CN112488858A

CN112488858A - Chronic disease data management method and system

Info

Publication number: CN112488858A
Application number: CN202011334679.XA
Authority: CN
Inventors: 王雪莲; 汤晋军
Original assignee: Taikang Insurance Group Co Ltd; Taikang Pension Insurance Co Ltd
Current assignee: Taikang Insurance Group Co Ltd; Taikang Pension Insurance Co Ltd
Priority date: 2020-11-24
Filing date: 2020-11-24
Publication date: 2021-03-12

Abstract

The invention discloses a chronic disease data management method and system, and relates to the technical field of computers. One embodiment of the method comprises: setting a plurality of process nodes according to a service process managed by the chronic disease patient, and managing the chronic disease data of the patient according to the execution logic of the process node currently corresponding to the patient; each flow node module comprises a chronic disease signing module, a patient filing module, a medication management module, a chronic disease management module and a health file module; when the patient is filed by the current corresponding process node of the patient, the patient filing module acquires prescription information of the patient from the docked hospital management information system, verifies the prescription information according to the verification rule, and outputs early warning reminding information about the patient when the prescription information is not verified. The implementation mode can integrate all business processes related to chronic disease management, realize the full-process and refined chronic disease management of process series connection and data series connection, and realize the abuse of severe chronic disease fund in the chronic disease management process.

Description

Chronic disease data management method and system

Technical Field

The invention relates to the technical field of computers, in particular to a chronic disease data management method and system.

Background

At present, various forms of chronic diseases management (chronic diseases are also called chronic diseases) are carried out continuously in various places, and the management work mainly aims at the two major chronic diseases of hypertension and diabetes. The existing management aiming at chronic diseases shows a plurality of companies and schemes, such as: various solutions are provided by commercial insurance companies, health management science and technology companies and even some internet companies, but most of the solutions are fragmented or only made in a form that does not deeply dig pain spots for solving the problems. At present, no solution can solve the problem of slow patient compliance in the slow disease management process, the problem of slow disease management doctor motility, the problem of whole slow disease management process sustainability from the perspective of an overall solution, and the prior art also lacks a corresponding solution for the slow disease fund abuse behavior.

In the process of implementing the invention, the inventor finds that at least the following problems exist in the prior art:

complete flow, refined management of chronic diseases cannot be realized, and abuse of chronic disease funds cannot be technically avoided.

Disclosure of Invention

In view of this, embodiments of the present invention provide a chronic disease data management method and system, which can integrate all business processes involved in chronic disease management, implement full-process and refined chronic disease management of process concatenation and data concatenation, and technically realize strict control of the abuse of chronic disease fund in the chronic disease management process.

To achieve the above object, according to an aspect of an embodiment of the present invention, there is provided a chronic disease data management method.

A chronic disease data management method, comprising: setting a plurality of process nodes according to a service process managed by a chronic patient, wherein each process node has respective execution logic; managing the chronic disease data of the patient according to the execution logic of the flow node corresponding to the patient currently; wherein, each process node comprises a chronic disease contract, patient filing, medication management, chronic disease management and a health file; the managing the patient's chronicity data comprises: determining that the patient meets the chronic disease contract condition at the flow node of the chronic disease contract; acquiring filing data of a patient at a process node of patient filing; recommending medication data about the patient at a flow node of medication management; generating or updating a follow-up plan for the patient at a flow node of chronic disease management; generating a health profile of the patient at a process node of the health profile; when the patient is documented by the currently corresponding process node, the managing the chronic disease data of the patient includes: acquiring prescription information of the patient from a docked hospital management information system, verifying the prescription information according to a verification rule, and outputting early warning reminding information about the patient when the prescription information is not verified.

Optionally, the profiling data comprises an evaluation index value related to a preset disease category; when the patient is documented by the currently corresponding process node, the managing the chronic disease data of the patient further comprises: generating current risk assessment data and/or future risk assessment data regarding the patient; obtaining current risk assessment data of the patient based on a risk assessment model according to the assessment index value; and dynamically adjusting the current risk assessment data based on the risk assessment model according to the input correction value of the assessment index value to obtain future risk assessment data of the patient.

Optionally, the risk assessment model is established based on a medical knowledge base, and the current risk assessment data includes risk prompt information; the method further comprises the following steps: transmitting the risk cue information and result data of the medical intervention on the patient for the risk cue information back to the medical knowledge base for updating the risk assessment model.

Optionally, when the flow node currently corresponding to the patient is medication management, the managing the chronic disease data of the patient includes: and obtaining the medication data of the patient based on the saved medication record of the patient, or obtaining the health index value and the disease category information of the patient from the collected filing data of the patient, and obtaining the medication data of the patient based on a medicine knowledge base and a medicine compatibility taboo rule according to the health index value and the disease category information of the patient.

Optionally, when the flow node currently corresponding to the patient is medication management, the managing the chronic disease data of the patient further includes: acquiring medical diagnosis information of the patient from the docked hospital management information system in real time, and forwarding the medical diagnosis information to a medical insurance network server to monitor the abnormality of the diagnosis and treatment data of the patient, wherein the medical diagnosis information comprises one or more of patient information, diagnosis information, medical advice information and prescription information; the monitoring the patient for abnormalities in the clinical data includes monitoring the patient for one or more of abnormalities in prescription, abnormalities in purchase of medications, abnormalities in use of chronically ill funds.

Optionally, when the flow node currently corresponding to the patient is chronic disease management, the managing the patient's chronic disease data includes: generating or updating a follow-up plan of the patient according to the health condition data of the patient, and generating and storing a follow-up record of the time, wherein the health condition data of the patient is obtained from the filing data and/or the historical follow-up record of the patient; and updating the current risk assessment data of the patient based on the risk assessment model according to the assessment index value in the follow-up record.

Optionally, when the flow node currently corresponding to the patient is a chronic disease contract, the managing the chronic disease data of the patient includes: according to the input patient identity information, the patient is verified by using a back-end medical insurance core system which is in butt joint, so that the patient is determined to meet the contract condition of chronic diseases; the method further comprises the following steps: and under the condition that the current corresponding process node of the patient documents the patient, manages the medication, manages the chronic disease or records the health, confirming that the patient has completed the chronic disease contract in advance before managing the chronic disease data of the patient.

