Intelligent health management system

Abstract

The invention provides an intelligent health management system. The intelligent health management system comprises an intelligent chronic disease management system, a client terminal, a big data center and an intelligent medical decision. Wherein the intelligent chronic disease management system is used for managing chronic disease files of patients; the client terminal is used for accessing the intelligent chronic disease management system, uploading patient information to the intelligent chronic disease management system, and / or receiving a chronic disease file of the intelligent chronic disease management system; the big data center is used for collecting multi-modal data about smart health and providing the multi-modal data to the smart chronic disease management system and the smart medical decision; and the intelligent medical decision is used for analyzing the multi-modal data and generating an intelligent clinical decision scheme for the chronic disease file. Through the intelligent health management system, scattered data fusion is realized, information intercommunication is realized, intelligent medical decisions are provided by using big data, and continuous, convenient, efficient and personalized disease health management requirements of patients are met.

Description

Technical Field

[0001] The present application relates to the field of intelligent medical technology, and in particular to an intelligent health management system. Background Art

[0002] Although the medical field has a huge amount of data, the data has multiple dimensions and non-uniform data formats, and single-modal data cannot fully and effectively reveal the characteristics of the research object. With the rapid development of information technology, machine learning technology is applied in the medical field to mine valuable information from medical data to provide intelligent medical decision-making support. The development of smart chronic disease medical care is a strategic need for medical and health reform. Summary of the invention

[0004] In order to solve the above technical problems, this application proposes a smart health management system, which includes: a smart chronic disease management system, a customer terminal, a big data center and intelligent medical decision-making; wherein,

[0005] The smart chronic disease management system is used to manage patients' chronic disease files;

[0006] The client terminal is used to access the smart chronic disease management system, upload patient information to the smart chronic disease management system, and / or receive chronic disease files from the smart chronic disease management system;

[0007] The big data center is used to collect multimodal data on smart health and provide it to the smart chronic disease management system and the smart medical decision-making;

[0008] The intelligent medical decision is used to analyze the multimodal data and generate an intelligent clinical decision plan for the chronic disease file.

[0009] Among them, the smart chronic disease management system is also used to collect patients' electronic medical records from the hospital information system, collect patients' grassroots follow-up data from the grassroots medical data resource platform, and / or collect patients' real-time vital signs data from smart wearable devices.

[0010] The smart chronic disease management system includes a data layer, a functional layer, and a management layer;

[0011] The data layer is used to collect archival data; the functional layer is used for patient management, progress quality management, unit personnel management, and / or equipment management; the management layer includes chronic disease classification management, doctor stratification management, institution grading management, and / or account management;

[0012] Among them, the client terminal includes a doctor terminal and a patient terminal; the doctor terminal and the patient terminal access the smart chronic disease management system through the WeChat applet, and the doctor terminal and the patient terminal communicate and interact through the WeChat applet.

[0013] Among them, the smart chronic disease management system is also used to push the intelligent clinical decision-making plan to the doctor terminal, and the doctor terminal confirms the intelligent clinical decision-making plan and then pushes it to the patient terminal.

[0014] Among them, the intelligent medical decision is also used to extract modal features from each modal data in the multimodal data, screen relevant disease features from the modal features of the multimodal data for the chronic disease file, input the disease features into the classifier model, and output the intelligent clinical decision plan related to the chronic disease file.

[0015] Among them, the intelligent clinical decision-making plan includes a disease risk prediction plan, a disease intelligent treatment plan, and / or a disease intelligent diagnosis plan.

[0016] Wherein, the intelligent medical decision is also used to delete redundant features and invalid features in the multimodal data through a data cleaning algorithm;

[0017] Among them, the data cleaning algorithm includes a ridge regression algorithm, a bridge regression algorithm, a partial least squares algorithm, a principal component analysis algorithm, a linear judgment analysis algorithm, and / or an independent component analysis algorithm.

[0018] Among them, the platform display interface of the smart chronic disease management system includes gender ratio, age distribution, number of people managed in real time at community health centers, chronic disease classification statistics, real-time blood pressure monitoring, number of people classified by blood pressure, blood pressure compliance statistics, and / or today's family blood pressure measurement absence list.

[0019] Among them, the platform menu functions of the smart chronic disease management system include: management center, patient center, unit personnel management, progress quality management, health education management, and / or doctor guide list.

