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Diabetes & Prediabetes
CGM-backed programs, A1C tracking, and lifestyle coaching for type 2 and prediabetes.
Healthcare / Chronic Care App
What is a chronic care app?
A chronic care app is software that helps patients with long-term conditions, such as diabetes, heart failure, hypertension or COPD, manage their care between visits. It connects home devices, medication reminders and care plans to the care team and the EHR. Agnotic Technologies builds them with CCM and RPM documentation and HIPAA safeguards.
CCM + RPM
Time and device-day tracking for CPT 99490 and 99453 to 99458
FHIR R4
Readings and care plans synced to the EHR
Home devices
BP cuffs, CGMs, scales and pulse oximeters
Trusted by global innovators
Industry Overview
How does a chronic care app work?
A chronic care app works as a loop between home and clinic. Patients log symptoms and medications while home devices send readings; rules flag readings outside the care plan; care managers review the flags, message patients and document time for CCM or RPM billing; and the results sync to the EHR.
Industry Challenges
Why do chronic care apps lose patients?
The same problems come up when teams scope chronic care software.
Logbook fatigue: self-tracking without feedback loses patients quickly.
Missed medication: patients stop or skip medicines, and the care team often finds out only after a downstream event.
Billing complexity: CCM, RPM and principal care management codes have overlapping but distinct documentation rules, so time is easy to underbill.
Care-team overload: without triage, care managers drown in low-risk alerts and miss the patients who need help.
Our Approach
How we build chronic care apps
Programs that keep patients engaged and keep billing documentation complete.
Connected Home Devices
BP cuffs, CGMs, scales, pulse oximeters, and peak-flow meters flow directly into the app and the EHR.
Adherence & Behavior
Pill-reminder nudges, refill prediction, and behavior-change content tuned per condition and literacy level.
Reimbursement Engine
Automatic time-on-task tracking, documentation packets, and claim-ready summaries for CCM / RPM / PCM CPT codes.
Capabilities
What goes into a chronic care app?
Capabilities we build into chronic care programs.
Condition Care Pathways
Condition pathways for diabetes, heart failure, hypertension, COPD, CKD and obesity, set by your clinicians.
Home Device Integration
Direct sync from Dexcom, Abbott, Omron, Withings, iHealth, and Apple/Google Health.
Medication Adherence
Pill reminders, refill prediction, and pharmacy integrations for home delivery.
Symptom & Outcome Tracking
Condition-specific PROMs and symptom diaries with longitudinal trending.
Care-Team Messaging
Asynchronous messaging with triage SLAs and escalation to video visit or nurse call.
Risk Stratification
ML-assisted stratification to focus care managers on rising-risk patients first.
Education & Coaching
Literacy-tuned content, coaching journeys, and group programs for behavior change.
CCM / RPM / PCM Billing
Time-on-task logs, documentation, and claim-ready summaries for each CPT code.
EHR Sync
Two-way sync with Epic, Oracle Health (Cerner) and athenahealth via SMART on FHIR and FHIR write-backs.
How It Works
How is a chronic care app built?
How readings, rules and care-team work flow from home to the EHR.
Patient App Layer
iOS, Android, and SMS journeys that share a single clinical model.
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Device & Pharmacy Ingestion
BLE device SDKs and Surescripts pharmacy integrations into the clinical core.
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Care Engine
Condition pathways, risk stratification, and reimbursement tracking run over FHIR data.
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Clinician Workspace
Care-manager dashboards, triage queues, and documentation tools.
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EHR Integration
SMART on FHIR, FHIR write-back, and HL7 v2 interfaces to the source-of-truth EHR.
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Engineering Stack
Technology stack
A pragmatic stack chosen for reliability, speed, and ease of operation.
Standards
FHIR R4USCDI v3SMART on FHIRHL7 v2LOINCSNOMED CT
Devices & Pharmacy
DexcomAbbott LibreViewOmron ConnectApple HealthKitSurescripts
Backend
Node.jsPythonGraphQLPostgreSQLTimescaleDB
Apps
React NativeNext.jsTailwind
AI / ML
PyTorchscikit-learnMLflow
Infra
AWS HIPAAAzure HIPAAKubernetesVault
Measured Impact
What should a chronic care program measure?
Measures we build reporting around, agreed with your clinical team before launch.
Adherence
Doses taken versus prescribed
Readings
Days with device readings per patient
Escalations
Out-of-range readings reviewed on time
Billing
CCM and RPM time documented per patient
My Lauren Maternal Health Platform | Built by Agnotic
A HIPAA-ready maternal health platform enabling remote patient monitoring, care coordination, and personalized engagement from pre-pregnancy through postpartum.
Case Study
LERA Health: Women's Health App Platform
A women’s health product experience focused on guided care journeys, education, and compliance-aware workflows to support long-term engagement.
Case Study
Use Cases
Which conditions does it support?
Common chronic care programs we design for.
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CHF & Cardiac
Daily weight, BP, and symptom tracking with heart-failure-specific escalation rules.
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Hypertension
Home BP cuffs, titration protocols and monitoring for uncontrolled hypertension.
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COPD & Asthma
Peak-flow, spirometry, and exacerbation-risk monitoring with action-plan support.
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Obesity & GLP-1 Programs
GLP-1 titration support, side-effect tracking, and lifestyle coaching for weight-management programs.
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Value-Based Care
ACO and VBC programs that need HEDIS, MIPS, and Stars measure lift.
Integrations
Which systems does it connect to?
We connect to the systems your teams already know.
EHR
EpicOracle Health (Cerner)athenahealth
Devices
DexcomAbbott LibreViewOmron
Pharmacy
Surescripts
Comms
Twilio
CRM
Salesforce Health Cloud
Compliance-First Development Services Backed by Global Standards
We build secure, scalable products designed for privacy, interoperability, and regulatory readiness from day one across every sector we serve.
