CN117275735A - Intelligent medical management system and method based on chronic disease management - Google Patents
Intelligent medical management system and method based on chronic disease management Download PDFInfo
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Abstract
An intelligent medical management system and a management method based on chronic disease management acquire physical examination chronic disease patient information, outpatient service patient information and hospitalized patient information; analyzing the illness state and illness state change trend of each patient, and setting a management target and a management plan; assigning a management plan doctor and a management plan nurse to each patient for tracking and follow-up the patient, adjusting a management plan in real time according to the change of the illness state of the patient in the tracking and follow-up process, providing service according to the requirement of the patient, and evaluating the illness state of the patient again when the patient tracking and follow-up visit is full of one year; for the patients who reach the management target, adjusting and tracking the follow-up frequency, and resetting the management target and the management plan for the patients who do not reach the management target; the medical nursing device realizes medical nursing of pre-hospital and post-hospital professions which are homogeneous with those in the hospital, can effectively improve the life quality of patients, improves the satisfaction degree of the patients, and can truly promote the effective self-management of chronic diseases and the overall health literacy of national people.
Description
Technical Field
The invention relates to a medical management system, in particular to an intelligent medical management system and method based on chronic disease management.
Background
Along with the aggravation of the aging trend of society, the incidence rate of chronic diseases rises year by year, great influence is generated on human health, the traditional chronic disease management mode of hospitals has the problem of fragmented management, continuous and whole-course management of patients cannot be realized, and poor medical experience and low life quality of the patients are caused, so that the problem of how to realize standardized and standardized management of chronic disease patients is always a problem to be solved in the medical care field.
At present, although Internet platforms such as 'about nurses' appear in the country, which can provide nursing services for patients, the platforms are more focused on the delivery of nursing technology, the health literacy of the national citizens can not be improved in the true sense, and the effective self-management of chronic diseases by the patients can not be realized, so that the continuous whole-course professional support is provided for the patients and the families thereof, the patients experience the medical care of the professional before and after the hospital with the same quality in the hospital, the hospitalization experience and the hospitalization conclusion of the patients are further improved, and the life quality is improved.
Disclosure of Invention
The invention aims to overcome the defects of the prior art and provides an intelligent medical management system and an intelligent medical management method based on chronic disease management; the system can be in butt joint with accurate sub-health people, chronic disease patients, discharge patients or special people suffering from diseases and inconvenient to move, provides whole-course tracking and personalized management for the patients, can effectively improve the life quality of the patients, improves the satisfaction degree of the patients, provides a new chronic disease management mode for medical institutions, and is beneficial to improving the medical service quality.
To achieve the above object, in a first aspect, the present invention provides an intelligent medical management system based on chronic disease management, including:
the patient information acquisition module is used for acquiring chronic disease patient information, outpatient service patient information and inpatient treatment patient information of the conventional physical examination of the physical examination center, which meet preset chronic disease management standards;
the disease analysis module is in communication connection with the patient information acquisition module and is used for analyzing the acquired disease condition and the change trend of the patient, setting a management target based on the analysis result, making a management plan and creating an electronic file for each patient;
the data storage module is in communication connection with the patient information acquisition module and the illness state analysis module and is used for storing the patient information and the electronic file information created by the illness state analysis module;
the knowledge enabling module is in communication connection with the data storage module and periodically pushes health education knowledge to the patient according to the stored management targets and management plans;
the management module is in communication connection with the illness state analysis module and the data storage module, and is responsible for assigning tasks to the management case doctor and the management case nurse according to the management target and the management plan, supervising the execution condition of the management case doctor and the management case nurse, and timely adjusting the management target and the management plan according to the patient, the management case doctor, the management case nurse and the feedback information;
the medical care execution terminal is in communication connection with the data storage module and the management module, and is used for receiving the assignment task of the management module, providing health consultation, tracking follow-up visit, technical delivery, on-door nursing and drug delivery service for patients according to the management target and the management plan, and feeding back the assignment task execution result and the patient condition to the management module;
and the patient terminal is in communication connection with the knowledge enabling module, the management module and the medical care execution terminal, and is used for receiving the information pushed by the knowledge enabling module, carrying out health consultation, appointment service, hospitalization service, on-the-door nursing service, technical delivery service and drug delivery service, and feeding back the illness state change condition to the management module.
