糖尿病线上线下一体化管理平台在互联网应用中的实践

The Practice of the Online and Offline Integrated Management Platform of Diabetes in Internet Application

目的:实现糖尿病患者基于"五驾马车"的院内外一体化管理,实现管理连续性,提升患者健康管理水平。方法:通过管理模式创新以及信息化支撑两个手段,管理模式方面通过建设"糖尿病强化管理站"开展封闭式的"学员"管理,建立患者档案;信息化方面通过智能化糖尿病管理系统、远程协同系统,保障院内外血糖管理的连续性,以及医院-社区-家庭管理模式的开展。结果:在三级医院和社区医院间建立了业务协同平台,实现了糖尿病分级管理,智能化管理系统实现血糖连续监测,充分发挥社区医生资源,从而更科学地控制糖尿病的发病,提升治疗达标率。结论:糖尿病院内外一体化管理模式,符合国家分级诊疗急慢分治要求,可有效地对居民糖尿病慢病进行管理。

Objective: To realize the integrated management of diabetes patients inside and outside the hospital based on "five carriages", realize the continuous management, and improve the level of health management of patients. Methods: By means of management mode innovation and information support, in terms of management mode the closed "student" management is made and patient files are established through the construction of "Intensive Management Station of Diabetes";and in terms of informatization the continuity of blood glucose management inside and outside the hospital is ensured through the intelligent diabetes management system and remote collaborative system, and the hospital-community-family management mode is adopted. Results: A business collaboration platform is established between tertiary hospitals and community hospitals, the hierarchical management of diabetes is realized, the intelligent management system continuously monitors blood glucose, and the advantages of resources of community doctors are given full play to, so as to control the incidence of diabetes more scientifically and improve the compliance rate of treatment. Conclusion: The integrated management mode of diabetes inside and outside the hospital meets the requirements for separate treatment of acute and chronic diseases of national hierarchical diagnosis and treatment, and can effectively manage chronic diabetes of residents.