WO2019041710A1 - 基于健康检查一体机的慢病管理系统及方法 - Google Patents
基于健康检查一体机的慢病管理系统及方法 Download PDFInfo
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- WO2019041710A1 WO2019041710A1 PCT/CN2017/120304 CN2017120304W WO2019041710A1 WO 2019041710 A1 WO2019041710 A1 WO 2019041710A1 CN 2017120304 W CN2017120304 W CN 2017120304W WO 2019041710 A1 WO2019041710 A1 WO 2019041710A1
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- G—PHYSICS
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- G16Z99/00—Subject matter not provided for in other main groups of this subclass
Definitions
- the invention relates to the technical field of chronic disease management, in particular to a chronic disease management system and method based on a health check and integrated machine.
- Chronic diseases usually refer to chronic diseases such as high blood pressure, high blood fat, diabetes, and psychosis.
- the treatment of chronic diseases usually lasts for a long time. Patients need long-term hospitalization, or long-term travel between home and hospital, which takes up a lot of time for patients. The patient is inconvenienced.
- the current chronic disease management system does not timely monitor the daily inspection items of the patient during the rehabilitation period or observation period after the hospital is diagnosed, that is, it is impossible to automatically supervise whether the patient completes the daily examination of the patient and the self-executing chronic disease management program according to the plan, thereby It may lead to delay in the patient's condition, prolonged treatment period, and no effective treatment effect, and can not completely recover the patient.
- the existing chronic disease management system cannot timely report the implementation effect of the management of chronic disease patients, nor does it assist the doctor to adjust the chronic disease management plan in a timely manner, resulting in a low effect of chronic disease management.
- the main object of the present invention is to provide a chronic disease management system and method based on a health check-up integrated machine, aiming at solving the problem that the existing chronic disease management system cannot timely feedback the management effect of the chronic disease patient management and assisting the doctor to timely adjust the chronic disease management program. technical problem.
- the present invention provides a chronic disease management system based on a health check and integrated machine, which is operated in a chronic disease management server, which is connected with a medical system platform and a self-service health check set in a community medical institution.
- a chronic disease management server which is connected with a medical system platform and a self-service health check set in a community medical institution.
- the chronic disease management system includes: a follow-up plan generation module, configured to read a daily follow-up plan prepared by the doctor for the patient from the storage unit of the chronic disease management server, and import the check-up item of the daily follow-up plan into the medical order system platform, Find the inspection items of the daily follow-up plan and the corresponding plan dates in the doctor's system platform, and combine the plan items close to the current date to generate the patient's current follow-up plan; the doctor's monitoring module is used to monitor whether the doctor's order system platform transmits the doctor's orders.
- the doctor's system platform transmits the doctor's order, compare the inspection items of the follow-up plan with the inspection items transmitted by the doctor's system platform to determine the patient's unplanned and planned items; the chronic disease tracking module is used to plan the patient.
- the external inspection project and the planned inspection project are sent to the patient's mobile intelligent terminal to notify the patient to the self-service health check-in machine of the nearest community medical institution for project inspection; the chronic disease assessment module is used for receiving from the self-service health check-in machine.
- the chronic disease management module is configured to receive, from the doctor's workstation, the inspection items and inspection cycle information adjusted by the doctor according to the patient's examination result and the execution effect, and periodically adjust The subsequent inspection items and inspection cycle information are sent to the patient's mobile intelligent terminal.
- the chronic disease management module is further configured to send the examination result and the performance effect of the patient to the doctor workstation for the doctor to adjust the examination item and the examination period of the patient.
- the chronic disease management module is further configured to generate a chronic disease management service plan table and input the adjusted inspection item and the inspection cycle information when the adjusted inspection item and the inspection cycle information are received from the doctor workstation.
- the disease management service plan table the patient's inspection items and inspection periods are periodically scanned in the service plan list, and when the inspection cycle enters the planned execution time window, the inspection items and inspection cycle information are transmitted to the patient's mobile intelligent terminal.
- the follow-up plan generating module generates the patient's current follow-up plan, which comprises: extracting the check item of the scheduled follow-up plan from the daily follow-up plan, and grouping the check items of the scheduled follow-up plan according to the planned date, and The combination of test items with a planned date close to the current date is used as the initial follow-up plan; the equivalent follow-up items in the daily follow-up plan in the initial follow-up plan and the initial follow-up plan are removed, and the patient's follow-up plan is generated.
- the medical order monitoring module compares the inspection item of the current follow-up plan with the inspection item transmitted by the medical order system platform to determine the unplanned inspection item and the planned inspection item of the patient, and specifically includes: extracting the inspection transmitted by the medical order system platform from the medical order Project; determine whether there is a transmitted inspection item in this follow-up plan; if there is no transmitted inspection item in this follow-up plan, it is determined that the transmitted inspection item is the patient's unplanned examination item; if there is a transmission in this follow-up plan The inspection item determines that the transmitted inspection item is the patient's planned inspection item.
- the invention also relates to a chronic disease management method based on a health check and integrated machine, which is applied to a cloud server, which is connected with a medical system platform and a self-service health check-in machine installed in a community medical institution, and the method includes the following Step: Read the daily follow-up plan set by the doctor for the patient from the storage unit of the chronic disease management server, and import the inspection items of the daily follow-up plan into the medical order system platform; look up the inspection items and corresponding items of the daily follow-up plan in the medical order system platform The planned date, and the planned date is close to the current date of the test item combination and the patient's follow-up plan is generated; whether the doctor's order system platform transmits the doctor's order; when the doctor's system platform transmits the doctor's order, compare the check item and the doctor's plan of the follow-up plan
- the inspection items transmitted by the system platform determine the patient's unplanned inspection project and the planned inspection project; the patient's unplanned inspection project and the planned inspection project are sent to the
- the health check-integrator-based chronic disease management method further comprises the step of: receiving, from the doctor workstation, the inspection item and the examination period information adjusted by the doctor according to the examination result and the execution effect of the patient.
- the step of periodically transmitting the adjusted inspection item and the inspection period information to the patient's mobile intelligent terminal comprises the steps of: transmitting the patient's examination result and the execution result to the doctor workstation for the doctor to adjust the patient's examination item and inspection Cycle; when receiving the adjusted inspection items and inspection cycle information from the doctor workstation, generate a chronic disease management service schedule and put the adjusted inspection items and inspection cycle information into the chronic disease management service plan; The inspection list and the inspection cycle of the patient are scanned in the plan list, and when the inspection cycle enters the planned execution time window, the inspection item and the inspection cycle information are transmitted to the patient's mobile intelligent terminal.
- the step of combining the inspection items with the planned date close to the current date and generating the patient's current follow-up plan includes the following steps: extracting the inspection item that should be followed up from the daily follow-up plan, and the current follow-up plan
- the inspection items are grouped according to the planned date, and the combination of the test items whose planned date is close to the current date is used as the initial follow-up plan; the equivalent follow-up items in the daily follow-up plan and the initial follow-up plan in the initial follow-up plan are removed, and the patient is generated. This follow-up plan.
- the step of comparing the inspection item of the current follow-up plan with the inspection item transmitted by the medical order system platform to determine the patient's unplanned inspection item and the planned inspection item includes the following steps: extracting the inspection transmitted by the medical order system platform from the medical order Project; determine whether there is a transmitted inspection item in this follow-up plan; if there is no transmitted inspection item in this follow-up plan, it is determined that the transmitted inspection item is the patient's unplanned examination item; if there is a transmission in this follow-up plan The inspection item determines that the transmitted inspection item is the patient's planned inspection item.