The patient information acquisition module further comprises:
a patient information input sub-module: all patient information for physical examination centers, outpatient visits, and hospitalizations;
a multi-source data integration sub-module: for integrating data from different medical institutions and health monitoring devices;
patient information transfer sub-module: the system comprises a patient information pushing module, a disease analysis module and a data processing module, wherein the patient information pushing module is used for pushing patient information meeting preset chronic disease management standards to the disease analysis module;
the preset chronic disease management criteria include: patients with chronic medical history, long-term administration history, multiple hospitalization and other conditions.
The disease analysis module adopts a medical knowledge base and an expert knowledge base to evaluate the disease of the patient, judges the severity of the disease and predicts the change trend of the disease.
The condition analysis module further includes a condition prediction sub-module for predicting patient condition progress based on a machine learning algorithm.
The knowledge enabling module further comprises:
the classification summarizing sub-module is used for classifying and summarizing the patient files into different disease types according to the disease conditions of the patient;
the knowledge base construction submodule is used for collecting and arranging the nursing knowledge, the medication knowledge and the professional knowledge of the treatment scheme of various diseases and establishing a knowledge base;
the knowledge pushing sub-module is used for retrieving the matched professional knowledge from the knowledge base according to the disease types of the patients and pushing the matched professional knowledge to the patient terminal of the corresponding patient;
and the interactive education sub-module is used for adjusting the difficulty and frequency of pushing the content according to the interactive feedback of the patient.
The knowledge base construction submodule acquires professional knowledge of various diseases through doctor input, web crawlers and medical document retrieval modes, and the knowledge content comprises: disease control methods, medication instructions, diet conditioning knowledge, disease etiology, symptoms, treatment regimens, medication regimen expertise, and health education and disease education knowledge for patients.
The management module further comprises a performance evaluation sub-module for evaluating the work performances of the management case doctors and the management case nurses and the satisfaction degree of patients.
In a second aspect, the present invention provides an intelligent medical management method based on chronic disease management, comprising the steps of:
s1: respectively acquiring chronic disease patient information, outpatient service patient information and hospitalized patient information of a conventional physical examination of a physical examination center which accords with a preset chronic disease management standard;
s2: analyzing the illness state and illness state change trend of each patient according to the acquired patient information, dividing management stages of each patient according to analysis results, and setting management targets and management plans;
s3: assigning a management doctor and a management nurse to each patient according to the management targets and the management plans, carrying out tracking follow-up and technical delivery on the patient, and pushing health education knowledge related to the patient diseases to the patient at regular time;
s4: in the follow-up process, the management plan is adjusted in real time according to the change of the illness state of the patient, and health consultation, treatment service, hospitalization service, on-gate nursing and drug delivery service are provided according to the demands of the patient;
s5: when the follow-up visit is carried out on the patient for one year, the illness state of the patient is estimated again, and whether the illness state change of the patient reaches the management target is judged;
s6: for patients who achieve the management objective, the follow-up frequency is adjusted to once a year, the management objective and the management plan are reset for patients who do not achieve the management objective, and the patients are provided with services according to the reset management objective and management plan.
The management stage comprises a diagnosis stage, a treatment stage and a follow-up stage, the management plan comprises a diagnosis stage management plan, a treatment stage management plan and a follow-up stage management plan, and the management targets comprise the transition of the patient condition from the treatment stage to the follow-up stage.
The tracking follow-up visit comprises a follow-up visit, a remote online follow-up visit and a telephone follow-up visit, and is used for collecting the disease change information, the life information and the medication information of the patient, and the technical delivery comprises the step of providing a physical examination for the patient.
