400-618-1171
2016年10月，《“健康中国 2030”规划纲要》发布，明确建立信息共享、互联互通机制，推进慢性病防、治、管整体融合发展，实现医防结合，为基层利用互联网技术手段提高慢病管理效率奠定了基础。
In October 2016, the Outline of the "Healthy China 2030" Plan was released, clearly establishing a mechanism for information sharing and interconnection, promoting the integrated development of chronic disease prevention, treatment and management, and realizing the combination of medical treatment and prevention, laying the foundation for the grassroots to improve the efficiency of chronic disease management by using Internet technology.
随后，国家密集出台了《中国防治慢性病中长期规划（2017—2025 年）》、《关于促进“互联网+医疗健康”发展的意见》、《关于深入开展“互联网+医疗健康”便民惠民活动的通知》、《关于完善“互联网+”医疗服务价格和医保支付政策的指导意见》、《关于深入推进“互联网+医疗健康”“五个一”服务行动的通知》、《“十四五”城乡社区服务体系建设规划》、《“十四五”国民健康规划》、《中共中央关于进一步全面深化改革、推进中国式现代化的决定》等诸多纲领性文件，逐步强调健全基本公共卫生服务、家庭医生签约、信息化平台建设以及利用互联网技术来促进医防融合与慢病管理。（点击查询往期解读：携康数智化时代医防融合的携康探索）
Subsequently, the country intensively issued the Medium and Long term Plan for the Prevention and Control of Chronic Diseases in China (2017-2025), the Opinions on Promoting the Development of "Internet plus Health", the Notice on Deepening the Activities of "Internet plus Health" for the Convenience and Benefit of People, the Guiding Opinions on Improving the "Internet plus" Medical Service Price and Medical Insurance Payment Policy, the Notice on Deepening the "Five Ones" Service Action of "Internet plus Health", the "Fourteenth Five Year Plan" Plan for the Construction of Urban and Rural Community Service System, the "Fourteenth Five Year Plan" National Health Plan, the CPC Central Committee's Decision on Further Deepening Reform and Promoting Chinese path to modernization, and many others The programmatic document gradually emphasizes the improvement of basic public health services, the signing of family doctors Information platform construction and the use of Internet technology to promote the integration of medicine and prevention and chronic disease management. (Click to search for previous interpretation: Exploring the integration of medical and prevention in the era of smart healthcare technology)
基层医疗服务的数字化、医防融合与慢病管理注定是一项长期且艰巨的任务，需政府、社区、医疗机构、企业等多方力量参与。为了让老百姓在家门口获得更高水平的医疗卫生服务，携康凭借多年积累的BT+IT技术及服务经验，创新摸索出了一条怎样的县域医防融合慢病一体化管理思路？未来，基层医防融合、慢病管理还面临什么样的挑战？
The digitization of primary healthcare services, the integration of medical prevention and treatment, and chronic disease management are destined to be a long-term and arduous task that requires the participation of multiple forces such as the government, communities, medical institutions, and enterprises. In order to provide higher level medical and health services for the general public at their doorstep, with years of accumulated BT+IT technology and service experience, what kind of county-level medical prevention and chronic disease integration management concept has been innovatively explored by Liankang? What challenges will the integration of grassroots medical prevention and chronic disease management face in the future?
01慢病患者多、发病率高、管理难度大
01 Many patients with chronic diseases, high incidence rate and difficult management
我国基层医防融合慢病管理道阻且长
The management of chronic diseases in the integration of primary healthcare and prevention in China is hindered and lengthy
随着人口老龄化、居民生产生活方式的不断变化，我国慢性病发病率总体呈上升趋势，慢性病死亡人数占居民总死亡的比例超过80%，而慢性病由于发病率高、病程长、有效控制率低、经济负担重等特点，已经成为威胁群众健康、影响经济社会发展的重大问题[1]。
With the aging of the population and the continuous change of residents' production and lifestyle, the overall incidence rate of chronic diseases in China is on the rise, and the number of deaths from chronic diseases accounts for more than 80% of the total deaths of residents. However, chronic diseases have become a major problem threatening people's health and affecting economic and social development due to their high incidence rate, long duration, low effective control rate, heavy economic burden and other characteristics [1].
