Primary Care Physician Attitudes Toward Referring Patients To A Remote Patient Monitoring Program For Hypertension

Background: Home blood pressure monitoring (HBPM) is recommended by national hypertension (HTN) guidelines as an evidence-based approach to improve HTN control. The use of wireless BP devices that transmit data to the electronic health record (EHR) makes HBPM eligible for remote patient monitoring (RPM) billing codes. Little is known about barriers and facilitators to HTN RPM program referral. Methods: We implemented a HTN RPM program at two adult primary care clinics in New York City. Patients were loaned a two-way tablet and wireless BP cuff and received virtual nursing support. We conducted 1:1 semi-structured interviews with primary care physicians (PCPs) from these clinics to elucidate attitudes about the program. Barriers and facilitators were categorized according to the Theoretical Domains Framework (TDF), which includes 14 domains of behavior change helpful for guiding implementation. Interviews were conducted by video, audio-recorded, and professionally transcribed. Three study physicians (NL, IK, CO) independently coded transcripts using content analysis, coming to consensus for discrepancies. Results: We interviewed 13 PCPs (7 had referred patients, 6 had not), at which point saturation of ideas was reached. Most barriers and facilitators fell into the following TDF domains: knowledge, beliefs about consequences , environmental context and resources . PCPs knew the evidence supporting HBPM and were aware of the RPM program, but confusion about eligibility, ordering, and program features were barriers to referral. Most PCPs were confident in their ability to manage RPM data and felt the program increased patient engagement in care. However, some questioned whether it would improve the status quo and others worried it might increase anxiety in certain patients. Virtual nursing support and EHR integration were seen as program benefits. However, some were concerned about increased workload, interruptions, and insufficient support to manage data between visits. Reimbursement from billing was not a strong incentive to refer. Conclusion: Improving communication during implementation, developing workflows to minimize interruptions, and increasing support structures may be needed to promote uptake of HTN RPM programs in primary care.