Post-diagnosis disease management follow-up visit system and method thereof

Abstract

The invention discloses a post-diagnosis disease management follow-up visit system and a post-diagnosis disease management follow-up visit method, and belongs to the technical field of medical information management. The medical staff terminal is used for configuring a follow-up task list generated by the follow-up path according to follow-up management and receiving task push at an intervention node; the patient terminal is used for receiving a follow-up form generated according to the follow-up plan configuration at the follow-up node, and a patient checks and fills the follow-up form according to the health condition of the patient; the follow-up form content filled by the patient is automatically synchronized to the follow-up work station; according to the post-hospital disease management follow-up visit system and the follow-up visit method thereof, the basic information and the doctor seeing information of the patient are acquired by connecting the HIS, the EMR and other systems of the hospital, and the medical record information generated by the whole-process doctor seeing of the patient is used as the basis for accurately developing the follow-up visit service, so that the post-hospital management coverage rate and the post-hospital management quality are improved.

Description

Technical Field

[0001] The present invention belongs to the technical field of medical information management, and in particular relates to a post-diagnosis disease management follow-up system and method. Background Art

[0002] The disease management cycle can be divided into three stages: before diagnosis (prevention), during diagnosis (treatment), and after diagnosis (rehabilitation). Due to the uneven distribution of medical resources and technical limitations, the post-diagnosis stage is still a weak link in the full-cycle management of the disease. Follow-up work is an important part of disease management. However, the post-diagnosis follow-up work of various medical institutions currently lacks effective management tools, has low follow-up coverage, poor content targeting, lack of high-quality doctor-patient interaction, and loss of follow-up data. It fails to provide strong guarantees for medical quality, resulting in poor compliance of patients during the post-diagnosis rehabilitation process and inability to obtain immediate health guidance. Therefore, it is necessary to develop a new post-diagnosis disease management follow-up system and its follow-up method to solve existing problems. Summary of the invention

[0003] The purpose of the present invention is to provide a post-diagnosis disease management follow-up system and a follow-up method thereof, so as to solve the problems of low follow-up coverage and poor content pertinence.

[0004] To achieve the above-mentioned object, the present invention provides the following technical solutions: a post-diagnosis disease follow-up system, comprising a follow-up workstation, a medical staff terminal, and a patient terminal; The follow-up workstation includes a medical information docking module, a medical knowledge base module, a follow-up management module, and an education management module; the medical information docking module includes an in-hospital standard data set consisting of all medical information generated by the patient during outpatient, hospitalization, and physical examination, the in-hospital standard data set includes the patient's basic information, medical records, examination and test results, hospitalization records and other data, as well as a health data set about the patient's health status input by the patient and / or medical staff, the health data set includes the patient's self-reported health status, daily health monitoring data, external medical equipment data, etc.; the in-hospital standard data set is docked with the hospital's EMR system, HIS system, LIS system, and PACS system, etc., and the corresponding patient's data set is obtained through technical methods such as interface transmission and queue monitoring. The specific method is real-time monitoring through MQ message queue technology. The MQ message queue is implemented using the Apache Kafka system. The producer transmits the data message to the message queue, and the consumer monitors the message queue in real time and obtains the data message. The message transmission process adopts an asynchronous non-blocking mechanism to ensure the efficiency and reliability of data transmission. Receive transmission data and store these messages in the database. For messages that fail to be received, technicians will check and process them. The medical knowledge base includes the guide library, drug library, disease library, inspection library, professional follow-up form library, medical scale library and health education library issued by authoritative medical associations. The follow-up management module is used to screen the target follow-up patient group according to the characteristic information of the patient group, such as: patient sources including outpatient, hospitalization, physical examination, discharge, age range, age range is defined as 0-18 years old (children), 19-65 years old (adults), 66 years old and above (elderly), gender, disease diagnosis, treatment department, etc., and configure targeted follow-up paths, including the follow-up questionnaires and sending times sent to patients at each time of the follow-up path. The screening rules are formulated based on the patient sources including outpatient, hospitalization, physical examination, diagnosis, department, age, gender and other conditions. Among the screened follow-up patient groups, the system will create a corresponding follow-up project for each patient and generate a follow-up task at the configured follow-up time node. Among them, follow-up tasks that require manual intervention from medical staff will be automatically added to the task list of the medical terminal; the education management module is used to formulate a post-diagnosis education plan for patients, and the education tasks generated according to the education plan will be automatically pushed through the patient terminal.