预计到2026年，糖尿病、高血压两大慢病的发病率分别逼近14.4%、27.8%[2]，群众慢病负担日益加重，尤其是基层慢病管理已迫在眉睫。
It is estimated that by 2026, the incidence rate of the two major chronic diseases, diabetes and hypertension, will approach 14.4% and 27.8% respectively [2], and the burden of chronic diseases will become increasingly heavier, especially the chronic disease management at the grass-roots level.
今年9月，国家明确基本公共卫生服务经费人均财政补助标准提高至94元，继续用于扩大老年人，高血压、2型糖尿病等慢性病患者。同时，在基本公共卫生服务高血压、糖尿病两种慢性病患者健康服务基础上，加强呼吸道疾病防治，组织开展慢性阻塞性肺疾病患者健康服务[3]。
In September of this year, the state made it clear that the per capita financial subsidy standard for basic public health services was increased to 94 yuan, which will continue to be used to expand the elderly, patients with chronic diseases such as hypertension and type 2 diabetes. At the same time, on the basis of basic public health services for patients with hypertension and diabetes, we will strengthen the prevention and treatment of respiratory diseases and organize health services for patients with chronic obstructive pulmonary disease [3].
当前，我国正处于数字化转型时期，鉴于互联网对医疗健康发展的积极效应，各地纷纷探索“互联网+”慢病管理模式，并取得了一定成效，但由于我国基层人口基数大、慢病患者多、医疗资源分散、服务供给碎片化以及政策割裂等，政策执行陷入困境[4]。
At present, China is in the period of digital transformation. In view of the positive effect of the Internet on medical and health development, all regions have explored the "Internet plus" chronic disease management model, and achieved some results. However, due to the large population base at the grass-roots level in China, many chronic disease patients, decentralized medical resources, fragmented service supply, and policy fragmentation, policy implementation is in trouble [4].
这些痛点将矛头直指如何高效实现不同层级大批量的居民健康数据采集和慢病筛查？如何全面整合与共享分散在不同机构的健康数据？又如何最终实现慢病患者自我管理的依从性和连续性？
These pain points point directly at how to efficiently achieve large-scale collection of residents' health data and chronic disease screening at different levels? How to comprehensively integrate and share health data scattered across different institutions? How to ultimately achieve compliance and continuity in self-management for chronic disease patients?
02构建县、乡、村三级“1+X”慢病共管服务模式
02 Build a "1+X" chronic disease co management service model at the county, township, and village levels
携康县域医防融合慢病一体化管理思路
Integrated management of chronic diseases with the integration of medical prevention and control in Kang County
国外慢病管理平台相关研究早于国内，理论基础、网站评估、推广应用等都已有一定成熟度[5]。在数字化技术快速发展的背景下，智能化软件和设备种类繁多，从应用模式角度，国内外数字化慢病管理应用可分为四类：单一APP模式、“智能硬件+后台算法+APP”模式、一体化平台模式、整合线上与线下资源的O2O（Online to Offline）模式[6]。
The research on chronic disease management platforms abroad predates that in China, and the theoretical foundation, website evaluation, promotion and application have all reached a certain level of maturity. In the context of rapid development of digital technology, there are various types of intelligent software and devices. From the perspective of application modes, digital chronic disease management applications at home and abroad can be divided into four categories: single APP mode, "intelligent hardware+backend algorithm+APP" mode, integrated platform mode, and O2O (Online to Offline) mode that integrates online and offline resources.
