The ExpertCare Hypertension Prescribing Solution

Unlike other clinical decision support software which makes recommendations based on one comorbidity at a time, ExpertCare will make a recommendation based on any combination of the following conditions:

• Diabetes (all types)
• Proteinuria (defined as an ACR › 30)
• Angina
• Myocardial Infarction (recent i.e. ‹ 1year and past i.e. › 1year)
• Atrial fibrillation
• Heart failure

ExpertCare thus overcomes one of the main criticisms of NICE, that the guidelines are monothematic, and therefore difficult to implement in real-world situations where patients have comorbidities.

The six conditions listed above have been chosen for the following reasons:

• They have a significant impact on hypertension treatment decisions
• NICE makes recommendations on appropriate prescribing for these conditions
• Hypertension management needs to consider the wider risks conferred by comorbidity

ExpertCare interprets the patient’s coded electronic record to infer the presence of any condition which might influence the treatment of hypertension and provides context sensitive advice taken from the SPC of all drugs used in the treatment of hypertension.

The clinician is notified of

• Drug indications, cautions and contraindications
• Advice on initiation, monitoring and discontinuation
• Routine dosage advice
• Dose adjustments required in the presence of renal or hepatic impairment

However, it is up to the prescriber to evaluate this information based on clinical context. For example, childhood asthma might be a caution to the issue of a beta-blocker whereas current asthma would be a contraindication.

The prescriber can continue a hypertension drug for any indication but will be asked for a reason which will be recorded for the benefit of future users. Further recommendations by ExpertCare will take into consideration the retained drug. For example, clonidine retained for the prophylaxis of migraine.

ExpertCare does not duplicate the functionality of the GP healthcare record where interactions are highlighted when a new drug is added. In our next version of ExpertCare, we will add warnings to flag up the risk of bradycardia with certain drug combinations. Similarly, we will also indicate when there is an increased likelihood of hyperkalaemia.

ExpertCare will record the reason for not taking a drug class to inform future consultations. The clinician can then ask for a further recommendation.

In this situation, ExpertCare is sophisticated in that it always makes recommendations which support the effective management of relevant comorbidity. For example, a patient with hypertension and atrial fibrillation, who opts not to take a beta-blocker, will be recommended a rate-limiting calcium channel blocker instead.

ExpertCare has the functionality to indicate a drug which belongs to a local formulary.