[0020] Compared with the prior art, the beneficial effects of the present application are: the smart health management system includes: a smart chronic disease management system, a client terminal, a big data center and intelligent medical decision-making; wherein, the smart chronic disease management system is used to manage the patient's chronic disease files; the client terminal is used to access the smart chronic disease management system, upload patient information to the smart chronic disease management system, and / or receive the chronic disease files of the smart chronic disease management system; the big data center is used to collect multimodal data about smart health and provide it to the smart chronic disease management system and the intelligent medical decision-making; the intelligent medical decision-making is used to analyze the multimodal data and generate intelligent clinical decision-making solutions for the chronic disease files. Through the above-mentioned smart health management system, decentralized data fusion is realized, information intercommunication is realized, and big data is used to provide intelligent medical decisions to meet patients' continuous, convenient, efficient and personalized disease health management needs. BRIEF DESCRIPTION OF THE DRAWINGS

[0021] In order to more clearly illustrate the technical solutions in the embodiments of the present application, the drawings required for use in the description of the embodiments will be briefly introduced below. Obviously, the drawings described below are only some embodiments of the present application. For ordinary technicians in this field, other drawings can be obtained based on these drawings without creative work.

[0022] in:

[0023] Figure 1 It is a structural diagram of an embodiment of a smart health management system provided by the present application;

[0024] Figure 2 This is a functional diagram of an embodiment of the intelligent chronic disease management system provided by the present application;

[0025] Figure 3 It is a structural diagram of an embodiment of the intelligent chronic disease management system provided by the present application;

[0026] Figure 4 It is a structural diagram of another embodiment of the intelligent chronic disease management system provided by the present application;

[0027] Figure 5 This is a schematic diagram of the login interface of an embodiment of the smart chronic disease management system provided by the present application;

[0028] Figure 6 This is a schematic diagram of the platform interface of an embodiment of the smart chronic disease management system provided by the present application;

[0029] Figure 7 This is a functional interface diagram of an embodiment of the smart chronic disease management system provided by the present application;

[0030] Figure 8It is a functional schematic diagram of the client terminal provided by this application;

[0031] Fig. 9 This is a schematic diagram of the interface of an embodiment of a doctor terminal provided by the present application;

[0032] Fig.10 This is a schematic diagram of the interface of an embodiment of a patient terminal provided by the present application;

[0033] Fig.11 It is a schematic diagram of the structure of the client terminal provided by this application;

[0034] Fig.12 This is a business process diagram of an embodiment of a big data center provided by the present application;

[0035] Fig.13 It is a schematic diagram of the framework flow of intelligent medical decision-making provided by this application;

[0036] Fig.14 It is a flow chart of an embodiment of community chronic disease management provided by this application. DETAILED DESCRIPTION

[0037] The following will be combined with the drawings in the embodiments of the present application to clearly and completely describe the technical solutions in the embodiments of the present application. Obviously, the described embodiments are only part of the embodiments of the present application, not all of the embodiments. Based on the embodiments in the present application, all other embodiments obtained by ordinary technicians in this field without creative work are within the scope of protection of this application.

[0038] The terms "first", "second", "third", "fourth", etc. (if any) in the specification and claims of the present application and the above-mentioned drawings are used to distinguish similar objects, and are not necessarily used to describe a specific order or sequence. It should be understood that the data used in this way can be interchangeable where appropriate, so that the embodiments of the present application described herein can, for example, be implemented in an order other than those illustrated or described herein. In addition, the terms "including" and "having" and any of their variations are intended to cover non-exclusive inclusions, for example, a process, method, system, product or device that includes a series of steps or units is not necessarily limited to those steps or units that are clearly listed, but may include other steps or units that are not clearly listed or inherent to these processes, methods, products or devices.

[0039] In view of the shortcomings of existing technologies, according to policy guidelines, we apply Internet technologies, rationally integrate medical resources, and thus form a big data center. Through machine learning, we can achieve intelligent medical decision-making, explore smart chronic disease management, formulate and promote process specifications for community smart chronic disease medical care, and meet patients' needs for continuous, convenient, efficient and personalized disease health management. This application proposes a smart health management system based on multimodal data and its health management model. For details, please refer to Figure 1 , Figure 1 The smart health management system 100 involved in this application mainly includes: a smart chronic disease management system 11, a client terminal 12, a big data center 13 and a smart medical decision 14.

