University of Rochester Medicine Improves Population Health and Hypertension Outcomes with SeamlessMD

University of Rochester Medicine (URochester Medicine), an 8-hospital academic health system serving the Rochester, New York region, partnered with SeamlessMD to support a broad range of clinical programs, including hypertension, heart failure (CHF), urology biopsy, endoscopy, colorectal cancer screening, COPD, and stroke. As part of this enterprise-wide digital care strategy, URochester Medicine launched an Epic-integrated hypertension program to improve blood pressure control, increase patient engagement, and advance population health outcomes across a diverse patient population – including many Spanish-speaking patients and individuals facing elevated social vulnerability.

With hypertension representing a critical priority for the health system, URochester Medicine sought a scalable solution that could be embedded into everyday clinical workflows while empowering patients to better manage their condition between visits.

Key Results

• 12.07 mmHg reduction in average systolic blood pressure among patients with elevated baseline blood pressure
• 5.73 mmHg reduction in average diastolic blood pressure
• 20% increase in blood pressure readings within target range

Transforming Hypertension Care Through Epic and MyChart

Prior to SeamlessMD, URochester Medicine's hypertension program faced workflow challenges including manual patient enrollment, limited Epic integration, and English-only patient content. To scale its population health efforts, URochester Medicine partnered with SeamlessMD in 2024 to create a bilingual (English and Spanish) hypertension care journey embedded directly within Epic and MyChart workflows.

Through the program, patients receive personalized education, reminders, and self-management tools to help them better understand and manage their blood pressure between clinic visits. Clinicians can monitor blood pressure readings, medication adherence, and lifestyle trends directly within Epic, while automated workflows provide patients with personalized guidance based on their submitted data.

Meaningful Improvements in Blood Pressure Control

The program produced significant improvements among patients with elevated blood pressure at baseline. Average systolic blood pressure decreased from 146.42 mmHg to 134.35 mmHg, while average diastolic blood pressure decreased from 88.75 mmHg to 83.01 mmHg. These improvements exceeded commonly cited thresholds for clinically meaningful blood pressure reduction.

In addition, the percentage of blood pressure readings within the target range increased from 65% in month one to 77% by month six – a relative improvement of 20%.

Supporting Patients Between Visits

The bilingual digital care journey helps patients stay engaged in their care through interactive education, medication reminders, blood pressure tracking, and self-care guidance. The program also supports continuous remote monitoring, allowing care teams to identify at-risk patients earlier and intervene when needed.

Dr. Lara Evans, Associate Chief Officer for Patient Engagement and Director for Patient Reported Outcomes at URochester Medicine, shared:

We have been impressed with the magnitude of blood pressure reduction we're seeing with SeamlessD. Not only is it clinically meaningful, but at scale, these improved clinical outcomes also translate into significant cardiovascular risk reductions with fewer heart attacks and strokes. This is so important for our entire patient population, but it is especially noteworthy that we had such significant clinical impact in a higher risk, more vulnerable community.

Patients also reported positive experiences with the program, citing increased awareness of their blood pressure and improved self-management habits.

Looking Ahead

Building on the success of its hypertension program, URochester Medicine continues to expand and optimize its use of SeamlessMD across multiple clinical areas, including heart failure (CHF), COPD, stroke, urology biopsy, endoscopy, and colorectal cancer screening, creating a more connected and scalable approach to patient engagement and population health management.

Read the full case study to learn how URochester Medicine is leveraging Digital Care Journeys to improve population health outcomes and deliver more proactive, connected care.