Software-driven chronic disease management: Algorithm design and implementation in a community-based blood pressure control pilot.

Background: Optimal guideline-directed medical therapy is rarely attained in practice, resulting in inadequate control of diseases such as hypertension, with poorer results in under-resourced communities. Technology, including artificial intelligence-driven decision support and software-driven workflow transformation, can potentially improve disease outcomes at a reduced cost, although it must be integrated with a holistic approach.

Methods: We describe the design of a software platform that enables rapid iterative remote management of >20 conditions across cardiac-kidney-metabolic disease.