[0040] Among them, the smart chronic disease management system 11 is used to manage the patient's chronic disease files. The client terminal 12 is used to access the smart chronic disease management system 11, upload patient information to the smart chronic disease management system 11, and / or receive the chronic disease files of the smart chronic disease management system 11. The big data center 13 is used to collect multimodal data about smart health and provide it to the smart chronic disease management system 11 and the smart medical decision 14. The smart medical decision 14 is used to analyze multimodal data and generate intelligent clinical decision solutions for chronic disease files.

[0041] Specifically, the smart chronic disease management system 11 is the core of the framework, which mainly realizes the integration, sharing, exchange and display of medical information and the pre-processing of interoperability of institutional systems at all levels. The client terminal 12 is mainly implemented through WeChat applet, continuing the family doctor contract service. The big data center 13 is used to support the operation and management of the entire platform, including data collection, data storage, data processing and analysis.

[0042] Intelligent medical decision-making 14 based on multimodal data is based on the big data center 13, and uses machine learning to collect, mine and fuse multimodal data to provide intelligent medical decision-making support. The intelligent medical decision-making platform integrates the information resources of medical and health institutions at all levels through a smart chronic disease management system 11 based on multimodal data, establishes a follow-up database, pathogenic risk database and endpoint event tracking system for 1X chronic diseases, and uses data mining and machine learning technologies to build a disease early warning model, provide intelligent medical decision-making, and realize the comprehensive management of chronic disease pathogenic factors, treatment efficacy and prognosis throughout the entire cycle. It not only comprehensively improves the accuracy and efficiency of medical decision-making of community doctors in chronic disease prevention and control, but also provides patients with precise diagnosis and treatment services and realizes personalized health management.

[0043] Specifically, the functions and implementation methods of each component in the smart health management system 100 are introduced below:

[0044] The smart chronic disease management system 11 is also used to collect the patient's electronic medical records from the hospital information system, collect the patient's primary follow-up data from the primary medical data resource platform, and / or collect the patient's real-time vital signs data from the smart wearable device. Figure 2 , Figure 2 This is a functional diagram of an embodiment of the intelligent chronic disease management system provided in this application.

[0045] like Figure 2 As shown, the smart chronic disease management system 11 is connected to the external general hospital HIS (Hospital Information System), community health system and wearable devices, and can collect patient-related file data from the above external systems or external devices. The smart chronic disease management system uses the collected file data to implement functions including but not limited to: management center, patient center, unit personnel management, progress quality management, and health education.

[0046] Specifically, the smart chronic disease management system 11 realizes data interconnection and interoperability with the HIS system of general hospitals and the community health system, builds a complete chronic disease comprehensive monitoring system, strengthens the management level of blood pressure, blood sugar, blood lipids and other data of the target population, and controls cardiovascular risk factors. Through the smart chronic disease management system 11, patients, unit personnel, and progress quality are uniformly managed, the risk assessment and follow-up management of chronic diseases are strengthened, the early diagnosis rate and standardized treatment level are improved, and the deep connection between general hospitals and grassroots community health institutions is strengthened to promote hierarchical diagnosis and treatment.

[0047] For details, please refer to 3. Figure 3 It is a structural diagram of an embodiment of the intelligent chronic disease management system provided by this application.

[0048] like Figure 3 As shown, the smart chronic disease management system 11 includes a data layer 111, a management layer 112 and a functional layer 113. Among them, the data layer 111 is the bottom layer of the smart chronic disease management system 11. Relying on the questionnaire of the smart chronic disease management system 11, data collection is carried out to form basic data. By connecting with the hospital HIS system, the patient's electronic medical records, tests, examinations and other data information in the hospital are obtained. By connecting with the data resource platform of the grassroots medical and health structure, the grassroots follow-up data of the managed patients are obtained. It can also obtain real-time vital sign data of the family by connecting to smart wearable devices to realize information fusion, data storage, processing and analysis. The management layer 112 includes chronic disease classification management, doctor hierarchical management, institution hierarchical management, and account management. The functional layer 113 includes patient management, progress quality management, unit personnel management, and equipment management.

[0049] Furthermore, if Figure 2 and Figure 3 The smart chronic disease management system 11 shown can be installed and run in the hospital server. Figure 4 , Figure 4 It is a structural diagram of another embodiment of the intelligent chronic disease management system provided by this application.

