CN111105853A - Hospital-community-family three-in-one chronic disease health management system - Google Patents

Hospital-community-family three-in-one chronic disease health management system Download PDF

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CN111105853A
CN111105853A CN201911257284.1A CN201911257284A CN111105853A CN 111105853 A CN111105853 A CN 111105853A CN 201911257284 A CN201911257284 A CN 201911257284A CN 111105853 A CN111105853 A CN 111105853A
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patient
community
hospital
cloud platform
family
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留菁菁
韩雷
徐英英
王陈芳
徐梦丽
王力勇
瞿中洁
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Third Affiliated Hospital of ZCMU
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Third Affiliated Hospital of ZCMU
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    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H10/00ICT specially adapted for the handling or processing of patient-related medical or healthcare data
    • G16H10/60ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H40/00ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices
    • G16H40/60ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices for the operation of medical equipment or devices
    • G16H40/67ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices for the operation of medical equipment or devices for remote operation
    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H50/00ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
    • G16H50/20ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics for computer-aided diagnosis, e.g. based on medical expert systems
    • GPHYSICS
    • G16INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16HHEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H80/00ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring

Abstract

A hospital-community-family three-in-one chronic disease health management system. The invention provides a physical examination device and a cloud platform connected with the physical examination device, wherein the cloud platform is connected with a patient end, a hospital end and a community end, databases of all patients are stored in the cloud platform, the patient end is bound with the corresponding patient and used for accessing the database of the corresponding patient, the community end is bound with a plurality of corresponding patient ends and used for accessing the database of the bound patient, the hospital end is bound with a plurality of patient ends and used for accessing the database of the bound patient, the physical examination device is used for carrying out physical examination on the patient and uploading the identity information and the physical examination result of the current physical examination patient to the cloud platform, the cloud platform sends the physical examination result to the corresponding patient end and the community end according to the identity information of the current patient, and meanwhile, the database information of the corresponding patient is updated. The cloud platform system synchronizes the physical examination and self-evaluation of the patient to the cloud platform and shares the physical examination and self-evaluation to the community end, the patient end and the family end, realizes the joint supervision of the family and the follow-up tracking of the community health hospital to the patient, and improves the health management effect of the patient.

Description

Hospital-community-family three-in-one chronic disease health management system
Technical Field
The invention belongs to the technical field of medical instruments, relates to a cloud platform built based on a novel interaction medium, namely a WeChat applet, and relates to a hospital-community-family three-in-one chronic disease health management system.
Background
With the improvement of living standard of people, the onset of type 2 diabetes tends to rise year by year. The traditional Chinese medicine is the most popular chronic non-infectious disease with high disability rate and high lethality rate at present due to severe acute and chronic complications. Effective health management is critical for the prevention and control of diabetes. However, most of domestic management modes are not perfect at present, and a comprehensive effect is difficult to achieve only through single-level health management.
Studies have demonstrated that effective health management is critical in the prevention and control of diabetes. Most patients have the conditions of poor cognition, insufficient attention degree and inadequate self-management in diabetes. The family blood sugar monitoring lacks follow-up visits of professional medical staff, even if patients adjust the medicine scheme according to self feelings, professional guidance is lacked, so that the blood sugar control is poor, and the risk of diabetic complications is increased. At present, the health management service system of the community health service organization is still imperfect, and the service mode is relatively lagged behind; although the comprehensive hospital has professional skill and level for developing health management of chronic diseases, the comprehensive hospital is limited by functions, and has multiple treatments and light management. With the continuous promotion of the grading diagnosis and treatment test point work, the community basic medical and health service needs to be combined, and the function of a community health service center in chronic disease management is improved.
