Chronic disease tracking management system

Abstract

The invention discloses a chronic disease tracking management system, and belongs to the technical field of chronic disease patient management, and the system comprises a primary medical worker training module which is used for carrying out the skill and knowledge training of primary medical workers; the patient baseline data collection module is used for collecting patient baseline data and performing data analysis; the patient tracking guidance module is used for providing main control index monitoring guidance, daily nursing guidance, prevention control guidance, insulin injection guidance and the like for the patient; the prevention and improvement action plan module is used for monitoring health indexes of the patient, and regularly evaluating and timely adjusting a treatment scheme; analyzing and providing improvement suggestions according to the living habits of the patient; and the medical nutrition treatment module is used for formulating a personalized diet scheme with balanced nutrition for the patient. The system is intelligent, personalized and comprehensive, the chronic disease management level is integrally improved, and chronic disease prevention and treatment work is facilitated.

Description

Technical Field

[0001] The present invention mainly relates to the technical field of chronic disease patient management, and specifically to a chronic disease tracking and management system. Background Art

[0002] With the development of society and the improvement of people's living standards, chronic diseases have become one of the main diseases affecting human health. In my country, the number of patients with chronic diseases has increased year by year, bringing a heavy burden to families and society. The key to chronic disease management lies in long-term, systematic and personalized tracking and guidance of patients, so as to effectively control the disease and reduce the incidence of complications.

[0003] In the existing technology, chronic disease management mainly relies on the manual services of medical staff, but due to the limited number of medical staff, it is difficult to effectively manage a large number of chronic disease patients. In addition, the traditional chronic disease management model has the following shortcomings:

[0004] (1) The skills and knowledge levels of primary care medical staff vary, resulting in low levels of management of patients with chronic diseases;

[0005] (2) Patient follow-up guidance lacks personalization and is difficult to meet the needs of different patients;

[0006] (3) The prevention and improvement action plans were not implemented properly, and the patient health indicators were not monitored and the treatment plans were not adjusted in a timely manner;

[0007] (4) Insufficient analysis of patients’ lifestyle habits and suggestions for improvement lead to poor results in the prevention and treatment of chronic diseases. Summary of the invention

[0008] The technical solution of the present invention aims at the technical problem that the existing technical solutions are too single, and provides a solution that is significantly different from the existing technologies. It mainly provides a chronic disease tracking and management system to solve the technical problems that the traditional chronic disease management model proposed in the above background technology has many shortcomings.

[0009] The technical solution adopted by the present invention to solve the above technical problems is:

[0010] A chronic disease tracking and management system, comprising:

[0011] Primary care medical staff training module, used to train primary care medical staff in skills and knowledge;

[0012] Patient baseline data collection module, used to collect patient baseline data and perform data analysis;

[0013] Patient tracking and guidance module, used to provide patients with guidance on monitoring of main control indicators, daily care guidance, prevention and control guidance, insulin injection guidance, etc.;

[0014] The prevention and improvement action plan module is used to monitor the patient's health indicators, conduct regular assessments and timely adjust treatment plans; and analyze the patient's living habits and provide improvement suggestions;

[0015] Medical nutrition therapy module, used to develop a personalized and nutritionally balanced dietary plan for patients.

[0016] Furthermore, the grassroots medical staff training module includes:

[0017] The online training platform unit stores the causes, pathology, clinical manifestations, and treatment methods of common chronic diseases, so that primary care workers can learn relevant knowledge about chronic diseases.

[0018] Practical skills training unit, including operation video tutorials and practical online teaching platform, used to train medical staff's practical skills;

[0019] The assessment and evaluation unit has an online examination system to evaluate the learning outcomes of medical staff and ensure the effectiveness of training.

[0020] Furthermore, the patient baseline data collection module includes:

[0021] The questionnaire design unit designs questionnaires covering basic information, condition, and lifestyle habits based on the characteristics of patients with chronic diseases;

[0022] The data collection and analysis unit collects patient baseline information through an online questionnaire system and performs data analysis.