The beneficial effects of the invention are as follows: according to the chronic disease management system and method, the butt joint is realized by accurately carrying out the real-time analysis, the whole course tracking and the personalized management on the diseases with sub-healthy people, chronic disease patients and discharge patients or special people suffering from diseases and inconvenient actions, the medical care of the patients, which are professional before and after the hospital and are homogeneous in the hospital, is realized, the life quality of the patients can be effectively improved, the satisfaction degree of the patients is improved, a disease health professional knowledge system is energized to a guarantee object through a knowledge energizing module, the effective self management of the chronic diseases and the overall health literacy of the national body can be truly improved, and meanwhile, a novel chronic disease management mode is provided for medical institutions, and the medical service quality is improved.
Drawings
FIG. 1 is a system block diagram of a chronic disease management-based intelligent medical management system of the present invention;
fig. 2 is a flow chart of the intelligent medical management method based on chronic disease management of the present invention.
Detailed Description
The invention is further described in connection with the following embodiments:
example 1:
referring to fig. 1, an intelligent medical management system based on chronic disease management, comprising:
the patient information acquisition module is used for acquiring chronic disease patient information, outpatient service patient information and inpatient treatment patient information of the conventional physical examination of the physical examination center, which meet preset chronic disease management standards;
the disease analysis module is in communication connection with the patient information acquisition module and is used for analyzing the acquired disease condition and the change trend of the patient, setting a management target based on the analysis result, making a management plan and creating an electronic file for each patient;
the data storage module is in communication connection with the patient information acquisition module and the illness state analysis module and is used for storing the patient information and the electronic file information created by the illness state analysis module;
the knowledge enabling module is in communication connection with the data storage module and periodically pushes health education knowledge to the patient according to the stored management targets and management plans;
the management module is in communication connection with the illness state analysis module and the data storage module, and is responsible for assigning tasks to the management case doctor and the management case nurse according to the management target and the management plan, supervising the execution condition of the management case doctor and the management case nurse, and timely adjusting the management target and the management plan according to the patient, the management case doctor, the management case nurse and the feedback information;
the medical care execution terminal is in communication connection with the data storage module and the management module, and is used for receiving the assignment task of the management module, providing health consultation, tracking follow-up visit, technical delivery, on-door nursing and drug delivery service for patients according to the management target and the management plan, and feeding back the assignment task execution result and the patient condition to the management module;
and the patient terminal is in communication connection with the knowledge enabling module, the management module and the medical care execution terminal, and is used for receiving the information pushed by the knowledge enabling module, carrying out health consultation, appointment service, hospitalization service, on-the-door nursing service, technical delivery service and drug delivery service, and feeding back the illness state change condition to the management module.
The patient information acquisition module further comprises:
a patient information input sub-module: all patient information for physical examination centers, outpatient visits, and hospitalizations;
a multi-source data integration sub-module: for integrating data from different medical institutions and health monitoring devices;
patient information transfer sub-module: the system comprises a patient information pushing module, a disease analysis module and a data processing module, wherein the patient information pushing module is used for pushing patient information meeting preset chronic disease management standards to the disease analysis module;
preset chronic disease management criteria include: patients with chronic medical history, long-term administration history, multiple hospitalization and other conditions.
The disease analysis module adopts a medical knowledge base and an expert knowledge base to evaluate the disease of the patient, judges the severity of the disease and predicts the change trend of the disease.
The disease analysis module further comprises a disease prediction sub-module for predicting the disease progress of the patient based on a machine learning algorithm.
Wherein the knowledge enabling module further comprises:
the classification summarizing sub-module is used for classifying and summarizing the patient files into different disease types according to the disease conditions of the patient;
the knowledge base construction submodule is used for collecting and arranging the nursing knowledge, the medication knowledge and the professional knowledge of the treatment scheme of various diseases and establishing a knowledge base;
the knowledge pushing sub-module is used for retrieving the matched professional knowledge from the knowledge base according to the disease types of the patients and pushing the matched professional knowledge to the patient terminal of the corresponding patient;
and the interactive education sub-module is used for adjusting the difficulty and frequency of pushing the content according to the interactive feedback of the patient.
The knowledge base construction submodule acquires professional knowledge of various diseases through doctor input, web crawlers and medical document retrieval modes, and the knowledge content comprises: disease control methods, medication instructions, diet conditioning knowledge, disease etiology, symptoms, treatment regimens, medication regimen expertise, and health education and disease education knowledge for patients.