携康县域医防融合慢病一体化管理解决方案则创新性地综合上述四种模式的优势，其核心是以实现县域内健康信息数据互联互通，推进基层卫生机构与县域内上级医院资源共享为目标，以全面整合基本公共卫生服务、家庭医生签约服务和医院医疗服务为手段，连通县域内慢病患者医疗处方、检验、影像、公卫服务等数据，实现医疗卫生机构共享一体化健康数据调阅使用功能，最终构建县、乡、村三级“1+X”慢病共管服务模式。
The integrated management solution for chronic diseases in Kangxian County innovatively combines the advantages of the four models mentioned above. Its core is to achieve interconnectivity of health information data within the county, promote resource sharing between grassroots health institutions and higher-level hospitals within the county, and comprehensively integrate basic public health services, family doctor contract services, and hospital medical services. It connects medical prescription, testing, imaging, public health services and other data of chronic disease patients within the county, realizing the integration of health data retrieval and use by medical and health institutions, and ultimately building a "1+X" chronic disease co management service model at the county, township, and village levels.
具体而言，方案在架构设计层面，主要分为六大模块：
Specifically, the solution is divided into six major modules at the architecture design level:
一个慢病管理服务平台，即“1+X”中的1，在县域卫健系统部署携康慢病管理服务平台，统筹区域内诊疗与公共卫生服务、家庭医生签约服务、人口信息数据，创新医防融合平台。
A chronic disease management service platform, also known as 1 in "1+X", will be deployed in the county-level health system to integrate diagnosis and treatment with public health services, family doctor contract services, population information data, and innovate a medical prevention integration platform.
“1+X”中的X，则为以下模块：
The X in "1+X" is the following module:
一个慢病管理中心，即以县域内医共体牵头单位为慢病平台管理主体，负责管理区域内慢病筛查记录、慢病健康卡、慢病评估表、处方笺记录、医护人员绩效考核等。
A chronic disease management center, led by the county-level medical community as the main body of chronic disease platform management, is responsible for managing chronic disease screening records, chronic disease health cards, chronic disease assessment forms, prescription records, medical staff performance evaluations, etc. within the region.
一个慢病诊疗中心，即以县域内医联体牵头医院为慢病诊疗中心，提供远程影像、远程心电、卒中中心、双向转诊、远程视频会诊等服务。
A chronic disease diagnosis and treatment center, led by a medical consortium within the county, provides services such as remote imaging, remote electrocardiogram, stroke center, two-way referral, and remote video consultation.
多个慢病管理分中心，即以县域内基层医院、乡镇卫生院、社康服务中心为慢病管理分中心，部署携康全科工作站、健康管理一体机、家庭医生工作站、全科移动工作站等，负责辖区慢病筛查、预防、日常慢病管理的执行和监督。
Multiple chronic disease management sub centers, namely grassroots hospitals, township health centers, and social health service centers within the county, deploy comprehensive health workstations, health management all-in-one machines, family doctor workstations, and mobile general health workstations, responsible for the screening, prevention, and daily management of chronic diseases in the jurisdiction.
N个健康监测站，在县域内村卫生室、社区服务站、机关企事业单位设立健康监测站，部署携康智能健康服务包、24小时健康站、健康管理一体机等设备，负责日常慢病筛查及慢病管理执行，特别为区域内失独老人、五保户提供居家检测设备，最终实现三级联动、多点协同。
N health monitoring stations will be set up in village clinics, community service stations, government agencies, enterprises and institutions within the county, deploying smart health service packages, 24-hour health stations, health management integrated machines and other equipment, responsible for daily chronic disease screening and management execution, especially providing home testing equipment for elderly people who have lost their only child and five guarantee households in the region, ultimately achieving three-level linkage and multi-point collaboration.
同时，居民可利用居家检测设备如智能手环、血压仪、血糖仪、肺功能仪等，实时监测体征数据，并通过携康APP和小程序，连接各医院信息系统、家庭医生签约系统、公卫系统，构建医防一体化慢病管理信息平台，全方位、立体式、长程化开展慢病管理服务。
At the same time, residents can use home monitoring devices such as smart wristbands, blood pressure monitors, blood glucose meters, pulmonary function meters, etc. to monitor physical sign data in real time, and connect various hospital information systems, family doctor signing systems, and public health systems through portable health apps and mini programs to build a medical and prevention integrated chronic disease management information platform, providing comprehensive, three-dimensional, and long-term chronic disease management services.
