Integration of home blood pressure monitoring data into clinical workflows and shared decision-making is recommended to improve diagnostic accuracy and hypertension control.
Hypertension is a major public health issue associated with significant cardiovascular morbidity and mortality.1,2 In the United States, approximately 1 in 2 adults has hypertension, and among those with hypertension, only about 1 in 4 have their condition under control.1,3 Accurate blood pressure (BP) measurement is essential to estimating cardiovascular disease risk and guiding diagnosis and management of hypertension. Importantly, dynamic fluctuations in BP can be caused by diurnal and ambient changes, an acutely stressful experience, or even ingested diet or physical activity.1 Blood pressure patterns are evident across both short and long term periods, with overall higher BP levels in colder versus warmer months, in the daytime versus the nighttime, and during exposure to acutely stressful events.4 Blood pressure monitoring methods enable assessment of BP during static or dynamic conditions over time, thus capturing different aspects of BP variability.4 While office BP measurement is subject to white-coat and masked hypertension effects, often is not standardized, and has poor reproducibility, as many clinicians rely primarily on this method to guide hypertension treatment decisions.4 The recently published 2025 American College of Cardiology and American Heart Association guidelines recommend home blood pressure monitoring (HBPM) to confirm diagnosis of hypertension and for monitoring the initiation and titration of BP-lowering medication, along with patient education and counseling.1,5 Home blood pressure monitoring is widely available, with the cost of HBPM devices often covered by health insurance. Home blood pressure monitoring provides BP estimates that are based on a greater number of measurements than are obtained in the office setting, enhancing the accuracy and precision for detecting a patient’s true and “usual” BP levels, free from the “white coat effect” of office visits.1,6 Home blood pressure monitoring is an effective strategy to engage patients in self-monitoring of their condition and promotes ongoing shared decision-making to improve hypertension care and control.2 Uncertainty regarding patients’ ability to accurately measure their BP has been cited as a contributor to treatment inertia. However, it has been demonstrated that adults can accurately measure BP after a 3-minute video training.1,7 Effective integration of HBPM data into shared decision-making relies on adequate patient education and training, standardized measurement approaches, and the use of technology to streamline data transfer and interpretation. Benefits of Home Blood Pressure Monitoring for Shared Decision-Making Home blood pressure monitoring offers several significant clinical benefits that enhance hypertension management. Home blood pressure monitoring provides improved diagnostic accuracy by allowing patients to measure their BP multiple times daily in comfortable settings, creating a more accurate representation of their true BP patterns and enabling identification of white-coat hypertension (high clinic readings but normal home readings) and masked hypertension (normal clinic readings but high home readings).6 The large dataset of readings enables better-informed treatment decisions through reliable averaging over time, guiding medication adjustments with greater confidence while enriching the patient-clinician relationship through collaborative treatment assessment.1 Home blood pressure monitoring also facilitates targeted medication management by allowing cardiovascular nurses to identify specific timing of BP elevations and adjust medications accordingly to address issues like morning surges or nocturnal dipping.5,8 Additionally, HBPM enhances patient engagement and adherence as patients become more actively involved in their care, can observe their response to medications and lifestyle changes, and are motivated to promptly consult healthcare providers when readings are consistently elevated, ultimately reducing the risk of uncontrolled hypertension and related complications.2 Best Practices for Home Blood Pressure Monitoring For data to be clinically useful, patients must use validated devices and be properly trained on standardized measurement techniques. To incorporate shared decision-making into HBPM, patients and clinicians should collaboratively establish a monitoring schedule. This typically involves taking at least 2 readings 1 minute apart in the morning (before medication and eating) and 2 in the evening, with BP checked for a minimum of 3 days to a preferred 7 days before appointments.1,8 Patients are encouraged to follow the same schedule for every BP reading. Additionally, data documentation is essential; patients should record their BP measurements either digitally or in writing and share this data with their clinician. Patients may also be encouraged to calculate the average of their readings to track trends accurately. It is advised against using manual or subjective assessments, and some guidelines recommend excluding the first day’s readings, as they may be uncharacteristically high.6 Overall, the goal is to enhance patient engagement and decision-making with clinicians through these practices. To integrate HBPM into clinical and enhanced shared decision-making workflows effectively, the following approaches are recommended (Table 1): TABLE 1 - Best Practices for Standardized Home Blood Pressure Monitoring Technique1 Action Evidence-Based Guidance Validated Devices • Use automated, upper arm cuff–style monitors that have undergone clinical validation.