According to the application effect of Chenlihong in a certain community of Hangzhou elderly diabetic patients, the compliance and various quality of life indexes of the patients after intervention are superior to those of a control group (y2 is 5.01, and P is less than 0.05) by observing the interactive intervention mode of 'one community by one community in a hospital' and one family by one family in Hangzhou; after Liu Fang is subjected to three-in-one management on 92 elderly diabetic patients in 3 community health service centers for 1 year, the control condition, self-management behavior and life quality of the glycosylated hemoglobin (HbA1c) of the patients are remarkably improved compared with those before the management (P is less than 0.05). The previous example shows that the hospital-community-family integrated interactive management mode can effectively reduce the blood sugar level of the diabetic and improve the life quality of the diabetic. However, the mode has many limitations in popularization and application. Due to the reasons of lack of hygiene and talents, data information disconnection between patients, communities and hospitals and the like, the management of the diabetics by the hospitals and partial communities is not systematic and comprehensive.
Disclosure of Invention
The invention aims to solve the problems and provides a hospital-community-family three-in-one chronic disease health management system.
In order to achieve the purpose, the invention adopts the following technical scheme:
a hospital-community-family three-in-one chronic disease health management system comprises physical examination equipment and a cloud platform connected with the physical examination equipment, the cloud platform is connected with a patient end, a hospital end and a community end, a database of all patients is stored in the cloud platform, the patient side is bound with a corresponding patient and used for accessing a database of the corresponding patient, the community side is bound with a plurality of corresponding patient sides and used for accessing a database of the bound patient, the hospital side is bound with a plurality of patient sides and used for accessing databases of the bound patients, the physical examination equipment is used for carrying out physical examination on the patients and uploading the identity information and the physical examination results of the current physical examination patients to the cloud platform, and the cloud platform sends the physical examination result to the corresponding patient end and the community end according to the identity information of the current patient, and meanwhile, the database data of the corresponding patient is updated.
In the hospital-community-family three-in-one chronic disease health management system, the patient side is provided with a self-test module, so that the corresponding patient can upload a self-evaluation report to the cloud platform through the self-test module, and the content of the self-evaluation report comprises any one or more of exercise, diet, medication and related complications.
In the hospital-community-family three-in-one chronic disease health management system, the physical examination equipment comprises any one or a combination of more of a blood glucose meter, a blood pressure meter and a height and weight measuring instrument;
or, the physical examination equipment is intelligent blood glucose meter and motion bracelet that have cloud data function, and the physical examination equipment is uploaded the blood glucose value, the length of exercise and the step number of patient every day to the cloud platform through the network.
In the hospital-community-family three-in-one chronic disease health management system, the cloud platform is provided with a data processing module, and the data processing module is used for performing health analysis on the patient according to the physical examination result and the self-evaluation report of the patient and sending the analysis result to the patient side and the community side together;
the community end and the hospital end are both provided with referral modules so as to refer a specific patient to a specific hospital end or a specific community end.
In the hospital-community-family three-in-one chronic disease health management system, the hospital end and/or the community end are/is further used for carrying out information interaction with corresponding patients through the cloud platform, the cloud platform is provided with a timing module for the hospital end and/or the community end to set medicine taking reminding aiming at specific patients, and the cloud platform sends medicine taking reminding messages to the specific patients at set time.
In the hospital-community-family three-in-one chronic disease health management system, the chronic disease is any one of diabetes, cardiovascular and cerebrovascular diseases and chronic obstructive pulmonary diseases;
and the database data of each patient comprises an initial file, a subsequent file, and the self-evaluation report content, the physical examination result and the health analysis result of each time of the corresponding patient.
In the hospital-community-family three-in-one chronic disease health management system, the initial file of each patient database is established by the hospital end, the subsequent files are updated to the cloud platform from the hospital end, and the content of the initial file and the content of the subsequent files respectively comprise blood sugar monitoring, glycosylated hemoglobin, diabetes related complication monitoring and evaluation results during hospital admission, and any one or more indexes of a diabetes self-management behavior scale and a diabetes life quality specificity scale.
In the hospital-community-family three-in-one chronic disease health management system, the cloud platform also has a chronic disease knowledge base which is open to all users, and the community end and/or the hospital end uploads the chronic disease related knowledge to the chronic disease knowledge base for all users to refer to.
