CN116646043A - Multi-contact patient follow-up management method - Google Patents
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
- G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H50/00—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
- G16H50/20—ICT 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
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H50/00—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics
- G16H50/70—ICT specially adapted for medical diagnosis, medical simulation or medical data mining; ICT specially adapted for detecting, monitoring or modelling epidemics or pandemics for mining of medical data, e.g. analysing previous cases of other patients
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H80/00—ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring
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- Y02—TECHNOLOGIES OR APPLICATIONS FOR MITIGATION OR ADAPTATION AGAINST CLIMATE CHANGE
- Y02A—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE
- Y02A90/00—Technologies having an indirect contribution to adaptation to climate change
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Abstract
A method of multi-contact patient follow-up management comprising the steps of: s1: identifying disease information of the patient; s2: determining a follow-up plan based on the disease information; s3: a follow-up object is determined according to the follow-up plan. The follow-up visit at present is to the patient himself carry out the return visit, owing to receive reasons such as psychology, emotion, does not cooperate the follow-up visit also comparatively common, produces the influence of certain degree to the validity of follow-up visit, and this technical scheme is through confirming the follow-up visit plan according to disease type to confirm the object of follow-up visit according to the content of follow-up visit plan, can make follow-up visit object have higher compliance, and then promote patient's compliance.
Description
Technical Field
The application relates to the technical field of medical management, in particular to a medical management method for improving follow-up visit effectiveness.
Background
Follow-up refers generally to an observation method by which a hospital or healthcare facility communicates or otherwise regularly learns patient condition changes and directs patient recovery to a patient who was at a hospital visit. The purpose of the follow-up is: 1. evaluating curative effect, standardizing data, improving compliance of patient standard treatment, and promoting disease control to reach standard; 2. effectively controlling indexes related to diseases such as blood pressure, blood sugar, blood fat and the like, and delaying the occurrence of disease progress or complications; 3. detecting the change of the illness state, identifying the complications and the change of related concomitant diseases, carrying out early warning and supervising medical treatment, and realizing early discovery and early treatment.
However, the applicant has found that general follow-up often cannot be achieved, such as the follow-up being refused by the person or, although the follow-up is accepted, the patient is not engaged, etc. Therefore, in order to improve the quality of medical management, how to improve the effectiveness of follow-up visit is a technical problem to be solved.
Disclosure of Invention
The application aims to provide a multi-contact patient follow-up management method, which can effectively improve the follow-up effectiveness.
In order to achieve the above purpose, the present application provides the following technical solutions.
A method of multi-contact patient follow-up management comprising the steps of: s1: identifying disease information of the patient; s2: determining a follow-up plan based on the disease information; s3: and determining a follow-up object according to the follow-up plan, and generating a follow-up task. The applicant finds that the follow-up visit is carried out on the patient, but because the disease usually causes a certain psychological stress on the patient, a certain distortion exists in the description content of the follow-up visit, the follow-up visit quality is poor, further diagnosis and treatment at the later stage is affected, and due to psychological, emotional and other reasons, the follow-up visit is not matched, the follow-up visit is also common, the effectiveness of the follow-up visit is affected to a certain extent, and the follow-up factors are often related to the disease type, for example, when a cancer patient knows the disease condition, the follow-up visit is often due to the concern of the patient, the follow-up visit is difficult to be matched with behaviors of doctors and the like in a short period, but the condition of the patient is also familiar to the assistance personnel of family and the like, the description of the patient condition can be achieved, on the other hand, the treatment behavior of the patient can be supervised, the compliance of the patient is improved, and the assistance personnel can be matched with the medical treatment. According to the technical scheme, the follow-up plan is determined according to the disease types, and the follow-up object is determined according to the content of the follow-up plan, so that the follow-up object has higher compliance, and the compliance of a patient is further improved.