The management module further comprises a performance evaluation sub-module for evaluating the work performances of the management case doctors and the management case nurses and the satisfaction degree of patients.
Example 2:
referring to fig. 2, an intelligent medical management method based on chronic disease management includes the following steps:
s1: respectively acquiring chronic disease patient information, outpatient service patient information and hospitalized patient information of a conventional physical examination of a physical examination center which accords with a preset chronic disease management standard;
s2: analyzing the illness state and illness state change trend of each patient according to the acquired patient information, dividing management stages of each patient according to analysis results, and setting management targets and management plans;
s3: assigning a management doctor and a management nurse to each patient according to the management targets and the management plans, carrying out tracking follow-up and technical delivery on the patient, and pushing health education knowledge related to the patient diseases to the patient at regular time;
s4: in the follow-up process, the management plan is adjusted in real time according to the change of the illness state of the patient, and health consultation, treatment service, hospitalization service, on-gate nursing and drug delivery service are provided according to the demands of the patient;
s5: when the follow-up visit is carried out on the patient for one year, the illness state of the patient is estimated again, and whether the illness state change of the patient reaches the management target is judged;
s6: for patients who achieve the management objective, the follow-up frequency is adjusted to once a year, the management objective and the management plan are reset for patients who do not achieve the management objective, and the patients are provided with services according to the reset management objective and management plan.
The management stage comprises a diagnosis stage, a treatment stage and a follow-up stage, the management plan comprises a diagnosis stage management plan, a treatment stage management plan and a follow-up stage management plan, and the management targets comprise the transition of the patient condition from the treatment stage to the follow-up stage.
The tracking follow-up visit comprises a follow-up visit, a remote online follow-up visit and a telephone follow-up visit, which are used for collecting the disease change information, the life information and the medication information of the patient, and the technical delivery comprises the step of providing a physical examination for the patient.
Claims (10)
1. An intelligent medical management system based on chronic disease management, which is characterized in that: comprising the following steps:
the patient information acquisition module is used for acquiring chronic disease patient information, outpatient service patient information and inpatient treatment patient information of the conventional physical examination of the physical examination center, which meet preset chronic disease management standards;
the disease analysis module is in communication connection with the patient information acquisition module and is used for analyzing the acquired disease condition and the change trend of the patient, setting a management target based on the analysis result, making a management plan and creating an electronic file for each patient;
the data storage module is in communication connection with the patient information acquisition module and the illness state analysis module and is used for storing the patient information and the electronic file information created by the illness state analysis module;
the knowledge enabling module is in communication connection with the data storage module and periodically pushes health education knowledge to the patient according to the stored management targets and management plans;
the management module is in communication connection with the illness state analysis module and the data storage module, and is responsible for assigning tasks to the management case doctor and the management case nurse according to the management target and the management plan, supervising the execution condition of the management case doctor and the management case nurse, and timely adjusting the management target and the management plan according to the patient, the management case doctor, the management case nurse and the feedback information;
the medical care execution terminal is in communication connection with the data storage module and the management module, and is used for receiving the assignment task of the management module, providing health consultation, tracking follow-up visit, technical delivery, on-door nursing and drug delivery service for patients according to the management target and the management plan, and feeding back the assignment task execution result and the patient condition to the management module;
and the patient terminal is in communication connection with the knowledge enabling module, the management module and the medical care execution terminal, and is used for receiving the information pushed by the knowledge enabling module, carrying out health consultation, appointment service, hospitalization service, on-the-door nursing service, technical delivery service and drug delivery service, and feeding back the illness state change condition to the management module.
2. The intelligent medical management system based on chronic disease management according to claim 1, wherein: the patient information acquisition module further comprises:
a patient information input sub-module: all patient information for physical examination centers, outpatient visits, and hospitalizations;
a multi-source data integration sub-module: for integrating data from different medical institutions and health monitoring devices;
patient information transfer sub-module: the system comprises a patient information pushing module, a disease analysis module and a data processing module, wherein the patient information pushing module is used for pushing patient information meeting preset chronic disease management standards to the disease analysis module;
the preset chronic disease management criteria include: patients with chronic medical history, long-term administration history, multiple hospitalization and other conditions.