[0050] like Figure 4 As shown, the database, service layer, and application layer of the smart chronic disease management system 11 are flexibly deployed and can be deployed separately or separately. The database has an automatic backup mechanism every day. The main server of the smart chronic disease management system 11 consists of 1 application server, 1 database server, and 1 front-end application server.

[0051] The smart chronic disease management system 11 needs to have completely open data interaction with the hospital information system. The interactive data framework design adopts a research and development architecture based on service-oriented architecture (SOA). The transmission of real-time business data is realized by interface docking. The data exchange bus is responsible for data exchange with the hospital information system. The data exchange bus adapts to multiple in-hospital business systems (HIS, LIS, PACS, etc.) through interface adapters. The basic information data of patients is stored in the hospital database server, and the basic information data of patients and third-party interface data are counted and analyzed in the front-end machine. Follow-up management is carried out for target hypertensive patients and patients with cardiovascular and cerebrovascular diseases. Patients whose data do not meet the standards are reminded through text messages or public account information, so as to achieve more accurate and efficient management of patients.

[0052] The cardiovascular smart health management platform of the smart chronic disease management system 11 relies on the existing network structure of the hospital, deploys front-end machines in the DMZ (demilitarized zone) area, builds an Nginx cluster reverse proxy, realizes the isolation of internal and external networks, and uses load balancing technology to effectively reduce the pressure on the server, ensuring the stable operation of each application system and data security. Users obtain services through WeChat applets. Each terminal application accesses the front-end server in the DMZ area through the Internet to provide relevant interfaces. For the interaction between the platform service and the hospital HIS, the platform server accesses the front-end service in the DMZ area of ​​the hospital through the core interaction machine to synchronize the interface interaction machine data. The platform data is accessed by the data synchronization service in the DMZ area of ​​the hospital through the VPN (Virtual Private Network) tool to access the platform interface to complete the data interaction.

[0053] Specifically, the operation interface of the intelligent chronic disease management system 11 involved in this application can be found in Figure 5 , Figure 6 and Figure 7 , Figure 5This is a schematic diagram of the login interface of an embodiment of the smart chronic disease management system provided by this application. Figure 6 This is a schematic diagram of the platform interface of an embodiment of the smart chronic disease management system provided by this application. Figure 7 This is a functional interface diagram of an embodiment of the intelligent chronic disease management system provided by this application.

[0054] like Figure 5 As shown, the login interface of the smart chronic disease management system 11 supports the registration and login of medical staff with different roles, including specialists, general practitioners, and administrators, and grants different system usage permissions according to work needs.

[0055] like Figure 6 As shown, the platform display interface of the smart chronic disease management system 11 includes but is not limited to: gender ratio, age distribution, number of people managed in real time at community health centers, chronic disease classification statistics, real-time blood pressure monitoring, number of people classified by blood pressure, statistics on blood pressure compliance, and / or today's family blood pressure measurement failure list.

[0056] like Figure 7 As shown, the server of the smart chronic disease management system 11 covers hospitals, communities, and families, and transmits life data in real time. The main functions of the smart chronic disease management system 11 are as follows: (1) Management center, which displays the patient enrollment status, the number of chronic disease patients under the jurisdiction of each community, follow-up status, blood pressure compliance status, etc. in the form of charts; (2) Patient center, which displays all patients currently managed by the community and family doctors in the form of a list, is responsible for patient file creation, baseline information collection, follow-up, and generates intelligent medical decisions after entering data; (3) Unit personnel management, which realizes the management of unit personnel accounts and basic information; (4) Progress quality management, which realizes blood pressure warning management, risk stratification management, follow-up progress management, clinical event management, medication plan management, equipment management, and blood lipid and blood sugar monitoring management; (5) Health education management (6) Doctor guide list, real-time update of the latest medical consultation.

[0057] The above-mentioned intelligent chronic disease management system 11 based on multimodal data communicates and provides feedback through the client terminal 12, and the client terminal 12 involved in this application can include mobile terminals for medical staff, i.e., doctor terminals, and mobile terminals for patients / patients' families, i.e., patient terminals, according to user identity.

[0058] Please refer to Figure 8 , Figure 8 This is a functional diagram of the client terminal provided by this application. Figure 8 As shown, the doctor side and the patient side involved in this application access the smart chronic disease management system 11 through the WeChat applet, and the doctor side and the patient side communicate and interact through the WeChat applet to realize the online real-time communication function.