According to another aspect of the embodiments of the present invention, a chronic disease data management system is provided.

A chronically ill data management system, comprising: setting a plurality of process node modules according to a service process managed by a chronic patient, wherein each process node module has respective execution logic; managing the chronic disease data of the patient by a flow node module corresponding to the patient at present according to the execution logic of the flow node module; each flow node module comprises a chronic disease signing module, a patient filing module, a medication management module, a chronic disease management module and a health file module; the chronic disease contracting module is used for determining that the patient meets the chronic disease contracting condition; the patient profiling module is used for acquiring profiling data of the patient; the medication management module is configured to recommend medication data about the patient; the chronic disease management module is used for generating or updating a follow-up plan of the patient; the health file module is used for generating a health file of the patient; when the process node module currently corresponding to the patient is a patient profiling module, the patient profiling module further executes: acquiring prescription information of the patient from a docked hospital management information system, verifying the prescription information according to a verification rule, and outputting early warning reminding information about the patient when the prescription information is not verified.

Optionally, the profiling data comprises an evaluation index value related to a preset disease category; when the process node module currently corresponding to the patient is the patient profiling module, the patient profiling module further performs: generating current risk assessment data and/or future risk assessment data regarding the patient; obtaining current risk assessment data of the patient based on a risk assessment model according to the assessment index value; and dynamically adjusting the current risk assessment data based on the risk assessment model according to the input correction value of the assessment index value to obtain future risk assessment data of the patient.

Optionally, the risk assessment model is established based on a medical knowledge base, and the current risk assessment data includes risk prompt information; the patient profiling module is further to: transmitting the risk cue information and result data of the medical intervention on the patient for the risk cue information back to the medical knowledge base for updating the risk assessment model.

Optionally, when the flow node module currently corresponding to the patient is the medication management module, the medication management module further executes: and obtaining the medication data of the patient based on the saved medication record of the patient, or obtaining the health index value and the disease category information of the patient from the collected filing data of the patient, and obtaining the medication data of the patient based on a medicine knowledge base and a medicine compatibility taboo rule according to the health index value and the disease category information of the patient.

Optionally, when the flow node module currently corresponding to the patient is the medication management module, the medication management module further executes: acquiring medical diagnosis information of the patient from the docked hospital management information system in real time, and forwarding the medical diagnosis information to a medical insurance network server to monitor the abnormality of the diagnosis and treatment data of the patient, wherein the medical diagnosis information comprises one or more of patient information, diagnosis information, medical advice information and prescription information; the monitoring the patient for abnormalities in the clinical data includes monitoring the patient for one or more of abnormalities in prescription, abnormalities in purchase of medications, abnormalities in use of chronically ill funds.

Optionally, when the flow node module currently corresponding to the patient is the chronic disease management module, the chronic disease management module further performs: generating or updating a follow-up plan of the patient according to the health condition data of the patient, and generating and storing a follow-up record of the time, wherein the health condition data of the patient is obtained from the filing data and/or the historical follow-up record of the patient; and updating the current risk assessment data of the patient based on the risk assessment model according to the assessment index value in the follow-up record.

Optionally, when the flow node module currently corresponding to the patient is the chronic disease contracting module, the chronic disease contracting module further performs: according to the input patient identity information, the patient is verified by using a back-end medical insurance core system which is in butt joint, so that the patient is determined to meet the contract condition of chronic diseases; and under the condition that the current corresponding process node module of the patient is the patient filing module, the medication management module, the chronic disease management module or the health file module, the corresponding process node module is also used for confirming that the patient has completed the chronic disease contract in advance.

According to yet another aspect of an embodiment of the present invention, an electronic device is provided.

An electronic device, comprising: one or more processors; a memory for storing one or more programs which, when executed by the one or more processors, cause the one or more processors to implement the lenticulation data management method provided by embodiments of the invention.

According to yet another aspect of an embodiment of the present invention, a computer-readable medium is provided.

A computer readable medium, on which a computer program is stored, which when executed by a processor implements the method for chronic disease data management provided by embodiments of the present invention.

One embodiment of the above invention has the following advantages or benefits: setting a plurality of process node modules according to a service process managed by a chronic patient, wherein each process node module has respective execution logic; managing the chronic disease data of the patient by a flow node module corresponding to the patient at present according to the execution logic of the flow node module; each flow node module comprises a chronic disease signing module, a patient filing module, a medication management module, a chronic disease management module and a health file module; when the patient currently corresponding flow node module is the patient profiling module, the patient profiling module further executes: the method comprises the steps of obtaining prescription information of a patient from a docked hospital management information system, checking the prescription information according to a checking rule, and outputting early warning reminding information about the patient when the prescription information is not checked. The system can integrate all business processes related to chronic disease management, realize the full-process and refined chronic disease management of process series connection and data series connection, and can technically realize the abuse of chronic disease funds in the chronic disease management process.

Further effects of the above-mentioned non-conventional alternatives will be described below in connection with the embodiments.

Drawings

The drawings are included to provide a better understanding of the invention and are not to be construed as unduly limiting the invention. Wherein:

FIG. 1 is a schematic diagram of the main steps of a method for chronic disease data management according to an embodiment of the present invention;

FIG. 2 is a schematic diagram of a two-patient sign-up interface according to one embodiment of the invention;

FIG. 3 is a schematic illustration of an interface for patient profiling according to an embodiment of the present invention;

FIG. 4 is another interface diagram of patient profiling according to one embodiment of the present invention;

FIG. 5 is yet another interface schematic for patient profiling according to an embodiment of the present invention;

FIG. 6 is a schematic diagram of a risk assessment report according to one embodiment of the present invention;

FIG. 7 is a schematic illustration of two disease management reports according to one embodiment of the present invention;

FIG. 8 is a schematic illustration of a chronic disease management interface according to one embodiment of the present invention;

FIG. 9 is a schematic diagram of the main components of a chronic disease data management system according to one embodiment of the present invention;

FIG. 10 is an exemplary system architecture diagram in which embodiments of the present invention may be employed;

fig. 11 is a schematic structural diagram of a computer system suitable for implementing a terminal device or a server according to an embodiment of the present invention.