[0023] Furthermore, the patient tracking guidance module includes:

[0024] The main control indicator monitoring guidance unit provides patients with personalized main control indicator monitoring plans;

[0025] Daily care guidance unit, which teaches patients the key points of care in daily life through pictures, texts and / or videos;

[0026] The prevention and control guidance unit stores the relevant content of chronic disease prevention knowledge and / or the knowledge base of complication prevention;

[0027] The insulin injection guidance unit provides patients with insulin injection technique training.

[0028] Furthermore, the prevention and improvement action plan module includes:

[0029] Health monitoring units monitor patient indicators in real time through smart devices to achieve data-based management; and / or track patients' living habits through wearable devices and provide feedback to patients and medical staff through the system;

[0030] The evaluation plan unit conducts regular health assessments on patients and adjusts treatment plans when necessary;

[0031] The Risky Behavior Identification and Intervention Unit analyses patients’ lifestyle habits, identifies risky behaviors, and provides targeted intervention measures and / or develops individualized lifestyle improvement plans.

[0032] Furthermore, the medical nutrition therapy module includes:

[0033] Nutritional assessment unit, to assess the nutritional status of patients;

[0034] The personalized nutrition plan providing unit formulates a nutritionally balanced diet plan based on the patient's condition, constitution, and taste factors;

[0035] The nutrition education unit conducts online nutrition knowledge lectures to improve patients' nutritional literacy.

[0036] Furthermore, the grassroots medical staff training module also includes a training file establishment unit for recording the training history and achievements of medical staff.

[0037] Furthermore, it also includes a primary care work management module, specifically including:

[0038] Electronic health record unit, used to establish unified electronic health records and realize digital management of patient information;

[0039] Workflow Optimization Unit, used to design standardized chronic disease management processes;

[0040] The data-driven decision support unit uses big data analysis technology to provide decision support for grassroots health managers.

[0041] The remote collaboration platform unit promotes communication between grassroots medical staff and experts from higher-level hospitals by establishing a remote collaboration platform.

[0042] Furthermore, it also includes a high-risk population service module and an incentive mechanism module;

[0043] The high-risk population service module includes:

[0044] High-risk population identification unit, which identifies high-risk populations based on data analysis;

[0045] Lifestyle Intervention Program Module, which is used to develop specific lifestyle intervention programs for high-risk groups;

[0046] The community activity promotion unit works with the community to carry out activities to promote healthy lifestyles;

[0047] The Psychological Support Services Unit provides counseling and group counseling to help patients overcome psychological barriers to lifestyle changes;

[0048] The incentive mechanism module encourages patients to complete health tasks by establishing a points system.

[0049] Furthermore, it also includes an expert consulting service module and a peer communication and mutual assistance module;

[0050] Expert consulting service modules include:

[0051] Online expert consultation platforms that allow patients to communicate with professional doctors through video calls, instant messaging or appointment booking systems;

[0052] An expert database unit is used to recommend appropriate experts based on the patient's specific conditions;

[0053] Consultation record management unit, which is used to realize electronic management of consultation records, so that patients and doctors can track treatment progress;

[0054] The peer communication and mutual assistance module includes:

[0055] The peer support group unit promotes communication and mutual assistance among patients through the system platform;

[0056] a peer skills coaching unit, where instruction is provided by experienced patients;

[0057] Skill-based interactive simulation practice sessions to help patients master necessary self-care skills;

[0058] Skills challenges and certification modules to motivate patients to learn and improve their skills.

[0059] Compared with the prior art, the present invention has the following beneficial effects:

[0060] (1) The present invention can improve the skills and knowledge level of grassroots medical staff about chronic diseases through the grassroots medical staff training module; can improve patients' understanding of chronic diseases and daily care operation skills through the patient tracking and guidance module; can timely adjust the treatment plan according to the patient's health indicators through the prevention and improvement action plan module, and provide suggestions for improving living habits; and can formulate personalized and nutritionally balanced diet plans for patients through the medical nutrition treatment module. The present invention is intelligent, personalized and comprehensive, which improves the overall level of chronic disease management and contributes to the prevention and treatment of chronic diseases.

[0061] (2) The optimization scheme of the present invention can help diabetic patients improve their living habits in a more targeted manner, make health management more systematic, improve the efficiency of grassroots health management, and encourage high-risk groups to change their unhealthy lifestyles through the setting of grassroots nursing work management modules, high-risk population service modules, and incentive mechanism modules. It can better promote diabetic patients to develop good living habits; improve the grassroots nursing work management model; and encourage the key service objects of health management to change their unhealthy lifestyles.