Further, the method also comprises the following steps: s4: according to the determined follow-up object, basic information of the follow-up object is obtained; s5: and determining a follow-up mode according to the basic information or the communication content of the follow-up object. Thus, after the follow-up plan is determined, a proper follow-up mode (communication mode) is selected, so that the follow-up effectiveness can be further improved. For example, the follow-up object is used to use the WeChat, the follow-up is performed through the WeChat way, for example, the old can not use the WeChat, the follow-up is more suitable through the voice (telephone) mode, for example, the follow-up object is not hoped to be disturbed, the follow-up is performed through the mail, the follow-up object is easier and more prone to be matched.
Further, the selection of the follow-up objects comprises a patient and auxiliary personnel, the number of the follow-up objects can be 1 or more, and the follow-up modes among the follow-up objects can be different. As described above, different follow-up objects are determined according to the disease types, which has an important role in improving the effectiveness of follow-up and patient compliance, and the follow-up objects may include the patient himself, auxiliary personnel (relatives, caregivers, etc.), and the follow-up can be performed on the patient and the auxiliary personnel at the same time, which is beneficial to improving the effectiveness of follow-up and patient compliance.
Further, the disease information includes a disease type and a disease stage, and the follow-up plan is related to the disease type and the disease stage. Applicants have found that psychological stress and expectations of patients are inconsistent at different stages of the disease, and follow-up without distinguishing between disease stages often fails at different stages of the disease. Taking cancer patients as an example, in the initial diagnosis, the patients are full of fear and confusing for the diseases, so that the tumor patients bear huge psychological stress and need timely psychological intervention and support; when the disease is controlled, the patient desires to acquire corresponding knowledge, and hopes to know the whole treatment process of the disease, and professional diagnosis and treatment guidance support is needed; after rehabilitation, the patient often needs further rehabilitation and medication, and corresponding guidance is needed. Therefore, according to the general characteristics and general requirements of patients, different follow-up schemes are needed to be applied to different stages of diseases, namely, disease stage information needs to be acquired when the follow-up scheme is manufactured or adjusted.
Further, the method also comprises the following steps: s6: recording a follow-up mode, communication feasibility data and compliance data, and obtaining follow-up validity evaluation according to a model; s7: and judging whether the corresponding follow-up mode needs to be adjusted according to the validity evaluation result. Thus, a corresponding feedback mechanism is established, and unsuitable follow-up modes are adjusted in time, so that the follow-up effectiveness is improved.
Further, the method comprises follow-up interception verification, and specifically comprises the following steps: before the follow-up plan is executed, the type of the follow-up object is obtained, the content to be followed up is verified with the preset interception content corresponding to the follow-up object, the follow-up content which does not meet the requirement is intercepted or the follow-up personnel is reminded. In general, during the follow-up process, part of follow-up content can have adverse effect on the follow-up object, so the interception verification link is arranged, and the possibility of negative effect caused by follow-up can be effectively reduced.
Further, in step S7, when the communication feasibility data is in a better state, the follow-up mode is not required to be adjusted, and when the communication feasibility data is in a worse state, the follow-up mode is adjusted; and when the compliance data is in an optimized state or a qualified state, continuing to execute the follow-up plan, and when the compliance data is in a degraded state or a non-qualified state, adjusting the follow-up plan.
Further, step S1 includes the steps of: s11: extracting medical information through an application layer; s12: taking the extracted information as input to enter a follow-up rule engine; s13: and extracting the follow-up scheme to generate the required key information according to an information extraction module in the rule engine.
Further, step S2 includes the steps of: s21: rule matching is carried out according to the disease information; s22: performing follow-up scheme matching after rule matching; s23: a complete follow-up protocol output is formed.
Drawings
Fig. 1 is a flow chart of a method of multi-contact patient follow-up management.
Detailed Description
Fig. 1 illustrates a flow chart of a method of multi-contact patient follow-up management. The multi-contact patient follow-up management method comprises the following steps:
s1: disease information of the patient is identified. The disease information includes disease type and disease stage, and the follow-up plan is related to the disease type and disease stage.
The method specifically comprises the following steps:
s11: medical information extraction can be performed by various forms of information sources of the application layer (private letter, micro-letter group, micro-letter voice, phone voice): text information (symptoms, drugs, etc.), picture information (uploaded discharge summary, inspection report, imaging report, pathology report, outpatient medical record, etc.), active follow-up voice information (symptoms, drugs, adverse reactions, etc.), registered questionnaire information (designed for different disease types).