- the health care integrated machine-based chronic disease management system and method can automatically obtain the inspection items in the follow-up plan formulated by the doctor for the patient and send it to the patient's intelligent terminal periodically, thereby realizing
- the patient is monitored during the rehabilitation or observation period after the hospital is diagnosed and treated, and the implementation status of the follow-up plan is kept in time to avoid the patient's condition delay; in addition, the doctor can check the patient's examination according to the patient's examination result and execution effect. And the inspection cycle is adjusted, and timely monitoring is provided to the patient to perform a physical examination in time to improve the health management of the patient.
- FIG. 1 is a schematic diagram of an application environment of a preferred embodiment of a chronic disease management system based on a health check-integrator of the present invention
- FIG. 2 is a functional block diagram of a chronic disease management system based on a health check-up integrated machine of the present invention
- FIG. 3 is a flow chart of a preferred embodiment of a chronic disease management method based on the health check-integrator of the present invention.
- Fig. 1 is a schematic diagram of an application environment of a preferred embodiment of a chronic disease management system based on a health check-integrator in accordance with the present invention.
- the health check-integrator-based chronic disease management system 10 operates in the chronic disease management server 1, and the chronic disease management server 1 establishes a communication connection with the medical order system platform 2 through the communication network 4, and passes The communication network 4 establishes a communication connection with one or more self-service health check-in machines 3.
- the chronic disease management server 1 is a chronic disease management server installed in a smart medical institution, and the medical order system platform 2 is provided in a server or a computer in a smart medical institution.
- the chronic disease management server 1 includes, but is not limited to, a chronic disease management system 10 based on a health check-integrator, a communication unit 11, a processing unit 12, and a storage unit 13.
- the communication unit 11 is a wired communication interface or a wireless communication interface, for example, a communication interface supporting communication technologies such as GSM, GPRS, WCDMA, CDMA, TD-SCDMA, WiMAX, TD-LTE, and FDD-LTE.
- the processing unit 12 may be a central processing unit (CPU), a microcontroller (MCU), a data processing chip, or an information processing unit having a data processing function.
- the storage unit 13 can be a read only memory (ROM), an electrically erasable memory (EEPROM), a flash memory (FLASH), or a solid state hard disk.
- the chronic disease management server 1 can perform statistical analysis on the detection result of the patient, realize the requirement for effective management, evaluation and follow-up of chronic disease, and timely issue a monitoring reminder to the patient to avoid the patient's condition delay.
- the medical order system platform 2 is provided with a medical order system for doctors to open a doctor's prescription, and the doctor can open a medical order, check medical orders, and the like.
- the doctor can open the patient's chronic disease follow-up plan at the moment, select the required test items, and import it into the medical order system platform 2, saving The doctor manually prescribed the time of the doctor.
- the doctor's system platform 2 automatically matches the actual inspection items and the follow-up plan check items.
- the doctors choose different reasons, such as the patient's rejection and detection.
- the self-service health check-in machine 3 is installed in a residential community medical institution, such as a community medical service center or a "healthy house" set in a community medical service center.
- the self-service health check-in machine 3 includes, but is not limited to, an ID card reader, a medical human body scale, an infrared height detector, a body composition analyzer, an ultrasonic bone density measuring instrument, and a blood pressure measuring instrument. , intelligent blood glucose meter, cardiovascular function measuring instrument, electrocardiogram detector, blood oxygen detector, electronic vision measuring instrument, TCM body quality detector, printer and display screen.
- the chronically ill patients are in the rehabilitation period or observation period after the hospital treatment, and can go to the community health service center of the nearest community medical service center for daily physical examination.
- the self-service health check-up machine 3 automatically uploads the examination results to the chronic disease.
- the management server 1 facilitates the chronic disease manager or the doctor to grasp the physical condition of the patient in real time, so as to timely grasp the execution status of the chronic disease management follow-up plan, avoiding the long-term travel between the patient and the hospital, and the patient improves the convenience of the patient. .
- the communication network 4 can be a wired communication network or a wireless communication network.
- the communication network 4 may be a wireless communication network, including but not limited to a GSM network, a GPRS network, a CDMA network, a TD-SCDMA network, a TD-LTE network, an FDD-LTE network, and the like.
- the communication network 4 can also be a wired communication network, such as an Internet network and a TCP/IP protocol network.
- the medical order system platform 2 is connected to one or more doctor workstations 5 via a communication network 4, and the doctor workstation 5 can be a personal computer or a laptop computer, etc., and the doctor can open a doctor's workstation 5 or adjust a chronic disease management program.
- the mobile intelligent terminal 6 of the patient includes a smartphone, a PDA device, a notebook computer or other communication device carried by the patient, and can receive and display the chronic disease management related information issued by the chronic disease management server 1.
- Fig. 2 is a block diagram showing a preferred embodiment of the chronic disease management system based on the health check integrated machine of the present invention.
- the health check-integrator-based chronic disease management system 10 includes, but is not limited to, a follow-up plan generation module 101, a medical order monitoring module 102, a chronic disease tracking module 103, a chronic disease assessment module 104, and a slow Disease management module 105.
- the module referred to in the present invention refers to a series of computer program instruction segments that can be executed by the processing unit 12 of the cloud server 1 and that can perform fixed functions, which are stored in the storage unit 13 of the cloud server 1.
- the follow-up plan generation module 101 is configured to read the daily follow-up plan formulated by the doctor for the patient from the storage unit 13 of the chronic disease management server 1, and import the check-up item of the daily follow-up plan into the medical order system platform 2.
- the storage unit 13 of the chronic disease management server 1 stores a follow-up plan for a plurality of patients, wherein the daily follow-up plan of each patient includes the patient's examination item and the planned date.
- the daily follow-up plan for each patient is generated based on the doctor's treatment plan and stored in the storage unit 13 of the chronic disease management server 1.
- the treatment plan includes: examination plan, treatment plan and rehabilitation plan.
- the inspection plan includes information such as inspection project code, inspection project name, and cycle.
- the daily follow-up plan is automatically generated through the cycle.
- each routine follow-up plan can be manually changed by a doctor and requires a standardized diagnosis, treatment, and rehabilitation program that meets the patient's own condition.
- the process of the follow-up plan generation module 101 introducing the daily follow-up plan check item into the order system platform 2 is as follows: selecting the check item in the follow-up plan, and then coding the selected item, the project name and the patient card number into the middle of the order system platform 2 In the table.
- the medical order system platform 2 checks the item data through the patient code extraction intermediate table, and deletes the examination item data of the patient in the intermediate table.
- the follow-up plan generation module 101 is further configured to look up the inspection items of the daily follow-up plan and the corresponding planned dates in the medical order system platform 2, and combine the planned items whose planned dates are close to the current date and generate the current follow-up plan of the patient.
- the follow-up plan generation module 101 extracts the inspection items that should be followed up from the daily follow-up plan, and groups the inspection items that should be followed up according to the planned date, and sets the planned date close to the current date. Combine as an initial follow-up plan.
- the follow-up plan generation module 101 performs data processing on the check items of the initial follow-up plan, including: removing the equivalent follow-up items in the daily follow-up plan in the initial follow-up plan and the check items in the initial follow-up plan, and generating the patient's current follow-up plan. .