Detailed Description

Exemplary embodiments of the present invention are described below with reference to the accompanying drawings, in which various details of embodiments of the invention are included to assist understanding, and which are to be considered as merely exemplary. Accordingly, those of ordinary skill in the art will recognize that various changes and modifications of the embodiments described herein can be made without departing from the scope and spirit of the invention. Also, descriptions of well-known functions and constructions are omitted in the following description for clarity and conciseness.

Fig. 1 is a schematic diagram of main steps of a chronic disease data management method according to an embodiment of the present invention.

As shown in fig. 1, the chronic disease data management method according to an embodiment of the present invention mainly includes the following steps S101 to S102.

Step S101: setting a plurality of process nodes according to a service process managed by a chronic patient, wherein each process node has respective execution logic;

step S102: managing the chronic disease data of the patient according to the execution logic of the flow node corresponding to the patient at present; wherein, when the patient is documented by the currently corresponding flow node, managing the chronicity data of the patient comprises: the method comprises the steps of obtaining prescription information of a patient from a docked hospital management information system, checking the prescription information according to a checking rule, and outputting early warning reminding information about the patient when the prescription information is not checked.

In one embodiment, each flow node may include a chronic contract, patient profiling, medication administration, chronic management, health profile. Managing the patient's chronicity data may specifically include: determining that the patient meets the chronic disease contract signing condition at the flow node of the chronic disease contract signing; acquiring filing data of a patient at a process node of patient filing; recommending medication data about the patient at a flow node of the medication management; generating or updating a follow-up plan of a patient at a flow node of chronic disease management; and generating the health file of the patient at the process node of the health file.

Each process node can cover each link of the service process managed by the chronic patient. That is, for a certain patient, the slow disease contract is first performed, then the patient is filed, and then the patient is managed by medication management, slow disease management, health file, and the like. The execution logic of each process node realizes the operation process executed by the chronic disease data management of the process node.

In one embodiment, in the case where the patient currently corresponds to a process node that documents, administers, chronically administers, or otherwise archives the patient, the patient is pre-confirmed to have completed the chronical contract before administering the patient's chronical data. That is, the patient can be signed up and then can be subjected to subsequent data management operations such as filing and medication management.

Chronic diseases are chronic diseases, hypertension and diabetes are two major chronic diseases, and hypertension and diabetes can be also called as 'two diseases'. Chronic management for hypertension, diabetes is also referred to as dual disease management. At present, various forms of two-disease management work are carried out successively in various places. The leading departments are different, and the main departments comprise Wei-Jian-Wei-Jian-Wei-Jian. The overall life quality of the chronic disease patients is closely related to the life quality and the economic level of the chronic disease patients, so that a complete chronic disease management solution should be provided by combining the management of the chronic disease with the control of the medical expense of the chronic disease patients. In addition, attention is paid to prevent the occurrence of the behavior of casing insurance cheating when the chronic disease management and the outpatient clinic chronic disease fund (abbreviated as chronic fund) are used, so that the chronic fund can really help the chronic disease patients.

The embodiment of the invention provides a whole-series solution for government medical insurance, which can be guided by medical insurance departments, realizes the integrated management of public medical institutions (including second and third-level hospitals and community hospitals) and drug administration enterprises through the construction of chronic disease service centers, and realizes the control of outpatient chronic disease fund fees based on the embodiment of the invention.

The following describes in detail a specific embodiment of managing chronicity data of a patient when the patient corresponds to each flow node in the embodiment of the invention.

In one embodiment, when the patient currently corresponds to a procedure node that is a chronic contract, managing the patient's chronic data includes: and checking the patient by using the docked back-end medical insurance core system according to the input patient identity information so as to ensure that the patient meets the contract-signing conditions of chronic diseases.

For chronic management of hypertension and diabetes, a chronic contract may also be referred to as a two-disease contract. Taking the example of two disease signs, the current medical insurance authorities accept the participants to apply for the treatment of two diseases (including diabetes and hypertension) and are authorized by the medical insurance authorities to local community hospitals. The embodiment of the invention can solve the problem that the community hospital can not identify the state of the insured person. Those skilled in the art can understand that the application scenario of the chronic disease data management method according to the embodiment of the present invention is not limited to a community hospital, but may also be applied to various hospitals, management organizations, enterprises, service centers, and the like that perform chronic disease data management on patients.

When a contract is made between two diseases of a patient, a community hospital doctor or a manager inputs patient identity information, such as an identity number of a participant (i.e., the patient) through the chronic disease data management system of the embodiment of the present invention, and the chronic disease data management system of the embodiment of the present invention checks the patient directly through the identity number by docking with a back-end medical insurance office core system (an example of the back-end medical insurance core system), that is: verifying the insurance participation state of the insured person and the clinic chronic disease treatment application records (the insured person who applies for the clinic chronic disease can not apply for the treatment of the two diseases any more), automatically acquiring the information of the insured person such as the name, the sex, the medical personnel category, the contact telephone, the unit, the address and the like in the medical insurance core system, and signing the two diseases for the patient who passes the verification, namely according with the signing condition of the chronic disease. Then, the community doctor or the manager can select the contracting disease category of the insured person in the chronic disease data management system (according to the policy, the contract contracting disease category of the insured person can be applied for diabetes and hypertension at the same time), and upload the application data provided by the insured person. Fig. 2 is a schematic diagram of a two-patient contract interface according to an embodiment of the present invention, and the two-patient management platform in fig. 2 is an example of a chronic disease data management system according to an embodiment of the present invention.

After signing a contract, the chronic disease data management system of the embodiment of the invention supports community hospitals to perform filing service for the participants (namely patients). The patient profiling chronic disease data management interface according to an embodiment of the present invention can be seen in the schematic diagrams of the patient profiling interface shown in fig. 3 to 5.

