Digital Care Transformation

cholesterol hypertension risk U ndertreatment of hypercholesterolemia and hypertension (HTN) remains a persistent clinical challenge, even among patients at high cardiovascular risk. Approximately 30% to 50% of patients do not receive optimal medical treatment, even though most of these treatments are generic, established, are guideline-directed, and cost effective. 1,2 We designed and are actively implementing a remote, algorithmically driven, disease management program that uses navigators and pharmacists, supported by specialists, to initiate and titrate medications within the Mass General Brigham health system. We enrolled patients with uncontrolled low-density lipoprotein cholesterol (LDL-C) and/or blood pressure identified through medical record screening or direct referrals not meeting current guideline-directed therapeutic targets. Patients in the lipid program were categorized according to current guideline-specificied 3 hierarchical groups-established atherosclerotic cardiovascular disease, diabetes, severe hypercholesterolemia (LDL-C >190 mg/dL), or high-risk primary prevention-to determine treatment thresholds. Blood pressure was measured with digitally connected home blood pressure cuffs. Following guideline-recommended clinical algorithms, pharmacists (prescribing under collaborative drug therapy management programs) initiated and titrated medications. The supervising physician was readily available for additional clinical management. Nonlicensed navigators were the primary communication channel with patients, ordering laboratory tests and providing education at preset intervals until treatment targets (LDL-C guideline-directed thresholds 3 and average home blood pressure <130/80 mm Hg) were achieved. Primary care physicians were notified of identified patients and could defer patient enrollment. Clinical staff were supported by a custom-built software program (CardioCompass) external to the electronic health record that provided decision support, patientrelationship management and communication tools (eg, texting). 4,5 No in-person visits were required. The project was approved by our institutional review committee with a waiver for informed consent. We encourage investigators interested in data sharing and collaboration to contact the corresponding author.