In the hospital-community-family three-in-one chronic disease health management system, the system further comprises a family end connected to the cloud platform, 1-3 patients are bound to the family end, and the family end is used for accessing databases of corresponding patients and simultaneously sending the databases of corresponding patients to the corresponding family end whenever the databases of the corresponding patients have data updating.
In the hospital-community-family three-in-one chronic disease health management system, the cloud platform is built based on the WeChat applet and/or the WeChat public number, and the patient end, the family end, the community end and the hospital end are added into the system through the WeChat platform.
The invention has the advantages that: 1. the data sharing is promoted, the physical examination and self-evaluation of the patient can be synchronized with the cloud platform and shared to the community end, the patient end and the family end, so that the common supervision effect of the family and the follow-up tracking of the community health hospital on the patient are realized, and the health management effect on the patient is improved; 2. the hospital health file is released to become a part of patient self-management, so that the workload of medical staff is reduced, and the participation and self-management of the patient are promoted; 3. the hospital, the community and the family are managed jointly, so that a patient can be remotely monitored and professionally guided at home, the powerful technical advantages of the comprehensive hospital are exerted, the high radiation of the community health hospital and the family in regions is brought into play, resource integration and advantage complementation are realized, medical care resources are shared, regular follow-up and long-term intervention are facilitated to be effectively carried out, and the current situation of difficulty in visiting a patient in the third hospital is relieved; 4. a mainstream social platform WeChat is used as a medium, a chronic disease health management cloud platform is built based on a WeChat applet, and each port is associated with the cloud platform through the WeChat medium, so that mobile management is more convenient, and each end user can communicate more conveniently.
Drawings
Fig. 1 is a system block diagram of the hospital-community-home three-in-one chronic disease health management system of the present invention.
Detailed Description
The present invention will be described in further detail with reference to the accompanying drawings and specific embodiments.
The embodiment conforms to the arrival of big data and cloud computing era, provides a management system based on Internet and medical treatment, and carries out long-term detection and patient family management on patients through the platform of 'Internet + chronic disease management' of the embodiment.
The chronic disease is any one of diabetes, cardiovascular and cerebrovascular diseases and chronic obstructive pulmonary diseases, and the diabetes is taken as an example.
According to the embodiment, a hospital-community-family three-in-one chronic disease health management cloud platform with a cloud data processing function is built by taking a modern information technology as a medium, relying on WeChat (free mobile phone social software provided by Tencent corporation) with a high popularization rate as a carrier and binding a public subscription number with a chronic disease health management small program. Patients, family members, communities and hospitals all add the system to their WeChat accounts so as to be associated with the cloud platform. That is to say, connect four ports of having patient's end, family's end, hospital's end and community's end of cloud platform, believe applet as a neotype, need not to download, the instant available program, set up the cloud platform on this basis, it is more convenient, improve patient compliance.
Specifically, as shown in fig. 1, the three-in-one chronic disease health management system disclosed in this embodiment, a physical examination device and a cloud platform connected to the physical examination device, the cloud platform is connected to a patient end, a hospital end, a community end and a family end, after a patient is diagnosed with diabetes for the first time in a hospital, a medical staff in the hospital establishes a database for the patient at the hospital end, the database is uploaded to the cloud platform, and an initial file is entered in the database, the content of the initial file is blood sugar monitoring, glycated hemoglobin, diabetes-related complication monitoring, an evaluation result, a diabetes self-management behavior scale, a diabetes life quality specificity scale and the like at the time of first admission, and general data, BMI, waist-hip ratio, diabetes-related disease condition and complications at the time of discharge, and general laboratory examination, high risk factors: smoking and passive smoking, family history of diabetes, nutritional status, family economic status, etc. And simultaneously, sending the initial file to a community end of a community hospital in the administration place where the patient is located. Thereafter, the information related to the patient is updated to a database established at the hospital side, such as follow-up files, daily health examination data, and the like. The follow-up file is recorded by the hospital when the patient goes to the hospital for reexamination, and the content of the follow-up file is determined according to the reexamination content. The health file of the patient is released from the hospital and becomes the self-management part of the patient, so that the workload of medical staff is reduced, and the participation and self-management of the patient are promoted.