[0062] (3) The optimization scheme of the present invention improves patient participation and satisfaction and enhances interactivity through the setting of expert consultation service module and peer communication and mutual assistance module; helps patients to better manage their diseases and promotes patient self-management; can more comprehensively meet the health management needs of chronic disease patients and improve the practicality of the system.

[0063] The present invention will be explained in detail below with reference to the accompanying drawings and specific embodiments. BRIEF DESCRIPTION OF THE DRAWINGS

[0064] Figure 1 It is a structural block diagram of the present invention in the second embodiment;

[0065] Figure 2 It is a structural block diagram of the present invention in the third embodiment;

[0066] Figure 3 This is a structural block diagram of the present invention in Embodiment 4.

[0067] Figures: 1. Primary care medical staff training module; 11. Online training platform unit; 12. Practical skills training unit; 13. Assessment and evaluation unit; 14. Training file establishment unit; 2. Patient baseline data collection module; 21. Questionnaire design unit; 22. Data collection and analysis unit; 3. Patient tracking guidance module; 31. Main control indicator monitoring guidance unit; 32. Daily care guidance unit; 33. Prevention and control guidance unit; 34. Insulin injection guidance unit; 4. Prevention and improvement action plan module; 41. Health monitoring unit; 42. Assessment plan unit; 43. Risk behavior identification and intervention unit; 5. Medical nutrition therapy module; 51. Nutrition assessment unit; 52. Personalized nutrition plan provision unit; 53. Nutrition education module Education unit; 6. Primary care management module; 61. Electronic health record unit; 62. Workflow optimization unit; 63. Data-driven decision support unit; 64. Remote collaboration platform unit; 7. High-risk population service module; 71. High-risk population identification unit; 72. Lifestyle intervention plan unit; 73. Community activity promotion unit; 74. Psychological support service unit; 8. Incentive mechanism module; 9. Expert consultation service module; 91. Online expert consultation platform; 92. Expert database unit; 93. Consultation record management unit; 10. Peer communication and mutual assistance module; 101. Peer support group unit; 102. Peer skill guidance unit; 103. Skill interactive simulation practice unit; 104. Skill challenge and certification unit. DETAILED DESCRIPTION

[0068] To facilitate understanding of the present invention, the present invention will be described more comprehensively below with reference to the relevant drawings. Several embodiments of the present invention are given in the drawings, but the present invention can be implemented in different forms and is not limited to the embodiments described in the text. On the contrary, these embodiments are provided to make the content disclosed in the present invention more thorough and comprehensive.

[0069] Example 1: Please refer to the attached Figure 1 , a chronic disease tracking management system, including a primary care medical staff training module 1, a patient baseline data collection module 2, a patient tracking guidance module 3, a prevention and improvement action plan module 4, and a medical nutrition treatment module 5;

[0070] (1) Primary care medical staff training module 1 is used to train primary care medical staff in skills and knowledge. Specifically includes:

[0071] Online training platform unit 11: stores the causes, pathology, clinical manifestations, treatment methods, etc. of common chronic diseases such as diabetes and hypertension (in the form of documents, teaching videos, etc.) for primary care medical staff to learn relevant knowledge about chronic diseases;

[0072] Practical Skills Training Unit 12: including operation video tutorials, practical online teaching platforms, etc., used to train medical staff in blood sugar monitoring, insulin injection, dietary therapy and other skills;

[0073] Assessment and Evaluation Unit 13: Establish an online examination system to evaluate the learning outcomes of medical staff and ensure the effectiveness of training.

[0074] (2) Patient baseline data collection module 2 is used to collect patient baseline data and perform data analysis. Specifically including:

[0075] Questionnaire Design Unit 21: Design a questionnaire covering basic information, condition, lifestyle, etc. based on the characteristics of diabetic patients;

[0076] Data Collection and Analysis Unit 22: Collect patient baseline information through an online questionnaire system and conduct data analysis to provide reference for developing personalized treatment plans.

