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Updated: May 11, 2026

A Novel Digital Platform for a Monitored Home-based Cardiac Rehabilitation Program
Published on: April 19, 2019
HeartBeat Connections: A Rural Community of Solution for Cardiovascular Health
Gretchen A Benson1, Abbey Sidebottom, Jeffrey J VanWormer
1Department of Education, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA. gbenson@mhif.org
Insights
The HeartBeat Connections program uses electronic health records to identify high-risk individuals for cardiovascular disease (CVD) and provides personalized coaching to improve lifestyle behaviors and medication adherence, aiding in primary CVD prevention.
Area of Science:
- Public Health
- Cardiology
- Health Informatics
Background:
- Cardiovascular disease (CVD) remains the leading cause of mortality in the United States.
- Primary care settings face challenges in patient engagement and medication adherence for CVD risk factor control.
- Electronic health records (EHRs) offer opportunities for proactive identification and targeted prevention strategies.
Purpose of the Study:
- To describe the development and approach of the HeartBeat Connections (HBC) program.
- To leverage EHR data for population-based cardiovascular disease prevention in a rural community.
Main Methods:
- The HBC program utilizes EHR data to identify high-risk residents in a rural community.
- Participants receive targeted coaching from registered dietitians or nurses.
- Coaching focuses on lifestyle modifications and optimizing preventive medication therapy.
Main Results:
- The HBC program facilitates more frequent patient access to non-prescribing health professionals compared to standard clinical visits.
- Intervention is specifically designed to enhance lifestyle behaviors and medication adherence for primary CVD prevention.
Conclusions:
- The HBC program demonstrates a novel approach to cardiovascular disease primary prevention.
- Innovative, EHR-driven population health strategies are crucial for addressing barriers and reducing coronary events.
Background:
Cardiovascular disease (CVD) continues to be the leading cause of death among Americans. National guidelines emphasize early identification and control of CVD risk factors, but challenges remain in the primary care setting in terms of engaging patients and improving medical therapy adherence. The rapid growth of electronic health records (EHRs) provides a new way to proactively identify populations of high-risk patients and target them with prevention strategies. The HeartBeat Connections (HBC) program was developed as part of a population-based demonstration project aimed at reducing myocardial infarctions.
Methods:
HBC uses EHR data to identify residents at high CVD risk in a rural community. Participants receive coaching from a registered dietitian or a registered nurse focused on lifestyle behavior changes and preventive medication initiation/titration.
Discussion:
HBC provides patients with access to nonprescribing professionals on a more frequent basis than typical office visits, and it is focused specifically on helping patients improve lifestyle behaviors and medication adherence as they relate to the primary prevention of CVD.
Conclusion:
Innovative population health approaches that use EHR data to address common barriers to CVD prevention and engage communities in addressing population health needs are needed to help more patients prevent coronary events.
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