In one embodiment, when the patient is profiled by the flow node to which the patient currently corresponds, managing the patient's chronicle data may further comprise: acquiring filing data of a patient, wherein the filing data comprises an evaluation index value related to a preset disease species; generating current risk assessment data and/or future risk assessment data regarding the patient; obtaining current risk assessment data of the patient based on a risk assessment model according to the assessment index value; and dynamically adjusting the current risk assessment data based on the risk assessment model according to the input correction value of the assessment index value to obtain the future risk assessment data of the patient. Wherein the disease species is a chronic disease species, such as hypertension, diabetes, etc.

Collecting the filing data of the patient comprises recording the life history, family history and allergy history of the ginseng and guardian, and recording the physical and biochemical examination, symptoms, target organ damage condition and clinical complications of the ginseng and guardian according to the requirements, wherein the physical and biochemical examination comprises the evaluation index values of the height, waist circumference, weight, blood pressure, resting heart rate, triglyceride, total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, fasting blood glucose value and the like of the patient.

The chronic disease data management System underlying platform of the embodiment of the invention can be connected with all hospitals in the local city, can automatically synchronize the latest prescription of the insured person issued in the Hospital HIS (Hospital Information System) and display the latest prescription to the community doctors for reference and tracking record. Since the bottom platform is connected with all hospitals in the city, the prescription information (such as the content and the duration of the prescription) can be verified in real time through the verification rule, and the paramedics are controlled to make prescriptions and use medical insurance funds to purchase medicines for multiple times. If the participator has the suspected behavior of illegal prescription, the prescription information is not checked to be passed, the chronic disease data management system of the embodiment of the invention can output early warning reminding information about the patient through the terminal, for example, illegal reminding such as frequent medical attendance and illegal prescription opening is automatically prompted to be referred by doctors, so that the expense control of the chronic disease fund in the process of chronic disease data management is realized, and the abuse behavior of the chronic disease fund is avoided.

The chronic disease data management system of the embodiment of the invention can also provide a referral function, support referral to other secondary and tertiary hospitals in a hospital body and realize real grading diagnosis and treatment. After the referral application is made, the hospital receiving the referral can receive the referral application, and the offline referral operation can be carried out after the receiving hospital confirms.

The risk assessment model of the embodiment of the invention can be established based on a medical knowledge base. The current risk assessment data may include risk tips. The chronic disease data management method of the embodiment of the invention further comprises the following steps: and transmitting the risk prompt information and result data of medical intervention on the patient aiming at the risk prompt information back to the medical knowledge base for updating the risk assessment model.

The chronic disease data management system of one embodiment of the invention designs 58 national medical guideline knowledge bases (namely medical knowledge bases) at the bottom layer, and designs a risk assessment model on the basis of the medical knowledge bases. After data acquisition, the chronic disease data management system according to the embodiment of the present invention intelligently generates a current risk assessment report (i.e. current risk assessment data) based on the risk assessment model according to the acquired assessment index value, and performs hierarchical classification management on a chronic patient group, where the hierarchical management may include: management such as hierarchical analysis application, hierarchical classification, rating and qualitative, risk scoring and the like. The classification management can include management of chronic disease data for a group of patients with severe disease, long-term health, sudden changes, and the like. And giving out risk prompt information according to the index condition of the chronic disease patient. The risk prompt information and the results of medical staff intervention can be transmitted back to the medical knowledge base and the risk assessment model in real time to update the risk assessment model, and the data of the slow patient group can be updated in real time to adjust the risk index at any time.

The risk assessment report can be automatically generated after the patient is documented, corresponding assessment can be performed according to different disease types, and the risk assessment report shown in fig. 6 can be automatically given by taking hypertension as an example.

The chronic disease data management system of the embodiment of the invention provides an interactive function, for example, indexes such as total cholesterol, systolic pressure, weight and the like (namely an example of input correction values of evaluation index values) are manually adjusted in a risk index part, so that corresponding future risk evaluation data, such as future risk evaluation data of cardiovascular disease risk rate and change trend of relative risk multiple of the insured person in the future 10 years, are obtained, and community doctors can more pertinently guide the insured person to carry out chronic disease management. According to the risk assessment report, two disease management reports can be generated, as shown in fig. 7, the content of the two disease management reports can include basic information such as the name, sex, age, and name of the disease of the patient, and chronic disease data such as disease-related symptoms, allergy history, family history, lifestyle, medication compliance, adverse drug reactions, follow-up clinical evaluation, and prescription information.

In one embodiment, when the patient currently corresponds to a flow node for medication administration, managing the patient's chronicle data comprises: recommending medication data for the patient; the method comprises the steps of obtaining medication data of a patient based on stored medication records of the patient, or obtaining health index values and disease category information of the patient from collected filing data of the patient, and obtaining the medication data of the patient based on a medicine knowledge base and medicine compatibility taboo rules according to the health index values and the disease category information of the patient.

Considering the problems that the overall medical level of community doctors is possibly uneven, the overall level is low, a general practitioner system is absent and the like, in order to assist the community doctors to complete follow-up visits and real landing grading diagnosis and treatment of multiple diseases and slow diseases, the embodiment of the invention can automatically recommend medication data based on an embedded medicine knowledge base according to the health index value and the disease information of patients (participants and insurers) for the community doctors to refer. When a prescription is made, whether the medicine has incompatibility can be automatically judged through a built-in medicine knowledge base and a medicine incompatibility rule engine, and if the medicine has incompatibility, a doctor is automatically reminded.

In addition, due to inherent characteristics of chronic diseases, the course of disease is long, the prescription changes little, and the medicine taking record of the patient can be provided for the community doctors to call and follow up at any time.

