUNE 2010 THE JOURNAL OF CLINICAL HYPERTENSION 389

dableducational.org Web site. Less well-appreciatedis the need for storing and presenting data in a for-mat that can facilitate appropriate decision making.It is commonplace for patients to provide theirhealth care providers with hand-written lists ofHBP readings, typically without averaging values ordisplaying time trends. Occasionally, patients pre-pare spreadsheets that compile and display HBPdata in tabular or graphical form.

The widespread use of the Internet, along with aburgeoning array of applications, provides a tre-mendous opportunity to improve the usefulness ofHBP monitoring. Specifically, with the developmentof technology-based personal health records(PHRs), patients should be able to easily store,track, and display their HBP readings and sharethese results with their health care providers. How-ever, many people are not aware of these Websites, which vary considerably in the types of fea-tures that are offered. Accordingly, both patientsand physicians face difficulties in choosing anappropriate PHR that meets their needs.

The objective of this paper is to describe andcompare Web sites, also termed PHRs, that manageand present HBP data.

METHODSSee Appendix for glossary of terms.9 Available PHRswere found using 6 different methods. Five of thesemethods used online search tools: (1) a search for thefirst 40 results on the Google search engine using thekeywords ‘‘personal health record,’’ ‘‘personal healthrecord online,’’ ‘‘blood pressure tracker,’’ and‘‘personal health tool blood pressure’’; (2) theYahoo! directory listing for Online Personal HealthRecords; (3) the listing of Web-based, free PHRs athttp://www.myphr.com, a Web site established bythe American Health Information ManagementAssociation (AHIMA) and the AHIMA Foundation;(4) the listing of linked applications for online health

records services by Google Health; and (5) the listingof linked applications for online health recordsservices by Microsoft HealthVault. Finally, we evalu-ated the PHR software developed by 2 commonHBP manufacturers, Omron (Kyoto, Japan) andA&D (San Jose, CA), both of which provide soft-ware that can be downloaded from the Web.

The only inclusion criteria were the ability totrack BP measurements (often through a ‘‘tracker,’’‘‘monitor,’’ or ‘‘record’’) and free use (or free totry). The authors developed a list of 33 desirablefeatures, grouped into 4 domains: site administra-tion, HBP data entry, data presentation, andresources. To evaluate each feature, we visited theWeb site to determine if the feature was present orabsent. We then calculated the percent of featureson each Web site. One feature (alert thresholds forhigh BP) was further qualified by 2 subfeatures(personalized and fixed) that were not included inthe calculation of the percent score. All evaluationswere done between June and August 2009, andthen updated in November 2009.

RESULTSFrom a total of 60 candidate Web sites, 20 PHRswere identified and evaluated (see the Figure andTable I). Table II displays each of the 33 features(in rows), grouped according to 4 domains, for the20 Web sites (in columns), along with the percentof features offered. Overall, the percentage of fea-tures that each Web site offered ranged from 41%to 77% (median of 58%). The 3 Web sites withthe highest percent score were sponsored by theAmerican Heart Association (77%), Healthy CirclesLLC (77%), and Mayo Clinic (77%).

Table III provides a suggested process by whichpatients and providers can select a Web site. Thedecision to choose a particular Web site dependson several factors, including comorbid conditions(eg, diabetes) and the desire to track variables otherthan BP; technical factors (eg, stability of Web con-nectivity and features related to transfer and presen-tation of data); and patient support (eg, need forguidance on BP management).

Table IV is a summary table that displays the fre-quency of features across Web sites: universal ornearly universal (75%–100% of all Web sites), com-mon (50%–74%), uncommon (25%–49%), or infre-quent or absent (0%–24%). Basic features, such asstoring HBP data on the Web site (85%) and the abil-ity to display both tables and graphs of HBP data(100%), were universal or nearly universal. MostWeb sites had alert values and allowed measurementof other variables that patients might monitor,

Figure. Flow diagram of Web sites screened andincluded in analysis. BP indicates blood pressure.

THE JOURNAL OF CLINICAL HYPERTENSION VOL. 12 NO. 6 JUNE 2010390

including heart rate (85%), weight (80%), and serumglucose levels (75%). Seven PHRs had all of the uni-versal or nearly universal features (75% or more);these Web sites were hosted by the American HeartAssociation, Bloodindex, Cerner, Health CirclesLLC, Life Clinic, Mayo Clinic, and Zume Life.

Several Web sites (47%) could download datafrom HealthVault, a Microsoft Web-based applica-tion that stores data. A few Web sites (Google,Mayo Clinic, and WebMD) had an open field for-mat that allowed patients to enter and track vari-ables that they selected. Some features wereinfrequent or absent: averaged measurements at asingle sitting (20%), rolling averages of HBP read-ings (15%), analysis of diurnal changes in BP (5%),and support features that prompt patients to useproper technique in measuring HBP (0%). None ofthe Web sites directly link with common electronicmedical records. However, it should be noted thatsome electronic medical records that are not pub-licly available can communicate with HealthVaultand Google Health.

