How AI Can Impact Chronic Disease Management

By Trishan Panch, MD, MPH

Years ago, my staff and I pored over handwritten notes and unsigned prescriptions to address patients with chronic diseases. For the first time, we were using data to determine patients’ needs and deploying our clinical resources to meet those needs—before the patients suffered complications or sought care themselves. For most physicians today, this is a familiar and digitized process, but back then, dovetailing quality metrics with our patient population was an innovation.

We could see a trend emerge with patients who had gaps in care. Some patients were more familiar than others, and I came to understand a critical obstacle to chronic disease management: The patients most likely to benefit from primary care aren’t the patients who come for an office visit.

Digital health management can be used to support patients outside the four walls of care delivery; it offers the potential to extend clinical resources, with some encouraging results. Through this approach, more patients have been served with the same resources across multiple specialties. As many of these patients are capable of self-managing (at least some of the time), digital health management makes it easier and more effective to do so by virtually connecting patients and clinicians through platforms such as smartphone apps. These patients would otherwise have to be seen in primary care visits, diverting attention and resources from patients with higher acuity. However, digital health management can engage complex patients, including the elderly, in care management and deliver improvements in cost and outcomes.

We know that digital health management helps clinicians reach more patients, more effectively, with the same resources. But how can organizations make sure they offer digital health solutions to the right patients—those who are most likely to benefit? That’s where artificial intelligence (AI) comes in.

With so much about AI for healthcare in the news, some may wonder how much of it is hype. However, there have been huge tangible advantages in a subset of techniques called deep learning, which can produce superhuman results in focused tasks such as image recognition or language translation. These techniques are more A than I: They are loosely influenced by how the brain works, are implemented with computers, and leverage huge amounts of data and computational power.

But despite these advances—and what popular culture may tell us—there’s no reason to expect that sentient robots will replace clinicians any time soon. Instead, the intersection between these AI techniques and digital health management presents a unique and powerful opportunity to amplify clinicians’ work.

When organizations deliver digital health management solutions to patients, such as mobile apps, they can generate an entirely new data set on patient activity, patient-reported outcomes, and more insights. It can also be combined with information from the health system, such as claims data and EMR data. Through machine learning, organizations can then harness the data to prioritize members based on real-time needs, generate intervention alerts, and recommend follow-up actions with their providers.

This technology ultimately creates a positive feedback loop: Because patients receive timely, personalized support, they engage with clinicians more often. This generates more data, which in turn gives the care team the insight to provide the right clinical intervention to the right patient at the right time. Plus, this approach helps the organization as a whole learn which interventions are most effective and where clinical resources can be most meaningfully deployed.

To meet the needs of every patient, clinical services will need both technology that extends the reach of clinicians and data science solutions to focus that technology on the patients it will most likely benefit. I anticipate that this will allow clinicians to give more attention to the people who would not otherwise come to see them—the patients with the most complex needs, who would most benefit from the bespoke, compassionate care that only people can deliver and technology can help us amplify.

Trishan Panch, MD, MPH, is chief medical officer and co-founder of Wellframe.