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Big data + medical and prevention integration'New model of chronic disease management

According to relevant statistics from the National Health Commission,

75% of the elderly in my country suffer from at least one chronic disease.

43% had multiple comorbidities.

As the aging process accelerates,

How to effectively do 'prevention first,

Health management that combines prevention and treatment',

Improve the operating efficiency of the overall medical service system?

Common issues facing chronic disease management

  1. Lack of a comprehensive management system, many countries have not yet established complete personal files and electronic health record systems, resulting in the inability to share and transfer information between different hospitals or doctors.

  2. Management is decentralized and lacks coordination: Due to the lack of unified norms and guiding principles, there is a lack of effective collaboration and information sharing among various departments during the patient treatment process.This results in variability in treatment decisions, drug prescriptions, and follow-up.

  3. Doctors’ time is limited: Due to limited doctor resources, each doctor needs to deal with a large number of patients, which results in doctors often being unable to provide comprehensive and in-depth management services to each patient in a short period of time.

  4. Lack of active patient participation: Many patients with chronic diseases lack sufficient awareness of self-management and health education in their daily lives and are unable to actively participate in the management of their own diseases.

Big data + medical and prevention integration'New model of chronic disease management

At present, a number of county-level medical and prevention integrated smart chronic disease clinics have been officially put into operation. The 'big data + medical and prevention integration' new chronic disease management model with digital empowerment, online monitoring, real-time tracking, comprehensive services and other attributes allows the people in the jurisdiction to have It has established a more solid 'medical' reliance, effectively reduced the incidence of complications caused by chronic diseases, made chronic disease management more scientific, medical services more efficient, and people more satisfied with medical treatment.Taking 'two chronic diseases' health management as the entry point, focusing on the intelligent integration of medical and prevention, relying on digital, intelligent assisted diagnosis and treatment and information collection and other means to effectively enhance the connotation of integrated outpatient services for chronic diseases, and continuously improve the level of chronic disease diagnosis and treatment management at the grassroots level.

The medical and prevention integrated smart chronic disease clinic of the health center uses the smart chronic disease health management center system to form a regional medical service closed loop of 'medicine + medicine + testing' through big data monitoring and smart management, allowing doctors, patients, and family members to jointly manage chronic diseases. Carry out health management to fundamentally reduce the incidence rate and improve the cure rate and control rate.

Focus on health index to help classify chronic diseases

Based on the 'Two Chronic Diseases' health index and combined with the construction of integrated chronic disease outpatient clinics, we will optimize the practical application of the health index.

First, strengthen data governance.Continue to carry out classification, screening and sorting of missing data on health index scoring indicators, determine data tolerance standards based on the degree of missing index data, and formulate standards for blood lipids, homocysteine, hyperuricemia and other items in conjunction with the construction of an integrated chronic disease outpatient information system. Data filling scheme.

Second, it is an iterative exponential model.In accordance with the requirements of the 'Zhejiang Province's 'Two Chronic Diseases' Health Index Construction Guidelines (Trial)', methods such as manual comparison and verification, machine learning analysis, etc. are used to regularly carry out verification and revision of the scoring system and data models, and continue to improve them. Health index evaluation calculation model.

The third is to deepen practical application.Focusing on the closed loop of the entire process of 'two chronic diseases' including discovery, screening, assessment, management, and performance, a digital application system for county and rural three-level collaboration has been established to provide various information for residents, medical staff, medical and health institutions, and health administrative departments. Applications in various scenarios.

Solidify management paths to achieve organic integration of medicine and prevention

First, develop standardized diagnosis and treatment pathways.Sort out and formulate an integrated and standardized path for clinical diagnosis, treatment and follow-up management of 'two chronic diseases' to achieve homogenization of diagnosis and treatment of chronic diseases at the grassroots level, continue to improve the standardization level of clinic management, and achieve effective integration of medical and prevention.

The second is to establish a health prescription knowledge base.Led by the County Center for Disease Control and Prevention, clinical experts from the cardiovascular and cerebrovascular and endocrinology departments of the Medical Community General Hospital were selected to compare the standardized diagnosis and treatment paths of the 'two chronic diseases' and formulate health guidance and health intervention measures for the 'two chronic diseases'. , establish a health prescription knowledge base, which mainly involves 9 modules including risk factor intervention, BMI, smoking cessation and alcohol restriction, exercise guidance, dietary guidance, psychology and behavior, and medication guidance.

The third is to explore new models of digital intelligence at the grassroots level.The development of population health monitoring and early warning analysis functions based on health portraits, embedding artificial intelligence into routine diagnosis and treatment, and realizing iterative upgrades of regional health portraits, digital home medicine and other applications.

Currently Henan Lejia Electronic Technology Co., Ltd. has developed a number of Intelligent Health Examination Machine products through the integration of 'big data + medical and prevention integration' chronic disease management to serve chronic disease management, based on a full range of hardware + software + platform + services Health examination equipment realizes intelligent archiving and intelligent data collection, performs data analysis through cloud computing, performs health assessment, provides basic data for health guidance, realizes intelligent and integrated services for chronic disease management, and provides health services for community residents. Better scientific basis and guarantee.

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Company Profile

Henan Lejia Electronic Technology Co., Ltd. is located in the Electronic and Electrical Industrial Park of Zhengzhou High-tech Development Zone. It is a company specializing in the research and development, production and sales of intelligent all-in-one physical examination machines, Height and Weight Scale, ultrasonic physical examination machines, baby scales, Portable Physical Examination Case high-tech enterprises.The company has passed ISO9001 certification, CE certification, etc., allowing its products to quickly occupy the domestic market and are exported to the United States, the European Union, Russia, the Middle East, Latin America, Africa, Australia and other countries and regions, and are well received by customers.


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Henan Lejia Electronic Technology Co., Ltd. is a high-tech enterprise focusing on the research and development of health examination equipment and intelligent chronic disease management CASES integration, integrating production, sales and After-sale Service.

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