In one embodiment, when the patient currently corresponds to the flow node for medication administration, the method for managing the patient's chronic disease data further comprises: acquiring medical diagnosis information of a patient in real time from a docked hospital management information system, and forwarding the medical diagnosis information to a medical insurance network server to monitor the abnormality of diagnosis and treatment data of the patient, wherein the medical diagnosis information comprises one or more of patient information, diagnosis information, medical advice information and prescription information; monitoring the patient for abnormalities in the clinical data includes monitoring the patient for one or more of abnormalities in prescription, abnormalities in purchase of medications, abnormalities in use of chronically acquired funds.

The embodiment of the invention can provide a standardized interface to the HIS of the local hospital, acquire patient information, diagnosis information, medical orders, prescription information and the like in the HIS in real time, and forward the information to the network server of the medical insurance through the front-end processor arranged in the hospital, so that the management center deployed by the medical insurance bureau can check the prescription making condition, the medicine purchasing condition and the use condition of the main gate slow fund of each hospital in real time to monitor the diagnosis and treatment data abnormity of the patient.

In one embodiment, when the patient currently corresponds to a flow node for chronic disease management, managing the patient's chronic disease data includes: generating or updating a follow-up plan of the patient according to the health condition data of the patient, and generating and storing a follow-up record of the time, wherein the health condition data of the patient is obtained from the filing data and/or the historical follow-up record of the patient; and updating the current risk assessment data of the patient based on the risk assessment model according to the assessment index value in the follow-up record.

A schematic view of a chronic disease management interface according to an embodiment of the present invention is shown in fig. 8, and may include a patient follow-up visit, a follow-up visit reminder, a follow-up visit record, and the like.

In consideration of the flexibility of the solution, the first follow-up time may not be strictly limited, and may be agreed by, for example, offline patients (insurers) and community doctors according to practical conditions (doctor shift time, patient time). At that time, the patient (the insurer) can arrive at the community hospital for follow-up by date.

During follow-up, the information (filing data) provided during patient filing can be automatically synchronized, but a doctor can modify the follow-up information according to the follow-up condition, for example, the evaluation index value of the patient is modified according to the follow-up condition and is stored in the follow-up record, and the chronic disease data management system of the embodiment of the invention can provide an updated risk evaluation report according to the evaluation index value in the follow-up record. A follow-up plan is automatically generated based on the health data of the patient. The follow-up plan comprises the follow-up date of the whole year, the follow-up arrangement and the corresponding examination items at each follow-up time. The health data of the patient may be obtained from profiling data and/or historical follow-up records. The embodiment of the invention supports the follow-up plan adjusting function, and community doctors can adjust the follow-up plan according to actual conditions. The community doctor can conveniently adjust the follow-up visit plan by observing the key indexes of the patient, and key index display and automatic follow-up visit suggestion issuing can be provided according to the health condition, the disease information and the like of the participators for reference of the community doctor. Personalized treatment goals may also be output for reference by community physicians.

In the flow node of chronic disease management, two disease management reports may also be generated, and the contents of the two disease management reports are introduced above and are not described again.

For chronic disease management, continuous follow-up and patient compliance are important, so the embodiment of the invention makes detailed design for the follow-up, such as follow-up reminding, can make targeted management for patients who are going to follow-up or have not come to follow-up recently, and community doctors can make time change and short message reminding for the part of patients. The community doctor can review the detailed information of each follow-up of each patient in the record of each follow-up.

In one embodiment, when the flow node to which the patient currently corresponds is a health profile, a health profile including data of patient per visit information, prescription information, follow-up information, assessment reports, etc. may be generated for query.

In one embodiment of the invention, accurate personalized health risk product recommendation data can be generated and output according to the health level of a patient (a participant). For example, a corresponding relationship between the evaluation index value or risk evaluation data and the health risk product is established, and the health risk product matched with the evaluation index value or risk evaluation data of the patient is determined and output at the process nodes of patient profile creation, chronic disease management and the like.

The embodiment of the invention can closely track the state of illness of the patient with chronic diseases through the fine health management so as to adjust the medication and the corresponding treatment scheme at any time, can give out health trend evaluation through a large amount of data analysis through a detailed data acquisition background, can give out accurate and personalized health insurance product recommendation according to the health level of the patient (the patient protector), and provides guarantee for the economy of the patient (the patient protector) while guaranteeing the health level. And the subsequent accurate health monitoring index also objectively reflects the health management level of the community doctor on the patient, and can be used as a reference index for performance evaluation of the community hospital.

The embodiment of the invention depends on the domestic existing medical resources and medical systems, mainly depends on the medical resources of community hospitals and the follow-up system of public health, integrates all business processes related to chronic disease management to formulate an informatization scheme and a data flow solution, and serially connects the front and rear processes and data of the whole scheme, particularly, corresponding informatization construction and verification are carried out aiming at the use scene of the outpatient chronic disease fund, and aiming at two patients, namely, the diabetes and the hypertension patients, the whole-process chronic disease management is carried out by following patient follow-up visit, follow-up visit reminding, follow-up visit recording, on-line inquiry, prescription circulation and drug delivery from the contract signing of the two diseases, patient filing and drug administration management, and the background big data analysis is matched to track the individual chronic disease condition, analyze the whole big crowd chronic disease trend and reversely deduce the doctor working index and performance through the chronic disease management index.

Fig. 9 is a main configuration diagram of a chronic disease data management system according to one embodiment of the present invention.

As shown in fig. 9, the chronic disease data management system 900 according to an embodiment of the present invention sets a plurality of process node modules according to a business process of chronic disease patient management, and each process node module has its own execution logic. Each flow node module may specifically include a chronic disease contract signing module 901, a patient profile building module 902, a medication management module 903, a chronic disease management module 904, and a health profile module 905. The chronic disease data management system 900 according to the embodiment of the present invention may further include a user interface, through which a user may use the functions of the above-described process node modules, and in the data management process, the user interface corresponding to each process node module, such as a chronic disease contract signing interface, a patient filing interface, a medication management interface, a chronic disease management interface, a health archive interface, etc., may be displayed through the chronic disease data management system 900, and each interface may also display its own secondary interface as needed, for example, the chronic disease management interface may further include secondary interfaces such as a patient follow-up visit, etc., specifically, and the interface display form is not specifically limited in the embodiment of the present invention.

