上海市社区慢性病健康管理信息系统建设及应用成效  

Construction and effectiveness of the chronic disease health managemen information system in Shanghai communities

作　　者：杨沁平 徐璐璐 黎衍云[1] 严青华[1] 冯嘉宸 顾凯[1] 杨群娣[1] 郑杨[1] 毛丹 孙靖 王玉恒[1] 程旻娜[1] 施燕[1] YANG Qinping;XU Lulu;LI Yanyun;YAN Qinghua;FENG Jiachen;GU Kai;YANG Qundi;ZHENG Yang;MAO Dan;SUN Jing;WANG Yuheng;CHENG Minna;SHI Yan(Shanghai Municipal Center for Disease Control and Prevention,Shanghai 200336,China)

机构地区：[1]上海市疾病预防控制中心,上海200336

出　　处：《中国公共卫生》2024年第9期1156-1160,共5页Chinese Journal of Public Health

基　　金：上海市加强公共卫生体系建设三年行动计划项目(GWVI-8);上海市加强公共卫生体系建设三年行动计划重点学科建设项目(GWV-11.1-22);上海市卫生健康委员会卫生行业临床研究专项项目(20214Y0488);上海市卫生健康委员会卫生行业临床研究专项项目(20234Y0304)。

摘　　要：为支撑“以人为核心”慢性病健康管理业务工作的开展,上海市建设了社区慢性病健康管理信息系统,该系统通过信息登记管理和风险评估、慢性病筛查、患者评估、分类随访等功能为实现医防融合、医患协同的多种慢性病的全程、精准、高质量健康管理服务提供了高效的工具,有效推动了慢性病综合防治战略的实施和慢性病健康管理服务的深度转型。但该系统纳入管理的慢性病病种有待进一步增加、诊室环境的医生随访与家庭环境的自主管理交互融合有待增强,今后可进一步对系统进行病种整合和复合场景交互融合,以不断顺应慢性病防控的新形势、新挑战。To support the"people-centered"chronic disease health management work,Shanghai has developed a community chronic disease health management information system.This system provides an efficient tool for achieving integrated medical care and disease prevention,as well as collaborative management between doctors and patients,through functions such as information registration and management,risk assessment,chronic disease screening,patient evaluation,and categorized follow-up.It delivers comprehensive,precise,and high-quality health management services for various chronic diseases,effectively promoting the implementation of comprehensive chronic disease prevention and control strategies and the transformative development of chronic disease health management services.However,the system currently requires the inclusion of a broader range of chronic diseases and the enhancement of interactive integration between clinic-based doctor follow-ups and home-based self-management.Future improvements may include the integration of additional disease types and the fusion of complex interaction scenarios to continuously adapt to the new situations and challenges in chronic disease prevention and control.

关 键 词：慢性病 健康管理 信息系统 

分 类 号：R197.1[医药卫生—卫生事业管理]