S12: taking the extracted information as input to enter a follow-up rule engine;
s13: according to an information extraction module in the rule engine, extracting the key information required by the follow-up scheme to generate: : sex, age, contact, state of survival (whether self-care, whether smart phone operation is possible), primary disease diagnosis, complications, treatment scenario (hospitalization, home), treatment time and period, treatment modality (chemotherapy regimen), radiation therapy, targeted therapy (drug name), cellular immunotherapy (drug name), transplantation, palliative therapy); special requirements; behavior information. For example, in the treatment mode, the fields covered by the solid tumor include: chemotherapy (chemotherapy regimen), radiation therapy, targeted therapy (drug name), cellular immunotherapy (drug name), etc.; fields covered by hematological tumors include: chemotherapy (chemotherapy regimen), radiation therapy, targeted therapy (drug name), cellular immunotherapy (drug name), pre-implantation, post-implantation, etc.; fields covered by the chronic disease include: drug treatment (drug name), surgical treatment (surgical name), and the like.
For example, one patient added Multiple Myeloma (MM) at 2022.2.10, and the family members filled in the registered questionnaires when they were entered into the group, the information for filling in the questionnaires was as follows: name-Zhang three, birth month-1962.3, sex-male, office-Henan, office-Zhengzhou people hospital, the drug being used-Isxazomib, lenalidomide, dexamethasone. On-line consultation is initiated by the 2022.3.15 family members initiative private letter, which indicates that the patient has arthralgia in the process of taking medicine at home, and simultaneously, the latest (2022.2.20) outpatient record containing diagnosis and treatment information is uploaded.
Extracting and generating key follow-up information from the above information: sex-male, age-61 years, primary diagnosis-multiple myeloma, combined disease-hypertension, complications-bone pain, treatment cycle-28 days, treatment regimen-i Sha Zuomi d1, d8, d15 mg postprandial po+lenalidomide d1-d21 25m po+dexamethasone d1, d8, d15, d22 mg morning-start po, next review date 2022.3.20, and review items are dosage +review blood biochemistry.
S2: follow-up plans are determined from the disease information.
Specifically, step S2 includes the steps of:
s21: rule matching is carried out according to the disease information;
s22: performing follow-up scheme matching after rule matching;
s23: a complete follow-up protocol output is formed.
S3: a follow-up object is determined according to the follow-up plan. For example, interviewee roles are output according to major disease diagnosis, complications, survival status, capabilities required for follow-up tasks, and the like: if the survival state is 'no self-care ability', the special requirement is 'contact family', the disease diagnosis is 'AML, MM, lymphoma' and the like, and the complications have 'acute' and other fields for prompting serious illness, the system defaults that the interviewee is family; for example, follow-up procedures require supervision statistics on patient compliance data, and the system interviewee should be a family member.
S4: and acquiring basic information of the follow-up object according to the determined follow-up object. The selection of the follow-up objects comprises a patient and auxiliary personnel, the follow-up objects can be 1 or more, and the follow-up modes among the follow-up objects can be different.
S5: and determining a follow-up mode according to the basic information or the communication content of the follow-up object.
Outputting the follow-up mode according to the age, survival state, provided effective contact mode and the like of the follow-up object: questionnaires, private letters, weChat voices, telephones. For example, the following logic is selected for the follow-up mode: the age is more than or equal to 75 years old or the survival state is that the smart phone cannot be operated skillfully or the special requirement is that the phone is in hope of being contacted, and the phone is selected; the behavior information prompts that the group-entering questionnaire is completed and filled out, the questionnaire pushing is selected, the private letter task is further generated after the questionnaire pushing is failed, the micro letter voice task is generated after the private letter is failed, the telephone task is generated after the micro letter voice task is failed, if the telephone task is continuously prompted to fail for 3 months, and the lost visit is marked; in the daily operation process, if the patient/family member has the action of private letter/community active consultation, the follow-up staff can further collect the month follow-up information through the contact, and if the action information is '1 or more active consultation per natural month', the month follow-up task is finished by default, so that the patient/family member is not disturbed excessively/repeatedly.
