Diabetes management
Glucose monitoring, HbA1c tracking, and insulin-titration support.
Disease Management Software
Disease Management Software for Chronic Disease Programs
We build disease management platforms that run protocol-driven chronic care programs — diabetes, CHF, COPD, and hypertension — with RPM device data, evidence-based pathways, and outcome tracking payers can trust.
HIPAA-ReadyFHIR R4SOC 2 Type IIAudit Logged
Trusted by global innovators
What disease management software involves
Disease management software operationalizes evidence-based programs for chronic conditions — turning clinical guidelines for diabetes, congestive heart failure, COPD, or hypertension into protocol-driven pathways with defined interventions, thresholds, and escalation rules. The engineering challenge is encoding those protocols as FHIR PlanDefinition and CarePlan structures, then feeding them real-world data from RPM devices and the EHR so the program responds to what the patient is actually doing.
Generic care tools treat every patient the same. A real disease management platform stratifies by condition and risk, applies the right protocol, ingests glucose or blood-pressure readings, and escalates when a value crosses a threshold. We build that closed loop — protocol, monitoring, intervention, outcome — so programs demonstrably improve control and reduce avoidable utilization.
What it is
Turn guidelines into running programs
Disease management software takes the clinical guidelines for a chronic condition and runs them as a live program — enrolling patients, monitoring the right signals, and intervening at the right moment.
The payoff is control: better HbA1c, on-target blood pressure, fewer avoidable admissions. We build the closed loop of protocol, monitoring, and intervention that makes those outcomes repeatable.
Architecture
A protocol-driven engine wired to RPM device data and the EHR — so chronic disease programs act on real signals, not stale charts.
What We Build Into Disease Management Platforms
Each capability pairs a chronic-care workflow with the standard or data source that makes it evidence-based.
Protocol-Driven Pathways (FHIR PlanDefinition)
Evidence-based guidelines for diabetes, CHF, COPD, and hypertension encoded as FHIR PlanDefinition and CarePlan, so every enrolled patient follows the right pathway.
RPM & Device Data Integration
Ingest glucose, blood pressure, weight, and SpO2 readings from connected devices via HealthKit, Health Connect, and vendor APIs, mapped to FHIR Observation.
Risk Stratification by Condition
ICD-10 problem lists, lab values, and utilization signals stratify each cohort so high-risk patients get proactive outreach before they decompensate.
Threshold Alerts & Escalation
Configurable clinical thresholds trigger escalation to the care team when a reading or trend crosses program-defined limits, with a full audit trail.
Patient Education & Engagement
Condition-specific education, self-management prompts, and secure messaging tied to the patient's active protocol and goals.
Outcome & Quality Reporting
Track HbA1c control, blood-pressure targets, and readmission rates against program goals, with reporting aligned to value-based and payer requirements.
Where it fits
Chronic disease programs we support
Congestive heart failure
Daily weight and symptom tracking with decompensation alerts.
COPD management
SpO2 and symptom monitoring with exacerbation escalation.
Hypertension programs
Home BP monitoring toward guideline targets.
Payer disease management
Health-plan programs proving control across member cohorts.
Multi-condition programs
Comorbid patients enrolled in layered condition pathways.
Programs built to demonstrate control
Disease management only pays off when outcomes are measurable. We instrument protocols, device data, and results from day one.
FHIR
Protocols encoded as PlanDefinition and CarePlan
Real-time
RPM readings mapped to FHIR Observation
3–5 mo
Typical build to first live condition program
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards and compliance
Standards behind our disease management builds
FHIRHL7ICD-10LOINCHIPAA
Our Process
How We Deliver a Disease Management Build
We treat protocol encoding, device integration, and outcome reporting as parallel tracks from discovery.
1.
Discovery & Protocol Design
We map your target conditions and clinical guidelines, then encode them as FHIR PlanDefinition pathways with thresholds and escalation rules.
Evidence-based
2.
Core Build & Monitoring
We build the pathway engine, device-data ingestion, and threshold-alert logic that drives proactive intervention.
Closed-loop care
3.
Integration
We wire RPM device APIs, FHIR Observation mapping, and EHR write-back so program data lives alongside the clinical record.
Real-world data
4.
Rollout & Outcomes
Phased go-live with outcome dashboards, quality reporting, and protocol tuning as cohort data accumulates.
Measured impact
Featured case study
Read Case StudyLera Health: compliant women's health platform
Related proof of compliant delivery: for Lera Health we turned biomarker data into personalized, protocol-driven care plans on a HIPAA-ready data layer. It is not a chronic-disease product, but it shows how we operationalize data-driven, longitudinal care.
Why Partner With Us
15-Minute Scoping CallWhy teams choose Agnotic for disease management
Chronic disease programs need protocol rigor and real device data. We build both into a platform that proves its outcomes.
Protocol Rigor
Clinical guidelines encoded as versioned FHIR PlanDefinition pathways, so programs stay evidence-based and auditable as they evolve.
Device-Data Fluency
We integrate glucose, BP, and weight data through HealthKit, Health Connect, and vendor APIs, mapped cleanly to FHIR Observation.
Outcome Accountability
We build the reporting that proves control improvements and reduced utilization to payers and value-based partners.
Data-Driven Care Depth
Our longitudinal, biomarker-driven work means your team is not teaching us how personalized chronic care works.
Our relevant experience
Chronic disease programs that act on real signals.
Frequently Asked Questions
Cost depends on how many conditions you run and how much device data you ingest. A first condition program with encoded protocols, RPM integration, and outcome reporting is typically a three-to-five-month build; multi-condition, payer-grade platforms scale from there. We scope against your target conditions before quoting.
Ready to run chronic disease programs that prove control?
Tell us which conditions you manage and where your data lives. We'll return a phased plan with protocol encoding, device integration, and outcome reporting.
contact@agnotic.com
Partnerships
contact@agnotic.com