- the medical order monitoring module 102 is configured to monitor whether the medical order system platform 2 transmits the medical order.
- the inspection item transmitted by the current follow-up plan and the inspection item transmitted by the medical order system platform 2 are compared to determine the unplanned examination of the patient. Project and planned inspection projects.
- the doctor can open the medical order through the doctor workstation 5, and send the medical order to the chronic disease health management server 1 through the medical order system platform 2.
- the medical order monitoring module 102 compares the inspection items of the follow-up plan with the inspection items transmitted by the medical system platform 2, and includes the following steps: extracting the inspection items transmitted by the medical order system platform 2 from the medical order; determining whether there is a transmission in the follow-up plan.
- the chronic disease tracking module 103 is configured to send the patient's unplanned examination item and the planned examination item to the mobile intelligent terminal 6 of the patient to notify the patient to the self-service health check-in machine 3 of the community hospital to perform the item inspection.
- the chronic disease tracking module 103 automatically sends a message to the patient 7 days in advance according to the current follow-up plan, and reminds the patient to check in the nearest community hospital.
- Patients can go to the nearest community hospital to use the self-service health check-in machine 3 set up in the community hospital or with the help of a community doctor to check according to the unplanned inspection items and planned inspection items, for example, blood pressure measurement, blood oxygenation Inspection of blood test, blood glucose test, BMI value measurement, body composition measurement, cardiovascular function test, electrocardiogram test, and Chinese medicine psychological test.
- unplanned inspection items and planned inspection items for example, blood pressure measurement, blood oxygenation Inspection of blood test, blood glucose test, BMI value measurement, body composition measurement, cardiovascular function test, electrocardiogram test, and Chinese medicine psychological test.
- the patient places the resident second-generation provincial card in the photoelectric sensing area of the self-service health check-in machine 3 ID card reader, and the ID card reader can read the identity information stored on the patient's second-generation ID card magnetic strip, including Information such as name, age, date of birth, and address of residence can be read directly, saving the time for the patient to enter personally identifiable information, and the incorrect entry of personally identifiable information due to input errors during entry.
- the self-service health check-in machine 3 can automatically upload the inspection result corresponding to the inspection item and the identity information of the patient to the chronic disease management server 1 via the communication network 4.
- the chronic disease assessment module 104 is configured to perform statistical analysis on the test result when the patient's test result is received from the self-service health check-integrator 3 to evaluate the doctor's execution effect on the patient's chronic disease management, thereby allowing the doctor to adjust slowly. Treatment management and rehabilitation programs for disease management.
- the chronic disease assessment module 104 compares the test results of each test item (for example, blood pressure measurement) with the historical results, and uses statistical analysis charts to calculate historical trends, thereby reflecting the chronic disease patients in the hospital. The therapeutic effect during the recovery period or observation period after treatment.
- the statistical analysis chart may be a histogram, a pie chart, a line chart or a graph.
- the invention timely grasps the execution status of the chronic disease management follow-up plan through the chronic disease assessment module 104, realizes the requirement for effective management, evaluation and follow-up of chronic disease, and timely sends a monitoring reminder to the patient to avoid the patient's condition delay, thereby improving The effect of management on chronically ill patients.
- the chronic disease management module 105 is configured to receive, from the doctor workstation 5, the inspection item and the inspection period information adjusted by the doctor according to the examination result and the execution effect of the patient, and periodically transmit the adjusted inspection item and the inspection period information to the patient's movement. Intelligent terminal 6.
- the chronic disease management module transmits the examination result and the execution result of the patient to the doctor workstation 5 for the doctor to adjust the examination item and the examination period of the patient, and when the adjusted inspection item and the examination period information are received from the doctor workstation, Generate a chronic disease management service plan sheet and put the adjusted inspection items and inspection cycle information into the chronic disease management service plan table, periodically scan the patient's inspection items and inspection cycles in the service plan list, and when the inspection cycle enters the planned execution time At the time of the window, the inspection item and the examination period information are transmitted to the patient's mobile intelligent terminal 6 to supervise the patient's subsequent implementation of the chronic disease management.
- the chronic disease management service plan table is stored in the storage unit 13 of the chronic disease management server 1 so as to be able to call up the patient's chronic disease management service at any time.
- FIG. 3 there is shown a flow chart of a preferred embodiment of the chronic disease management method based on the health check-integrator of the present invention.
- the health care integrated machine-based chronic disease management method is applied to the chronic disease management server 1, and as shown in FIG. 1 and FIG. 2, the method includes the following steps S31 to S39.
- step S31 the daily follow-up plan prepared by the doctor for the patient is read from the chronic disease management server 1, and the inspection item of the daily follow-up plan is imported into the medical order system platform 2.
- the follow-up plan generation module 101 reads the daily follow-up plan formulated by the doctor for the patient from the storage unit 13 of the chronic disease management server 1, and imports the check-up item of the daily follow-up plan into the medical order system platform 2.
- the storage unit 13 of the chronic disease management server 1 stores a follow-up plan for a plurality of patients, wherein the daily follow-up plan of each patient includes the patient's examination item and the planned date. The daily follow-up plan for each patient is generated based on the doctor's treatment plan.
- the treatment plan includes: examination plan, treatment plan and rehabilitation plan.
- the inspection plan includes information such as inspection project code, inspection project name, and cycle.
- the daily follow-up plan is automatically generated through the cycle. It should be noted that each routine follow-up plan can be manually changed by a doctor and requires a standardized diagnosis, treatment, and rehabilitation program that meets the patient's own condition.
- the step of introducing the inspection item of the daily follow-up plan into the medical system platform comprises the following steps: selecting the inspection item in the follow-up plan, and then coding the selected item, the project name and the patient card number into the medical system platform.
- the medical order system platform 2 checks the item data through the patient code extraction intermediate table, and deletes the examination item data of the patient in the intermediate table.
- step S32 the inspection item of the daily follow-up plan and the corresponding planned date are searched in the medical system platform 2, and the inspection item combination whose planned date is close to the current date is generated and the patient's current follow-up plan is generated.
- the follow-up plan generation module 101 searches the medical order system platform 2 for the inspection items of the daily follow-up plan and the corresponding plan dates, and combines the planned items whose planned dates are close to the current date and generates the current follow-up plan of the patient.
- the follow-up plan generation module 101 extracts the inspection items that should be followed up from the daily follow-up plan, and groups the inspection items that should be followed up according to the planned date, and sets the planned date close to the current date. Combine as an initial follow-up plan.
- the follow-up plan generation module 101 performs data processing on the check items of the initial follow-up plan, including: removing the equivalent follow-up items in the daily follow-up plan in the initial follow-up plan and the check items in the initial follow-up plan, and generating the patient's current follow-up plan. .
- step S33 it is determined whether the medical order system platform 2 transmits the medical order.
- the medical order monitoring module 102 monitors whether the medical order system platform 2 transmits the medical order, if the medical order system platform 2 transmits the medical order, the process proceeds to step S34; if the medical order system platform 2 does not transmit the medical order, the process repeats the step S3 to guide the medical order system platform 2 to transfer the medical order .
- the doctor can open the medical order through the doctor workstation 5, and send the medical order to the chronic disease health management server 1 through the medical order system platform 2.