Each flow node module manages the chronic disease data of the patient according to respective execution logic, wherein the chronic disease signing module 901 is used for determining that the patient meets the chronic disease signing conditions; the patient profiling module 902 is used for collecting patient profiling data; the medication management module 903 is used to recommend medication data about a patient; the chronic disease management module 904 is used to generate or update a follow-up plan for the patient; the health profile module 905 is used to generate a health profile for the patient.

When a certain flow node currently corresponds to a patient, the patient's chronic disease data is managed by the flow node module corresponding to the flow node, and the specific operation performed to manage the patient's chronic disease data refers to the above description of the chronic disease data management method. For example, when the patient currently corresponds to patient profiling, then the patient profiling module 902 executes the patient profiling execution logic, i.e., performs the operations performed at the patient profiling flow node.

When the patient currently corresponds to a procedure node module that is the patient profiling module 902, the patient profiling module 902 performs: the method comprises the steps of obtaining prescription information of a patient from a docked hospital management information system, checking the prescription information according to a checking rule, and outputting early warning reminding information about the patient when the prescription information is not checked.

The profiling data comprises evaluation index values related to preset disease types. When the patient currently corresponds to the procedure node module for the patient profiling module 902, the patient profiling module 902 further performs: generating current risk assessment data and/or future risk assessment data regarding the patient; obtaining current risk assessment data of the patient based on a risk assessment model according to the assessment index value; and dynamically adjusting the current risk assessment data based on the risk assessment model according to the input correction value of the assessment index value to obtain the future risk assessment data of the patient.

Establishing a risk assessment model based on a medical knowledge base, wherein current risk assessment data comprise risk prompt information; the patient profiling module 902 is also for: and transmitting the risk prompt information and result data of medical intervention on the patient aiming at the risk prompt information back to the medical knowledge base for updating the risk assessment model.

When the flow node module currently corresponding to the patient is the medication management module 903, the medication management module 903 executes: and obtaining the medication data of the patient based on the saved medication record of the patient, or obtaining the health index value and the disease category information of the patient from the collected filing data of the patient, and obtaining the medication data of the patient based on a medicine knowledge base and a medicine compatibility contraindication rule according to the health index value and the disease category information of the patient.

When the flow node module currently corresponding to the patient is the medication management module 903, the medication management module 903 further executes: acquiring medical diagnosis information of a patient in real time from a docked hospital management information system, and forwarding the medical diagnosis information to a medical insurance network server to monitor the abnormality of diagnosis and treatment data of the patient, wherein the medical diagnosis information comprises one or more of patient information, diagnosis information, medical advice information and prescription information; monitoring the patient for abnormalities in the clinical data includes monitoring the patient for one or more of abnormalities in prescription, abnormalities in purchase of medications, abnormalities in use of chronically acquired funds.

When the flow node module currently corresponding to the patient is the chronic disease management module 904, the chronic disease management module 904 performs: generating or updating a follow-up plan of the patient according to the health condition data of the patient, and generating and storing a follow-up record of the time, wherein the health condition data of the patient is obtained from the filing data and/or the historical follow-up record of the patient; and updating the current risk assessment data of the patient based on the risk assessment model according to the assessment index value in the follow-up record.

When the flow node module currently corresponding to the patient is the chronic disease contracting module 901, the chronic disease contracting module 901 executes: and checking the patient by using the docked back-end medical insurance core system according to the input patient identity information so as to ensure that the patient meets the contract-signing conditions of chronic diseases.

When the current corresponding flow node module of the patient is the health profile module 905, the health profile module 905 may perform: and generating a health record comprising data of each visit information, prescription information, follow-up information, evaluation report and the like of the patient for inquiry.

In the case that the currently corresponding flow node module of the patient is the patient profiling module 902, the medication management module 903, the chronic disease management module 904, or the health file module 905, the corresponding flow node module is also used to confirm in advance that the patient has completed the chronic disease contract.

The users of the chronic disease data management system of the embodiment of the invention include, but are not limited to, operation/management personnel, personnel in the medical insurance department, personnel in the office of medical insurance subordinate to the medical insurance center, doctors in hospitals, pharmacists in drug stores, and the like. The embodiment of the invention realizes that the two-disease patients are monitored by an informatization means from enjoying the two-disease treatment in the basic medical insurance after contracting the two-disease, and the expense control means is combined in the subsequent medication management and follow-up visit management processes, so that the two-disease treatment fund is strictly controlled and the chronic disease course of the two-disease patients is finely managed, the two-disease fund really plays a role and prevents the abuse behavior.

In addition, in the implementation of the chronic disease data management system in the embodiment of the present invention, the functions of each process node module are described in detail in the above-mentioned chronic disease data management method, and thus the detailed description of the operations performed by the corresponding process node is referred to above, and therefore the repeated contents are not described again here.

Fig. 10 illustrates an exemplary system architecture 1000 to which the chronicity data management method or the chronicity data management system of embodiments of the present invention may be applied.

As shown in fig. 10, the system architecture 1000 may include

terminal devices

1001, 1002, 1003, a network 1004, and a server 1005. The network 1004 is used to provide a medium for communication links between the

terminal devices

1001, 1002, 1003 and the server 1005. Network 1004 may include various connection types, such as wired, wireless communication links, or fiber optic cables, to name a few.

A user may use the

terminal devices

1001, 1002, 1003 to interact with a server 1005 via a network 1004 to receive or transmit messages or the like. The

terminal devices

1001, 1002, 1003 may have installed thereon various messenger client applications such as shopping applications, web browser applications, search applications, instant messenger, mailbox clients, social platform software, etc. (by way of example only).

The

terminal devices

1001, 1002, 1003 may be various electronic devices having a display screen and supporting web browsing, including but not limited to smart phones, tablet computers, laptop portable computers, desktop computers, and the like.

The server 1005 may be a server that provides various services, such as a backend management server (for example only) that supports shopping websites browsed by users using the

terminal devices

1001, 1002, 1003. The backend management server may analyze and perform other processing on the received data such as the product information query request, and feed back a processing result (for example, target push information, product information — just an example) to the terminal device.