• Consult reputable validation lists (eg, American Medical Association validated device listing).• Avoid wrist and finger monitors due to reduced reliability and susceptibility to measurement error. Cuff size selection • Measure the patient’s arm circumference to determine appropriate cuff size.• Select a cuff that fits the measured range to ensure accuracy and avoid over or underestimation of blood pressure. Premeasurement requirements • Ensure the patient has emptied their bladder.• Avoid exercise, caffeine, or smoking for at least 30 minutes before measurement.• Encourage the patient to relax for a minimum of 5 minutes before taking a reading. Patient positioning • Have the patient sit in a chair with back support, feet flat on the floor, and legs uncrossed.• Position the arm so that the cuff is placed on a bare upper arm, supported at heart level. During the measurement • Instruct the patient to remain silent and avoid conversation.• Refrain from phone use, watching TV, or any activity that may increase sympathetic stimulation.• Ensure the patient stays still and relaxed throughout the reading. Challenges to Overcome Integrating high-quality HBPM measurements into clinical decision-making faces several significant challenges that must be addressed.1,2 Inaccurate data and calibration issues arise from patient errors in measurement technique and device malfunctions, producing inconsistent or erroneous readings that require the use of validated devices.9,10 The wide variability in available BP monitoring devices, each with different designs, technologies, and accuracy levels, can lead patients to select inappropriate devices without adequate knowledge, while manual recording and reporting of readings create data gaps and errors.9,10 Clinical workflow integration presents another barrier, as the time-consuming manual entry of HBPM data into electronic health records burdens busy primary care providers, and inconsistent data fields and formats complicate data location and interpretation. Additionally, some clinicians struggle to interpret borderline or significantly fluctuating HBPM readings when comparing them with office BP measurements, leading to “clinical inertia” or reluctance to intensify treatment when necessary. Finally, health literacy profoundly influences patients’ ability to engage effectively in HBPM, as those with limited understanding of hypertension may misinterpret BP levels or fail to recognize the importance of sharing data with clinicians for shared decision-making. Technological Solutions and Tools Advancements in technology offer promising solutions to address many of the challenges associated with integrating HBPM into clinical practice. Electronic health record integration through modern systems can automatically transfer HBPM readings via Bluetooth technology or patient portals directly into the electronic health record, providing cardiovascular nurses and other clinicians with immediate access to data visualizations that facilitate faster and more informed decision-making.2,11 Clinical decision support tools further enhance this process by analyzing home BP data to provide actionable insights, including calculating average values and identifying problematic trends that require attention. Additionally, remote patient monitoring platforms utilize connected BP monitors that automatically transmit readings in real-time, eliminating the burden of manual logging while improving data accuracy and enhancing communication between patients and clinicians.11 These technological solutions collectively streamline the HBPM process, reduce errors, and support more effective clinical workflow integration.9 Practical Steps for Implementation The latest hypertension guidelines provide clear guidance for cardiovascular nurses and other clinicians on how to integrate these best practices with patient care.1,5 Additionally, the American Heart Association and the American Medical Association, in a joint scientific statement on HBPM, provide recommendations for implementation and address the feasibility of using this method for hypertension management.9 This technique requires substantial clinician support to ensure accuracy and consistent communication to foster shared decision-making approaches.2 Furthermore, cardiovascular nurses should pay close attention to barriers that may impede HBPM implementation.5 They must understand both patient-perceived barriers and clinician-identified barriers, such as limited digital literacy, among others.9 Practical implementation steps can be outlined for patients using guidance from American Heart Association infographics and by practicing HBPM techniques during clinical visits (Table 2).TABLE 2: Practical Steps for Implementation of Home Blood Pressure Monitoring and Shared Decision-Making8 , 12Conclusions The integration of HBPM data into shared decision-making for medication initiation and titration and lifestyle modification is poised to transform hypertension management. The key challenge is not simply measurement, but integration of HBPM data into clinical workflows, and using it to support shared decision-making; engaging patients in understanding the data, setting goals, and adjusting treatment collaboratively. Effective hypertension management necessitates a collaborative approach that empowers patients while also leveraging technology and accurate data.
Himmelfarb et al. (Wed,) studied this question.