Hypertension remains one of the most common—and costly—chronic conditions in the U.S., driving cardiovascular disease, hospitalizations and poor health outcomes. A peer-reviewed study published in the Journal of General Internal Medicine adds to a growing body of evidence that digital medicine, when paired with team-based care, can meaningfully improve blood pressure control while reducing care gaps.
The study evaluates the Ochsner Health digital medicine program for hypertension, a technology-enabled care model that combines home blood pressure monitoring, pharmacist-led medication management, and health coaching. The findings point not only to better clinical outcomes, but also to fewer emergency department visits and hospitalizations—signals of progress in both quality and value.
Ochsner Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Key results from the study reveal that Ochsner Health Digital Medicine demonstrated a powerful impact on blood pressure control and statistically significant reductions in systolic BP for all participants. Furthermore, BP control increased from 57.1% to 76.1% for patients who are Black and 61.3% to 77.7% for patients who are white, according to a release from Ochsner. About 5,000 patients were included in this study.
“This research reflects our commitment to our communities and validates our expertise in delivering the highest quality, patient-centered care through innovative and accessible platforms by a team that specializes in cardiometabolic conditions," said Eboni Price-Haywood, MD, MPH, MMM, system medical director for Ochsner Health Outcomes and Inclusion and lead author of the study.
“By engaging patients where they are, we are not just managing a condition. We are empowering individuals to take an active role in their health,” Dr. Price-Haywood said. “The significant improvement in hypertension control, especially in medically underserved populations, shows the profound potential of digital medicine and demonstrates how our scalable solution can extend these outcomes across multiple care settings and populations.”
A team-based digital approach to hypertension
Patients enrolled in the program use Bluetooth-enabled blood pressure cuffs to transmit readings from home directly to Ochsner’s digital medicine care team. That team includes licensed clinicians—during the study period, primarily clinical pharmacists—who manage medications between physician visits, as well as health coaches who support education, behavior change and lifestyle skills.
“The role of the licensed clinician—such as a pharmacist—is to manage medications between doctor visits,” Dr. Price-Haywood said. “There's also a team of health coaches who support educational behavioral changes, lifestyle skills and things of that nature to complement.”
Researchers assessed BP control over time to compare outcomes against matched patients receiving usual care.
“Those who participated in the digital medicine program had higher rates of blood pressure control by the end of the study. There were other significant findings for all of the participants,” Dr. Price-Haywood said.
Closing gaps in blood pressure control
One of the most striking findings emerged when results were stratified by race and ethnicity. Hypertension control improved substantially for both Black and white patients enrolled in the program, which is an important marker of comprehensive effectiveness.
“An additional key finding was with blood pressure control, which we analyzed stratified by race and ethnicity,” Dr. Price-Haywood said. “And we were able to demonstrate that the blood pressure control increased from 57% to 76% for Black patients who participated as well as for white patients from 61% to about 78%.”
Those gains underscore the program’s ability to deliver consistent benefits across populations, particularly among patients who historically experience worse cardiovascular outcomes.
The study also found additional socioeconomic benefits that could have a serious impact when it comes to providing more patients with opportunities to receive quality health care.
“Beyond blood pressure control, the program demonstrated significant reductions in costly acute care utilization, including both emergency department and use and hospitalizations,” Dr. Price-Haywood said. “Concurrently, we also demonstrated that primary care costs remained stable. This is a good finding because the purpose of this type of programming is to shift from a reactive, episodic care model over to preventive managed care.”
Why the model works
Several features of the digital medicine model contribute directly to improved outcomes, particularly among Medicare patients managing chronic conditions.
“The elements of the care model that supported these improvements are the asynchronous communication with the care team between doctor visits,” Dr. Price-Haywood said. “The program also has embedded within it educational tools, and the ability to monitor the blood pressure and adjust the medications with the help of the clinical pharmacists.”
Importantly, the program does not replace primary care—it extends it.
“This model is a collaborative care model between primary care and clinical pharmacists,” she said. “So, it does not replace the doctor's visits. Instead, it complements them and gives the patients more touchpoints.”
Those additional touch points help patients stay engaged, informed and supported in managing their condition—without the burden of more frequent in-person visits.
Engagement, reminders and medication adherence
For many patients, barriers to care begin long before clinical decision-making. Time away from work, transportation challenges and unfamiliarity with digital health tools can all derail chronic disease management.
“There are many barriers that community members face in seeking access to care,” Dr. Price-Haywood said. “For example, taking time off from work for a clinic visit is a barrier.
Using technology for health care in and of itself is a relatively new concept for most patients who still have in mind that traditional model of face-to-face with a doctor—despite the fact that most people are active with technology in their daily lives using cell phones.”
