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 R4HL7 v2Audit Logged
Trusted by global innovators
What is disease management software?
Disease management software runs evidence-based programs for chronic conditions such as diabetes, heart failure, COPD and hypertension. It enrolls patients, applies a condition protocol, takes in device and EHR data, and alerts the care team when a reading crosses a threshold. Agnotic Technologies builds it as a custom platform on FHIR R4, connected to your EHR.
Each program encodes clinical guidelines as FHIR PlanDefinition and CarePlan structures, stratifies patients by condition and risk, and ingests glucose or blood-pressure readings from RPM devices and the EHR, closing the loop from protocol to intervention.
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.
Disease management 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 goes into chronic disease management software?
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
Which chronic disease programs do 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
ICD-10
Condition coding for cohort risk stratification
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 standards-based FHIR 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
Which standards does disease management software use?
FHIRHL7ICD-10LOINCHIPAA
Our Process
How do we build disease management software?
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
Facts and sources
Which rules shape disease management software?
Short facts we design chronic care programs around, each linked to its primary source.
The HL7 FHIR R4 PlanDefinition resource defines plans as sharable, executable artifacts, general enough to describe clinical decision support rules, order sets and protocols.
Source: HL7 International, FHIR R4 PlanDefinitionMedicare'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 CY 2026 Physician Fee Schedule final rule describes separate code sets for chronic care management of multiple chronic conditions and principal care management of a single high-risk condition, and adds RTM codes 98984, 98985, 98986 and 98979 for shorter monitoring periods and management time.
Source: CY 2026 Physician Fee Schedule final rule, 90 FR (govinfo)The HIPAA Security Rule requires administrative, physical and technical safeguards for electronic protected health information.
Source: 45 CFR Part 164 Subpart C (eCFR)
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 choose Agnotic for disease management software?
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, how much device data you ingest, and how deep the EHR and outcome reporting go. A first condition program with encoded protocols, RPM integration and outcome reporting is the usual starting scope. We scope against your target conditions before quoting.
The timeline is driven by device-integration access and EHR data feeds more than the pathway engine, plus how many conditions the first release covers. We secure those feeds early, encode the protocol in parallel, and give you a dated plan after discovery.
Yes. Agnotic signs a business associate agreement before any PHI is shared, and development and test environments use synthetic patients and readings. HIPAA safeguards such as encryption, role-based access and audit logging are built in from the first sprint.
Yes. We scope the first release to one workflow, usually one condition program with its protocol, device readings and threshold alerts against one EHR. More conditions, devices and payer reporting follow on the same base.
AI tools help our engineers draft code and tests, but a person reviews every change, and it passes the same automated tests and security checks as any other code, including the tests on protocol thresholds and alerts. Which tools may see your code or data is agreed with you at the start.
Buy if a packaged program fits your conditions and data sources. Build when you need custom protocols, specific device integrations, or outcome reporting a vendor cannot provide. We often build the differentiated protocol and monitoring layer and integrate existing tools around it.
We ingest device readings through Apple HealthKit, Health Connect, and vendor APIs, mapping them to FHIR Observation with LOINC coding. Program and outcome data write back to Epic, Oracle Health (Cerner), or athenahealth via FHIR R4 and HL7 v2 so it lives alongside the clinical record.
We instrument control metrics (HbA1c, blood-pressure targets, weight trends, readmission rates) against each program's goals from day one. Reporting is built to align with value-based and payer quality requirements so impact is defensible, not anecdotal.
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