3. The intelligent medical management system based on chronic disease management according to claim 1, wherein: the disease analysis module adopts a medical knowledge base and an expert knowledge base to evaluate the disease of the patient, judges the severity of the disease and predicts the change trend of the disease.
4. The intelligent medical management system based on chronic disease management according to claim 1, wherein: the condition analysis module further includes a condition prediction sub-module for predicting patient condition progress based on a machine learning algorithm.
5. The intelligent medical management system based on chronic disease management according to claim 1, wherein: the knowledge enabling module further comprises:
the classification summarizing sub-module is used for classifying and summarizing the patient files into different disease types according to the disease conditions of the patient;
the knowledge base construction submodule is used for collecting and arranging the nursing knowledge, the medication knowledge and the professional knowledge of the treatment scheme of various diseases and establishing a knowledge base;
the knowledge pushing sub-module is used for retrieving the matched professional knowledge from the knowledge base according to the disease types of the patients and pushing the matched professional knowledge to the patient terminal of the corresponding patient;
and the interactive education sub-module is used for adjusting the difficulty and frequency of pushing the content according to the interactive feedback of the patient.
6. The intelligent medical management system based on chronic disease management according to claim 5, wherein: the knowledge base construction submodule acquires professional knowledge of various diseases through doctor input, web crawlers and medical document retrieval modes, and the knowledge content comprises: disease control methods, medication instructions, diet conditioning knowledge, disease etiology, symptoms, treatment regimens, medication regimen expertise, and health education and disease education knowledge for patients.
7. The intelligent medical management system based on chronic disease management according to claim 1, wherein: the management module further comprises a performance evaluation sub-module for evaluating the work performances of the management case doctors and the management case nurses and the satisfaction degree of patients.
8. An intelligent medical management method based on chronic disease management is characterized by comprising the following steps:
s1: respectively acquiring chronic disease patient information, outpatient service patient information and hospitalized patient information of a conventional physical examination of a physical examination center which accords with a preset chronic disease management standard;
s2: analyzing the illness state and illness state change trend of each patient according to the acquired patient information, dividing management stages of each patient according to analysis results, and setting management targets and management plans;
s3: assigning a management doctor and a management nurse to each patient according to the management targets and the management plans, carrying out tracking follow-up and technical delivery on the patient, and pushing health education knowledge related to the patient diseases to the patient at regular time;
s4: in the follow-up process, the management plan is adjusted in real time according to the change of the illness state of the patient, and health consultation, treatment service, hospitalization service, on-gate nursing and drug delivery service are provided according to the demands of the patient;
s5: when the follow-up visit is carried out on the patient for one year, the illness state of the patient is estimated again, and whether the illness state change of the patient reaches the management target is judged;
s6: for patients who achieve the management objective, the follow-up frequency is adjusted to once a year, the management objective and the management plan are reset for patients who do not achieve the management objective, and the patients are provided with services according to the reset management objective and management plan.
9. The intelligent medical management method based on chronic disease management according to claim 8, wherein: the management stage comprises a diagnosis stage, a treatment stage and a follow-up stage, the management plan comprises a diagnosis stage management plan, a treatment stage management plan and a follow-up stage management plan, and the management targets comprise the transition of the patient condition from the treatment stage to the follow-up stage.
10. The intelligent medical management method based on chronic disease management according to claim 8, wherein: the tracking follow-up visit comprises a follow-up visit, a remote online follow-up visit and a telephone follow-up visit, and is used for collecting the disease change information, the life information and the medication information of the patient, and the technical delivery comprises the step of providing a physical examination for the patient.
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| CN117995339A (en) * | 2024-04-07 | 2024-05-07 | 吉林大学 | Nursing information on-line management system based on multi-source data fusion |
| CN118230925A (en) * | 2024-05-23 | 2024-06-21 | 南京纳实医学科技有限公司 | Intelligent analysis management system for chronic disease course queue |
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| CN117012364A (en) * | 2023-10-08 | 2023-11-07 | 吉林大学 | Medical health service cloud platform based on industrial Internet technology |
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