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- 2025-06-05
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¡¡¡¡The Chronic Disease Follow up Management System is an information-based tool for managing chronic disease patients. It integrates patient health data, optimizes follow-up processes, and strengthens doctor-patient communication, providing efficient and accurate solutions for chronic disease prevention and control. Its advantages are mainly reflected in the following aspects:
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¡¡¡¡Improve management efficiency and reduce the burden on medical staff
¡¡¡¡¹Å°åÂý²¡ÖÎÀíÒÀÀµÈ˹¤¼Í¼ºÍµç»°Ëæ·Ã£¬£¬£¬£¬Ð§ÂʵÍÏÂÇÒÒ×ÍÉ»¯¡£¡£¡£¡£ÏµÍ³Í¨¹ý×Ô¶¯»¯¹¤¾ß£¬£¬£¬£¬¿ÉÅúÁ¿ÌìÉúËæ·ÃÍýÏ룬£¬£¬£¬×Ô¶¯ÍÆËÍÓÃÒ©ÌáÐÑ¡¢¸´Õï֪ͨÖÁ»¼ÕßÊÖ»ú£¬£¬£¬£¬ïÔÌÖØ¸´ÀͶ¯¡£¡£¡£¡£ÀýÈ磬£¬£¬£¬¸ßѪѹ»¼ÕßµÄѪѹ¼à²â¡¢ÓÃÒ©µ÷½âµÈͨÀýËæ·Ã£¬£¬£¬£¬ÏµÍ³ÄÜÆ¾Ö¤Ô¤Éè¹æÔò×Ô¶¯´¥·¢Ê¹Ãü£¬£¬£¬£¬Ò½»¤Ö°Ô±Ö»Ðè¹Ø×¢Òì³£Êý¾Ý£¬£¬£¬£¬ÊÂÇéÁ¿¿É½µµÍ¡£¡£¡£¡£Í¬Ê±£¬£¬£¬£¬ÏµÍ³Ö§³Ö¶à»¼ÕßÐÅÏ¢ÅúÁ¿µ¼Èë¡¢·Ö×éÖÎÀí£¬£¬£¬£¬×èÖ¹ÊÖ¹¤ÖÂÀí²¡ÀúµÄ·±Ëö¡£¡£¡£¡£
¡¡¡¡Traditional chronic disease management relies on manual recording and telephone follow-up, which is inefficient and prone to errors. The system can generate follow-up plans in batches through automated tools, automatically push medication reminders and follow-up notifications to patients' mobile phones, and reduce repetitive labor. For example, routine follow-up of hypertension patients, such as blood pressure monitoring and medication adjustment, can be automatically triggered by the system according to preset rules. Medical staff only need to pay attention to abnormal data, and the workload can be reduced. At the same time, the system supports batch import and grouping management of multiple patient information, avoiding the tedious process of manually organizing medical records.
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¡¡¡¡Realize data interconnection and precise risk warning
¡¡¡¡ÏµÍ³¿É¶Ô½ÓÒ½ÔºHISϵͳ¡¢¿ÉÒÂ×Å×°±¸µÈ£¬£¬£¬£¬ÊµÊ±Í¬²½»¼ÕßµÄÌå¼ì±¨¸æ¡¢ÓÃÒ©¼Í¼¡¢ÉúÃüÌåÕ÷Êý¾Ý¡£¡£¡£¡£Í¨¹ýÊý¾ÝÕûºÏÆÊÎö£¬£¬£¬£¬ÏµÍ³ÄÜ×Ô¶¯ÌìÉú¿µ½¡µµ°¸£¬£¬£¬£¬Ö±¹ÛչʾѪѹ¡¢ÑªÌǵÈÖ¸±êµÄת±äÇ÷ÊÆ¡£¡£¡£¡£µ±Êý¾ÝÁè¼ÝÇå¾²¹æÄ£Ê±£¬£¬£¬£¬ÈçÌÇÄò²¡»¼Õ߿ո¹ÑªÌÇÒ»Á¬3Ìì¸ßÓÚ£¬£¬£¬£¬ÏµÍ³»áÁ¬Ã¦ÏòÒ½»¤¶ËÍÆËÍÔ¤¾¯£¬£¬£¬£¬²¢ÌáÐÑ¿ÉÄܵIJ¢·¢Ö¢Î£º¦¡£¡£¡£¡£ÕâÖÖ¶¯Ì¬¼à²â±È¹Å°å°´ÆÚËæ·Ã¸üʵʱ£¬£¬£¬£¬ÓÐÖúÓÚÔçÆÚ¸ÉÔ¤£¬£¬£¬£¬½µµÍ¼±ÐÔÊÂÎñ±¬·¢ÂÊ¡£¡£¡£¡£
¡¡¡¡The system can be integrated with hospital HIS systems, wearable devices, etc., to synchronize patients' physical examination reports, medication records, and vital sign data in real time. Through data integration and analysis, the system can automatically generate health records and visually display the trend of changes in indicators such as blood pressure and blood sugar. When the data is out of the safe range, such as the fasting blood glucose of diabetes patients is higher than for three consecutive days, the system will immediately push an alert to the medical and nursing end, and prompt the possible risk of complications. This dynamic monitoring is more timely than traditional regular follow-up, which helps with early intervention and reduces the incidence of acute events.