携康在优化基层慢病筛查和分类管理层面，主要思路为建立县、乡、村三级筛查体系，采取门诊35岁以上居民必查血压、血糖的常态化筛查，与公共卫生年度体检集中筛查相结合；确保一次服务即可实现医疗卫生协同服务，提升工作效率的同时实现医卫融合发展。
At the level of optimizing the screening and classification management of chronic diseases at the grassroots level, the main idea of Liankang is to establish a three-level screening system at the county, township, and village levels, adopt regular screening of blood pressure and blood sugar for residents over 35 years old in outpatient clinics, and combine it with centralized screening of public health annual physical examinations; Ensure that one service can achieve collaborative medical and health services, improve work efficiency, and achieve integrated development of medical and health.
在促进慢病分级管理和医疗联动层面，主要思路为以医防融合慢病管理中心为一级管理平台，其他医院及基层医疗机构为分中心；以村医、家庭医生团队为常态监测和随访服务端，结合重点人群的居家可穿戴社保监测相结合，织牢慢病数据监测网，开展多层级管理服务；在医疗联合体内部署远程会诊中心，实现实时会诊、双向转诊的上下联动服务机制；同时，将远程会诊中心的入口延伸至村医、家庭医生团队的智能健康包管理端，充分利用好每一次诊疗、公卫和慢病随访服务，充分发挥好医防融合的便利和效率。
At the level of promoting chronic disease classification management and medical linkage, the main idea is to use the Medical Prevention Integrated Chronic Disease Management Center as the primary management platform, with other hospitals and grassroots medical institutions as sub centers; Using village doctors and family doctor teams as regular monitoring and follow-up services, combined with home wearable social security monitoring for key populations, we will establish a solid chronic disease data monitoring network and provide multi-level management services; Deploy remote consultation centers within the medical consortium to achieve a top-down linkage service mechanism of real-time consultation and two-way referral; At the same time, extending the entrance of the remote consultation center to the intelligent health package management end of village doctors and family doctor teams, fully utilizing every diagnosis and treatment, public health, and chronic disease follow-up service, and fully leveraging the convenience and efficiency of medical prevention integration.
在强化居民慢病自我管理层面，主要思路是在做好早筛、早诊的同时，坚持以预防为主的方针。慢病管理系统以统一宣教内容规划各个宣传点、移动巡诊车大屏、乡镇卫生院宣教大屏，并定期机动巡回宣教；鼓励和引导居民开展全民健康运动，教育引导健康饮食，管理自身的健康行为；培训指导居民使用自助健康一体机自测和家庭健康检测，提高健康管理自我参与率，全面参与慢病防控。
The main idea in strengthening residents' self-management of chronic diseases is to adhere to the principle of prevention as the main approach while conducting early screening and diagnosis. The chronic disease management system plans various propaganda points, mobile inspection vehicle screens, and township health center propaganda screens with unified propaganda content, and regularly conducts mobile touring propaganda; Encourage and guide residents to carry out nationwide health campaigns, educate and guide healthy eating, and manage their own health behaviors; Train and guide residents to use self-service health all-in-one machines for self testing and home health testing, improve their self participation rate in health management, and fully participate in chronic disease prevention and control.
总体而言，携康县域医防融合慢病一体化管理解决方案，以全面筛查、全过程监测为抓手，搭建县域医防融合慢病一体化管理平台，实施早发现、早诊断、早治疗，实现一个系统、一个标准；多医联动、预防为主；自我参与、群防群控；最终构建县、乡、村三级“1+X”慢病共管服务模式。
Overall, with the integration of medical prevention and chronic disease management solutions in Kang County, a county-level integrated management platform for medical prevention and chronic disease will be built with comprehensive screening and full process monitoring as the starting point. Early detection, diagnosis, and treatment will be implemented to achieve one system and one standard; Multi medical collaboration and prevention as the main approach; Self participation, group prevention and control; Ultimately, establish a "1+X" chronic disease co management service model at the county, township, and village levels.
