信息化支撑的整合式社区慢性病健康管理模式探索

针对国内现有的慢性病管理模式存在的机构功能定位不清、技术支持不足、信息化不充分等问题，本研究提出将“以人为核心”的整合式健康管理理念融入我国社区慢性病管理，探讨基于信息化支撑的整合式社区慢性病健康管理模式的内涵和做法，通过信息技术应用，创新实现社区慢性病健康管理的技术整合、数据整合和服务整合，精准高效地实现“以人为核心”、多病种、全周期的筛查、诊断、治疗、干预、随访管理、健康促进等一体化的社区慢性病综合防治服务。上海市应用该模式为197.51万居民提供整合式社区健康管理服务。基于信息化支撑的整合式社区慢性病健康管理模式有助于实现“以人为核心”的整合式慢性病健康管理，有待开展中长期防治效果以及经济学的评估，为我国慢性病防治事业发展提供参考经验。

Research on an integrated community-based chronic disease management model driven by massive databases

China’s chronic disease management suffers from problems such as unclear institutional function， insufficient information technology application， and weak regulation support. On the basis of current chronic disease management condition in China， this paper proposes to apply the concept of “people-centered” integrated health management to community chronic disease management and discusses the content and procedure of establishing an integrated community-based chronic disease management model driven by massive databases. The model innovatively combines technology integration， data integration and service integration， and can accurately and efficiently realize the "people-centered" full-course health management of various chronic diseases. Shanghai has provided integrated community-based chronic disease management service for 1.98 million citizens through applying this model. The model warrants further effectiveness and economic evaluation. This study provides precious experience for the development of chronic disease prevention and treatment in China.