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I have been working at Iora Health for over two years now. From day one, I have shared a value with the company and my colleagues to make sure each of my patients feel cared for, seen and heard. I know how to take care of my patients when they step into our office, but when they have to fend for themselves in the Big Bad City on their own….what is a health coach to do?

Luckily for us, we have a whole team of folks in Cambridge that have created our very own software to help us keep track of our patients medical and wellness needs. They constantly revamp our system as needs arise. In my first year, I would document notes in the chart, type in blood pressure readings, make tasks (our reminder system) for myself to follow up on important matters. I knew this data would serve a greater purpose in the long run, but a major pitfall my first year was that the only way to ensure care needs were being followed up was to continually ping myself with reminders. Or hope they would come in on their own and review the chart when they arrived in the office.

As they say, the squeaky wheel gets oiled, and I find truth in that here — the patients I remember best come in often, keep in touch, stay on our radar. However, many patients do not keep in touch and they ought to be on our minds. I used to fear that these patients would fall through the cracks if I did not happen to set a reminder. Year two has upped the ante and empowered all of us. For a year I have been plugging in data and now the software team has given us the gift to use this information to our advantage: we can target specific care needs.

We use the data to show us the general story about our patients so we can learn how to focus our efforts. We call this type of storytelling population health management. I can now plug in certain metrics that I want to see within my patient panel: Who has a BMI out of range, smokes, has had a blood pressure reading higher than 140/90 and is over the age of 40? POOF — a lovely spreadsheet with the patients that fit my criteria pops up. I can filter folks by a plethora of different criteria combinations. I can look at their charts and see if I notice any trends. This new ability to search my patients for specific data points serves as a safety net to my current personal tasking system. This empowers me because I can focus my energies on people who need the attention and we as a team can use our time more effectively to come up with how to focus our outreach efforts.

This summer we took on a major initiative to review, organize data & processes and think about how to best help every patient with an elevated blood pressure in our practice. In the context of a relatively young population without many chronic diseases, we focus on hypertension and other early warning signs for later life problems. High blood pressure generally is not symptomatic until our bodies have taken a beating for many years so it is not often front-of-mind until there is a cardiac episode. We realized we could keep better track of helping patients lower their blood pressure using all the tools at our disposal—coaching around lifestyle changes, counseling and medications.

We began by reviewing their charts but also meeting in teams to consider the big picture of our patients and think about them as human beings with passions and challenges, not just data points. As a team, we came up with some questions we wanted to have answered through information already documented in their charts and minds:

  • What factors are contributing to their high blood pressure (biological, lifestyle, other)?
  • Do they have other cardiac risk factors?
  • How motivated are they to change?
  • What barriers do they have?
  • What is their attitude toward medications?
  • What missing data/markers do we need to get (blood work, blood pressure, etc.)?

Then we came up with criteria for a plan:

  • When will their next blood pressure check be?
  • Where (at the office, home, a pharmacy)?
  • What is the lifestyle/behavior change plan?
  • What is the plan for medications?

This also fits our model better because we believe food and exercise heal just as much as a medication, if not more so for many patients. I have been better able to provide coaching to empower patients now that we have created more structure around the information we gather together and learning more about patient attitudes.

The results were exciting. We reengaged with patients we saw first when we opened two years ago; we made sure patients were up to date on all of their indicated screenings, and we began to have better and deeper conversations about their risk of heart disease and they could do to manage it.

The short-term outcomes were great — our hypertension control rate jumped almost 15%, just from being more organized and using these population management tools. The longer-term outcomes from lifestyle change will take longer to see, but we know we are on the right track!

Knowledge is power. In health care there are many moving parts and copious amounts of information—it takes a whole team to manifest these efforts. At Iora, not only is the doctor thinking of patients, but a whole team is thinking about their health even when they might not be doing the same.