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基层公卫最头疼的事，不是没有政策，是政策落地时全卡在“最后一公里”。一个村医背着几十斤的纸质表册走村入户，测完血压血糖手写记录，回诊所再录电脑，录完发现漏了项目，再打电话问——这种场景每天都在发生。
The biggest headache for grassroots public health is not the lack of policies, but being stuck in the "last mile" when policies are implemented. A village doctor carrying dozens of pounds of paper booklets walked into the village, took blood pressure and blood sugar handwritten records, returned to the clinic and recorded them on the computer. After recording, he found that there were missing items and called to ask - this scene happens every day.
问题的根子不在人，在工具。
The root of the problem lies not in people, but in tools.
国家基本公卫第三版规范对慢病管理的要求写得很死：高血压患者每年至少4次面对面随访，糖尿病患者每年4次免费空腹血糖检测加4次面对面随访。随访表单必须完整、数据必须真实、时间节点不能超期。纸质记录做不到实时质控，超期了不知道，缺项了不知道，等上级考核才发现，整改都来不及。
The requirements of the third edition of the National Basic Public Health Standard for chronic disease management are very rigid: hypertension patients should be followed up at least four times a year face to face, and diabetes patients should be followed up four times a year with free fasting blood glucose detection and four times a year face to face. The follow-up form must be complete, the data must be authentic, and the time nodes cannot exceed the deadline. Paper records cannot achieve real-time quality control. If they exceed the deadline, we will not know. If there are missing items, we will not know. It will only be discovered after the superior assessment, and there is no time for rectification.
家签随访一体机解决的，就是“自动”两个字。
The all-in-one home visa follow-up machine solves the problem of "automatic".
自动采集，自动上传，自动校验。蓝牙血压计、血糖仪、额温枪测完，数据直接传进平板，不用手抄，不用二次录入。身份证读卡器刷一下，居民信息自动带出，档案真假当场核验。随访表单里的基础项——姓名、年龄、上次随访日期、上次用药——系统自动填好，医生只需要填变化的部分。一个高血压随访，原来十几分钟，现在几分钟。
Automatic collection, automatic upload, and automatic verification. After measuring with Bluetooth blood pressure monitor, blood glucose meter, and forehead thermometer, the data is directly transmitted to the tablet without the need for manual copying or secondary input. Swipe the ID card reader, and the resident information will be automatically taken out. The authenticity of the file will be verified on the spot. The basic items in the follow-up form - name, age, last follow-up date, last medication - are automatically filled in by the system, and doctors only need to fill in the changed parts. A follow-up for hypertension, which used to take ten minutes, now takes a few minutes.
更关键的是“质控前移”。 系统内置校验规则：随访日期超没超期、必填项空没空、血压值在不在合理范围、空腹血糖≥16.7mmol/L这种危急值有没有触发转诊提示。数据还没上传，问题先报出来了。离线状态下也能存，回去联网自动传，偏远地区没信号照样干活。
More importantly, 'quality control moving forward'. The system has built-in verification rules: whether the follow-up date has expired or not, whether the required fields are empty or not, whether the blood pressure value is not within a reasonable range, and whether the critical value of fasting blood glucose ≥ 16.7mmol/L triggers a referral prompt. The data hasn't been uploaded yet, so the problem was reported first. It can also be stored offline, automatically transmitted when connected to the internet, and can still work in remote areas without signal.
签约履约也在同一个设备上跑完。 居民手写签名，签约协议当场生成可打印。履约记录、检测数据、随访表单全部打通，不再“签约是一套系统、随访是另一套系统、公卫平台又是第三套系统”。
The signing and performance are also completed on the same equipment. Residents sign by hand, and the signed agreement is generated on the spot and can be printed. All performance records, testing data, and follow-up forms have been fully integrated, no longer "signing is one system, follow-up is another system, and the public health platform is a third system".
现在选设备，盯三个硬指标。
Now select the equipment and focus on three hard indicators.
第一，看能不能对接你所在省市的公卫平台。数据传不上去，再好的机器也是废铁。采购时明确要求供应商对接本地平台，并在合同里写死免费升级条款。
Firstly, see if it can connect with the public health platform in your province or city. Data cannot be transmitted, even the best machine is useless. Clearly require suppliers to connect with local platforms during procurement and include free upgrade clauses in the contract.
第二，看离线能力。下乡随访十有八九没网。设备必须能在断网状态下完成建档、随访、数据存储，联网后自动补传。存储容量至少要扛住6000人次以上的检查数据。
Secondly, consider offline capabilities. Nine out of ten follow-up visits to rural areas are not available online. The device must be able to complete archiving, follow-up, and data storage in a disconnected state, and automatically transmit data after networking. The storage capacity should withstand at least 6000 person times of inspection data.
第三，看危急值提醒够不够醒目。基层医生面对的是真实生命风险，血压≥180/110、血糖≥16.7这些红线值，必须在测量完成的那一刻就跳出来，用颜色、弹窗、声音任何有效的方式提醒医生“这个人现在需要处理”。
Thirdly, check whether the critical value reminder is prominent enough. Grassroots doctors face real life risks, such as blood pressure ≥ 180/110 and blood glucose ≥ 16.7. These red line values must be displayed at the moment of measurement completion, using any effective means such as color, pop ups, or sound to remind doctors that 'this person needs to be treated now'.
政策在推“数智赋能签约服务”，家庭医生首诊负责制也在逐步落地。工具选对了，村医的时间才真的花在“看人”上，而不是“填表”上。
The policy is promoting "digital intelligence empowerment contract services", and the first visit responsibility system for family doctors is gradually being implemented. Choosing the right tool, the village doctor's time is truly spent on "looking at people" rather than "filling out forms".
本文由家签随访一体机友情奉献.更多有关的知识请点击:http://www.yidehealthy.com/我们将会对您提出的疑问进行详细的解答，欢迎您登录网站留言.
This article is a friendly contribution from the home follow-up machine For more information, please click: http://www.yidehealthy.com/ We will provide detailed answers to your questions. You are welcome to log in to our website and leave a message
