Should You Join This Medical Technology Effort?

As part of her morning routine, 74-year-old Cynthia Nolan takes a blood pressure and glucose reading and submits the information through a mobile app to her doctor with Ochsner Health. The uptown New Orleans resident, who has hypertension and diabetes, is one of over 28,500 people across the country participating in the Ochsner Health’s Digital Medicine Program.

Before enrolling in the program 6 years ago, Nolan’s glycated hemoglobin level measured 7.0. A few weeks ago, at her primary care physician’s office, it was 6.1 and has dipped as low as 5.9. Her blood pressure is a healthy 105/65 mm Hg. As part of the program, a dedicated remote care team, staffed largely by clinical pharmacists, monitors Nolan’s data. Originally, a nurse from the program called Nolan about twice a week to check in. As her readings got better, that dropped to once a month. Lately, they haven’t had to call her at all.

“It was so easy to adjust to it,” said Nolan, who works for the Louisiana Office of Motor Vehicles issuing driver’s licenses and registering cars. “I try to tell my counterparts and my friends about the program. I love it.”

The Digital Medicine Program started in 2015 as an internal quality improvement project to achieve better rates of hypertension control among patients at Ochsner Health. It has since expanded to encompass the management of hypertension, diabetes, and hypercholesterolemia for patients across the country.

Some people think of the initiative as remote patient monitoring, but that is just a part of the program, said Dan Shields, CEO of Digital Medicine at Ochsner Health. “This really is a clinical care model to treat these conditions” and augment management provided by primary care physicians, Shields said.

“We really need to, as a country, transform primary care,” Shields told Medscape Medical News. “Primary care is not sustainable as it is right now, only because we’re going to have far, far too many patients to treat with the number of providers we have. To the extent that we can use digital tools to help them effectively treat a larger panel size of patients, it’s going to become instrumental in how we deliver primary care.”

More Data, Better Outcomes

Patients with cardiometabolic conditions are encouraged by their primary care physicians to enroll in the program, which typically is covered by their insurer. Once enrolled, they receive a digital blood pressure cuff, a continuous glucose monitor or glucometer, and sometimes a scale, depending on their needs. The mobile app provides some general health coaching and encourages patients to begin submitting data every day or as often as possible, which goes into their electronic health record (EHR). Proprietary algorithms built into the EHR follow the patient’s data. If readings are out of range or trending that way, the app alerts a member of the remote care team, who reaches out to the patient to help intervene or adjust their medication. Any changes are documented in the EHR to inform the primary care physician overseeing the patient.

Victoria Smith, MD, an associate medical director for Primary Care and Ambulatory Quality Leader at Ochsner Health and a family medicine physician in Louisiana, estimates about 100 of her patients participate in the program.

“It makes a big difference for both physicians as well as our patients,” said Smith. She splits her time between seeing patients in a primary care clinic in the New Orleans suburb of Kenner and supervising five additional primary care clinics.

For example, someone with controlled hypertension might come to her office twice a year, and during those visits, their blood pressure looks perfect. “But over the year, things may be changing. Maybe they’re not taking their medicine,” Smith said. “I don’t know that because I have just these two readings. By having digital medicine, I’m able to actually have more readings on what’s going on.”

Smith said she generally has 20 minutes or so to spend with each patient. So she appreciates how health coaches with the program check in with her patients and talk to them about lifestyle management, including diet and exercise, which she might be able to touch on only briefly during an office visit, as well as colleagues who help monitor her patients’ health metrics.

“In this day and age, it can’t be just the physician managing everything,” Smith said. “We really have to have teams helping us.”

While there have been some challenges finding blood pressure cuffs large enough for Smith’s patients with obesity or Spanish-speaking health coaches for her Latino patients, such cases are unusual, she said: “Most of my patients really value and enjoy it and see the benefit in having others on the team in addition to me,” she said.

When the program started a decade ago, 60% of patients in the Ochsner Health had their blood pressure under control, said internist Kenny Cole, MD, system vice president of Clinical Improvement at Ochsner Health, during a presentation at 2025 Global Conference of the Healthcare Information and Management Systems Society (HIMSS25) in Las Vegas.

The American Medical Group Association had a campaign called Measure Up/Pressure Down, encouraging its members to achieve hypertension control rates of over 80% — a significant challenge in Louisiana with its high rates of obesity and salt intake, Cole said. But with the adoption of their EHR, they began finding that by adhering to evidence-based protocols and pathways, with less variability among physicians, 80% of patients in the system could bring their blood pressure under control within 6 months, he said.

The program has since grown to encompass its health system employees and is used by about 30 external clients, including payers, employers, and other health systems, for patients in 38 states. On average, more than 90% of participants have brought their hypertension and diabetes into healthy ranges, Shields said at the HIMSS meeting.

These clinical outcomes can be translated into less use of high-cost healthcare settings, Cole added. The number of emergency room visits has dropped 38%, and hospital admissions are down 27% among enrolled members, he said. And patients like the program, which has a 98% retention rate, he noted.

Studies have shown it would take a primary care physician 26.7 hours per day to deliver all recommended evidence-based care, Cole said. When he was in practice, the last thing he felt like doing after work was grabbing the latestissue of The New England Journal of Medicine to stay up to date.

With the rapid explosion of medical knowledge — doubling every 73 days as of 2020, he said — “It is literally beyond the capacity of the human brain to stay up to date with the tens of thousands of trials that get published every year and all of the evidence-based medicine that enters the realm of our learning.” That’s where the team-based approach can assist.

Clinicians with the program are now looking to expand into the management of chronic kidney disease, atrial fibrillation, and heart failure, Shields said. “We’re doing it because it’s the right next step, but also it’s what our system needs the most,” he said. “If it’s good for our patients, it’s probably going to be good for patients somewhere else in the country, too.”

Karen Blum is a freelance medical/science writer in the Baltimore area.