Similarly, the patient side is used for binding the corresponding patient, and the patient binds the patient side with the account number of the corresponding patient side in a mode of logging in the patient side through the WeChat applet and inputting the identity information of the patient side. The patient can access the own database through the patient end to obtain the own health record at any time.
The family end binds 1-3 patients, and the family end logs in through the WeChat applet and inputs the identity information of the family end and the associated patients so as to register and bind the corresponding patients. The family end can directly log in and access the database of the patient associated with the family end, and the database of the corresponding patient is sent to the corresponding family end when the database of the corresponding patient has data updating. The family member end of the embodiment can acquire the information of the patient through the cloud platform, and the purpose of common management and supervision is achieved.
The community health hospital logs in through the WeChat applet and inputs community information of the community health hospital to establish a community end, then the community end is associated with users in all jurisdictions, when a user is diagnosed as diabetes and a database is established, the community end binds the patient and the patient end of the patient, acquires health files of the patient and health management information uploaded by the patient in time, and performs online interaction with the patient and the like. Similarly, the community end can acquire the database of the patients in the jurisdiction at any time by accessing the cloud platform.
The patient side is multiple, namely each patient side corresponds to one patient, the community side is multiple, namely each community health hospital in the jurisdiction area corresponds to one community side, and the hospital side can also be multiple, wherein the hospitals and the communities belong to a flat relation, and the database of a specific patient can be shared in a referral mode. Specifically, the community end and the hospital end are both provided with a referral module so as to refer a specific patient to a specific hospital end or a specific community end. For example, the a hospital may refer the patient to the B hospital or a lower-level community health care department, and the B hospital or the lower-level community health care department can directly acquire information such as the visit condition of the patient in the a hospital in the cloud platform. Similarly, the community end can refer patients to other community ends or superior hospitals, so that personnel at all levels can search each other, required information can be retrieved, data sharing is realized, health management efficiency is improved, and management superiority is reflected.
Furthermore, the physical examination equipment is used for carrying out physical examination on the patient and uploading the identity information and the physical examination result of the current physical examination patient to the cloud platform, the cloud platform sends the physical examination result to the corresponding patient side and the community side according to the identity information of the current patient, meanwhile, the database data of the corresponding patient are updated, and the doctor at the hospital side can directly obtain the physical examination result from the database when the patient is in follow-up treatment.
The physical examination equipment can be any one or combination of a plurality of blood glucose meters, blood pressure meters and height and weight measuring instruments; or the physical examination equipment is an intelligent blood glucose meter and a sports bracelet with cloud data functions, and the physical examination equipment is connected with the cloud platform by itself or is connected with the cloud platform through a patient end. The physical examination equipment uploads the blood glucose value, the exercise duration and the step number of the patient to the cloud platform through the network. For example, physical examination equipment such as a networked blood glucose meter, a blood pressure meter, a height and weight measuring instrument and the like is configured in a specified point of a community, a patient goes to the specified point by himself to perform physical examination, and the physical examination equipment acquires identity information of the patient, sends a physical examination self-examination result of the patient to a cloud platform and stores the physical examination self-examination result into a database of the patient. The physical examination equipment can acquire the identity information of the patient by adding the identity information to the patient or reading card information with identity information such as a citizen card and an identity card.
Preferably, the management of the diabetic is closely related to the life style of the patient, so the patient end also has a self-testing module, and the self-testing module is filled with health-related questionnaires such as life style for self-evaluation. Specifically, the self-evaluation module sends the self-evaluation report filled by the patient to the cloud platform and stores the self-evaluation report into the database of the patient according to the contents of exercise, diet, medication, related complications and the like of the self-evaluation report.
Further, the cloud platform is provided with a data processing module, and the data processing module is used for carrying out health analysis on the patient according to the physical examination result and the self-evaluation report of the patient and storing the health analysis in the database of the patient. Then, the cloud platform sends the physical examination result, the self-evaluation report and the analysis result of the patient to the patient end, the family end and the community end together, the community end can evaluate the patient according to the received information, and gives individualized health guidance and intervention to the patient in time according to the patient diagnosis condition, for example, the patient is guided to adjust diet, move evolution or further admit to a hospital to change a treatment scheme, and the patient is subjected to referral according to the evaluation result.