It should be noted that the chronic disease data management method provided by the embodiment of the present invention may be executed by the

terminal devices

1001, 1002, 1003 or the server 1005, and accordingly, the chronic disease data management system may be disposed in the

terminal devices

1001, 1002, 1003 or the server 1005.

It should be understood that the number of terminal devices, networks, and servers in fig. 10 is merely illustrative. There may be any number of terminal devices, networks, and servers, as desired for implementation.

Referring now to FIG. 11, shown is a block diagram of a computer system 1100 suitable for use in implementing a terminal device or server of an embodiment of the present application. The terminal device or the server shown in fig. 11 is only an example, and should not bring any limitation to the functions and the scope of use of the embodiments of the present application.

As shown in fig. 11, the computer system 1100 includes a Central Processing Unit (CPU)1101, which can perform various appropriate actions and processes in accordance with a program stored in a Read Only Memory (ROM)1102 or a program loaded from a storage section 1108 into a Random Access Memory (RAM) 1103. In the RAM 1103, various programs and data necessary for the operation of the system 1100 are also stored. The CPU 1101, ROM 1102, and RAM 1103 are connected to each other by a bus 1104. An input/output (I/O) interface 1105 is also connected to bus 1104.

The following components are connected to the I/O interface 1105: an input portion 1106 including a keyboard, mouse, and the like; an output portion 1107 including a signal output unit such as a Cathode Ray Tube (CRT), a Liquid Crystal Display (LCD), and a speaker; a storage section 1108 including a hard disk and the like; and a communication section 1109 including a network interface card such as a LAN card, a modem, or the like. The communication section 1109 performs communication processing via a network such as the internet. A driver 1110 is also connected to the I/O interface 1105 as necessary. A removable medium 1111 such as a magnetic disk, an optical disk, a magneto-optical disk, a semiconductor memory, or the like is mounted on the drive 1110 as necessary, so that a computer program read out therefrom is mounted into the storage section 1108 as necessary.

In particular, according to embodiments of the present disclosure, the processes described above with reference to the main step schematic may be implemented as computer software programs. For example, the disclosed embodiments of the invention include a computer program product comprising a computer program embodied on a computer readable medium, the computer program comprising program code for performing the method shown in the main step diagram. In such an embodiment, the computer program may be downloaded and installed from a network through the communication portion 1109 and/or installed from the removable medium 1111. The above-described functions defined in the system of the present application are executed when the computer program is executed by a Central Processing Unit (CPU) 1101.

It should be noted that the computer readable medium shown in the present invention can be a computer readable signal medium or a computer readable storage medium or any combination of the two. A computer readable storage medium may be, for example, but not limited to, an electronic, magnetic, optical, electromagnetic, infrared, or semiconductor system, apparatus, or device, or any combination of the foregoing. More specific examples of the computer readable storage medium may include, but are not limited to: an electrical connection having one or more wires, a portable computer diskette, a hard disk, a Random Access Memory (RAM), a read-only memory (ROM), an erasable programmable read-only memory (EPROM or flash memory), an optical fiber, a portable compact disc read-only memory (CD-ROM), an optical storage device, a magnetic storage device, or any suitable combination of the foregoing. In the present application, a computer readable storage medium may be any tangible medium that can contain, or store a program for use by or in connection with an instruction execution system, apparatus, or device. In this application, however, a computer readable signal medium may include a propagated data signal with computer readable program code embodied therein, for example, in baseband or as part of a carrier wave. Such a propagated data signal may take many forms, including, but not limited to, electro-magnetic, optical, or any suitable combination thereof. A computer readable signal medium may also be any computer readable medium that is not a computer readable storage medium and that can communicate, propagate, or transport a program for use by or in connection with an instruction execution system, apparatus, or device. Program code embodied on a computer readable medium may be transmitted using any appropriate medium, including but not limited to: wireless, wire, fiber optic cable, RF, etc., or any suitable combination of the foregoing.

The principal step diagrams and block diagrams in the figures illustrate the architecture, functionality, and operation of possible implementations of systems, methods and computer program products according to various embodiments of the present application. In this regard, each block in the main step diagrams or block diagrams may represent a module, segment, or portion of code, which comprises one or more executable instructions for implementing the specified logical function(s). It should also be noted that, in some alternative implementations, the functions noted in the block may occur out of the order noted in the figures. For example, two blocks shown in succession may, in fact, be executed substantially concurrently, or the blocks may sometimes be executed in the reverse order, depending upon the functionality involved. It will also be noted that each block of the block diagrams or block diagrams, and combinations of blocks in the block diagrams or block diagrams, can be implemented by special purpose hardware-based systems that perform the specified functions or acts, or combinations of special purpose hardware and computer instructions.

The modules described in the embodiments of the present invention may be implemented by software or hardware. The described modules may also be provided in a processor, which may be described as: a processor comprises a chronic disease signing module, a patient filing module, a medication management module, a chronic disease management module and a health file module. Where the names of these modules do not in some cases constitute a limitation on the module itself, for example, a patient profiling module may also be described as a "module for acquiring patient profiling data".

As another aspect, the present invention also provides a computer-readable medium that may be contained in the apparatus described in the above embodiments; or may be separate and not incorporated into the device. The computer readable medium carries one or more programs which, when executed by a device, cause the device to comprise: setting a plurality of process nodes according to a service process managed by a chronic patient, wherein each process node has respective execution logic; managing the chronic disease data of the patient according to the execution logic of the flow node corresponding to the patient currently; wherein, each process node comprises a chronic disease contract, patient filing, medication management, chronic disease management and a health file; the managing the patient's chronicity data comprises: determining that the patient meets the chronic disease contract condition at the flow node of the chronic disease contract; acquiring filing data of a patient at a process node of patient filing; recommending medication data about the patient at a flow node of medication management; generating or updating a follow-up plan for the patient at a flow node of chronic disease management; generating a health profile of the patient at a process node of the health profile; when the patient is documented by the currently corresponding process node, the managing the chronic disease data of the patient further comprises: acquiring prescription information of the patient from a docked hospital management information system, verifying the prescription information according to a verification rule, and outputting early warning reminding information about the patient when the prescription information is not verified.

