慢性病随访系统在社区医疗体系中的应用研究  

Research on the application of chronic disease follow-up system in community medical system

作　　者：邢鲁民 李昕 徐民 XING Lu-min;LI Xin;XU Min(The Information Center,The First Affiliated Hospital of Shandong First Medical University,Jinan 250014,China;不详)

机构地区：[1]山东省第一医科大学第一附属医院信息中心,山东济南250014 [2]中国社会科学院商学院,北京100732 [3]澳门城市大学数据科学研究院,澳门999078 [4]山东省政法学院经济贸易法学院,山东济南250015 [5]山东省第一医科大学第二附属医院院长办公室,山东济南250014

出　　处：《中国医学装备》2021年第3期129-133,共5页China Medical Equipment

基　　金：山东省科技厅发展计划(2010GSF10816)“医院数字信息体系构建与优化应用的研究”。

摘　　要：目的:拟构建社区慢性病管理专项信息化系统,为社区慢性病随访管理中医患沟通途径及社区慢性病患者随访数据关联提供便利。方法:在对慢性病社区随访需求及现状分析基础上,提出患者信息随访与康复指导相结合的慢性病管理方案,并基于健康档案管理理念构建慢性病患者。采用轻量级Java开发策略,基于Spring、Spring MVC结合Spring Data等框架构建社区慢性病随访系统。结果:通过构建社区慢性病随访系统,在随访过程中建立直观的医患沟通途径,并在慢性病患者健康档案管理中建立数据整合策略,健全健康档案内容,为实时掌握患者的治疗效果及康复状况,建立针对性治疗建议创造条件。结论:采用信息化方法建立基于新型社区慢性病管理模式的信息化系统并应用于患者随访及诊疗,为社区慢性病预防控制及诊断治疗提供平台支撑,有助于健全患者健康档案,建立全生命周期管理体系,在慢性病预防宣传、诊断治疗及随访回馈等环节实施管理及干预,有望提高慢性病随访管理效率和社区慢性病患者整体健康水平。Objective:To construct information system for special project of chronic disease management in community so as to provide convenience for the relevance between the approach of doctor-patient communication and follow-up data of patients with chronic disease of community in the follow-up management of chronic disease of community.Methods:Based on the analysis of the requirement and current situation of community follow-up of chronic diseases,the paper put forward a chronic disease management scheme of combining the information follow-up of patient and the rehabilitation guidance,and constructed patients with chronic disease on the basis of the concept of health archive management.Based on the framework of Spring,Spring MVC and Spring Data,a follow-up system of community chronic disease was constructed by adopting Java development strategy with lightweight class.Results:Through the construction of the follow-up system of community chronic disease,the paper established a direct way of doctor-patient communication in the follow-up process,and established data integration strategy and improved the content of health archive in the management of health archive for patients with chronic disease so as to create conditions for real time grasping the therapeutic effect and rehabilitation situation of patients and establishing targeted therapy.Conclusion:An information system that based on chronic management model is established by using information method,and it can be used in the follow-up,diagnosis and treatment for patients so as to provide platform support for prevention,control,diagnosis and treatment of chronic disease in community.It contributes to improve the health archive of patients,and establish the whole life-cycle management system.The implementations of management and intervention in prevention,propaganda,diagnosis,treatment,follow-up and feedback of chronic disease are expected to improve the follow-up management efficiency of chronic disease and the overall health level of patients with chronic disease in co

关 键 词：随访 慢性病 信息系统 社区医疗 

分 类 号：R197.324[医药卫生—卫生事业管理]