Ochsner digital medicine program is designed to meet patients where they are at—leveraging technology already embedded in daily life.
“The digital medicine program really optimizes the use of smart device technology that we have in the cell phone,” she said. “And it actively engages patients using that technology via text messaging to remind patients to submit their blood pressure readings.”
Visual cues and education reinforce those reminders.
“There’s a stoplight color coding of the blood pressure readings to give you a sense if you are above, below or at target,” Dr. Price-Haywood said. “Also, there are educational tips on healthy behaviors that come through the program app.”
Those frequent interactions appear to pay dividends in medication adherence—an important driver of long-term cardiovascular outcomes.
“Participants who enrolled in a digital medicine program had higher odds of adherence at six, 12 and 18 months compared to nonparticipants,” she said. “The frequent touch points engender a sense of accountability that increases the patient's self-awareness but also encourages consistency in self-care behaviors.”
Dr. Price-Haywood added that even physicians and care teams benefit from reminders.
“I can speak from personal experience because I'm actually a participant in the digital hypertension program,” she said. “Even as a physician, it's just human nature that it's very helpful to get that reminder that these are the healthy behaviors with which you're supposed to engage.”
Preventing escalation through continuous monitoring
There were also fewer emergency department visits and hospitalizations among digital medicine participants—an outcome closely tied to continuous monitoring and timely intervention.
“The key to the program's success, I believe, is that it follows a data-driven collaborative chronic care disease management protocol,” Dr. Price-Haywood said. “The continuous monitoring provides the information necessary for implementing the timely clinical interventions.
“This approach is a major shift from what may be a reactive, episodic approach to care to more preventive, managed care,” she said. “That's really the direction that we have to move in for population health and promoting value-based care.”
Addressing social drivers of health
The program’s impact is also shaped by how it addresses social drivers of health—factors that can make chronic disease control more difficult—because “the more social barriers an individual has, the more difficult it is for them to achieve the best health outcomes,” Dr. Price-Haywood said.
Ochsner Health has implemented a systemwide strategy to collect data on transportation, financial strain, food insecurity, health literacy and stress. Digital medicine helps mitigate several of those barriers at once.
“The most valuable aspect of our digital medicine program is the fact that the care is more convenient and accessible and surmounts things like transportation barriers,” she said. “But in terms of literacy, having a pharmacist who explains the medications, as well as having health coaches who share practical advice, is important and paramount to the success of the program.”
Lessons for scaling digital care
For health systems looking to replicate the model, Dr. Price-Haywood emphasizes the need to align financing, staffing and technology. That includes investing in nonphysician providers, health coaches and guideline-directed treatment algorithms, as well as building technology that integrates seamlessly with the EHR.
Successful scale also depends on tightly integrating digital care into existing clinical workflows.
“A critical development with this program was creating an app that interacts with the electronic medical record system,” Dr. Price-Haywood said. “This app has actually reduced the number of steps that a patient has to take to interact.”
Equally important is technical support and attention to the patient experience.
“Being aware of what the patient sees and what they're using I think is incredibly important,” Dr. Price-Haywood said. “Tech support of some nature is also incredibly important for troubleshooting.”
Looking ahead
As Ochsner continues to expand the program, they are looking at other populations within their region.
“I would like to see the program expand into the rural populations,” Dr. Price-Haywood said. “The problem that we have to solve is how to deliver care that's convenient, affordable, and scalable given the unique challenges those populations face.”
Ultimately, she said, digital medicine must move beyond monitoring alone.
“Monitoring is not the same as managing,” she said. “It's the care management activities that actually drive the outcome change.”
For Ochsner, the goal is clear: empower patients, reduce inequities and deliver better outcomes—regardless of insurance type or ZIP code.
“At the end of the day, we need to leverage technology to help empower patients so that we can teach them to live their best life and control their health at the same time,” Dr. Price-Haywood said. “If they can receive it in the most convenient way, it appears they can have better outcomes in the process.”
Ochsner Digital Medicine partners with external health systems to implement these evidence-based programs by fully integrating into Epic and provider workflows.
Patient care is delivered in one of two ways. The Digital Medicine team reviews the:
- Partner health system’s patient data and provides clinical recommendations for partner clinicians to act on, such as medication changes, therapy optimizations or lab orders.
- Data directly, engages with patients and makes clinical changes as needed—without requiring additional clinical staffing from the partner.
All documentation flows into Epic to maintain continuity of care, and the program can be delivered as a white-labeled solution aligned with the partner’s brand, including use of the Digital Medicine app and patient tech support team. Learn more about how Ochsner can help.
