门诊糖尿病患者全程一体化管理信息平台的设计与应用

Design and application of an integrated management information platform for outpatients with diabetes

目的:构建门诊糖尿病患者全程一体化管理信息平台,以有效解决门诊糖尿病患者从医院到家庭的医疗延续需求。方法:按照门诊糖尿病患者就诊路径,以电子病历为基础,自主研发门诊糖尿病患者信息管理平台。观察使用信息平台对糖尿病患者进行一体化管理的效果。结果:实施后患者空腹血糖、餐后2小时血糖、糖化血红蛋白达标率分别从入组前的28.1%、41.4%、18.8%提高到入组后3个月的59.3%、58.7%、46.6%,P值均<0.05;糖尿病健康知识知晓率达到90.9%;胰岛素使用、口服药服用依从性分别从85.4%、95.9%提高到93.6%、98.6%,低血糖发生率从1.7%降低到0.8%,P值均<0.05。结论:基于信息平台的门诊糖尿病患者全程一体化管理能明显提高门诊糖尿病患者血糖和糖化血红蛋白的达标率,提高患者的健康知识知晓率及遵医行为依从性,降低低血糖的发生率。

Objective:To build a whole-process integrated management information platform for outpatients with diabetic,in order to effectively solve the continuous medical needs of outpatients with diabetic from the hospital to the family.Methods:According to the treatment path of outpatients with diabetic,with electronic medical records as the center,an information platform for outpatients with diabetic was developed independently.The effects of the information were observed.Results:Three months after enrollment,the fasting blood sugar,2-hour postprandial blood sugar,and glycated hemoglobin compliance rate of patients increased from 28.1%,41.4%,and 18.8%to 59.3%,58.7%,and 46.6%respectively.The awareness rate of health knowledge reached 90.9%.The compliance of insulin use and oral medication adherence increased from 85.4%and 95.9%to 93.6%and 98.6%respectively.The incidence of hypoglycemia decreased from 1.7%to 0.8%.Conclusion:Based on the information platform,the whole-process integrated management of outpatients with diabetic can significantly improve the rate of compliance of blood glucose and glycosylated hemoglobin in outpatients with diabetes,and improve the awareness rate of patients'health knowledge and compliance behavior,and reduce the incidence of hypoglycemia.