家医随访一体机

　　家医签约随访系统简介

　　Introduction to the Family Medical Contract Follow up System

　　家庭医生签约及慢性病随访系统（简称为家医签约随访系统）是一套基于移动互联网、物联网和人工智能等信息化手段，用以提升家庭医生签约服务的覆盖率及高血压患者健康管理、2型糖尿病患者健康管理等国家基本公共卫生服务项目的智慧化程度与效率的软件系统及配套智能设备。可以自动录入随访对象的基本信息与随访记录，自动采集检查数据，自动对疾病档案、体检数据进行历史校验与质量控制，辅助医务人员完成家庭医生电子签约，一键批量上传家庭医生签约情况、疾病档案、随访记录至公共卫生平台，减少医务人员手写纸质表单与录入信息至电脑的操作，降低工作负荷与人力成本，提高家庭医生签约、慢病随访的工作效率与考核质量，最终实现基层医疗卫生机构公共卫生服务能力的提质增效。

　　The family doctor signing and chronic disease follow-up system (referred to as the family doctor signing and follow-up system) is a set of software systems and supporting intelligent equipment based on mobile Internet, Internet of Things, artificial intelligence and other information means to improve the coverage of family doctor signing services and the intelligence and efficiency of national basic public health service projects such as hypertension patient health management, type 2 diabetes patient health management. It can automatically input the basic information and follow-up records of follow-up objects, collect examination data, perform historical verification and quality control on disease files and physical examination data, assist medical staff in completing electronic family doctor contracts, and upload family doctor contract status, disease files, and follow-up records to the public health platform with one click in bulk, reducing the need for medical staff to manually write paper forms and enter information into computers, reducing workload and labor costs, improving the efficiency and assessment quality of family doctor contract signing and chronic disease follow-up, and ultimately achieving the improvement and efficiency of public health service capabilities in grassroots medical and health institutions.

　　家医签约随访系统包括软件、硬件及运营服务，主要由

　　The home medical contract follow-up system includes software, hardware, and operational services, mainly consisting of

　　软件：家庭医生签约随访系统

　　Software: Family Doctor Contract Follow up System

　　硬件：家庭医生签约及公共卫生随访智能设备（便携式背包，蓝牙耳温计，蓝牙血糖仪，蓝牙血压仪）

　　Hardware: Smart devices for family doctor contract signing and public health follow-up (portable backpack, Bluetooth ear thermometer, Bluetooth blood glucose meter, Bluetooth blood pressure monitor)

　　服务：调研，部署，流程融合及前期陪跑等服务；24小时快速响应服务

　　Services: research, deployment, process integration, and pre run accompanying services; 24-hour rapid response service

　　一、家庭医生签约功能

　　1、 Family doctor signing function

　　01支持家庭医生签约，可上传至公卫平台

　　01 Supports signing contracts with family doctors and can be uploaded to public health platforms

　　02可自由配置服务包内容，家庭医生团队

　　02 Free configuration of service package content, family doctor team

　　03实现电子签约，协议支持打印家庭医生签约功能

　　03 Implementation of electronic signing, protocol supports printing of family doctor signing function

　　二健康档案/慢病专档建立功能

　　Function of establishing health records/chronic disease files

　　01下乡入户支持医生档案新建、更新至公卫平台，可反质控公卫平台档案完整度

　　01 Going to the countryside and entering households supports the creation and update of doctor files to the public health platform, which can reverse the quality control of the integrity of public health platform files

　　02提高区域档案建档率、完整率、动态更新率

　　02 Improve the filing rate, completeness rate, and dynamic update rate of regional archives

　　03强大的搜索功能方便医生高效管理掌握辖区人员档案动态

　　03 Powerful search function facilitates efficient management and mastery of personnel file dynamics in the jurisdiction by doctors

　　三、慢病随访功能

　　3、 Chronic disease follow-up function

　　01支持下乡入户慢病随访，可直接上传至公卫平台

　　01 Support rural and household chronic disease follow-up, which can be directly uploaded to the public health platform

　　02每季度随访日期提醒跟进，便于医生管理，可补录做超时随访

　　02 Quarterly follow-up date reminder for easy management by doctors, and overtime follow-up can be recorded

　　03数据状态缺项、上传状态提醒，通过系统质控提高随访达标率

　　03 Data status missing items, upload status reminder, improve follow-up compliance rate through system quality control

　　04历史数据可与本次随访做校验，减少重复录入工作，提高随访效率

　　04 Historical data can be verified with this follow-up to reduce duplicate input work and improve follow-up efficiency

　　四、慢病随访功能

　　4、 Chronic disease follow-up function

　　支持尿微量白蛋白、大便潜血等POCT检测项目拓展。一可丰富健康体检项目，满足群众更多的健康需求；二则有助于机构贯彻落实国家、地方有关重大慢病的最新政策。

　　Support the expansion of POCT testing projects such as urinary microalbumin and fecal occult blood. One can enrich the health examination items and meet more health needs of the public; Secondly, it helps institutions implement the latest policies on major chronic diseases at the national and local levels.

　　在过去的基本公共卫生服务实践中，因尿微量白蛋白、大便潜血的检测样本为尿液、粪便，往往通过现场采集、运回院内、集中检验的形式。尿液、粪便运输不便的问题制约了早期肾病、消化道恶性肿瘤筛查的普及。通过智慧公卫的POCT服务拓展，可就地检验，几分钟得到结果，极大地提高早期肾病、消化道恶性肿瘤筛查的普及性。

　　In the past practice of basic public health services, due to the fact that the test samples for urinary microalbumin and fecal occult blood were urine and feces, they were often collected on-site, transported back to the hospital, and centrally tested. The problem of inconvenient transportation of urine and feces has hindered the popularization of screening for early kidney disease and gastrointestinal malignancies. By expanding the POCT service of Smart Public Health, on-site testing can be conducted and results can be obtained in a few minutes, greatly improving the popularity of screening for early kidney disease and gastrointestinal malignancies.

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