04
04
强化顶层设计、多方联动、辅助诊疗
Strengthen top-level design, multi-party linkage, and auxiliary diagnosis and treatment
为基层提供更便捷、精准的慢病管理服务
Provide more convenient and accurate chronic disease management services for grassroots level
我国基层医防融合、慢病管理是一项艰巨的任务，面临着医疗资源配置不均，如财政补助、硬件设施、人员技术等不均衡，优秀人才、高精尖技术、智能化信息技术、高新设备等较难在基层聚集，慢病管理与优质医疗资源很难充分整合，影响管理效果[7]。
The integration of grassroots medical prevention and chronic disease management in China is a daunting task, facing uneven allocation of medical resources such as financial subsidies, hardware facilities, personnel technology, etc. Excellent talents, high-precision technology, intelligent information technology, high-tech equipment, etc. are difficult to gather at the grassroots level, and chronic disease management and high-quality medical resources are difficult to fully integrate, affecting management effectiveness.
同时，基层群众对慢病管理手段的信任度不高、信息孤岛、重防轻医或重医轻防等现象依然存在。
At the same time, there are still phenomena such as low trust in chronic disease management methods among grassroots people, information silos, and a focus on prevention over medical treatment or medical treatment over prevention.
因此，推动基层医疗与预防的深度融合，实现慢性病管理的一体化，离不开所有利益相关者的通力合作。政府应当积极促进社会资本参与基层医疗数字化建设进程，同时加强监管与评估机制。基层医疗机构应通过制定和实施人才引进及激励政策，吸引并培育基层人才，提升他们的专业能力；基层医疗机构和社区还需引入营养学、心理咨询等多领域的专业人士，为居民提供全面覆盖的慢病管理服务.同时，各方力量还应通过宣传数字化慢病管理模式，提升基层民众自我健康管理、慢病管理的依从性和连续性。
Therefore, promoting the deep integration of primary healthcare and prevention, and achieving the integration of chronic disease management, cannot be achieved without the joint efforts of all stakeholders. The government should actively promote the participation of social capital in the digital construction process of grassroots healthcare, while strengthening regulatory and evaluation mechanisms. Grassroots medical institutions should attract and cultivate grassroots talents and enhance their professional abilities by formulating and implementing talent introduction and incentive policies; Grassroots medical institutions and communities also need to introduce professionals from multiple fields such as nutrition and psychological counseling to provide residents with comprehensive coverage of chronic disease management services At the same time, all parties should also promote the digital chronic disease management model to enhance the compliance and continuity of grassroots people's self health management and chronic disease management.
在此基础上，携康计划进一步利用人工智能与数智化技术，优化慢病管理平台的诊疗辅助决策功能。该平台已累积了丰富的居民健康档案数据，相较于医生，智能平台能更高效地从这些数据海洋中筛选出关键信息，为每位患者预测出最优的治疗路径。临床医生则可依托系统的诊断与治疗建议，结合自身的专业知识与临床经验，做出更为精确、高效的诊疗决策，从而为患者定制最为合理的治疗方案。
On this basis, the Liankang Plan will further utilize artificial intelligence and digital technology to optimize the diagnosis and treatment assistance decision-making function of the chronic disease management platform. The platform has accumulated rich resident health record data. Compared to doctors, the intelligent platform can more efficiently filter key information from this ocean of data and predict the optimal treatment path for each patient. Clinical doctors can rely on systematic diagnosis and treatment recommendations, combined with their professional knowledge and clinical experience, to make more accurate and efficient diagnosis and treatment decisions, thereby customizing the most reasonable treatment plan for patients.
未来，通过上述多元主体的协同努力，进一步深化基层医防融合、慢病管理，最终为居民提供更加便捷、精确、高效且安全的全生命周期管理服务。
In the future, through the collaborative efforts of multiple stakeholders mentioned above, we will further deepen the integration of grassroots medical prevention and chronic disease management, and ultimately provide residents with more convenient, accurate, efficient, and safe full life cycle management services.
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