- Step S34 comparing the inspection item of the current follow-up plan with the inspection item transmitted by the medical order system platform 2 to determine the unplanned inspection item and the planned inspection item of the patient; specifically, when the medical order system platform 2 transmits the medical order, the medical order monitoring module 102 Compare the inspection items of this follow-up plan with the inspection items transmitted by the medical order system platform 2 to determine the patient's unplanned inspection items and planned inspection items.
- the medical order monitoring module 102 compares the inspection items of the follow-up plan with the inspection items transmitted by the medical system platform 2, and includes the following steps: extracting the inspection items transmitted by the medical order system platform 2 from the medical order; determining whether there is a transmission in the follow-up plan.
- Step S35 the mobile intelligent terminal 6 that sends the patient's unplanned check item and the planned check item to the patient notifies the patient to the self-service health check-in machine 3 of the community hospital to perform the item check; specifically, the chronic disease tracking module 103 takes the patient The unplanned inspection item and the planned inspection item are sent to the patient's mobile intelligent terminal to notify the patient to the self-service health check-in machine 3 of the community hospital to perform the item inspection.
- the chronic disease tracking module 103 automatically sends a message to the patient 7 days in advance according to the current follow-up plan, and reminds the patient to check in the nearest community hospital.
- Patients can go to the nearest community hospital to use the self-service health check-in machine 3 set up in the community hospital or with the help of a community doctor to check according to the unplanned inspection items and planned inspection items, for example, blood pressure measurement, blood oxygenation Inspection of blood test, blood glucose test, BMI value measurement, body composition measurement, cardiovascular function test, electrocardiogram test, and Chinese medicine psychological test.
- the self-service health check-in machine 3 can automatically upload the inspection result corresponding to the inspection item and the identity information of the patient to the chronic disease management server 1 via the communication network 4.
- Step S36 when receiving the examination result of the patient from the self-service health check-integrator 3, performing statistical analysis on the inspection result to evaluate the execution effect of the doctor on the patient's chronic disease management; specifically, when from the self-service health check-up machine 3
- the chronic disease assessment module 104 performs a statistical analysis on the examination result to evaluate the doctor's execution effect on the patient's chronic disease management, thereby allowing the doctor to adjust the treatment plan and rehabilitation program of the chronic disease management.
- the chronic disease assessment module 104 compares the test results of each test item (eg, blood pressure measurement) with historical results, and uses statistical analysis charts (eg, histograms, pie charts, line drawings, or curves).
- Charts, etc. statistical trends, reflecting the treatment effect of chronically ill patients in the rehabilitation or observation period after hospital treatment, and timely grasp the implementation status of the chronic disease management follow-up plan, to achieve effective management, assessment and tracking of chronic diseases follow-up needs, and timely monitoring and reminding patients to avoid patient delays.
- Step S37 the chronic disease management module 105 sends the examination result and the execution effect of the patient to the doctor workstation 5 for the doctor to adjust the examination item and the examination period of the patient; in the embodiment, the doctor analyzes the patient's acceptance of the chronic disease management service through the doctor workstation 5. Since then, this task has examined the status and trends of the project and found the extent and relevance of the previous chronic disease management services to the patient's health status. Based on the analysis results, the inspection items and inspection cycles in the chronic disease management service are adjusted, and a new health management plan is established, including health management objectives, dietary prescriptions, exercise prescriptions, medication recommendations, and psychological adjustment programs.
- Step S38 when the chronic disease management module 105 receives the adjusted inspection item and the inspection cycle information from the doctor workstation, generates a chronic disease management service plan table and puts the adjusted inspection item and the inspection cycle information into the chronic disease management service plan table.
- the chronic disease management service plan table is stored in the storage unit 13 of the chronic disease management server 1 so as to be able to call up the patient's chronic disease management service at any time.
- the chronic disease management module 105 periodically scans the examination item and the inspection period of the patient in the service plan list, and sends the inspection item and the inspection period information to the mobile intelligent terminal 6 of the patient when the inspection period enters the planned execution time window.
- the chronic disease management module 105 compares the inspection period and the natural time of the chronic disease management service according to the time-driven rule. When the inspection cycle enters the planned execution time window, the inspection item and the inspection cycle information are sent to a short message, an email, etc. The method is pushed to the patient's mobile intelligent terminal 6 to supervise the patient's subsequent implementation of chronic disease management.
- the chronic disease management system and method based on the health check-in machine of the present invention can generate a corresponding daily follow-up plan according to the patient's diagnosis and treatment plan, and introduce it into the medical order system platform, by comparing the inspection items and medical orders of the follow-up plan.
- the inspection items transmitted by the system platform automatically know the inspection items in the follow-up plan formulated by the doctor for the patient, so as to monitor the daily examination and treatment of the patient during the rehabilitation period or observation period after the hospital treatment, and timely grasp the execution status of the follow-up plan.
- the doctor can adjust the patient's examination items and examination cycle according to the patient's examination results and execution results, and timely issue monitoring warnings to the patient to perform physical examination in time to improve patient health management. Effect.
- the health care integrated machine-based chronic disease management system and method can automatically obtain the inspection items in the follow-up plan formulated by the doctor for the patient and send it to the patient's intelligent terminal periodically, thereby realizing
- the patient is monitored during the rehabilitation or observation period after the hospital is diagnosed and treated, and the implementation status of the follow-up plan is kept in time to avoid the patient's condition delay; in addition, the doctor can check the patient's examination according to the patient's examination result and execution effect. And the inspection cycle is adjusted, and timely monitoring is provided to the patient to perform a physical examination in time to improve the health management of the patient.