[0005] The medical staff terminal pushes the follow-up plan to the patient's mobile terminal based on the follow-up plan path on the timeline; it includes a follow-up task list generated according to the follow-up path configured according to the follow-up management. Different manual intervention time nodes can be set when the follow-up plan is created; the medical staff terminal can receive task push at the configured intervention node, which is convenient for medical staff to efficiently perform follow-up tasks without omissions; the medical terminal is one of the mini-programs and apps.

[0006] The patient terminal is used to receive follow-up forms generated according to the follow-up plan configuration at the follow-up node. Patients can view and fill in the follow-up forms according to their own health status through the terminal; the content of the follow-up form filled in by the patient will be automatically synchronized to the follow-up workstation; the follow-up data received and filled in by the patient terminal and the follow-up data received and displayed by the follow-up workstation are synchronously stored in the same database on the hospital intranet; patients can view the health education articles pushed at the corresponding time point according to the education plan through the patient terminal; the patient terminal belongs to one of the Apps and mini-programs.

[0007] The above-mentioned post-diagnosis follow-up system provides authoritative and professional follow-up forms and follow-up path designs through the medical knowledge base, obtains the medical data generated by patients during the treatment process through the information docking module, and integrates the data generated by patients in the hospital with the data generated outside the hospital. The specific integration method is: integrating the patient data inside and outside the hospital, clearly and comprehensively displaying it on the system page, providing better support for medical staff for follow-up business; for abnormal physical sign data of patients inside and outside the hospital, giving medical staff abnormal message reminders, so that medical staff can fully grasp the real-time and comprehensive physical sign data of patients, and provide patients with better and more comprehensive follow-up services. It realizes cross-system docking of data, provides strong data support for the subsequent follow-up business, and facilitates medical staff to formulate targeted post-diagnosis follow-up plans according to the characteristics of different patient groups. The matching and accuracy of the follow-up are effectively guaranteed, and it provides a basis for the dynamic adjustment of the follow-up plan. The follow-up plan shares data with the medical and nursing terminals and the patient terminals, and the business processes are integrated. The follow-up questionnaire will be pushed to the patient terminal as soon as possible, and the patient will provide timely feedback on the post-diagnosis follow-up work. If the patient does not provide timely feedback, the medical and nursing terminal will remind the medical staff to intervene in the subsequent tasks that require manual intervention, thereby improving the continuity and effectiveness of the follow-up business, ensuring that the post-diagnosis follow-up work is closely and organically connected with the treatment process, and ensuring that the medical staff understands the patient's recovery status. It provides data support for the subsequent personalized and targeted health intervention, medication guidance, life guidance, etc., which is convenient for improving patient satisfaction and compliance, and is more conducive to the patient's recovery.

[0008] The medical information of the above patients includes but is not limited to: basic information of patients, physical signs, current medical history, past medical history, examination results, test results, admission diagnosis, medical advice, treatment process, operation records, discharge diagnosis, prescription information, etc.; the in-hospital standard data set is based on the national WS health standard data set.

