A clinician-led care group needed to unify Advanced Primary Care Management, Remote Patient Monitoring, and Behavioral Health Integration into one platform on top of a clinic's existing EHR. We mapped the CMS billing rules to the data model first, then defined six roles, wrote an 18-section specification, and prototyped all five web portals and the patient app end to end.
Talk to Our TeamA clinician-led group delivering primary, chronic, and remote patient care in partnership with rural and underserved hospitals and clinics
Product definition for a unified Advanced Primary Care Management, Remote Patient Monitoring, and Behavioral Health Integration platform across six user roles
FHIR (US Core), OAuth 2.0
In active development
The founder had lived the problem: clinics running chronic care and remote monitoring programs across an EHR, a spreadsheet, and a device portal, then reconciling billing by hand every month. What he needed was a product definition precise enough for engineers to estimate, designers to lay out, and a founder to put in front of a clinic.
The founder knew what was broken because he had lived it, but writing requirements meant six months away from the exam room he did not have.
Billing rules were not adjacent to the product, they determined whether a practice got paid, and no one on the build side knew them well enough to ask the right questions.
For a care management product, that timing is fatal. Fixing eligibility and documentation logic after screens are already designed costs far more than defining it first.
Consent before services start, 24/7 access to patient information, an electronic care plan, care transition follow up within 7 days, population risk stratification, and performance measurement: a practice cannot attest to most of that with a spreadsheet.
FHIR (US Core) for clinical data and OAuth 2.0 for authentication, layered on top of a clinic's existing EHR.
Advanced Primary Care Management pays as a monthly bundle rather than by documented minutes, and CMS attaches conditions to that bundle. Working through those conditions first determined the data model: eligibility evaluated against a live condition list rather than captured once, conditions carrying ICD-10 codes and severity, and device readings retained as documentation against the claim.
We defined six roles and drew the boundaries between them: super admin across clinics, clinic admin, physician, nurse, digital health navigator, and patient. The navigator role mattered most. CMS permits auxiliary personnel to deliver these services incident to the billing provider under general supervision, which lets a practice provide care management without routing every touchpoint through clinician time. Defining it as a full role was as much an economic decision as a product one.
The specification covers personas, architecture, per-role workflows, patient onboarding and consent, notifications, dashboard and reporting, integrations, mobile requirements, the API layer, non-functional requirements, service levels, and audit and compliance. Program rules mapped to the data model first, so eligibility, documentation, and consent requirements are architectural rather than retrofitted.
We prototyped the whole platform, not a selection: all six roles, five web portals plus the patient mobile app, clickable end to end, with a guided path through every entry point. A clinic admin arriving from an invitation, a physician joining an assigned clinic, a nurse signing in, a patient finding their own record. The billing logic was validated by the physician who bills it: the founder went through the G-code mapping himself and confirmed it before it went further.
That translation from frontline knowledge to a spec an engineering team can build from is the work we do before production code starts. In healthcare, the hard part is knowing which regulations are product requirements wearing a different hat.
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