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Abstract
一种基于健康检查一体机的慢病管理系统及方法，该方法包括步骤：从慢病管理服务器读取患者的日常随访计划；在医嘱系统平台中查找日常随访计划的检查项目和计划日期，并生成患者的本次随访计划；当医嘱系统平台传送医嘱时，确定患者的计划外检查项目和计划内检查项目并发送至患者的移动智能终端通知患者行项目检查；当从自助式健康检查一体机接收到检查结果时，对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果；将医生调整后的检查项目和检查周期信息定期发送至患者的移动智能终端。该方法能够实现对患者在康复期或观察期间的日常检查进行监控，并可辅助医生适时调整慢病管理方案，提高对慢病患者管理的效果。
Description
本发明涉及慢病管理的技术领域，尤其涉及一种基于健康检查一体机的慢病管理系统及方法。
慢病通常是指高血压、高血脂、糖尿病、精神病等慢性病，慢病的治疗通常持续时间长，患者需要长期住院，或者长期往返于家和医院之间，从而占用了患者大量的时间，给患者造成不便。并且，目前慢性病管理系统针对患者在医院诊疗后处于康复期或观察期间的日常检查项目没有及时监控，即无法自动监管患者是否按照计划完成对患者的日常检查和自我执行慢病管理方案，从而有可能导致患者的病情延误，治疗期限延长，得不到有效的治疗效果，而无法使患者完全得到康复。此外，现有慢性病管理系统不能及时反馈慢病患者管理的执行效果，也没有辅助医生适时调整慢病管理方案，从而导致慢病管理效果较低。
本发明的主要目的在于提供一种基于健康检查一体机的慢病管理系统及方法，旨在解决现有慢性病管理系统不能及时反馈慢病患者管理的执行效果和辅助医生适时调整慢病管理方案的技术问题。
为实现上述目的，本发明提供一种基于健康检查一体机的慢病管理系统，运行于慢病管理服务器中，该慢病管理服务器连接有医嘱系统平台和设置在社区医疗机构的自助式健康检查一体机。所述慢病管理系统包括：随访计划生成模块，用于从慢病管理服务器的存储单元中读取医生为患者制定的日常随访计划，并将日常随访计划的检查项目导入至医嘱系统平台，在医嘱系统平台中查找日常随访计划的检查项目和对应的计划日期，并将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划；医嘱监控模块，用于监控医嘱系统平台是否传送医嘱，当医嘱系统平台传送医嘱时，比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目；慢病跟踪模块，用于将患者的计划外检查项目和计划内检查项目发送至患者的移动智能终端通知患者到就近社区医疗机构的自助式健康检查一体机进行项目检查；慢病评估模块，用于当从自助式健康检查一体机接收到患者的检查结果时，对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果；慢病管理模块，用于从医生工作站接收医生根据患者的检查结果和执行效果调整后的检查项目和检查周期信息，并定期将调整后的检查项目及检查周期信息发送至患者的移动智能终端。
优选的，所述慢病管理模块还用于将患者的检查结果和执行效果发送至医生工作站供医生调整患者的检查项目和检查周期。
优选的，所述慢病管理模块还用于当从医生工作站接收到调整后的检查项目和检查周期信息时，生成慢病管理服务计划表并将调整后的检查项目和检查周期信息放入慢病管理服务计划表中，定期在服务计划列表中扫描患者的检查项目和检查周期，当检查周期进入计划执行时间窗口时，将检查项目及检查周期信息发送至患者的移动智能终端。
优选的，所述随访计划生成模块生成患者的本次随访计划具体包括：从日常随访计划中提取本次应该随访计划的检查项目，将本次应该随访计划的检查项目按照计划日期分组，并将计划日期接近当前日期的检测项目组合，作为初始随访计划；去除初始随访计划中的日常随访计划和初始随访计划的检查项目中意义等同的检查项目，生成患者的本次随访计划。
优选的，所述医嘱监控模块比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目具体包括：从医嘱中提取医嘱系统平台传送的检查项目；判断本次随访计划中是否存在传送的检查项目；如果本次随访计划中不存在传送的检查项目，则确定传送的检查项目为患者的计划外检查项目；如果本次随访计划中存在传送的检查项目，则确定传送的检查项目为患者的计划内检查项目。
本发明还一种基于健康检查一体机的慢病管理方法，应用于云服务器中，该慢病管理服务器连接有医嘱系统平台和设置在社区医疗机构的自助式健康检查一体机，该方法包括如下步骤：从慢病管理服务器的存储单元中读取医生为患者制定的日常随访计划，并将日常随访计划的检查项目导入至医嘱系统平台；在医嘱系统平台中查找日常随访计划的检查项目和对应的计划日期，并将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划；监控医嘱系统平台是否传送医嘱；当医嘱系统平台传送医嘱时，比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目；将患者的计划外检查项目和计划内检查项目发送至患者的移动智能终端通知患者到就近社区医疗机构的自助式健康检查一体机进行项目检查；当从自助式健康检查一体机接收到患者的检查结果时，对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果；从医生工作站接收医生根据患者的检查结果和执行效果调整后的检查项目和检查周期信息，并定期将调整后的检查项目及检查周期信息发送至患者的移动智能终端。
优选的，所述基于健康检查一体机的慢病管理方法还包括步骤：从医生工作站接收医生根据患者的检查结果和执行效果调整后的检查项目和检查周期信息。
优选的，所述定期将调整后的检查项目及检查周期信息发送至患者的移动智能终端的步骤包括如下步骤：将患者的检查结果和执行效果发送至医生工作站供医生调整患者的检查项目和检查周期；当从医生工作站接收到调整后的检查项目和检查周期信息时，生成慢病管理服务计划表并将调整后的检查项目和检查周期信息放入慢病管理服务计划表中；定期在服务计划列表中扫描患者的检查项目和检查周期，当检查周期进入计划执行时间窗口时，将检查项目及检查周期信息发送至患者的移动智能终端。
优选的，所述将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划的步骤包括如下步骤：从日常随访计划中提取本次应该随访计划的检查项目，将本次应该随访计划的检查项目按照计划日期分组，并将计划日期接近当前日期的检测项目组合，作为初始随访计划；去除初始随访计划中的日常随访计划和初始随访计划的检查项目中意义等同的检查项目，生成患者的本次随访计划。
优选的，所述比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目的步骤包括如下步骤：从医嘱中提取医嘱系统平台传送的检查项目；判断本次随访计划中是否存在传送的检查项目；如果本次随访计划中不存在传送的检查项目，则确定传送的检查项目为患者的计划外检查项目；如果本次随访计划中存在传送的检查项目，则确定传送的检查项目为患者的计划内检查项目。
相较于现有技术，本发明所述基于健康检查一体机的慢病管理系统及方法，能够自动获知医生为患者制定的随访计划中的检查项目并定时发送至患者的智能终端，从而实现对患者在医院诊疗后处于康复期或观察期间的日常检查和治疗进行监控，及时掌握随访计划的执行状况，避免患者的病情延误；此外，医生可以根据患者的检查结果和执行效果对患者的检查项目和检查周期进行调整，并适时向患者发出监控提醒及时执行进行身体检查，从而提高对患者健康管理的效果。