[0077] (3) Patient tracking and guidance module 3 is used to provide patients with blood glucose monitoring guidance, daily care guidance, prevention and control guidance, insulin injection guidance, etc. Specifically including:

[0078] Main control indicator monitoring guidance unit 31: Provide patients with personalized blood sugar monitoring plans, including monitoring frequency, methods, etc.;

[0079] Daily Care Guidance Unit 32: Through pictures, texts, videos, etc., it teaches patients the key points of care in daily life, such as skin care, foot care, etc.;

[0080] Prevention and control guidance unit 33: popularize diabetes prevention knowledge and improve patients' self-management ability;

[0081] Insulin injection guidance unit 34: Provide patients with insulin injection technique training to ensure safe and effective injections.

[0082] (4) Prevention and Improvement Action Plan Module 4 is used to monitor the patient's health indicators, conduct regular assessments, and adjust treatment plans in a timely manner; as well as analyze the patient's lifestyle habits and provide improvement suggestions. Specifically, it includes:

[0083] Health monitoring unit 41: real-time monitoring of blood sugar, blood pressure and other indicators of patients through smart devices to achieve data-based management;

[0084] Evaluation Program Unit 42: Regularly evaluate the patient's health and adjust the treatment plan when necessary;

[0085] Risky Behavior Identification and Intervention Unit 43: Analyze patients’ lifestyle habits, identify risky behaviors, and provide targeted intervention measures.

[0086] (5) Medical nutrition therapy module 5 is used to formulate personalized and nutritionally balanced dietary plans for patients. Specifically including:

[0087] Nutritional Assessment Unit 51: Assess the nutritional status of patients and provide a basis for formulating nutritional treatment plans;

[0088] Personalized nutrition plan provision unit 52: formulate a nutritionally balanced diet plan based on the patient's condition, constitution, taste and other factors;

[0089] Nutrition Education Unit 53: Conduct online nutrition knowledge lectures to improve patients’ nutritional literacy.

[0090] The above-mentioned chronic disease tracking and management system uses technologies such as big data and the Internet of Things to achieve real-time monitoring and analysis of patient health data, which reflects the intelligence of the present invention; it provides personalized health management plans based on factors such as the patient's condition and constitution, which reflects the personalization of the present invention; it has modules suitable for medical staff and patients respectively, which reflects the comprehensiveness of the present invention and is easy to use for grassroots medical staff and patients; it improves the overall level of chronic disease management and contributes to the prevention and treatment of chronic diseases.

[0091] Embodiment 2: This embodiment differs from Embodiment 1 in that:

[0092] Please refer to the attached Figure 1 The grassroots medical staff training module 1 also includes a training file establishment unit 14, which is used to record the training history and achievements of medical staff in order to conduct competency assessment and qualification certification.

[0093] The prevention and control guidance unit 33 also adds a knowledge base on complication prevention, educating patients through videos, articles, etc. on how to prevent complications by improving their lifestyle habits.

[0094] The health monitoring unit 41 uses the Internet of Things technology to track the patient's living habits, such as the number of steps, sleep quality, etc., through wearable devices, and feeds back to the patient and medical staff through the system.

[0095] The risky behavior identification and intervention unit 43 also develops personalized lifestyle improvement plans based on the analysis of the patient's lifestyle habits, including exercise, work and rest schedules, etc., and provides real-time reminders and guidance through mobile applications.

[0096] The rest is the same as the first embodiment.

[0097] Embodiment 3: This embodiment differs from Embodiment 2 in that:

[0098] Please refer to the attached Figure 2 , and also includes primary care work management module 6, high-risk population service module 7 and incentive mechanism module 8.

[0099] (6) Primary care work management module 6 specifically includes:

[0100] Electronic Health Records Unit 61: Establish a unified electronic health record to realize the digital management of patient information, which is convenient for medical staff to quickly query and update;

[0101] Workflow Optimization Unit 62: Design standardized chronic disease management processes to reduce duplication of work and improve work efficiency;

[0102] Data-driven decision support unit 63: Use big data analysis technology to provide decision support to grassroots health managers, such as resource allocation, health intervention priorities, etc.

[0103] Remote collaboration platform unit 64: Establish a remote collaboration platform to promote communication between grassroots medical staff and experts from higher-level hospitals and improve service quality.

