基于EHR对骨质疏松分级诊疗管理模式的探索与实践

The Exploration and Practice of Hierarchical Diagnosis Mode on the Basis of Electronic Health Record in Osteoporosis Chronic Diseases

目的探讨EHR对骨质疏松分级诊疗管理模式的临床效果。方法以上海市某社区慢性病管理团队为例,依托瑞金-卢湾医联体"全-专门诊"进行分级诊疗,介绍该区域医联体内专科与全科医生团队如何开展区域医联体特色的家庭医生"1+1+1"签约服务,建立个人EHR,通过调阅区、市两级EHR查阅患者区域内就诊信息,对签约骨质疏松患者进行管理,分析管理效果。结果研究对象疼痛症状、身体机能、社会适应能力和精神心理功能较一年前得分均有下降(P<0.05);骨代谢指标β-CTX、PICP、PTH和BGP明显下降(P<0.05),维生素D升高(P<0.001);L1~3、股骨颈、wards三角、大粗隆和total髋的骨密度有提高(P<0.05)。结论 EHR对骨质疏松分级诊疗、实施区域医联体特色的签约服务和建立个人EHR等方案可改善骨质疏松患者生活质量,值得推广。

OBJECTIVE To explore the effect of hierarchical diagnosis mode on the basis of electronic health record in osteoporosis chronic disease. METHODS Taking a chronic disease management team in a community in Shanghai as an example, relying on the"full-specialized diagnosis"of Ruijin-Luwan Medical Association, it introduces how to carry out the family doctors with characteristics of regional medical union"1+1+1"contract service, establishes personal EHR, checks the information of the patients in the patient area through the EHR in the reading area and the city, manages the contracted osteoporosis patients, and analyzes the management effect. RESULTS The scores of subjects’ pain symptom, physical function, social adaptability, mental and psychological function are all decreased compared with 1 year ago(P<0.05);bone metabolism indexes such as β-CTX, PICP, PTH and BGP are significantly decreased(P<0.05), Vitamin D increased(P<0.001);bone density of L1~3, femoral neck, wards triangle, gross trochanter, and total hip increase(P<0.05). CONCLUSION EHR is used for the diagnosis and treatment of osteoporosis. The implementation of the regional medical consortium signature service and the establishment of personal EHR and otEHR programs can improve the quality of life of osteoporosis patients, which are worthy of promotion.