图1是本发明基于健康检查一体机的慢病管理系统优选实施例的应用环境示意图；
图2为本发明基于健康检查一体机的慢病管理系统的功能模块图；
图3是本发明基于健康检查一体机的慢病管理方法优选实施例的流程图。
本发明目的的实现、功能特点及优点将结合实施例，参照附图做进一步说明。
为更进一步阐述本发明为达成预定发明目的所采取的技术手段及功效，以下结合附图及较佳实施例，对本发明的具体实施方式、结构、特征及其功效，详细说明如下。应当理解，此处所描述的具体实施例仅仅用以解释本发明，并不用于限定本发明。
参照图1所示，图1是本发明基于健康检查一体机的慢病管理系统优选实施例的应用环境示意图。在本实施例中，所述基于健康检查一体机的慢病管理系统10运行于慢病管理服务器1中，所述慢病管理服务器1通过通信网络4与医嘱系统平台2建立通信连接，并通过通信网络4与一台或多台自助式健康检查一体机3建立通信连接。所述慢病管理服务器1是设置在智慧医疗机构中的一台慢病管理服务器，所述医嘱系统平台2设置在智慧医疗机构中的一台服务器或计算机。
所述慢病管理服务器1包括，但不仅限于，基于健康检查一体机的慢病管理系统10、通信单元11、处理单元12及存储单元13。所述通信单元11为一种有线通讯接口或无线通讯接口，例如，支持GSM、GPRS、WCDMA、CDMA、TD-SCDMA、WiMAX、TD-LTE、FDD-LTE等通讯技术的通讯接口。所述的处理单元12可以为一种中央处理器（CPU）、微控制器（MCU）、数据处理芯片、或者具有数据处理功能的信息处理单元。所述存储单元13可以为一种只读存储器（ROM）、电可擦写存储器（EEPROM）、快闪存储器（FLASH）或固体硬盘等。所述慢病管理服务器1可以患者的对检测结果进行统计分析，实现有效进行慢病管理、评估和跟踪随访的需求，并适时向用患者发出监控提醒，避免患者的病情延误。
所述医嘱系统平台2内安装有用于医生为患者开医嘱的医嘱系统，医生可开药品医嘱、检查医嘱等。在医嘱系统平台2中结合本发明的基于健康检查一体机的慢病管理系统10，医生可打开此刻患者的慢病随访计划，勾选需要做的检查项目，导入到医嘱系统平台2中，节省医生手动开具医嘱的时间。当医生传送医嘱后，医嘱系统平台2自动匹配实际开具的检查项目医嘱和随访计划的检查项目，对比出不同，医生选填不同原因，例如，患者拒绝、已检测等原因。
所述自助式健康检查一体机3设置在居民社区医疗机构中，例如社区医疗服务中心或者设置在社区医疗服务中心的“健康小屋”中。在本实施例中，所述自助式健康检查一体机3包括，但不仅限于，身份证读卡器、医用人体秤、红外身高检测仪、人体成份分析仪、超声骨密度测量仪、血压测量仪、智能血糖仪、心血管功能测量仪、心电图检测仪、血氧检测仪、电子视力测量仪、中医体质检测仪、打印机以及显示屏等。慢病患者在医院诊疗后处于康复期或观察期间，可以到就近的社区医疗服务中心的自助式健康检查一体机3进行日常身体检查，自助式健康检查一体机3将检查结果自动上传到慢病管理服务器1便于慢病管理师或医生实时掌握患者的身体状况，从而及时掌握慢病管理随访计划的执行状况，避免了患者长期往返于家和医院之间，而患者提高了患者使用的便利性。
所述通信网络4可以是有线通信网络或无线通信网络。在本实施例中，所述通信网络4可以为无线通信网络，包括但不限于，GSM网络、GPRS网络、CDMA网络、TD-SCDMA网络、TD-LTE网络、FDD-LTE网络等无线传输网络。所述通信网络4也可以有线通信网络，例如Internet网络及TCP/IP协议网络。所述医嘱系统平台2通过通信网络4与一台或多台医生工作站5连接，所述医生工作站5可以为个人计算机或笔记本电脑等，医生可以通过医生工作站5开立医嘱或者调整慢病管理方案。在本实例中，所述患者的移动智能终端6包括患者随身携带的智能手机、PDA设备、笔记本电脑或者其它通信设备，可以接收并显示慢病管理服务器1发出的慢病管理相关信息。
参照图2所示，图2是本发明基于健康检查一体机的慢病管理系统的优选实施例的模块示意图。在本实施例中，所述基于健康检查一体机的慢病管理系统10包括，但不局限于，随访计划生成模块101、医嘱监控模块102、慢病跟踪模块103、慢病评估模块104以及慢病管理模块105。本发明所称的模块是指一种能够被所述云服务器1的处理单元12执行并且能够完成固定功能的一系列计算机程序指令段，其存储在所述云服务器1的存储单元13中。
所述随访计划生成模块101用于从慢病管理服务器1的存储单元13中读取医生为患者制定的日常随访计划，并将日常随访计划的检查项目导入至医嘱系统平台2。在本实施例中，慢病管理服务器1的存储单元13存储有多个患者的随访计划，其中，每个患者的日常随访计划包括患者的检查项目及计划日期。每个患者的日常随访计划是根据医生的诊疗方案生成的，并存储在慢病管理服务器1的存储单元13中。其中诊疗方案包括：检查方案、治疗方案和康复方案。其中的检查方案带有检查项目编码、检查项目名称、周期等信息。根据诊疗方案并结合具体的病历信息，通过周期自动生成日常随访计划。需要说明的是，每项日常随访计划可以由医生进行手动更改，并且需要符合患者自身情况的标准化诊断、治疗、康复方案。随访计划生成模块101将日常随访计划的检查项目导入医嘱系统平台2的过程如下：选择随访计划中的检查项目，然后将已选择的项目编码，项目名称和患者诊疗卡号插入医嘱系统平台2的中间表中。医嘱系统平台2通过患者编码提取中间表检查项目数据，删除中间表中此患者的检查项目数据。
所述随访计划生成模块101还用于在医嘱系统平台2中查找日常随访计划的检查项目和对应的计划日期，并将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划。在本实施例中，随访计划生成模块101从日常随访计划中提取本次应该随访计划的检查项目，将本次应该随访计划的检查项目按照计划日期分组，并将计划日期接近当前日期的检测项目组合，作为初始随访计划。然后，随访计划生成模块101对初始随访计划的检查项目进行数据处理，包括：去除初始随访计划中的日常随访计划和初始随访计划的检查项目中意义等同的检查项目，生成患者的本次随访计划。
所述医嘱监控模块102用于监控医嘱系统平台2是否传送医嘱，当医嘱系统平台2传送医嘱时，比较本次随访计划的检查项目和医嘱系统平台2传送的检查项目来确定患者的计划外检查项目和计划内检查项目。在本实施例中，医生可以通过医生工作站5开立医嘱，并通过医嘱系统平台2将医嘱发送至慢病健康管理服务器1。其中，医嘱监控模块102比较本次随访计划的检查项目和医嘱系统平台2传送的检查项目包括如下步骤：从医嘱中提取医嘱系统平台2传送的检查项目；判断本次随访计划中是否存在传送的检查项目；如果本次随访计划中不存在传送的检查项目，则确定传送的检查项目为患者的计划外检查项目；如果本次随访计划中存在传送的检查项目，则确定传送的检查项目为患者的计划内检查项目。
所述慢病跟踪模块103用于将患者的计划外检查项目和计划内检查项目发送至患者的移动智能终端6通知患者到社区医院的自助式健康检查一体机3进行项目检查。在本实施例中，慢病跟踪模块103自动根据本次随访计划，提前7天向患者发送信息，提醒患者就近的社区医院进行检查。患者可以到就近的社区医院利用设置在社区医院的自助式健康检查一体机3的自行或者在社区医生的帮助下，按照计划外检查项目和计划内检查项目进行检查，例如，血压测量、血氧检测、血糖检测、BMI值测量、体成分测量、心血管功能检查、心电图检测、中医心理测试等检查项目的检查。患者将居民二代省份证放置在自助式健康检查一体机3的身份证读卡器的光电感应区域，身份证读卡器能够读取患者的二代身份证磁条上存储的身份信息，包括姓名、年龄、出生年月日以及居住地址等信息直接读入，可以节省患者录入个人身份信息的时间，以及由于录入时的输入错误造成个人身份信息的录入错误。自助式健康检查一体机3能够将检查项目对应的检查结果以及患者的身份信息通过通信网路4自动上传到慢病管理服务器1。
