大数据背景下区域慢性疾病监测系统设计与应用  

Design and Application of Regional Chronic Disease Monitoring System under the Background of Big Data

作　　者：白雪 朱宇 BAI Xue;ZHU Yu(Ningbo Yinzhou District Health Bureau,Ningbo 315100,Zhejiang,China)

机构地区：[1]宁波市鄞州区卫生健康局,浙江省宁波市315100

出　　处：《中国卫生信息管理杂志》2024年第6期895-901,共7页Chinese Journal of Health Informatics and Management

基　　金：鄞州区卫生健康科技计划项目(2023Y31)。

摘　　要：目的解决慢性疾病监测难的问题,实现慢性病早期筛查,有效预防和控制疾病的发生发展。方法通过分析慢性疾病及其相关危险因素的实验室特征,构建和实施慢性疾病一体化健康管理模式,对特定慢性疾病及其相关危险因素实施干预措施,减少主要健康危险因素。结果建立了慢性疾病(慢性肾脏病和血液病)的早期监测系统,实施规范化的诊断治疗和个体化的行为干预指导,形成全周期、闭环的综合诊疗模式。结论通过慢性疾病的早期监测系统开展前期筛查、疾病的早期干预、规范治疗、精准随访等健康全流程管理,能够实现优质高效的疾病管理与健康促进,逐步建立以人的健康为中心,医疗、预防和保障为一体的全周期、闭环的综合诊疗模式,提升患者的生命质量。Objective In order to solve the problem of difficult monitoring of chronic diseases,achieve early screening of chronic diseases,and effectively prevent and control the occurrence and development of diseases.Methods By analyzing the laboratory characteristics of chronic diseases and their related risk factors,constructing and implementing an integrated health management model for chronic diseases,implementing intervention measures for specific chronic diseases and their related risk factors,and reducing major health risk factors.Results We have established an early monitoring system for chronic diseases(chronic kidney disease and hematological diseases),implemented standardized diagnosis and treatment,and personalized behavioral intervention guidance,forming a comprehensive diagnosis and treatment model with a full cycle and closed-loop approach.Conclusion Through the early monitoring system of chronic diseases,the whole process of health management can be carried out,including early screening,early intervention,standardized treatment,and precise follow-up.This can achieve high-quality and efficient disease management and health promotion,gradually establish a comprehensive diagnosis and treatment model centered on human health,integrating medical treatment,prevention,and protection throughout the entire cycle,and improve the quality of life of patients.

关 键 词：慢性肾脏病 血液病 监测预警 医防融合 

分 类 号：R-058[医药卫生] R319