[0059] The doctor side mainly assists doctors in remote monitoring and intervention, and its main functions are risk assessment, clinical decision-making, follow-up services, patient management, remote consultation and medical guidelines. The patient side / family side mainly realizes patient self-management and family collaborative management, and its main functions are management plan function, reminder service function, health analysis report, health education, health feedback function, and seeking medical advice.

[0060] For more information about the user interface on the doctor side, please refer to Fig. 9 , Fig. 9 This is a schematic diagram of the interface of an embodiment of a doctor terminal provided in this application.

[0061] like Fig. 9 As shown in the figure, the doctor's side is the chronic disease health workstation. The interface functions include four major modules: "Home", "Patient List", "Medical Guide", and "Message". The functions of each module are introduced as follows: (1) Home: Real-time push of follow-up status, blood pressure measurement status, blood pressure compliance status, and blood pressure warning status of patients with family contracts signed by general practitioners, and efficient management of family-signed chronic disease patients; (2) Patient List: This module allows you to quickly view family-signed chronic disease patients. By clicking on any patient in the list, you can enter the patient details. The related functions of the patient details interface are basic information, medication plan, evaluation report, device binding, life monitoring data, and sending information; (3) Medical Guide: The system pushes professional information on chronic disease management related to chronic disease diagnosis, treatment, etc. In this module, you can view the relevant information pushed by the system. (4) Message: In this module, medical staff can view patients' messages.

[0062] For details, please refer to the patient user interface. Fig.10 , Fig.10 It is a schematic diagram of the interface of an embodiment of a patient terminal provided in the present application.

[0063] like Fig.10 As shown in the figure, the patient side is a chronic disease health assistant, and the interface functions include four major modules: "Home", "Contracted Team", "Internet Hospital", and "Personal Profile". The functions of each module are introduced as follows: (1) Home: The message center reminds patients of blood pressure measurement, follow-up, and life data warning in real time; patients can enter life data in real time; view personalized assessment reports, and provide dietary guidance, mental health, and exercise guidance suggestions; (2) Contracted Team: View the contracted family doctor team and consult online; (3) Internet Hospital: Provide online medical services; (4) Personal Profile: The related functions displayed include basic information, medication plan, message reminders, connecting with family members, online follow-up, device management, and viewing life data analysis charts transmitted by wearable devices or manually entered.

[0064] Further, the specific structure of the client terminal involved in this application can be found in Fig.11 , Fig.11 It is a structural diagram of the client terminal provided by this application.

[0065] like Fig.11 As shown, the client terminal of this application adopts Tencent Mini Program, that is, WeChat Mini Program. The Mini Program configures a network security channel through localized network whitelist configuration, domain name resolution, and SSL (Secure Socket Layer) certificate to protect customer information security. The system encrypts customer sensitive data to avoid leakage and attack.

[0066] Developers use WeChat developer tools to debug and develop functions in the development environment, and can move them online to the production environment after review and release, enabling rapid deployment of service codes and updated versions. Customer basic data is stored in the local Level 3 security data center server, and data interaction with third-party platforms generally uses HTTPS or webservice to achieve data interconnection. Developers provide a unified service message delivery interface through mini-programs to reach users with service messages.

[0067] Please refer to the business process of the big data center 13 in the smart health management system 100 protected by this application. Fig.12 , Fig.12 It is a business process diagram of an embodiment of a big data center provided by this application.

[0068] like Fig.12 As shown, the big data center 13 of the embodiment of the present application provides one-stop support services for big data services based on the entire life cycle of big data services, including but not limited to: data source, data planning, data collection and preprocessing, data storage and management, data analysis and mining, and big data business applications.

[0069] The data source layer includes internal data sources, equipment collection data sources, and shared exchange data sources. Data planning: formulate big data standards and specifications, and conduct data source analysis. Data collection and preprocessing: clean, classify, catalog, and store acquired data. Data storage and management: realize distributed storage and distributed data management. Data analysis and mining: extract required data features from the storage data module and perform information fusion. Big data business applications mainly realize intelligent medical decision support.

[0070] The intelligent medical decision 14 in the smart health management system 100 protected by this application is used to analyze multimodal data and generate intelligent clinical decision solutions for chronic disease records.