所述慢病评估模块104用于当从自助式健康检查一体机3接收到患者的检查结果时，对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果，从而供医生调整慢病管理的治疗方案和康复方案。在本实施例中，慢病评估模块104对每一个检查项目（例如测量血压）的检查结果与历史结果进行比对分析，并采用统计分析图表统计出历史趋势，从而反映出慢病患者在医院治疗后处于康复期或观察期间的治疗效果。所述统计分析图表可以为柱状图、饼状图、线条图或者曲线图等。本发明通过慢病评估模块104及时掌握慢病管理随访计划的执行状况，实现有效进行慢病管理、评估和跟踪随访的需求，并适时向用患者发出监控提醒，避免患者的病情延误，从而提高对慢病患者管理的效果。
所述慢病管理模块105用于从医生工作站5接收医生根据患者的检查结果和执行效果调整后的检查项目和检查周期信息，并定期将调整后的检查项目及检查周期信息发送至患者的移动智能终端6。具体地，所述慢病管理模块将患者的检查结果和执行效果发送至医生工作站5供医生调整患者的检查项目和检查周期，当从医生工作站接收到调整后的检查项目和检查周期信息时，生成慢病管理服务计划表并将调整后的检查项目和检查周期信息放入慢病管理服务计划表中，定期在服务计划列表中扫描患者的检查项目和检查周期，当检查周期进入计划执行时间窗口时，以及将检查项目及检查周期信息发送至患者的移动智能终端6，以监督患者后续慢病管理的执行情况。在本实施例中，所述慢病管理服务计划表存储在慢病管理服务器1的存储单元13中，以便能够后续对患者的慢病管理服务随时调出使用。医生通过执行微调慢病管理服务，能够提高对患者健康管理的效果。
参考图3所示，是本发明基于健康检查一体机的慢病管理方法的优选实施例的流程图。在本实施例中，所述基于健康检查一体机的慢病管理方法应用于慢病管理服务器1中，结合图1和图2所示，该方法包括如下步骤S31至步骤S39。
步骤S31，从慢病管理服务器1中读取医生为患者制定的日常随访计划，并将日常随访计划的检查项目导入至医嘱系统平台2。具体地，随访计划生成模块101从慢病管理服务器1的存储单元13中读取医生为患者制定的日常随访计划，并将日常随访计划的检查项目导入至医嘱系统平台2。在本实施例中，慢病管理服务器1的存储单元13存储有多个患者的随访计划，其中，每个患者的日常随访计划包括患者的检查项目及计划日期。每个患者的日常随访计划是根据医生的诊疗方案生成的。其中诊疗方案包括：检查方案、治疗方案和康复方案。其中的检查方案带有检查项目编码、检查项目名称、周期等信息。根据诊疗方案并结合具体的病历信息，通过周期自动生成日常随访计划。需要说明的是，每项日常随访计划可以由医生进行手动更改，并且需要符合患者自身情况的标准化诊断、治疗、康复方案。在步骤S31中，所述将日常随访计划的检查项目导入医嘱系统平台的步骤包括如下步骤：选择随访计划中的检查项目，然后将已选择的项目编码，项目名称和患者诊疗卡号插入医嘱系统平台2的中间表中；医嘱系统平台2通过患者编码提取中间表检查项目数据，删除中间表中此患者的检查项目数据。
步骤S32，在医嘱系统平台2中查找日常随访计划的检查项目和对应的计划日期，并将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划。具体地，随访计划生成模块101在医嘱系统平台2中查找日常随访计划的检查项目和对应的计划日期，并将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划。在本实施例中，随访计划生成模块101从日常随访计划中提取本次应该随访计划的检查项目，将本次应该随访计划的检查项目按照计划日期分组，并将计划日期接近当前日期的检测项目组合，作为初始随访计划。然后，随访计划生成模块101对初始随访计划的检查项目进行数据处理，包括：去除初始随访计划中的日常随访计划和初始随访计划的检查项目中意义等同的检查项目，生成患者的本次随访计划。
步骤S33，判断医嘱系统平台2是否传送医嘱。具体地，医嘱监控模块102监控医嘱系统平台2是否传送医嘱，若医嘱系统平台2传送医嘱，流程执行步骤S34；若医嘱系统平台2没有传送医嘱，流程重复执行步骤S3指导医嘱系统平台2传送医嘱。在本实施例中，医生可以通过医生工作站5开立医嘱，并通过医嘱系统平台2将医嘱发送至慢病健康管理服务器1。
步骤S34，比较本次随访计划的检查项目和医嘱系统平台2传送的检查项目来确定患者的计划外检查项目和计划内检查项目；具体地，当医嘱系统平台2传送医嘱时，医嘱监控模块102比较本次随访计划的检查项目和医嘱系统平台2传送的检查项目来确定患者的计划外检查项目和计划内检查项目。其中，医嘱监控模块102比较本次随访计划的检查项目和医嘱系统平台2传送的检查项目包括如下步骤：从医嘱中提取医嘱系统平台2传送的检查项目；判断本次随访计划中是否存在传送的检查项目；如果本次随访计划中不存在传送的检查项目，则确定传送的检查项目为患者的计划外检查项目；如果本次随访计划中存在传送的检查项目，则确定传送的检查项目为患者的计划内检查项目。
步骤S35，将患者的计划外检查项目和计划内检查项目发送至患者的移动智能终端6通知患者到社区医院的自助式健康检查一体机3进行项目检查；具体地，慢病跟踪模块103将患者的计划外检查项目和计划内检查项目发送至患者的移动智能终端通知患者到社区医院的自助式健康检查一体机3进行项目检查。在本实施例中，慢病跟踪模块103自动根据本次随访计划，提前7天向患者发送信息，提醒患者就近的社区医院进行检查。患者可以到就近的社区医院利用设置在社区医院的自助式健康检查一体机3的自行或者在社区医生的帮助下，按照计划外检查项目和计划内检查项目进行检查，例如，血压测量、血氧检测、血糖检测、BMI值测量、体成分测量、心血管功能检查、心电图检测、中医心理测试等检查项目的检查。自助式健康检查一体机3能够将检查项目对应的检查结果以及患者的身份信息通过通信网路4自动上传到慢病管理服务器1。
步骤S36，当从自助式健康检查一体机3接收到患者的检查结果时，对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果；具体地，当从自助式健康检查一体机3接收到患者的检查结果时，慢病评估模块104对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果，从而供医生调整慢病管理的治疗方案和康复方案。在本实施例中，慢病评估模块104对每一个检查项目（例如测量血压）的检查结果与历史结果进行比对分析，并采用统计分析图表（例如柱状图、饼状图、线条图或曲线图等）统计出历史趋势，从而反映出慢病患者在医院治疗后处于康复期或观察期间的治疗效果，并及时掌握慢病管理随访计划的执行状况，实现有效进行慢病管理、评估和跟踪随访的需求，并适时向用患者发出监控提醒，避免患者的病情延误。
步骤S37，慢病管理模块105将患者的检查结果和执行效果发送至医生工作站5供医生调整患者的检查项目和检查周期；在本实施例中，医生通过医生工作站5分析患者接受慢病管理服务以来，本次任务有关检查项目的状态和变化趋势，发现既往慢病管理服务对患者健康状况的影响程度和关联性。根据分析结果，调整慢病管理服务中的检查项目和检查周期，并建立新的健康管理方案，包括健康管理目标、膳食处方、运动处方、用药建议及心理调整方案等。
步骤S38，慢病管理模块105从医生工作站接收调整后的检查项目和检查周期信息时，生成慢病管理服务计划表并将调整后的检查项目和检查周期信息放入慢病管理服务计划表中；在本实施例中，该慢病管理服务计划表存储在慢病管理服务器1的存储单元13中，以便能够后续对患者的慢病管理服务随时调出使用。医生通过执行微调慢病管理服务，能够提高对患者健康管理的效果。
