Here at Kinsights, we’re really proud of our pediatric personal health record (PPHR), which has empowered thousands of parents to keep better track of their child’s health than ever before.
A PPHR is a unique design challenge – the user is typically a parent, with little to no formal medical training, but a need to effectively capture and understand the many complex pieces of their child’s health history over time.
In some cases, this means little things, like showing how a child’s percentile (for, say, weight) changes over time, rather than the standard approach, which is basically always going to be “up and to the right” for a growing child.
In other cases, it means more significant efforts, like supporting the
various immunization schedules of Canadian provinces
, alternative
growth charts
for children with special needs, developing a patient- and family-friendly
format for printing and exporting medical history
in cooperation with the White House, and many others. Parents have been let down by the healthcare industry’s lack of interoperability and terrible patient portals, and we do our best to help close that gap.
So when we started getting requests from parents to track their child’s blood pressure readings, we wanted to make sure we did it as usefully as possible. Parents who are dealing with children with blood pressure issues are often struggling with major challenges, like heart defects, kidney disease, genetic disorders, or obesity. Our solution needed to keep it easy to track, while unlocking all the insights a caregiver or provider needs to understand the child’s condition and history.
Many of us are probably reasonably familiar with charts like this, showing that, for most adults, we want to keep our blood pressure below a systolic reading of 120 and a diastolic reading of 80 (commonly “120 over 80” or 120/80). For decades, this was thought to be the “ideal” number, but anything under 140 was generally okay. In 2003, the guidelines in the US were adjusted to reflect the research showing that even values as low as 120 could be unsafe.
This chart was definitely not written for use with patients who are children. Just a few minutes of research got us the goods we were looking for:
The standard pediatric blood pressure reference tables aren’t terribly difficult to read, but they are unique compared to other growth charts: they not only vary percentiles by age, but also by the height of the child. It also reflects the difference between pediatric blood pressures and those of adults: a dangerous blood pressure could be as low as 94/49 in an infant boy, and even a 7 year old girl can be in a state of prehypertension at 106/69.
This seems like a small difference, but it actually has a major impact in practice. When we started talking to primary-care pediatricians about how they assess blood pressure in their patients, they often said
they use 120/80 as their benchmark
unless the child has a particular condition. They usually knew there were more specific tables, but either didn’t have them handy enough to use, or didn’t know when they were appropriate. The results?
Nearly three quarters of children with hypertension go undiagnosed:
https://jama.jamanetwork.com/article.aspx?articleid=208557
Great Examples Were Few and Far Between
When designing interfaces for most consumer products, it’s common to go looking at examples in other software products. Unfortunately, in healthcare, even finding screenshots of medical record systems can be a huge challenge, and licenses for them can cost millions of dollars. So we went about it the slower way and asked around.
We asked pediatricians how they saw these tables and percentiles in use in their electronic medical record systems (EMRs), and we generally got three responses:
- They’re not used in the EMR. Many EMRs, even the ones hospitals spend hundreds of millions of dollars on, don’t reflect these pediatric standards when entering a blood pressure measurement. Many of them still flag values based on the adult standards, even if the patient is a young child.
- Percentiles are listed in history logs. When you dive into a patient’s blood pressure history, the table of data has a column showing the percentile. One renal (kidney) specialist we talked to said “They just added it a few months ago, and it’s really helpful. I use it enough that I know what the percentiles mean.”
- Percentiles are shown and evaluated in the interface. From what we’d heard and seen, only the top pediatric-focused EMR platforms, like Office Practicum, displayed percentile information as the readings were entered. In Office Practicum’s case, they also code the value as red/orange if the reading is high enough to warrant concern. This seemed great, and certainly very useful, but their interface and user experience left a lot to be desired, especially when it comes to our audience.
So we definitely wanted to follow the lead of Office Practicum, at a minimum, and expose not only the percentiles but also the evaluation of those readings. But more, for our implementation, we wanted to make sure these figures were put into context as effectively and easily-understood as possible.
Bells, Whistles, and Consistency
There’s nothing sexy about charting blood pressure, but our research turned up a number of other factors we wanted to take into consideration, including:
- The formula on which the charts are based only reflect BP readings for children over age 3. Children younger than that have different standards, including some for newborns. We wanted to take those into account as well.
- A single BP reading isn’t really enough to know anything, since we can all be a little stressed when we go to the doctor’s. So it’s important to see readings in the context of time, even at a glance.
- Since we’re going to be showing time-series data based on age, that’s a lot like our current growth charts for height, weight, BMI, and head circumference. So we wanted to use the same tools as much as possible. The wrinkle is that, unlike all the other charts, the percentiles actually shift as the child’s height changes over time, so we’d have to create a custom chart for each child.
Pulling it All Together
After taking this all into account and playing with a zillion variations, we came up with a blood pressure tracking tool that does pretty much everything we’d like, without being overwhelming.
When you land on a child’s records page, the blood pressure history is a first-class citizen, sitting alongside our other growth-related measurement trackers:
This is easy to understand for anyone dealing with blood pressure, and it clearly shows the percentiles, how those percentiles are evaluated for this overweight child, and a quick view of how that’s changed over time. We can see that this child has had reasonably high readings for a while, growing higher steadily over time – this isn’t a sudden change.
When you dive into the history and chart, you might see something like this:
As the child’s height changes over time, we adjust the percentile areas to create a familiar growth-chart interface for blood pressure history, highlighting readings that fall into prehypertension (orange) or hypertension (red) zones as appropriate. Below the chart (not shown) is a table with all of the raw data, percentiles, and other potentially useful info like the pulse pressure.
Hopefully, we’ve ended up with something both simple and powerful for parents and providers alike. It takes a bit of extra effort and research, but it’s our hope that those few extra hours of time on our part can help build a culture in pediatric digital health that handles some of this low-hanging fruit. It’s changes like these which, when adopted by the right products at the right time, can really have an impact on pediatric health.
Blood pressure tracking is available for all Kinsights members today, and we’ll be making small improvements and tweaks over the coming weeks. If it’s useful to you, be sure to reach out and let us know how we can make it even better!