[0009] The technical effects and advantages of the present invention are as follows: the post-diagnosis disease management follow-up system and its follow-up method obtain the patient's basic information and medical information by connecting to the hospital's HIS, EMR and other systems, and use the medical record information generated by the patient's full medical treatment process as the basis for accurately carrying out follow-up services, thereby improving the coverage and quality of post-hospital management, and conducting standardized management of post-diagnosis follow-up by connecting data inside and outside the hospital, thereby improving the efficiency of post-diagnosis follow-up while reducing the workload of medical staff, and improving the patient's post-diagnosis management effect and satisfaction through accurate information collection and analysis; authoritative and professional follow-up forms and follow-up path designs are provided through the medical knowledge base, and the information docking module obtains the medical data generated by the patient during the medical treatment process, and integrates the data generated by the patient in the hospital with the data generated outside the hospital, integrates the patient data inside and outside the hospital, and clearly and comprehensively displays them on the system page, providing better support for medical staff for subsequent services; for abnormal physical sign data of patients inside and outside the hospital, abnormal message reminders are given to medical staff, allowing medical staff to fully understand the patient's The system can provide patients with better and more comprehensive follow-up services by using real-time and comprehensive vital sign data of patients; it realizes cross-system data docking, provides strong data support for the subsequent follow-up business, and facilitates medical workers to formulate targeted post-diagnosis follow-up plans according to the characteristics of different patient groups. The matching and accuracy of the follow-up are effectively guaranteed, and it provides a basis for the dynamic adjustment of the follow-up plan; at the same time, the follow-up plan is shared with the medical terminal and the patient terminal data, and the business process is integrated. The follow-up questionnaire will be pushed to the patient terminal as soon as possible, and the patient will give feedback on the post-diagnosis follow-up work in time. If the patient does not give feedback in time, the medical terminal will remind the medical staff to intervene in the subsequent tasks that require manual intervention, so as to improve the continuity and effectiveness of the follow-up business, ensure that the post-diagnosis follow-up work is closely and organically connected with the treatment process, ensure that the medical staff understands the patient's recovery status, and provide data support for the subsequent personalized and targeted health intervention, medication guidance, life guidance, etc., so as to improve the patient's satisfaction and compliance, and be more conducive to the patient's recovery. BRIEF DESCRIPTION OF THE DRAWINGS

[0010] Figure 1 A schematic diagram of cross-system data interaction in an embodiment of the present invention; Figure 2 This is a flow chart of carrying out follow-up services in an embodiment of the present invention; Figure 3 This is a schematic diagram of the state flow after the follow-up plan is released in an embodiment of the present invention; Figure 4 Schematic diagram of the state flow of follow-up tasks after the follow-up plan is released in an embodiment of the present invention. DETAILED DESCRIPTION

[0011] The following will be combined with the drawings in the embodiments of the present invention to clearly and completely describe the technical solutions in the embodiments of the present invention. Obviously, the described embodiments are only part of the embodiments of the present invention, not all of the embodiments. Based on the embodiments of the present invention, all other embodiments obtained by ordinary technicians in this field without creative work are within the scope of protection of the present invention.

[0012] The present invention provides Figure 1 A post-diagnosis disease follow-up system as shown in , including a follow-up workstation, a medical staff terminal, and a patient terminal; The follow-up workstation includes a medical information docking module, a medical knowledge base module, a follow-up management module, and an education management module; the medical information docking module includes an in-hospital standard data set consisting of all medical information generated by patients during outpatient, hospitalization, and physical examination, as well as a health data set about the health status of patients input by patients and / or medical staff; the in-hospital standard data set is docked with the hospital's EMR system, HIS system, LIS system, and PACS system, etc., and the corresponding patient data set is obtained through technical methods such as interface transmission and queue monitoring; the medical knowledge base includes a guide library, a drug library, a disease library, a test and examination library, a professional follow-up form library, a medical scale library, and a health education material library issued by an authoritative medical association; the follow-up management module is used to screen the target follow-up patient group according to the characteristic information of the patient group, such as: the patient source includes outpatient, hospitalization, physical examination, discharge, age range, gender, disease diagnosis, and treatment department, etc., and configure a targeted follow-up path, including the follow-up questionnaire sent to the patient at each time of the follow-up path and the sending time. Among the selected follow-up patients, the system will create a corresponding follow-up project for each patient and generate follow-up tasks at the configured follow-up time node. Among them, follow-up tasks that require manual intervention by medical staff will be automatically added to the task list of the medical terminal; the education management module is used to formulate a post-diagnosis education plan for patients, and the education tasks generated according to the education plan will be automatically pushed through the patient terminal.

