Chronic Care GPS

We at Chronic care GPS are building a data analysis and visualization app for patients with multiple Chronic care needs. Using this app, patients can compare their personal health against population health to identify care gaps, alternate treatments and get advise on improving quality of life. They can manage all aspects of their care and track progress. 

Background - Chronic diseases by definition are lifelong and incurable. From the onset, they have profound impact on quality of life. Combination of symptoms, care management, multiple physician visits etc. can be overwhelming and might cause severe mental issues.

It has been observed that active involvement of patients in managing all aspects of their treatment is paramount for better care outcomes. An overload of data, care complexity, personal or cultural belief systems, confusing and complicated treatment regimens, cost etc. are barriers to patient engagement which then leads to decline in care, causing additional health issues, higher costs etc. (it’s a vicious cycle)

It is natural for a patient dealing with chronic diseases, managing their work and family pressures etc. to feel helpless and lost. They need a personal team of physicians, counselors, nutritionists and others to fill this gap and get them back on track. Such a personal care team can be a very costly affair.

Chronic care GPS fills this gap with a digital solution.

Vision - Analyze longitudinal population health data to draw insights and provide tangible outcomes which can be leveraged by other to better manage their chronic diseases. Users can learn and adapt positive practices of healthier outliers in their peer group. This will lead to better care outcomes, reduce cost of care and improved quality of life. 

Problem statement - Chronic diseases affect close to half US adult population and the numbers are rising. Some of these diseases are leading causes of death and financial burden in the United States. This leads to an overwhelming burden on health care system (financial impact of chronic care mgmt. is over $ 3.5 T annually, almost 90% of overall healthcare spend). 

Typical challenges faced by patients with multiple Chronic diseases are

1. They visit multiple care providers which results in care coordination gaps

2. Suboptimal care results in higher costs for individuals and undesirable care outcomes 

3. Social conditions might force some to skip care, impacting health and resulting in emergency visits.

Solution - Proposed app (Chronic care GPS - CC GPS) provides a comprehensive view of 'my' health. It can also respond to user queries by analyzing health data from all the subscribers (population health). This app tracks individual's progress vis a vis rest of the population with similar medical profile. 

Benefits for Individuals   

1. Current state - compare my current condition to the lifetime path (timeline)

2. Direction - Is my current treatment on-track to improve my overall health?

3. Alerts - What am I doing right, where can I improve?

4. Group wisdom - insights from population data which can help me (Healthier Outliers)

5. What caused my last emergency and how can I prevent it?

Benefits for Payers and Providers

1. Leverage Population health analysis and trends for planning

2. Identify care disparities in local settings and address them

3. Risk analysis and stratification 

4. Reduce emergency visits / cost and improve care outcomes

Under the hood - This app processes EHR, Pharmacy, Claims and other data from multiple sources, creates a data lake for AI / ML to build individual and group trends, models and predictions. Based on this analysis, user queries can be responded with insights, advise and alternatives for dealing with chronic diseases. 

Competitors - Generally chronic care or other healthcare apps focus on care management like symptoms tracking, medication management and appointments tracking. Some also provide telehealth or integration with wearable devices. 

This app takes the digital health solution a few steps forward by combining population health (of similar profiles) and comparing it with individual's health which enables user to make informed decisions.   

(Schematic representation of data flow)