[0071] Among them, intelligent medical decision-making based on multimodal data 14, under the premise of following the clinical guidelines in the medical decision-making process, uses artificial intelligence technology to integrate medical big data to form interactive clinical decision support to assist medical workers in making decisions. By inputting patient information, clinical decisions customized for the specific situation of the patient are automatically generated, mainly including: assisting doctors in clinical diagnosis before diagnosis and treatment; assisting doctors in analyzing candidate plans during diagnosis and treatment; personalized health education prescriptions; mining risk factors for cardiovascular events after diagnosis and treatment, integrating multi-time point trend characteristics, and establishing a high-precision cardiovascular disease risk prediction model to help doctors identify high-risk groups early and intervene in time.

[0072] In the process of interacting with other parts of the smart health management system 100, the smart chronic disease management system 11 pushes the intelligent clinical decision plan generated by the intelligent medical decision 14 to the doctor terminal, which confirms it, or pushes the intelligent clinical decision plan to the patient terminal after making adjustments. Through the intelligent medical decision 14, on the one hand, it can refer to the decision plan of big data to generate more targeted and accurate intelligent clinical decision plans for patient files; on the other hand, it can reduce the work pressure of doctors. Most of the automatically generated intelligent clinical decision plans only need to be confirmed by doctors. Doctors can make minor adjustments based on their own judgment and quickly give decision plans for patient files.

[0073] Please refer to Fig.13 , Fig.13 This is a schematic diagram of the framework flow of intelligent medical decision-making provided by this application.

[0074] like Fig.13 As shown, the intelligent medical decision 14 extracts modal features from each modal data in the multimodal data, namely Fig.13 The intelligent medical decision 14 selects relevant disease features from the modal features of the multimodal data for the chronic disease files in the intelligent chronic disease management system 11, inputs the disease features into the classifier model, and outputs the intelligent clinical decision plan related to the chronic disease files.

[0075] The number of classifier models can be one or more. If multiple classifier models are used, each classifier model is trained for a specific type of decision solution. If one classifier model is used, the classifier model needs to be trained to output multiple types of decision solutions. Fig.13 The disease risk prediction model, disease intelligent treatment model and disease intelligent diagnosis model shown in the figure are shown in the figure. It should be noted that the specific type of classifier model selects appropriate machine learning algorithms and constructs classifiers according to different diseases to generate intelligent medical decision support.

[0076] Through intelligent medical decision-making 14, the smart health management system 100 can search for relevant file records from big data for different patient files, and use the relevant file records to generate intelligent clinical decision plans corresponding to the patient files. It can make the most of the advantages of big data, so that in the process of generating decision plans, on the one hand, it reflects the relevance to patient files, and on the other hand, it reflects the search and matching of big data, taking into account more expert experience, and improving the pertinence and accuracy of decision plans.

[0077] Furthermore, before using big data, it is necessary to consider that there are a large number of redundant and invalid features in the feature set of big data. If the uncleaned big data is directly input into the intelligent medical decision-making 14, the amount of data processing will increase greatly and the accuracy of the decision results of the intelligent medical decision-making 14 will be affected.

[0078] Specifically, the intelligent medical decision 14 can delete redundant features and invalid features in the multimodal data through a data cleaning algorithm, wherein the data cleaning algorithm includes a ridge regression algorithm, a bridge regression algorithm, a partial least squares algorithm, a principal component analysis algorithm, a linear judgment analysis algorithm, and / or an independent component analysis algorithm.

[0079] Please continue reading Fig.14 , Fig.14 It is a flow chart of an embodiment of community chronic disease management provided by this application.

[0080] The community chronic disease management of this application uses an intelligent chronic disease management system based on multimodal data for chronic disease management. The target population enters personal baseline data through the target population port, such as personal basic information, family history, past history, test indicators, previous medications, living habits, etc. and follow-up data. At the same time, the hospital resource data of the patient's visit, the archival data of the community hospital, and the vital signs data automatically transmitted by wearable devices are integrated into the system to form a big data center, and the data is integrated to form intelligent predictions (ASCVD risk assessment, stroke risk assessment), to produce more comprehensive personalized guidance and suggestions for patients with chronic diseases.

[0081] Specific personalized guidance recommendations include but are not limited to: hypertension risk stratification, primary and secondary prevention recommendations for antiplatelet therapy, antihypertensive treatment plans and blood pressure control targets, glucose-lowering treatment plans and blood sugar control targets, lipid-lowering treatment plans and targets, personalized health education, life-cycle tracking and follow-up, and development of a cardiovascular disease early warning model.