[0013] The medical staff terminal includes a follow-up task list generated according to the follow-up path configured according to the follow-up management. Different manual intervention time nodes can be set when creating the follow-up plan; detailed medical information of the follow-up object, including but not limited to: diagnosis information, medical order information, test information, examination images, health history, past history and other information; follow-up project information of the follow-up object, including the reasons for past follow-ups, information on the follow-up path, information on the issuance of follow-up questionnaires at the follow-up time node, information filled in the follow-up questionnaire and follow-up conclusions; the medical staff terminal can receive task push at the configured intervention node, which is convenient for medical staff to efficiently perform follow-up tasks without omissions; the follow-up node can provide two methods of questionnaire follow-up and voice follow-up. Medical staff can directly broadcast calls through the terminal to collect follow-up information from the follow-up object; the medical terminal is one of the mini-programs and apps.

[0014] The patient terminal is used to receive the follow-up form generated according to the follow-up plan configuration at the follow-up node. The patient can view and fill in the follow-up form according to his or her health status through the terminal; the content of the follow-up form filled in by the patient will be automatically synchronized to the follow-up workstation; the patient can view the health education articles pushed at the corresponding time point according to the education plan through the patient terminal; the patient uploads the blood sugar data, blood pressure data, and height and weight data measured in the out-of-hospital scene through the patient terminal. The system will automatically calculate the patient's BMI index according to the BMI calculation formula, and synchronize the patient's blood sugar data and blood pressure data to the follow-up workstation. The doctor can timely understand the patient's physical health status at the follow-up workstation. The patient terminal is one of the App and the mini program.

[0015] Furthermore, if Figure 1 As shown, in order to realize the interconnection of patient data inside and outside the hospital, the system is connected with the hospital system, such as HIS, EMR, LIS, PACS, etc. through the interface to obtain the medical data and personal basic data generated by the patient in the hospital. This part of information will be stored in the system database deployed in the hospital for the follow-up workstation to call. The data of the patient terminal and the medical terminal are stored in the off-hospital database and kept in real time synchronization with the follow-up workstation in the hospital.

[0016] The present invention further provides Figure 2 A follow-up method of a post-diagnosis disease management follow-up system is shown, comprising the following steps: a) Follow-up plan configuration step, which is used to define the characteristics of the follow-up object, including the patient source (outpatient, inpatient, physical examination, discharge), age range, gender, disease diagnosis, and treatment department; configure the follow-up path and the follow-up nodes that constitute the follow-up path; define the content and time period of the follow-up task for each follow-up node; select the sending method of the follow-up task, which can be one of SMS, WeChat, and phone call; b) Automated follow-up steps: The follow-up plan sends follow-up content to the configured follow-up objects at regular intervals according to the configured content. Patients can receive and provide feedback on the follow-up content through the patient terminal. The follow-up data received and fed back by the patient terminal and the follow-up data received and displayed by the follow-up workstation are synchronously stored in a database and saved in the hospital's intranet; c) Manual intervention step: if the follow-up task exceeds the set threshold and does not receive any feedback, it will automatically enter the task list of the medical staff at the follow-up workstation, and the medical staff will intervene manually to collect the patient's health information.

[0017] like Figure 3 As shown, after the medical staff completes the creation of the follow-up plan at the follow-up workstation, the plan is in an unpublished state. At this time, the plan can still be re-edited and adjusted. The medical staff can change the follow-up object, follow-up content and the time period for sending the follow-up plan.

[0018] Furthermore, the corresponding follow-up person in charge can open the follow-up plan he is responsible for in the follow-up list, and the follow-up plan will be changed to being executed. The executed follow-up plan will screen out the target follow-up population from the hospital system according to the characteristics of the follow-up objects configured in the follow-up plan, and create corresponding follow-up sending tasks for all follow-up objects according to the follow-up path. During the execution cycle of the follow-up plan, the follow-up system will automatically execute the created follow-up tasks, and collect and count the follow-up forms filled out and uploaded by the patients. After the execution cycle of the follow-up plan ends, the status of the follow-up plan changes to ended, and the completed follow-up plan can be managed or deleted through the follow-up workstation.

