HomeSafe: Postpartum Hypertensive Care Enabled by Electronic Health Record Digital Blood Pressure Capture and Population Health Management

The objective is to present stepwise refinements to <i>HomeSafe</i>, an Epic-tethered, population-health-coordinated postpartum pathway for blood pressure (BP) surveillance after hypertensive disease of pregnancy (HDP). <i>HomeSafe</i> was designed for HDP people identified during their delivery hospitalization. The program incorporated prepopulated orders for home BP measurement and submission through a smartphone application linked to the electronic health record (Epic). A population health coordinator (PHC) was integrated at Year 2 to support registry tracking, expanded digital support and metric-driven reviews. Study data were managed using REDCap (Research Electronic Data Capture); a secure, web-based application hosted by the Massachusetts General Brigham Digital Research Applications team. Year-to-year analyses were performed for BP submission and route, predictors of timely BP return (≥1 BP in 7 days), 6-week postpartum visit attendance, and clinical and demographic variables.Across 24 months, 640 postpartum HDP individuals were enrolled; 68.6% (439/640) submitted BP in a timely fashion. In Year 1, 44.9% of BPs submission was by Epic (44.9%), portal (8.2%), or phone (15.5%). No BP was submitted by 31.4%. With a PHC (Year 2), Epic-routed capture increased to 56.5%, and phone/portal-dependent routes decreased to 11.6% (<i>p</i> = 0.0006). Program enrollment increased from 245 to 485 (<i>p</i> < 0.001) without changes in delivery volume. Independent negative predictors of BP return were Black non-Hispanic race, public insurance, and multiparity; HDP subtype, delivery mode, antihypertensive use, and neonatal intensive care unit admission were not predictive. <i>HomeSafe</i> engagement strongly predicted 6-week postpartum visit attendance (89.9 vs. 65.4%, <i>p</i> < 0.0001). <i>HomeSafe</i>, an EHR-tethered, postpartum BP surveillance pathway, when partnered with a population health management approach and a coordinator provides significant improvements in BP ascertainment, enrollment scalability, and 6-week postpartum engagement. Persistent disparities by race and insurance status highlight a need for equity-focused approaches. · HomeSafe-Epic-linked monitoring of postpartum blood pressure.. · Population health tenets improve postpartum surveillance.. · Gaps in postpartum surveillance of high-risk person remain..