In addition, the cloud platform also stores a health index threshold, and when the health index in the patient physical examination result exceeds the health index threshold, an alarm prompt is automatically sent to the patient end, the community end and the family end.
Certainly, if the community doctor needs to perform individualized health guidance and intervention on the patient, the community end needs to perform information interaction with the patient end, so the hospital end and/or the community end are/is also used for performing information interaction with the corresponding patient through the cloud platform, so that the community doctor can interact with the patient irregularly, and the compliance of the patient is improved.
And preferably, the cloud platform is provided with a timing module for the hospital end and/or the community end to set the medicine taking reminding for the specific patient, the medicine taking time reminding can be set, the health management burden of health management personnel of the community end/the hospital end is relieved, the health of the patient is managed in batch conveniently, the probability of taking medicine on time by the patient is improved, and the cloud platform sends the medicine taking reminding message, the diet exercise attention and the like to the specific patient at set time. For example, three diabetic patients, namely C1, C2 and C3, are bound at the community end, and the specific illness states of the three diabetic patients are different, so that the dosage and the medication time of the three diabetic patients are different, and community medical staff set the dosage and the medication time for the three diabetic patients respectively in a cloud platform through the community end: c1 eats one A1 class medicine respectively at the morning 9, the noon 12 and the evening 6, C2 eats two A1 class medicines respectively at the morning 9, the noon 12 and the evening 6, C3 eats one A1 class medicine respectively at the morning 9 and the evening 6, so that the cloud platform sends medicine taking reminders to corresponding patient terminals of C1, C2 and C3 respectively at the morning 9 and the evening 6, sends medicine taking reminders to C1 and C2 at the noon 12, and the medicine taking reminding content contains medicine amount information, thereby being beneficial to the patient to take medicines according to the amount on time to effectively control diabetes.
Preferably, in order to improve the popularity of the diabetes basic knowledge, a diabetes knowledge base which is disclosed for all users is also arranged in the cloud platform, and diabetes related knowledge in the diabetes knowledge base is uploaded and smaller by staff at the community end and/or the hospital end. For example, the diabetes-related knowledge relates to the principles of diabetes diet and exercise, a self-blood sugar monitoring method, the knowledge of diabetes patients taking medicines, an insulin injection method, and the prevention of various acute and chronic complications, etc., so that the patients can understand the disease-related knowledge and learn the skills for solving the problems, actively participate in the disease management, enhance the self-care ability and improve the quality of life. Meanwhile, the platform at least pushes articles such as diabetes related knowledge to the patient end and the family end through corresponding public numbers, and the pushed articles are simultaneously stored in a diabetes knowledge base so as to be conveniently viewed by a user at any time.
Real-time data sharing is realized to this embodiment, and community doctor's online follow-up visit, communication, guide and hospital health archives release and hospital doctor's online guide three combined management, and all relevant personnel all can in time accurately learn relevant information such as the state of an illness, diagnosis and treatment of corresponding patient on "cloud platform", can make the patient also obtain remote monitoring and professional guidance at home, reducible patient's frequency of being in hospital and medical expenses, really implement the service theory of "running one time at most". The method not only gives play to the powerful technical advantages of the comprehensive hospital, but also brings high radiation of community health hospitals and families in regions, realizes resource integration and advantage complementation, enables medical care resources to be shared, is beneficial to effective development of regular follow-up visits and long-term intervention, and relieves the current situation of difficult visit of the third hospital.
The specific embodiments described herein are merely illustrative of the invention. Various modifications or additions may be made to the described embodiments or alternatives may be employed by those skilled in the art without departing from the scope of the invention as defined in the appending claims, the invention being defined as directly connected or indirectly connected.
Although the terms patient side, family side, cloud platform, physical examination device, community side, hospital side, wechat applet, etc. are used more herein, the possibility of using other terms is not excluded. These terms are used merely to more conveniently describe and explain the nature of the present invention; they are to be construed as being without limitation to any additional limitations that may be imposed by the spirit of the present invention.