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, and strict access controls.
General Data Protection Regulation
Implement lawful consent flows, data minimization, and secure processing for global data privacy.
Fast Healthcare Interoperability Resources
Enabling standardized health data exchange through standards-based API mappings.
Health Level Seven International
Supporting enterprise-grade interoperability for clinical messaging and record workflows.
Our Edge
Why Global Leaders Choose Us
We combine deep technical expertise with industry-specific knowledge to deliver solutions that aren't just functional, but transformational.
Enterprise-Grade Security
We implement rigorous security protocols and compliance standards (HIPAA, GDPR, SOC2) across all industrial solutions to protect sensitive data.
High-Performance Scaling
Our architectures are built to handle massive data loads and user bases, keeping performance steady whether you're serving ten or ten million.
Accelerated Time-to-Market
Using our suite of internal tools and proven frameworks, we cut setup work so your first release reaches users sooner.
Embedded AI Integration
Beyond simple wrappers, we build deep-learning integrations and predictive analytics directly into the core of your industry-specific workflows.
Engagement Model
How does an engagement work?
A scoping call, a fixed-scope first release, then scale and support.
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Scoping call
We map your conditions, care team, devices and billing programs.
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Fixed-scope first release
One condition pathway with device sync, alerts and care-manager review working end to end.
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Billing and EHR
CCM and RPM documentation and EHR sync added before the program scales.
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Scale and support
More conditions, devices and sites, with our team supporting the product.
Facts and sources
Rules behind chronic care apps
Short facts we design around, each linked to its primary source.
Medicare's remote physiologic monitoring codes include CPT 99453, 99454, 99457 and 99458, and the CY 2026 Physician Fee Schedule added 99445 and 99470 for shorter monitoring periods and shorter management time.
Source: Federal Register, November 5, 2025 (CY 2026 Physician Fee Schedule final rule, CMS-1832-F)The HIPAA Security Rule requires administrative, physical and technical safeguards for electronic protected health information.
Source: 45 CFR Part 164 Subpart C (eCFR)A HIPAA covered entity may share protected health information with a business associate, such as a software vendor, only under a business associate agreement that commits the vendor to safeguard it.
Source: 45 CFR 164.502(e) and 164.504(e) (eCFR)ONC certification criterion 170.315(g)(10) requires certified EHRs to offer a standardized API for patient and population services based on HL7 FHIR.
Source: 45 CFR 170.315 (eCFR)
Voice of success
We don't just build products; we forge lasting partnerships. See how we've helped industry leaders transform their vision into technical reality.
“I can clearly see how Agnotic has a unique way of handling end-to-end development. They are always active on quick chat and provide support quickly.”
Aaron Phelan
Founder, Benchmark
“Agnotic combines deep technical expertise with strong domain knowledge. They understand the business context, anticipate challenges, and make collaboration smooth and effective.”
John Pasmore
Founder, Latimer
“Agnotic is the best technical team we evaluated. Their engineering excellence made our work dramatically easier and allowed us to stay focused on what matters most for maternal care outcomes. They took full ownership of the technical execution, and we are always happy to continue working together.”
Kim Smith
Founder, My Lauren
Related services
Where should you start?
Detailed pages for the services chronic care teams ask us about.
Care management software
Care plans, CCM time tracking and care-team tasks.
Remote patient monitoring software development
Device data, alerts and RPM billing support.
Clinical decision support
Rules and alerts that help care teams act on readings.
Patient engagement software development
Reminders, education and messaging between visits.
HIPAA requirements for software teams
The safeguards we build into every healthcare product.
Healthcare software development
All the healthcare products and integrations we build.
More in Healthcare
More Healthcare Solutions
Explore other production-grade engineering platforms we deliver across healthcare.
Cross-Industry Reach
The Same Engineering Patterns, Across Other Industries
The technical patterns behind this platform translate naturally into adjacent verticals.
Frequently Asked Questions
A product category. There is no single standard for chronic care apps, but they rely on standards such as HL7 FHIR for EHR data and on Medicare billing rules for CCM and RPM.
Clinical owners set the care pathways and alert rules, care managers run the program day to day, and engineers maintain the app, device integrations and billing logic as rules and devices change.
If you run CCM or RPM programs, or want patients with long-term conditions to stay engaged between visits, usually yes. If you only need occasional device readings, a remote monitoring feature inside an existing app may be enough.
Yes. We build time-on-task logging, documentation and claim-ready summaries for CCM (99490, 99439), RPM (99453, 99454, 99457, 99458) and principal care management codes.
Dexcom and Abbott for CGM; Omron, iHealth and Withings for blood pressure and weight; Apple HealthKit and Android Health Connect for consumer devices. We add device partners per program.
Yes. We can capture HEDIS, MIPS and Stars measure data and report it for ACO and value-based care programs.
SMART on FHIR launch, FHIR write-back of observations and care-plan events, and HL7 v2 interfaces where sites require it, with Epic, Oracle Health (Cerner), athenahealth and others.
Chronic care management (CCM) is a Medicare-billed service in which a care team coordinates ongoing care for patients with two or more chronic conditions under a care plan. Chronic care management software holds that care plan, logs staff time and keeps the documentation each code needs. A chronic care app is the patient side of the same program.
A hypertension program is a common example. The patient takes a home blood pressure reading, the cuff sends it to the app, a reading outside the care plan's range creates an alert, and a care manager calls the patient and documents the time for RPM billing.
Industries
A Unified Vision that Caters to Diverse Industry Demands
Planning a chronic care app?
Tell us which condition and program you want to start with, and we will scope a first release with you.
contact@agnotic.com
Partnerships
contact@agnotic.com