According to the technical scheme of the embodiment of the invention, a plurality of process nodes are set according to the business process managed by the patient with the chronic disease, each process node has respective execution logic, and the patient data with the chronic disease is managed according to the execution logic of the process node currently corresponding to the patient; each flow node module comprises a chronic disease signing module, a patient filing module, a medication management module, a chronic disease management module and a health file module; when the patient is documented by the currently corresponding flow node, managing the patient's chronicle data includes: the method comprises the steps of obtaining prescription information of a patient from a docked hospital management information system, checking the prescription information according to a checking rule, and outputting early warning reminding information about the patient when the prescription information is not checked. All business processes related to chronic disease management can be integrated, the complete process and refined chronic disease management of process series connection and data series connection is realized, and abuse of chronic disease funds can be strictly controlled in the chronic disease management process.

The above-described embodiments should not be construed as limiting the scope of the invention. Those skilled in the art will appreciate that various modifications, combinations, sub-combinations, and substitutions can occur, depending on design requirements and other factors. Any modification, equivalent replacement, and improvement made within the spirit and principle of the present invention should be included in the protection scope of the present invention.

Claims

1. A chronic disease data management system, comprising: setting a plurality of process node modules according to a service process managed by a chronic patient, wherein each process node module has respective execution logic;

managing the chronic disease data of the patient by a flow node module corresponding to the patient at present according to the execution logic of the flow node module; each flow node module comprises a patient filing module, a medication management module and a chronic disease management module, wherein the patient filing module is used for acquiring filing data of the patient; the medication management module is configured to recommend medication data about the patient; the chronic disease management module is used for generating or updating a follow-up plan of the patient; when the process node module currently corresponding to the patient is a patient profiling module, the patient profiling module further executes: acquiring prescription information of the patient from a docked hospital management information system, verifying the prescription information according to a verification rule, and outputting early warning reminding information about the patient when the prescription information is not verified.

2. The system of claim 1, wherein said profiling data comprises an assessment index value associated with a predetermined disease category;

when the process node module currently corresponding to the patient is the patient profiling module, the patient profiling module further performs: generating current risk assessment data and/or future risk assessment data regarding the patient; obtaining current risk assessment data of the patient based on a risk assessment model according to the assessment index value; and dynamically adjusting the current risk assessment data based on the risk assessment model according to the input correction value of the assessment index value to obtain future risk assessment data of the patient.

3. The system of claim 2, wherein the risk assessment model is built based on a medical knowledge base, the current risk assessment data including risk tips; the patient profiling module is further to: transmitting the risk cue information and result data of the medical intervention on the patient for the risk cue information back to the medical knowledge base for updating the risk assessment model.

4. The system of claim 2, wherein when the flow node module currently corresponding to the patient is the medication management module, the medication management module further performs: and obtaining the medication data of the patient based on the saved medication record of the patient, or obtaining the health index value and the disease category information of the patient from the collected filing data of the patient, and obtaining the medication data of the patient based on a medicine knowledge base and a medicine compatibility taboo rule according to the health index value and the disease category information of the patient.

5. The system of claim 4, wherein when the flow node module currently corresponding to the patient is the medication management module, the medication management module further performs: acquiring medical diagnosis information of the patient from the docked hospital management information system in real time, and forwarding the medical diagnosis information to a medical insurance network server to monitor the abnormality of the diagnosis and treatment data of the patient, wherein the medical diagnosis information comprises one or more of patient information, diagnosis information, medical advice information and prescription information; the monitoring the patient for abnormalities in the clinical data includes monitoring the patient for one or more of abnormalities in prescription, abnormalities in purchase of medications, abnormalities in use of chronically ill funds.

6. The system of claim 2, wherein when the procedure node module currently corresponding to the patient is the chronic disease management module, the chronic disease management module further performs: generating or updating a follow-up plan of the patient according to the health condition data of the patient, and generating and storing a follow-up record of the time, wherein the health condition data of the patient is obtained from the filing data and/or the historical follow-up record of the patient; and updating the current risk assessment data of the patient based on the risk assessment model according to the assessment index value in the follow-up record.

7. The system of claim 1, wherein when the procedure node module currently corresponding to the patient is the chronic contracting module, the chronic contracting module further performs: according to the input patient identity information, the patient is verified by using a back-end medical insurance core system which is in butt joint, so that the patient is determined to meet the contract condition of chronic diseases; and under the condition that the current corresponding process node module of the patient is the patient filing module, the medication management module, the chronic disease management module or the health file module, the corresponding process node module is also used for confirming that the patient has completed the chronic disease contract in advance.

8. A chronic disease data management method, comprising:

setting a plurality of process nodes according to a service process managed by a chronic patient, wherein each process node has respective execution logic;

managing the chronic disease data of the patient according to the execution logic of the flow node corresponding to the patient currently; wherein, each process node comprises a chronic disease contract, patient filing, medication management, chronic disease management and a health file; the managing the patient's chronicity data comprises: determining that the patient meets the chronic disease contract condition at the flow node of the chronic disease contract; acquiring filing data of a patient at a process node of patient filing; recommending medication data about the patient at a flow node of medication management; generating or updating a follow-up plan for the patient at a flow node of chronic disease management; generating a health profile of the patient at a process node of the health profile; when the patient is documented by the currently corresponding process node, the managing the chronic disease data of the patient further comprises: acquiring prescription information of the patient from a docked hospital management information system, verifying the prescription information according to a verification rule, and outputting early warning reminding information about the patient when the prescription information is not verified.

9. An electronic device, comprising:

one or more processors;

a memory for storing one or more programs,

the one or more programs, when executed by the one or more processors, cause the one or more processors to implement the method of claim 8.

10. A computer-readable medium, on which a computer program is stored, which, when being executed by a processor, carries out the method of claim 8.