步骤S39，慢病管理模块105定期在服务计划列表中扫描患者的检查项目和检查周期，当检查周期进入计划执行时间窗口时，将检查项目及检查周期信息发送至患者的移动智能终端6。在本实施例中，慢病管理模块105按照时间驱动的规则比较慢病管理服务的检查周期和自然时间，当检查周期进入计划执行时间窗口时，将检查项目及检查周期信息以短信、邮件等方式推送至患者的移动智能终端6，以监督患者后续慢病管理的执行情况。
本发明所述基于健康检查一体机的慢病管理系统及方法能能够根据患者的诊疗方案生成对应的日常随访计划，并将其导入至医嘱系统平台，通过比较本次随访计划的检查项目和医嘱系统平台传送的检查项目，自动获知医生为患者制定的随访计划中的检查项目，从而实现对患者在医院诊疗后处于康复期或观察期间的日常检查和治疗进行监控，及时掌握随访计划的执行状况，避免患者的病情延误；此外，医生可以根据患者的检查结果和执行效果对患者的检查项目和检查周期进行调整，并适时向用患者发出监控提醒及时执行进行身体检查，从而提高对患者健康管理的效果。
本领域技术人员可以理解，上述实施方式中各种方法的全部或部分步骤可以通过相关程序指令完成，该程序可以存储于计算机可读存储介质中，存储介质可以包括：只读存储器、随机存储器、磁盘或光盘等。
以上仅为本发明的优选实施例，并非因此限制本发明的专利范围，凡是利用本发明说明书及附图内容所作的等效结构或等效流程变换，或直接或间接运用在其他相关的技术领域，均同理包括在本发明的专利保护范围内。
相较于现有技术，本发明所述基于健康检查一体机的慢病管理系统及方法，能够自动获知医生为患者制定的随访计划中的检查项目并定时发送至患者的智能终端，从而实现对患者在医院诊疗后处于康复期或观察期间的日常检查和治疗进行监控，及时掌握随访计划的执行状况，避免患者的病情延误；此外，医生可以根据患者的检查结果和执行效果对患者的检查项目和检查周期进行调整，并适时向患者发出监控提醒及时执行进行身体检查，从而提高对患者健康管理的效果。
Claims (10)
- 一种基于健康检查一体机的慢病管理系统，运行于慢病管理服务器中，该慢病管理服务器连接有医嘱系统平台和设置在社区医疗机构的自助式健康检查一体机，其特征在于，所述慢病管理系统包括：随访计划生成模块，用于从慢病管理服务器的存储单元中读取医生为患者制定的日常随访计划，并将日常随访计划的检查项目导入至医嘱系统平台，在医嘱系统平台中查找日常随访计划的检查项目和对应的计划日期，并将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划；医嘱监控模块，用于监控医嘱系统平台是否传送医嘱，当医嘱系统平台传送医嘱时，比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目；慢病跟踪模块，用于将患者的计划外检查项目和计划内检查项目发送至患者的移动智能终端通知患者到就近社区医疗机构的自助式健康检查一体机进行项目检查；慢病评估模块，用于当从自助式健康检查一体机接收到患者的检查结果时，对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果；慢病管理模块，用于从医生工作站接收医生根据患者的检查结果和执行效果调整后的检查项目和检查周期信息，并定期将调整后的检查项目及检查周期信息发送至患者的移动智能终端。
- 如权利要求1所述的基于健康检查一体机的慢病管理系统，其特征在于，所述慢病管理模块还用于将患者的检查结果和执行效果发送至医生工作站供医生调整患者的检查项目和检查周期。
- 如权利要求2所述的基于健康检查一体机的慢病管理系统，其特征在于，所述慢病管理模块还用于当从医生工作站接收到调整后的检查项目和检查周期信息时，生成慢病管理服务计划表并将调整后的检查项目和检查周期信息放入慢病管理服务计划表中，定期在服务计划列表中扫描患者的检查项目和检查周期，当检查周期进入计划执行时间窗口时，将检查项目及检查周期信息发送至患者的移动智能终端。
- 如权利要求1所述的基于健康检查一体机的慢病管理系统，其特征在于，所述随访计划生成模块生成患者的本次随访计划具体包括：从日常随访计划中提取本次应该随访计划的检查项目，将本次应该随访计划的检查项目按照计划日期分组，并将计划日期接近当前日期的检测项目组合，作为初始随访计划；去除初始随访计划中的日常随访计划和初始随访计划的检查项目中意义等同的检查项目，生成患者的本次随访计划。
- 如权利要求1所述的基于健康检查一体机的慢病管理系统，其特征在于，所述医嘱监控模块比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目具体包括：从医嘱中提取医嘱系统平台传送的检查项目；判断本次随访计划中是否存在传送的检查项目；如果本次随访计划中不存在传送的检查项目，则确定传送的检查项目为患者的计划外检查项目；如果本次随访计划中存在传送的检查项目，则确定传送的检查项目为患者的计划内检查项目。
- 一种基于健康检查一体机的慢病管理方法，应用于云服务器中，该慢病管理服务器连接有医嘱系统平台和设置在社区医疗机构的自助式健康检查一体机，其特征在于，该方法包括如下步骤：从慢病管理服务器的存储单元中读取医生为患者制定的日常随访计划，并将日常随访计划的检查项目导入至医嘱系统平台；在医嘱系统平台中查找日常随访计划的检查项目和对应的计划日期，并将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划；监控医嘱系统平台是否传送医嘱；当医嘱系统平台传送医嘱时，比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目；将患者的计划外检查项目和计划内检查项目发送至患者的移动智能终端通知患者到就近社区医疗机构的自助式健康检查一体机进行项目检查；当从自助式健康检查一体机接收到患者的检查结果时，对检查结果进行统计分析以评估医生对患者的慢病管理的执行效果；从医生工作站接收医生根据患者的检查结果和执行效果调整后的检查项目和检查周期信息，并定期将调整后的检查项目及检查周期信息发送至患者的移动智能终端。
- 如权利要求6所述的基于健康检查一体机的慢病管理方法，其特征在于，该方法包括步骤：将患者的检查结果和执行效果发送至医生工作站供医生调整患者的检查项目和检查周期。
- 如权利要求7所述的基于健康检查一体机的慢病管理方法，其特征在于，所述定期将调整后的检查项目及检查周期信息发送至患者的移动智能终端的步骤包括如下步骤：当从医生工作站接收到调整后的检查项目和检查周期信息时，生成慢病管理服务计划表并将调整后的检查项目和检查周期信息放入慢病管理服务计划表中；定期在服务计划列表中扫描患者的检查项目和检查周期，当检查周期进入计划执行时间窗口时，将检查项目及检查周期信息发送至患者的移动智能终端。
- 如权利要求6所述的基于健康检查一体机的慢病管理方法，其特征在于，所述将计划日期接近当前日期的检查项目组合并生成患者的本次随访计划的步骤包括如下步骤：从日常随访计划中提取本次应该随访计划的检查项目，将本次应该随访计划的检查项目按照计划日期分组，并将计划日期接近当前日期的检测项目组合，作为初始随访计划；去除初始随访计划中的日常随访计划和初始随访计划的检查项目中意义等同的检查项目，生成患者的本次随访计划。
- 如权利要求6所述的基于健康检查一体机的慢病管理方法，其特征在于，所述比较本次随访计划的检查项目和医嘱系统平台传送的检查项目来确定患者的计划外检查项目和计划内检查项目的步骤包括如下步骤：从医嘱中提取医嘱系统平台传送的检查项目；判断本次随访计划中是否存在传送的检查项目；如果本次随访计划中不存在传送的检查项目，则确定传送的检查项目为患者的计划外检查项目；如果本次随访计划中存在传送的检查项目，则确定传送的检查项目为患者的计划内检查项目。
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