区域慢性病智能健康管理平台设计与实现  

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

作　　者：温俊 潘玉霞 王亚青 叶飞 陈亚 卢姗[4] 彭丽 WEN Jun;PAN Yuxia;WANG Yaqing;YE Fei;CHEN Ya;LU Shan;PENG Li(The Fourth Affiliated Hospital of Nanjing Medical University,Nanjing 210031,China;Taishan Street Community Health Service Center,Nanjing Jiangbei New Area,Nanjing 210031,China;Jiangsu Yahuan Software Co.Ltd.,Nanjing 210024,China;Jiangsu Province Hospital,Nanjing 210029,China)

机构地区：[1]南京医科大学第四附属医院,南京210031 [2]南京江北新区泰山街道社区卫生服务中心,南京210031 [3]江苏亚寰软件股份有限公司,南京210024 [4]江苏省人民医院,南京210029

出　　处：《医学信息学杂志》2024年第3期70-76,共7页Journal of Medical Informatics

基　　金：江苏省卫生健康委医学科研项目(项目编号:Z2022048);江苏省南京市卫生科技发展专项(项目编号:YKK21248);南京医科大学医学大数据临床科研专项(项目编号:zsj202206)。

摘　　要：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。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.

关 键 词：慢性病 区域化健康管理 全息健康档案 

分 类 号：R-058[医药卫生]