[0019] Furthermore, if Figure 4 As shown, a number of follow-up tasks will be created during the execution of the follow-up plan. These follow-up tasks can be configured in detail through the follow-up workstation, including the manual intervention time nodes of the follow-up plan and the expiration time of the follow-up plan. The manual intervention refers to the follow-up method in which the system automatically reminds the follow-up person in charge to conduct manual follow-up intervention on the patient when the follow-up task is issued at the specified time and the patient does not fill in and upload it immediately within the specified time. The medical terminal provides a dialing function, which provides convenience for medical staff to contact patients directly at the terminal, further improves the compliance of patients after diagnosis, increases the frequency of communication between doctors and patients, and increases the stickiness between medical services and patients.

[0020] The post-diagnosis disease management follow-up system and its follow-up method obtain the patient's basic information and medical information by connecting to the hospital's HIS, EMR and other systems, and use the medical record information generated by the patient's full medical process as the basis for accurately conducting follow-up services, thereby improving the coverage and quality of post-hospital management, and conducting standardized management of post-diagnosis follow-up by connecting data inside and outside the hospital, thereby improving the efficiency of post-diagnosis follow-up while reducing the workload of medical staff, and improving the patient's post-diagnosis management effect and satisfaction through accurate information collection and analysis; through the medical knowledge base, authoritative and professional follow-up forms and follow-up path designs are provided, and the information docking module obtains the medical data generated by the patient during the medical treatment process, and integrates the data generated by the patient in the hospital with the data generated outside the hospital, integrating the patient data inside and outside the hospital, and clearly and comprehensively displaying it on the system page, providing better support for medical staff for subsequent business; for abnormal physical signs data of patients inside and outside the hospital, abnormal message reminders are given to medical staff, allowing medical staff to fully grasp the real-time and comprehensive status of patients. The system uses the vital sign data of patients to provide patients with better and more comprehensive follow-up services; it realizes cross-system data docking, provides strong data support for the subsequent follow-up business, and facilitates medical workers to formulate targeted post-diagnosis follow-up plans according to the characteristics of different patient groups. The matching and accuracy of the follow-up are effectively guaranteed, and it provides a basis for the dynamic adjustment of the follow-up plan; at the same time, the follow-up plan is shared with the medical terminal and the patient terminal data, and the business process is integrated. The follow-up questionnaire will be pushed to the patient terminal as soon as possible, and the patient will provide feedback on the post-diagnosis follow-up work in a timely manner. If the patient does not provide feedback in time, the medical terminal will remind the medical staff to intervene in the subsequent tasks that require manual intervention, improve the continuity and effectiveness of the follow-up business, ensure that the post-diagnosis follow-up work is closely and organically connected with the treatment process, ensure that the medical staff understands the patient's recovery status, and provide data support for the subsequent personalized and targeted health intervention, medication guidance, life guidance, etc., so as to improve the patient's satisfaction and compliance, and be more conducive to the patient's recovery.

[0021] Finally, it should be noted that the above is only a preferred embodiment of the present invention and is not intended to limit the present invention. Although the present invention has been described in detail with reference to the aforementioned embodiments, it is still possible for those skilled in the art to modify the technical solutions described in the aforementioned embodiments or to make equivalent substitutions for some of the technical features therein. Any modifications, equivalent substitutions, improvements, etc. made within the spirit and principles of the present invention should be included in the protection scope of the present invention.

Claims

1. A post-diagnosis disease management follow-up system, characterized by: include: Follow-up workstation; The follow-up workstation includes: Medical information docking module, including in-hospital standard data sets and health data sets; Medical knowledge base module, used to store medical database; The follow-up management module is used to screen the target follow-up patient group and configure targeted follow-up paths based on the characteristic information of the patient group; The education management module is used to formulate a post-diagnosis education plan for patients, and automatically push the education tasks generated according to the education plan to patients; A medical staff terminal, configured to generate a follow-up task list according to the follow-up path of the follow-up management configuration and receive task push at the intervention node; The patient terminal is used to receive the follow-up form generated according to the follow-up plan configuration at the follow-up node, and the patient reviews and fills in the follow-up form according to his or her own health status; the content of the follow-up form filled in by the patient will be automatically synchronized to the follow-up workstation.

