区域慢性病智能健康管理平台设计与实现

目的/意义 落实糖尿病、高血压等慢性病综合防控策略,推动医疗、公共卫生融合的居民健康管理。方法/过程 以打通业务联动和数据融合为基础,设计构建区域化慢性病智能健康管理平台,建立患者全息健康档案,采集日常监测数据,实现建档、诊疗、随访、饮食/运动管理、风险评估、智慧宣教等系统功能。结果/结论 平台使用初期为数千例糖尿病与高血压患者提供区域内一体化健康管理服务,实现慢性病患者健康信息全面掌控与监测,逐步构建居民健康全流程闭环管理模式。

Design and Implementation of a Regionalized Intelligent Health Management Platform for Chronic Diseases

Purpose/Significance To implement comprehensive prevention and control strategies for chronic diseases such as diabetes and hypertension, and topromote the integrated development of medical treatment and public health on residents’ health management.Method/Process On the basis of opening up business linkage and data integration, a regionalized intelligent health management platform for chronic diseases is designed and built, comprehensive health files for patients are established, daily monitoring data are collected, and the system functions such as file establishment, diagnosis and treatment, follow-up visit, diet/exercise management, risk assessment, and intelligent education are realized.Result/Conclusion In the initial use of the platform, it provides integrated health management services within the region for thousands of patients with diabetes and hypertension, realizes full-dimensional control and monitoring of health information for patients with chronic diseases, and gradually builds a closed-loop management mode for the whole process of residents’ health.