DISCUSSIONIn this paper, which described and compared 20Web sites that patients can use to manage and pres-

ent HBP readings, there was considerable variationin the number of desirable features provided, rang-ing from 41% to 77% (median 58%). Basic fea-tures, such as the ability to display graphs andtables and the presence of a privacy policy, werenearly universal. However, other desirable features,such as the ability to create rolling averages of BPor link with electronic medical records, were rareor absent. More than half of the Web sites allowedfor concomitant entry of other relevant variables,such as heart rate, weight, lipids, and hemoglobinA1c. In a few instances, there was a major defect,such as a privacy policy that allows advertisementsto be served to the user based on the medical his-tory.

Despite the fact that most contemporary guide-lines recommend HBP monitoring 1,7,10 and thatover half of hypertensive patients use HBP devices,4

the processes by which patients enter, manage, anddisplay HBP readings has received little attention.To date, most professional organizations haveissued recommendations without addressing thepractical issues related to collecting and managingsuch data. Our study is a first and admittedlydescriptive effort to provide guidance to patientsand physicians on this emerging technology.

Table I. Characteristics of Web Sites, Including Sponsor, Name, Version, and URL

Web Site Sponsor Web Site Name Version URL

ActiveHealth Management ActivePHR 9.22 https://www.activehealthphr.net

American Collegeof Cardiology

CardioSmart – https://apps.peoplechart.com/hypertension

American Heart Association Heart360 – https://www.heart360.org

Bloodindex Blood Pressure Diary Beta http://www.bloodindex.orgCerner Heart Failure Diary

in IQHealth– http://www.emoryhealthcare.org/connecting/

personal-health-record.htmlhttp://www.carenewengland.org/body.cfm?id=257

Google Google Health Beta https://www.google.com/healthHealthy Circles LLC Healthy Circles Beta https://www.healthycircles.comJohn’s Creek Web Solutions Blood Pressure Tracker – http://www.bloodpressuretracker.com

Life Clinic Life Clinic Health Charts – https://www.lifeclinic.com/Member/Login/login.aspMayo Clinic Mayo Clinic Health Manager – https://healthmanager.mayoclinic.comMediKEEPER MediKEEPER – http://www.medikeeper.com

Microsoft Microsoft HealthVault – http://healthvault.comNomoreclipboard.com Nomoreclipboard.com – http://www.nomoreclipboard.comPureWellness USWellness – https://www.uswellness.comRevolution health Blood Pressure Tracker – https://www.revolutionhealth.com/trackers/

blood-pressureWebMD WebMD Health Manager – https://healthmanager.webmd.comZume Life Inc Zume Life 2.07 http://www.zumelife.com

A&D Medical BP diary 0.07 http://www.lifesourceonline.com/and_med.nsf/html/bp+diary

Omron Omron Health

Management Software

1.3 http://www.omronhealthcare.com/product/software.asp

Soundtells Blood Pressure Tracker 7.1 http://www.soundtells.com/BloodPressure


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.


This report has limitations. First, we did notrate each Web site overall or by feature. Wedecided against ratings because applying grades isa highly subjective process and because patientshave different needs. Second, the authors, rather

than actual patients, identified those features thatwere deemed desirable. Nonetheless, the authorshad a wide spectrum of expertise (primary caremedicine, nephrology, hypertension, nursing, BPmeasurement, and behavioral change). Third,

Table IV. Features of Web Sites Categorized by Frequency

Universal or

Nearly Universal

(75%–100%)

Common

(50%–74%)

Uncommon

(25%–49%)

Infrequent or

Absent

(0%–24%)

Privacy policy 100% Printable graph 70% Uploadsto Microsoft

HealthVault

47% Averaged BPin single sitting

20%

Stores date of entry 100% Printable table 70% Downloads fromMicrosoftHealthVault

47% Stores openfield variablea

15%

Corrects typographicalerrors

100% Stores lipid readings 60% Uploads data fromautomated device

45% Calculatesrolling averages

15%

Presents HBP data in

graph

100% Support for

reaching goals

60% Stores HbA1c

readings

40% Analysis of

diurnal changes

5%

Presents HBP data intable

100% Downloadable data 55% Instructions on HBPtechnique

30% Links tocommon EMR

0%

Allows multipleentries per day

90% Reminders on HBPfrequency

30% Reminders onHBP technique

0%

Gives alert thresholds 90%Stores BP data on

Web site

85%

Stores heart rate readings 85%Records health history 80%

Stores weight readings 80%Stores time of entry 75%Stores glucose readings 75%

Stores medication list 75%

aCan other clinically relevant variables be programmed by the user through an open field? Abbreviations: BP, blood pressure;EMR, electronic medical record; HbA1c, hemoglobin A1c; HBP, home blood pressure.

Table III. Suggested Process for Selecting a Personal Health Record for Home Blood Pressure Readings

Step 1: From the rows in Table II, select the features that you believe are most useful for a particular patient. Listed below are

types of patients along with types of Web sites that these patients should consider.