[0082] The following are some typical cases to understand the working process of community chronic disease management:

[0083] (1) After receiving treatment at a general hospital, a patient is transferred to a community health service center. General practitioners at the community health service center can use this system to view the patient's general hospital treatment records and transfer patients and information to the community health service center.

[0084] (2) After the patient's file is created at the community health service center and the data is entered into the system, the general practitioner can obtain intelligent clinical decision support through the system or client. In the subsequent follow-up process, the vital sign data entered by the wearable device or manually by the patient can be viewed in real time through the system or client.

[0085] (3) If the patient changes his / her place of residence, the community family doctor can provide remote diagnosis and treatment and online follow-up through the platform.

[0086] (4) Establish a hypertension cohort follow-up database, a pathogenic risk database, and an efficient endpoint event tracking system that can conduct precision treatment efficacy and prognosis research, and establish a precise prevention and control system for community hypertension that integrates "prevention", "treatment", and "research".

[0087] The above description is only an implementation method of the present application, and does not limit the patent scope of the present application. Any equivalent structure or equivalent process transformation made using the contents of the present application specification and drawings, or directly or indirectly used in other related technical fields, are also included in the patent protection scope of the present application.

Claims

1. A smart health management system, characterized in that: The smart health management system includes: smart chronic disease management system, customer terminal, big data center and intelligent medical decision-making; The smart chronic disease management system is used to manage patients' chronic disease files; The client terminal is used to access the smart chronic disease management system, upload patient information to the smart chronic disease management system, and / or receive chronic disease files from the smart chronic disease management system; The big data center is used to collect multimodal data on smart health and provide it to the smart chronic disease management system and the smart medical decision-making; The intelligent medical decision is used to analyze the multimodal data and generate an intelligent clinical decision plan for the chronic disease file.

2. The smart health management system according to claim 1, characterized in that: The smart chronic disease management system is also used to collect patients' electronic medical records from hospital information systems, collect patients' primary follow-up data from primary medical data resource platforms, and / or collect patients' real-time vital signs data from smart wearable devices.

3. The smart health management system according to claim 2, characterized in that: The smart chronic disease management system includes a data layer, a functional layer and a management layer; Among them, the data layer is used to collect archival data; the functional layer is used for patient management, progress quality management, unit personnel management, and / or equipment management; the management layer includes chronic disease classification management, doctor stratification management, institution hierarchical management, and / or account management.

4. The smart health management system according to claim 1, characterized in that: The client terminal includes a doctor terminal and a patient terminal; the doctor terminal and the patient terminal access the smart chronic disease management system through the WeChat applet, and the doctor terminal and the patient terminal communicate and interact through the WeChat applet.

5. The smart health management system according to claim 4, characterized in that: The smart chronic disease management system is also used to push the intelligent clinical decision-making plan to the doctor terminal, and the doctor terminal confirms the intelligent clinical decision-making plan and pushes it to the patient terminal.

6. The smart health management system according to claim 1, characterized in that: The intelligent medical decision is also used to extract modal features from each modal data in the multimodal data, screen relevant disease features from the modal features of the multimodal data for the chronic disease file, input the disease features into a classifier model, and output an intelligent clinical decision plan related to the chronic disease file.

7. The smart health management system according to claim 6, characterized in that: The intelligent clinical decision-making scheme includes a disease risk prediction scheme, a disease intelligent treatment scheme, and / or a disease intelligent diagnosis scheme.

8. The smart health management system according to claim 6, characterized in that: The intelligent medical decision is also used to delete redundant features and invalid features in the multimodal data through a data cleaning algorithm; Among them, the data cleaning algorithm includes a ridge regression algorithm, a bridge regression algorithm, a partial least squares algorithm, a principal component analysis algorithm, a linear judgment analysis algorithm, and / or an independent component analysis algorithm.

9. The smart health management system according to claim 1, characterized in that: The platform display interface of the smart chronic disease management system includes gender ratio, age distribution, number of people managed in real time at the community health center, chronic disease classification statistics, real-time blood pressure monitoring, number of people classified by blood pressure, statistics on blood pressure compliance, and / or a list of families who did not measure their blood pressure today.

10. The smart health management system according to claim 1 or 9, characterized in that: The platform menu functions of the smart chronic disease management system include: management center, patient center, unit personnel management, progress quality management, health education management, and / or doctor guide list.

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