Common issues facing chronic disease management 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.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.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.