Type of Patient Type of Web Site or Software to ConsiderPatient with diabetes Web site that has fields for glucose and hemoglobin A1c values or that allows the user to

create new fields to track these variables

Patient who wishesto share home bloodpressure (HBP) readingswith his ⁄ her doctor

Web site that allows printing of HBP data in either a graphical or tabular form

Patient who wishes totry out several Web sites

Web site that interfaces with Microsoft HealthVault so that data can be easily uploaded anddownloaded without manual data entry

Patient with tenuous

connectivity to the Web

Software from device manufacturer that does not require Web connection after the software

is downloaded

Step 2: From the columns in Table II, identify the Web sites that have those features.

Step 3: Visit the Web site, trying both the desired features as well as other features that might be useful.


patients did not evaluate the Web sites. A host ofpractical issues precluded such an evaluation, par-ticularly the rapidly evolving, dynamic nature ofWeb sites. Fourth, our list of features is notexhaustive, and several of the features can be fur-ther subdivided (eg, for privacy policy, the degreeto which data is safeguarded through industry-approved security protocols). Finally, the list ofWeb sites may be incomplete. Nonetheless, becausewe used 6 strategies to identify Web sites, welikely identified the most commonly used Websites.

This report also has several strengths. To ourknowledge, this is the first attempt to identify keyfeatures of a technology that patients are increas-ingly using to manage HBP readings. Second, weevaluated Web sites on the basis of clinical featuresas well as features related to privacy and other non-clinical matters that are important to patients. Forsome users, security and interoperability might bemost important, while resources might be most use-ful for users who struggle with uncontrolled hyper-tension. Ease of data entry or quality of datapresentation may be more important for others.Third, we identified features that were rarely pres-ent yet desirable. By raising attention to thesefeatures, this report might influence Web site devel-opers to consider including these features inupdated versions of the Web sites.

In summary, use of HBP monitoring is increas-ingly recognized as a valuable tool in the manage-ment of patients with known or suspectedhypertension. Use of appropriately designed PHRsthat manage and present HBP data should greatlyenhance the utility of HBP monitoring and ulti-mately improve hypertension control.

Disclosures: The authors have nothing to disclose.

REFERENCES

1 Pickering TG, Miller NH, Ogedegbe G, et al. Call toaction on use and reimbursement for home blood pressuremonitoring: a joint scientific statement from the AmericanHeart Association, American Society of Hypertension, andPreventive Cardiovascular Nurses Association. Hyperten-sion. 2008;52:10–29.

2 Ohkubo T, Imai Y, Tsuji I, et al. Home blood pressuremeasurement has a stronger predictive power for mortal-ity than does screening blood pressure measurement: a

population-based observation in Ohasama, Japan. JHypertens. 1998;16:971–975.

3 Bobrie G, Chatellier G, Genes N, et al. Cardiovascularprognosis of ‘‘masked hypertension’’ detected by bloodpressure self-measurement in elderly treated hypertensivepatients. JAMA. 2004;291:1342–1349.

4 The 2006 Gallup Study of the Hypertension Market.Princeton, NJ: Multi-Sponsor Surveys Inc; 2006.

5 O’Brien E, Petrie J, Littler W, et al. An outline of therevised British Hypertension Society protocol for the eval-uation of blood pressure measuring devices. J Hypertens.1993;11:677–679.

6 O’Brien E, Mee F, Atkins N, et al. Evaluation of threedevices for self-measurement of blood pressure accordingto the revised British Hypertension Society Protocol: theOmron HEM-705CP, Philips HP5332, and Nissei DS-175. Blood Press Monit. 1996;1:55–61.

7 Pickering TG, White WB, American Society of Hyper-tension Writing Group. ASH Position Paper: Home andambulatory blood pressure monitoring. When and howto use self (home) and ambulatory blood pressuremonitoring. J Clin Hypertens (Greenwich). 2008;10:850–855.

8 Consumer Reports. Consumer Reports’ rating of bloodpressure monitors and blood glucose meters show big dif-ferences in accuracy and consistency. 2008;September.

9 National Alliance for Health Information Technology.Defining Key Health Information Technology Terms.Available at: http://www.nahit.org/images/pdfs/HITTerms-FinalReport051508.pdf.Accessed Sept. 1, 2009.

10 Chobanian AV, Bakris GL, Black HR, et al. Seventhreport of the Joint National Committee on Prevention,Detection, Evaluation, and Treatment of High Blood Pres-sure. Hypertension. 2003;42:1206–1252.

APPENDIX: GLOSSARY OF TERMS

Personal Health Record (PHR)—An electronicrecord of health-related information on an individ-ual that conforms to nationally recognized interop-erability standards and that can be drawn frommultiple sources while being managed, shared, andcontrolled by the individual.

Electronic Health Record (EHR)—An electronicrecord of health-related information on an individ-ual that conforms to nationally recognized interop-erability standards and that can be created,managed, and consulted by authorized cliniciansand staff across more than one health careorganization.

Electronic Medical Record (EMR)—An elec-tronic record of health-related information on anindividual that can be created, gathered, managed,and consulted by authorized clinicians and staffwithin one health care organization.


A Comparison of Web Sites Used to Manage and Present Home Blood Pressure Readings

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