Claims (10)

1. A hospital-community-family three-in-one chronic disease health management system is characterized by comprising physical examination equipment and a cloud platform connected with the physical examination equipment, wherein the cloud platform is connected with a patient end, a hospital end and a community end, databases of all patients are stored in the cloud platform, the patient end is bound with the corresponding patient and used for accessing the database of the corresponding patient, the community end is bound with a plurality of corresponding patient ends and used for accessing the database of the bound patient, the hospital end is bound with a plurality of patient ends and used for accessing the database of the bound patient, the physical examination equipment is used for performing physical examination on the patient and uploading the identity information and the physical examination result of the currently examined patient to the cloud platform, and the cloud platform sends the physical examination result to the corresponding patient end and the community end according to the identity information of the current patient, and simultaneously updating the database data of the corresponding patient.
2. The hospital-community-family triad chronic disease health management system according to claim 1, wherein the patient end has a self-test module for the corresponding patient to upload a self-evaluation report to the cloud platform through the self-test module, and the content of the self-evaluation report includes any one or more of exercise, diet, medication and related complications.
3. The hospital-community-home trinity chronic disease health management system of claim 2, wherein the physical examination device comprises any one or combination of a blood glucose meter, a blood pressure meter, a height and weight measuring instrument;
or, the physical examination equipment is intelligent blood glucose meter and motion bracelet that have cloud data function, and the physical examination equipment is uploaded the blood glucose value, the length of exercise and the step number of patient every day to the cloud platform through the network.
4. The hospital-community-family triad chronic disease health management system according to claim 3, wherein the cloud platform has a data processing module, and the data processing module is used for performing health analysis on the patient according to the physical examination result and the self-evaluation report of the patient and sending the analysis result to the patient side and the community side together;
the community end and the hospital end are both provided with referral modules so as to refer a specific patient to a specific hospital end or a specific community end.
5. The hospital-community-family three-in-one chronic disease health management system according to claim 4, wherein the hospital side and/or the community side is further configured to perform information interaction with corresponding patients through a cloud platform, the cloud platform is provided with a timing module for the hospital side and/or the community side to set medication reminding for specific patients, and the cloud platform sends medication reminding messages to the specific patients at set time.
6. A hospital-community-home three-in-one chronic disease health management system according to claim 5, wherein the chronic disease is any one of diabetes, cardiovascular and cerebrovascular diseases, chronic obstructive pulmonary disease;
and the database data of each patient comprises an initial file, a subsequent file, and the self-evaluation report content, the physical examination result and the health analysis result of each time of the corresponding patient.
7. The hospital-community-family three-in-one chronic disease health management system according to claim 6, wherein the initial file of each patient database is established at the hospital end, the subsequent file is updated to the cloud platform from the hospital end, and the contents of the initial file and the subsequent file include blood glucose monitoring at hospital admission, glycated hemoglobin, diabetes-related complications monitoring and evaluation results, and any one or more of diabetes self-management behavior scale and diabetes life quality specificity scale.
8. The hospital-community-family triad chronic disease health management system of claim 7, wherein the cloud platform further has a chronic disease knowledge base published to all users, and the community side and/or the hospital side uploads chronic disease related knowledge to the chronic disease knowledge base for all users to refer to.
9. The hospital-community-family triad chronic disease health management system according to any one of claims 1 to 8, further comprising a family end connected to the cloud platform, wherein 1 to 3 patients are bound to the family end, and the family end is used for accessing the database of the corresponding patient and simultaneously sending the database of the corresponding patient to the corresponding family end whenever the database of the corresponding patient has data update.
10. The hospital-community-family three-in-one chronic disease health management system according to any one of claims 1 to 8, wherein the cloud platform is built based on a wechat applet and/or a wechat public number, and the patient side, the family side, the community side and the hospital side are all added into the system through the wechat platform.
CN201911257284.1A 2019-12-10 2019-12-10 Hospital-community-family three-in-one chronic disease health management system Pending CN111105853A (en)

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