Ochsner Health System Hypertension Digital Medicine (HDM)
A technology-enabled and precision-based model of care to conveniently and proactively manage the nation’s most prevalent chronic condition.
Name of applicant
Job title of applicant
innovationOchsner, an innovation lab and accelerator founded by and part of Ochsner Health System
Financial structure of organization (choose one)
City, State, Country of organizational headquarters
New Orleans, LA, U.S.A.
Names, titles and affiliations of teammates
Richard V. Milani, MD, FACC, FAHA, Chief Clinical Transformation Officer
Jonathan Wilt, AVP and Chief Technology Officer
Kevin Driscoll, Product Engineer
Who is the primary purchaser of your innovation? (choose one)
In which care setting will your innovation primarily be used? (choose one)
How would you characterize your innovation? (choose one)
Process innovation (i.e., the series of steps or activities to achieve a particular outcome is unique)
Impact: Describe the value proposition of your innovation. How will this approach improve health care delivery? (200 words)
HDM is a groundbreaking new model to care for patients affected with high blood pressure, the most common chronic condition in the US. HDM is enabled by and integrated with technology tools including Epic and Apple HealthKit to allow continuous monitoring and proactive intervention and engagement. Using unique and collaborative methods combining innovative technologies, with a team of diverse health care professionals, HDM is precision-based and holistic, addressing multiple determinants of health. Patients measure their blood pressure from the comfort of home; PGHD is automatically sent into custom dashboards in the EMR and is reviewed by the HDM care team, providing a new, convenient way for patients to access care. Throughout participation in HDM, patients and providers are engaged as collaborators in gaining and maintaining hypertension control. The program also allows for clinical efficiency, as it is initiated by a provider's referral but is staffed by a team of dedicated pharmacists and health coaches and is integrated into the EMR. Blood pressure and other clinical data are combined with social and behavioral metrics to make personalized treatment goals and interventions.
Evidence: What data do you have to illustrate that your solution works? The more specific, the better. Please share any non-proprietary results including cost savings, improved outcomes, patient satisfaction, etc. (300 words)
Since its launch as a pilot at Ochsner in 2015, the program has yielded superior clinical outcomes, increases in patient activation and higher levels of patient satisfaction (see attached charts for more detail):
- Clinical: At 6 months, Digital Medicine patients have a 67% control rate compared with 24% usual care.
- Activation: Patient engagement increased after participation in the program. Activation at the highest level increased by one-third.
- Satisfaction: Participants consistently reported high levels of satisfaction compared with usual care.
Our financial model projects a significant IRR resulting cost savings avoidance of deadly and costly adverse events including stroke and myocardial infarction; however, due to the life cycle of the savings and the young age of the program, we are not yet able to validate the financial model. Further, the program’s focus on increasing patient activation is expected to produce additional benefits in terms of health outcomes and costs.
Dissemination: Describe your scale up plan including your target market and 2-4 milestones for the coming year. What are the biggest hurdles to dissemination and how do you plan to overcome these obstacles? (400 words)
The program was launched in February 2015 as a pilot at Ochsner Health System. The pilot was launched in multiple regions and physician participation was limited to 31 “innovator” and “early adopter” physicians. Through the pilot, the model was offered as a solution to manage hypertension for two capitated populations, commercial (Ochsner Employee Health Plan), and Medicare (Medicare Advantage). Due to the success of the pilot from a clinical, technical and cultural perspective, the focus for the remainder of 2016 has shifted to scaling and serving more patients within Ochsner as follows:
- Enroll All PCPs and Cardiologists: On April 1, 2016, the program was expanded to allow all 200+ primary care physicians and cardiologists to begin enrolling patients. As of May 1, more than 50% of eligible physicians signed up to participate.
- Increase Patient Enrollment: Through deliberate efforts to engage physicians and patients, patient enrollment has increased from approximately 100 at year-end to more than 350. We plan to launch additional initiatives to drive enrollment through technology and A key milestone is 750-1000 patients enrolled by the end of 2016.
- Increase Physician Acceptance: As we scale, we plan to introduce new tools designed to aid with the cultural change needed to embrace this new care model.
Once scaled within Ochsner, the immediate target market for the solution includes (i) commercial payors and employers; and (ii) our partner health systems inside the Ochsner Health Network.
Obstacles to broad dissemination include physician acceptance and smartphone penetration, both of which we are addressing, but the primary challenge is payor acceptance of a solution designed to profoundly change patient outcomes and behavior where the financial savings is produced over a period of several years through prevention.