For example, according to the MM's follow-up key information, the follow-up mode is "push questionnaire", but because the family members of the patient actively initiate online consultation in 3 months, the online medical assistant answers the questions of the patient, actively inquires and perfects the follow-up information in the month, and inputs the daily follow-up information in 3 months of the form, and the system defaults that the follow-up task in the month is completed.
S6: executing a follow-up plan, and executing a follow-up interception verification step before the follow-up plan executes the content transmission, in particular to acquiring the type of a follow-up object before the corresponding follow-up content is transmitted, verifying the content to be followed and preset interception content corresponding to the follow-up object, intercepting follow-up content which does not meet the requirement or reminding a follow-up person; and recording a follow-up mode, communication feasibility data and compliance data, and obtaining the effectiveness evaluation of follow-up according to the model.
For example, when generating "warning" information on the patient WeChat interaction page, if text information such as "bad prognosis", "death" appears in the communication process, the system can automatically intercept the information. The patient has information such as 'liveness has no meaning', 'depression', 'suicide' and the like in the dialogue, the system can warn, and the operation assistant can communicate with the family members of the patient in time after receiving the warning.
S7: and judging whether the corresponding follow-up mode needs to be adjusted according to the validity evaluation result. When the communication feasibility data is in a better state, the follow-up mode is not required to be adjusted, and when the communication feasibility data is in a worse state, the follow-up mode is adjusted; and when the compliance data is in an optimized state or a qualified state, continuing to execute the follow-up plan, and when the compliance data is in a degraded state or a non-qualified state, adjusting the follow-up plan.
Claims (9)
1. A method of multi-contact patient follow-up management comprising the steps of:
s1: identifying disease information of the patient;
s2: determining a follow-up plan based on the disease information;
s3: and determining a follow-up object according to the follow-up plan, and generating a follow-up task.
2. The method of multi-contact patient follow-up management as set forth in claim 1, further comprising the steps of:
s4: according to the determined follow-up object, basic information of the follow-up object is obtained;
s5: and determining a follow-up mode according to the basic information or the communication content of the follow-up object.
3. The multi-contact patient follow-up management method according to claim 2, wherein the selection of the follow-up objects includes the patient and the auxiliary personnel, the follow-up objects can be 1 or more, and the follow-up modes can be different among the follow-up objects.
4. The method of claim 1, wherein the disease information includes a disease type, a disease stage, and wherein the follow-up plan is related to the disease type, the disease stage.
5. A multi-contact patient follow-up management method according to claim 3, further comprising the steps of:
s6: recording a follow-up mode, communication feasibility data and compliance data, and obtaining follow-up validity evaluation according to a model;
s7: and judging whether the corresponding follow-up mode needs to be adjusted according to the validity evaluation result.
6. A multi-contact patient follow-up management method according to claim 3, comprising a follow-up intercept verification, comprising in particular the steps of:
before the follow-up program executes to send the corresponding follow-up content, the type of the follow-up object is obtained, the content to be followed up is verified with the preset interception content corresponding to the follow-up object, the follow-up content which does not meet the requirement is intercepted or the follow-up personnel is reminded.
7. The method according to claim 5, wherein in step S7, when the communication feasibility data is in a better state, the follow-up mode is not required to be adjusted, and when the communication feasibility data is in a worse state, the follow-up mode is adjusted; and when the compliance data is in an optimized state or a qualified state, continuing to execute the follow-up plan, and when the compliance data is in a degraded state or a non-qualified state, adjusting the follow-up plan.
8. The multi-contact patient follow-up management method according to claim 1, wherein step S1 includes the steps of:
s11: extracting medical information through an application layer;
s12: taking the extracted information as input to enter a follow-up rule engine;
s13: and extracting the follow-up scheme to generate the required key information according to an information extraction module in the rule engine.
9. The multi-contact patient follow-up management method according to claim 1, wherein step S2 includes the steps of:
s21: rule matching is carried out according to the disease information;
s22: performing follow-up scheme matching after rule matching;
s23: a complete follow-up protocol output is formed.
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