[0104] (7) Module 7 of services for high-risk groups specifically includes:

[0105] High-risk population identification unit 71: Through data analysis, identify high-risk groups and carry out targeted health education and intervention;

[0106] Lifestyle Intervention Program Unit 72: Develop specific lifestyle intervention plans for high-risk groups, such as smoking cessation, alcohol restriction, weight loss, etc.;

[0107] Community Activities Promotion Unit 73: Cooperate with the community to carry out healthy lifestyle promotion activities, such as health lectures, sports clubs, etc.;

[0108] Psychological Support Services Unit 74: Provides psychological counseling and group support to help patients overcome psychological barriers to lifestyle changes.

[0109] (8) Incentive mechanism module 8, through the establishment of a points system, patients are encouraged to complete health tasks, such as reaching daily step goals, healthy diet, etc. The points can be used to redeem health gifts or services.

[0110] The above chronic disease tracking and management system can help diabetic patients improve their living habits in a more targeted manner through personalized plans and tracking feedback; make health management more systematic by establishing electronic health records and standardized work processes; improve the efficiency of primary health management through data analysis and remote collaboration; and encourage high-risk groups to change their unhealthy lifestyles and reduce the occurrence of chronic diseases through education and intervention. It can better promote diabetic patients to develop good living habits; improve the management model of primary care work; and promote the transformation of unhealthy lifestyles of key service targets of health management.

[0111] Embodiment 4: This embodiment differs from Embodiment 3 in that:

[0112] Please refer to the attached Figure 3 , also includes an expert consulting service module 9 and a peer communication and mutual assistance module 10.

[0113] (9) Expert consulting service module 9 specifically includes:

[0114] 91, an online expert consultation platform, allows patients to communicate with professional doctors through video calls, instant messaging or appointment booking systems;

[0115] An expert database unit 92, used to recommend corresponding experts according to the specific conditions of the patient;

[0116] The consultation record management unit 93 is used to realize the electronic management of consultation records, so as to facilitate patients and doctors to track the progress of treatment.

[0117] (10) The peer communication and mutual assistance module 10 specifically includes:

[0118] Peer support group unit 101 promotes communication and mutual assistance among patients through the system platform; such as sharing of successful cases and experience exchange, so as to improve patients' self-management ability;

[0119] Peer Skills Instruction Unit 102, where experienced patients provide instruction on such subjects as insulin injection and blood sugar monitoring;

[0120] Skills interactive simulation exercise unit 103 is used to help patients master necessary self-care skills;

[0121] Skills Challenge and Certification Unit 104 is used to motivate patients to learn and improve their skill levels.

[0122] The above chronic disease tracking management system improves patient participation and satisfaction and enhances interactivity through expert consultation and peer support; health education and skill guidance among peers help patients better manage their diseases and promote self-management. The optimized system can more comprehensively meet the health management needs of chronic disease patients and improve the practicality of the system.

[0123] The above is an exemplary description of the present invention in combination with the accompanying drawings. It is obvious that the specific implementation of the present invention is not limited to the above-mentioned method. As long as such non-substantial improvements are made by adopting the method concept and technical solution of the present invention, or the concept and technical solution of the present invention are directly applied to other occasions without improvement, they are all within the protection scope of the present invention.

Claims

1. A chronic disease tracking and management system, characterized by: include: Primary care staff training module (1), used to train primary care staff in skills and knowledge; A patient baseline data collection module (2), used to collect patient baseline data and perform data analysis; Patient tracking and guidance module (3), used to provide patients with guidance on monitoring of main control indicators, daily care guidance, prevention and control guidance, insulin injection guidance, etc.; The prevention and improvement action plan module (4) is used to monitor the patient's health indicators, conduct regular assessments and timely adjust treatment plans; and analyze the patient's lifestyle habits and provide improvement suggestions; The medical nutrition therapy module (5) is used to develop a personalized and nutritionally balanced dietary plan for the patient.

2. A chronic disease tracking and management system according to claim 1, characterized in that: The grassroots medical staff training module (1) includes: The online training platform unit (11) stores the causes, pathology, clinical manifestations, and treatment methods of common chronic diseases, so that primary care workers can learn relevant knowledge about chronic diseases; Practical skills training unit (12), including operation video tutorials and practical online teaching platform, used to train medical staff in practical skills; The assessment and evaluation unit (13) is equipped with an online examination system to evaluate the learning outcomes of medical staff and ensure the effectiveness of training.