2. A post-diagnosis disease management follow-up system according to claim 1, characterized in that: The in-hospital standard data set is connected with the hospital's EMR system, HIS system, LIS system and PACS system through interface transmission and queue monitoring to obtain the patient's data set; The interface transmission and queue monitoring method comprises: real-time monitoring through an MQ message queue, receiving transmission data, and storing the transmission data in a database.

3. A post-diagnosis disease management follow-up system according to claim 1, characterized in that: The medical database includes: a guideline library, a drug library, a disease library, a test and examination library, a professional follow-up form library, a medical scale library and a health education material library published by an authoritative medical association.

4. A post-diagnosis disease management follow-up system according to claim 1, characterized in that: The characteristic information includes: patient origin, age range, gender, disease diagnosis and treatment department; Among them, patient source types include outpatient, inpatient, physical examination, and discharge.

5. A post-diagnosis disease management follow-up system according to claim 1, characterized in that: The follow-up management module formulates screening rules based on patient source, diagnosis, department, age, and gender, creates a corresponding follow-up project for each patient in the screened follow-up patient group, and generates a follow-up task at the configured follow-up time node; Among them, follow-up tasks requiring manual intervention will be automatically added to the task list of the medical terminal.

6. A post-diagnosis disease management follow-up system according to claim 1, characterized in that: The types of the medical staff terminal and the patient terminal are App and / or mini-program.

7. The follow-up method of the post-diagnosis disease management follow-up system according to claim 1, characterized in that: include: Follow-up plan configuration step, defining the characteristics of the follow-up subjects, including patient source, age range, gender, disease diagnosis, and treatment department; Configure a follow-up path and follow-up nodes constituting the follow-up path; Define the content and time period of each follow-up task; select the method of sending the follow-up task; Automated follow-up steps: The follow-up plan sends follow-up content to the configured follow-up subjects at regular intervals according to the configured content. The patients receive and provide feedback on the follow-up content through the patient terminal. The follow-up data received and fed back by the patient terminal and the follow-up data received and displayed by the follow-up workstation are stored in the database synchronously; In the manual intervention step, if the follow-up task exceeds the set threshold and no feedback is received, it will automatically enter the task list of the medical staff at the follow-up workstation. The medical staff will conduct manual intervention to collect the patient's health information.

8. The follow-up method of the post-diagnosis disease management follow-up system according to claim 7, characterized in that: In the follow-up plan configuration step, after the follow-up plan is created, the plan is in an unpublished state and can be re-edited and adjusted. The medical staff can change the follow-up object, follow-up content and follow-up sending time period of the follow-up plan.

9. The follow-up method of the post-diagnosis disease management follow-up system according to claim 7, characterized in that: The follow-up method also includes: the follow-up plan being executed screens out the target follow-up population from the hospital system according to the characteristics of the follow-up objects configured in the follow-up plan, and creates corresponding follow-up sending tasks for all follow-up objects according to the follow-up path; during the execution cycle of the follow-up plan, the follow-up system will automatically execute the created follow-up tasks, and collect and count the follow-up forms filled out and uploaded by the patients. After the execution cycle of the follow-up plan ends, the status of the follow-up plan is changed to ended, and the completed follow-up plan can be managed or deleted through the follow-up workstation.

10. The follow-up method of the post-diagnosis disease management follow-up system according to claim 9, characterized in that: The follow-up plan can create several follow-up tasks during execution, and the follow-up tasks can be configured in detail through the follow-up workstation; specifically including: the manual intervention time node of the follow-up plan and the expiration time of the follow-up plan; Among them, the manual intervention includes: when the follow-up task is issued at a specified time and the patient does not fill in and upload it immediately within the specified time, the system automatically reminds the follow-up person in charge to conduct manual follow-up intervention on the patient.

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