脑卒中协同服务云平台在医疗联合体中的应用研究

Application of the Cloud-based Collaborative Care Service-delivery Platform in the Regional Medical Consortium for Stroke Patients

医疗联合体(医联体)指在三级医院、二级医院与基层医疗卫生机构间加强联合,使医疗资源能够在联合体内共同分享,其在慢性病的一体化连续性医疗服务中具有明显优势。区域医疗信息化是医联体建设和实现分级诊疗的重要手段。本研究以慢性病中单病种致死、致残率较高的脑卒中为切入点,构建医联体内脑卒中协同服务云平台,对基层医疗卫生机构签约患者进行脑卒中风险评估与分级管理,优化脑卒中急救流程,对出院患者进行康复评估、随访及监测管理,并实现双向转诊、平台监控及调度管理等功能,有助于提高脑卒中专业诊疗服务能力和水平,保证医联体内诊疗的同质化。

The regional medical consortium（ RMC） refers to a association consisting of one or more tertiary hospitals,combined with one or more secondary hospitals and a number of grassroots medical institutions in one region of China,in which the medical services owned by this RMC can be shared by its members. RMC has obvious advantages in delivering integrative and continued care for chronic diseases. Regional medical informatization plays an important role in the construction of RMC and delivery of hierarchical diagnosis and treatment services in the members of RMC. Considering that stroke is a chronic disease with high mortality and disability rate,we constructed a cloud-based collaborative care service-delivery platform and applied it to the RMC to improve the professional capabilities and levels of diagnosis and treatment of stroke and ensure the consistency of qualities of diagnosis and treatment of stroke across the members in the RMC via providing stroke risk assessment and hierarchical management for residents signing a contract with a family doctor from grassroots medical institutions,optimizing the procedure of providing emergency care for stroke, delivering rehabilitation assessment, follow-up and surveillance and management for discharged patients,and offering dual referral,platform-based surveillance,dispatching and management of medical services.