3. The chronic disease tracking and management system according to claim 1, characterized in that: The patient baseline data collection module (2) comprises: Questionnaire design unit (21): based on the characteristics of patients with chronic diseases, a questionnaire covering basic information, condition, and lifestyle habits is designed; The data collection and analysis unit (22) collects patient baseline information through an online questionnaire system and performs data analysis.

4. The chronic disease tracking and management system according to claim 1, characterized in that: The patient tracking guidance module (3) comprises: A main control indicator monitoring guidance unit (31) provides patients with a personalized main control indicator monitoring plan; Daily care guidance unit (32), which teaches patients the key points of care in daily life through pictures, texts and / or videos; A prevention and control guidance unit (33) stores content related to chronic disease prevention knowledge and / or a knowledge base for complication prevention; The insulin injection guidance unit (34) provides patients with training on insulin injection techniques.

5. The chronic disease tracking and management system according to claim 1, characterized in that: The prevention and improvement action plan module (4) includes: A health monitoring unit (41) monitors patient indicators in real time through smart devices to achieve data-based management; and / or tracks the patient's living habits through wearable devices and provides feedback to the patient and medical staff through the system; Assessment plan unit (42), which regularly assesses the patient's health and adjusts the treatment plan when necessary; The risky behavior identification and intervention unit (43) analyzes patients’ lifestyle habits, identifies risky behaviors, and provides targeted intervention measures and / or develops personalized lifestyle improvement plans.

6. The chronic disease tracking and management system according to claim 1, characterized in that: The medical nutrition therapy module (5) comprises: Nutritional Assessment Unit (51), which assesses the nutritional status of patients; A personalized nutrition plan providing unit (52) formulates a nutritionally balanced diet plan based on the patient's condition, constitution, and taste factors; Nutrition education unit (53) conducts online nutrition knowledge lectures to improve patients' nutritional literacy.

7. The chronic disease tracking and management system according to claim 2, characterized in that: The grassroots medical staff training module (1) also includes a training file establishment unit (14) for recording the training history and achievements of medical staff.

8. A chronic disease tracking and management system according to any one of claims 1 to 7, characterized in that: It also includes a primary care work management module (6), which specifically includes: An electronic health record unit (61), used to establish a unified electronic health record and realize digital management of patient information; Workflow Optimization Unit (62), used to design standardized chronic disease management processes; The data-driven decision support unit (63) uses big data analysis technology to provide decision support for grassroots health managers. The remote collaboration platform unit (64) promotes communication between primary care medical staff and experts from higher-level hospitals by establishing a remote collaboration platform.

9. A chronic disease tracking and management system according to any one of claims 1 to 7, characterized in that: It also includes a high-risk population service module (7) and an incentive mechanism module (8); The high-risk population service module (7) comprises: A high-risk population identification unit (71), which identifies high-risk populations based on data analysis; Lifestyle intervention program module (72), which is used to develop specific lifestyle intervention programs for high-risk groups; Community Activities Promotion Unit (73), working with the community to carry out activities to promote healthy lifestyles; Psychological support service unit (74), which provides psychological counseling and group counseling to help patients overcome psychological barriers to lifestyle changes; The incentive mechanism module (8) encourages patients to complete health tasks by establishing a points system.

10. A chronic disease tracking and management system according to any one of claims 1 to 7, characterized in that: It also includes an expert consulting service module (9) and a peer communication and mutual assistance module (10); The expert consulting service module (9) includes: Online expert consultation platforms (91) allow patients to communicate with professional doctors through video calls, instant messaging or appointment systems; An expert database unit (92), used for recommending corresponding experts according to the specific conditions of the patient; A consultation record management unit (93), used to realize electronic management of consultation records, so as to facilitate patients and doctors to track treatment progress; The peer communication and mutual assistance module (10) includes: The peer support group unit (101) promotes communication and mutual assistance among patients through the system platform; peer skills coaching unit (102), where coaching is provided by experienced patients; Skill-based interactive simulation practice unit (103) to help patients master necessary self-care skills; Skills Challenge and Certification Unit (104) is used to motivate patients to learn and improve their skill levels.

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