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¡¡¡¡Optimize doctor-patient interaction and improve patient compliance
¡¡¡¡ÏµÍ³Ìṩ»¼Õß¶ËAPP»òС³ÌÐò£¬£¬£¬£¬Ö§³ÖÔÚÏßÎÊÕï¡¢Ö¢×´×ÔÆÀ¡¢¿µ½¡ÖªÊ¶ÍÆË͵ȹ¦Ð§¡£¡£¡£¡£»£»£»£»£»£»¼Õß¿ÉËæÊ±ÉÏ´«Ò»Ñùƽ³£¼à²âÊý¾Ý£¬£¬£¬£¬Ò½ÉúÔÚÏß´ðÒÉ£¬£¬£¬£¬Í»ÆÆÊ±¿ÕÏÞÖÆ¡£¡£¡£¡£ÀýÈ磬£¬£¬£¬¹ÚÐIJ¡»¼Õß³öÔººó£¬£¬£¬£¬¿Éͨ¹ýϵͳÉÏ´«ÖðÈÕÐÄÂÊ¡¢ÌåÖØÊý¾Ý£¬£¬£¬£¬Ò½ÉúÔ¶³Ìµ÷½âÖÎÁƼƻ®£¬£¬£¬£¬×èÖ¹»¼ÕßÒòÐж¯Î´±ã»òºöÊÓ²¡Çéµ¼Ö¸´·¢¡£¡£¡£¡£ÏµÍ³»¹ÄÜÆ¾Ö¤»¼Õ߯«ºÃÍÆË͸öÐÔ»¯¿µ½¡¿ÆÆÕ£¬£¬£¬£¬ÈçÒûʳ½¨Òé¡¢Ô˶¯½Ì³Ì£¬£¬£¬£¬ÌáÉý»¼Õß×ÔÎÒÖÎÀíÒâʶ¡£¡£¡£¡£
¡¡¡¡The system provides patient side apps or mini programs, supporting functions such as online consultation, symptom self-assessment, and health knowledge push. Patients can upload daily monitoring data at any time, and doctors can answer questions online, breaking the limitations of time and space. For example, after being discharged from the hospital, patients with coronary heart disease can upload daily heart rate and weight data through the system, and doctors can remotely adjust treatment plans to avoid recurrence caused by mobility issues or neglect of the condition. The system can also push personalized health education based on patient preferences, such as dietary advice and exercise tutorials, to enhance patients' self-management awareness.
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¡¡¡¡Support scientific decision-making and assist in public health management
¡¡¡¡ÏµÍ³ÄÚÖÃÊý¾ÝÆÊÎöÄ£¿£¿£¿é£¬£¬£¬£¬¿É°´²¡ÖÖ¡¢ÄêËê¶Î¡¢µØÇøµÈά¶ÈÌìÉúͳ¼Æ±¨±í£¬£¬£¬£¬ÎªÎÀÉú²¿·ÖÌṩ¾öÒéÒÀ¾Ý¡£¡£¡£¡£ÀýÈ磬£¬£¬£¬Ä³µØÇøÍ¨¹ýϵͳ·¢Ã÷ÌÇÄò²¡»¼Õß²¢·¢Ö¢±¬·¢Âʽϸߣ¬£¬£¬£¬¿ÉÕë¶ÔÐÔÔöÇ¿ÑÛµ×ɸ²é¡¢×㲿Õչ˻¤Ê¿µÈ¹«¹²ÎÀÉúЧÀÍ¡£¡£¡£¡£±ðµÄ£¬£¬£¬£¬ÏµÍ³»¹ÄÜ×·×ÙÂý²¡·À¿ØÕþ²ßµÄЧ¹û£¬£¬£¬£¬ÈçÒ½±£±¨Ïú±ÈÀýµ÷½âºó»¼ÕßÓÃÒ©ÒÀ´ÓÐÔµÄת±ä£¬£¬£¬£¬ÎªÕþ²ßÓÅ»¯ÌṩÊý¾ÝÖ§³Ö¡£¡£¡£¡£
¡¡¡¡The system has a built-in data analysis module that can generate statistical reports based on dimensions such as disease type, age group, and region, providing decision-making basis for the health department. For example, in an area where the incidence of complications of diabetes patients is found to be high, targeted public health services such as fundus screening and foot care can be strengthened. In addition, the system can also track the effectiveness of chronic disease prevention and control policies, such as changes in patient medication compliance after adjusting the reimbursement ratio of medical insurance, providing data support for policy optimization.
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