Intelligent management platform of grassroots chronic disease screening and preventing center

Abstract

The invention relates to the technical field of chronic disease prevention and treatment, and discloses a grassroots chronic disease screening and prevention center intelligent management platform which comprises a multi-disease follow-up visit management module, a signing-fulfillment-integral closed loop module, a risk assessment and health intervention module, a cross-system data linkage module, a data statistics and evaluation module and a multi-terminal adaptation and safety module. Through the multi-disease integrated follow-up management technology, the general situation that one person has multiple diseases can be adapted, combined filing of multiple chronic diseases and personalized follow-up plan generation are supported, follow-up tasks can be intelligently combined, the follow-up state can be accurately tracked, the medical care operation efficiency is remarkably improved, and a more efficient solution is provided for follow-up management of the basic chronic diseases.

Description

Technical Field

[0001] This invention relates to the field of chronic disease prevention and control technology, and more specifically discloses a smart management platform for grassroots chronic disease screening and prevention centers. Background Technology

[0002] Chronic diseases at the grassroots level refer to common chronic non-communicable diseases such as hypertension, diabetes, and chronic obstructive pulmonary disease within the scope of community and township primary healthcare services. Due to the continuous rise in the incidence of chronic diseases and the trend of "multiple diseases coexisting and affecting younger people", they have become a major factor threatening residents' health and consuming public medical resources. Therefore, systematic prevention and control are needed.

[0003] The prior art patent document with authorization announcement number CN117292848A discloses a "Health Management System and Method for Intelligent Screening of Chronic Diseases Based on the Integration of Medical Treatment and Prevention," which includes an application terminal for acquiring users' daily health data, including routine physical indicators, daily dietary data, daily medication data, and mental health data; the application terminal includes an analysis module for acquiring and analyzing the daily health data sent to users by the application terminal to obtain analysis results; a system platform including a feedback module for conducting expert diagnoses based on the analysis results provided by the analysis module and uploading the expert diagnoses; and a database for storing health data of healthy users and health data of non-healthy users. The patent document with authorization announcement number CN115798715B discloses a "Chronic Respiratory Disease Prevention and Control Information Management System Based on Data Analysis," which includes a platform module. The platform module includes a PC-side business system, a doctor-side WeChat mini-program, and a patient-side WeChat mini-program. The PC-side business system module includes a respiratory chronic disease screening system, a three-level collaborative system, and an intelligent assessment management system. The respiratory chronic disease screening system collects basic information about patients, screens for symptoms, and automatically generates screening results. The intelligent assessment management system assesses patients' symptoms.

[0004] While existing technologies can construct a collaborative system for screening, diagnosis, and follow-up, enabling tiered and continuous management of some chronic diseases and reducing the risk of acute exacerbations of specific chronic diseases, and can acquire multi-dimensional health data from users to provide preliminary management suggestions through data analysis, improve data detection accuracy by connecting to smart devices, and provide references for diagnosis and treatment through knowledge base support and data sharing, most existing technologies focus on the management of single or specific categories of chronic diseases, making it difficult to adapt to the common situation of "one person with multiple diseases" at the grassroots level. Data on different chronic disease management are isolated from each other, and the data interaction with external medical systems lacks a standardized, full-process linkage mechanism, which easily leads to data silos or data entry errors. At the same time, contracted services often lack closed-loop management of "contracting-fulfillment-tracking-feedback," making it difficult to guarantee service matching and fulfillment quality. Furthermore, no effective positive incentive mechanism for patients has been established, resulting in insufficient patient compliance in follow-up and health intervention. In addition, risk assessment often relies on a few test indicators and does not fully integrate multi-dimensional data such as lifestyle, family history, and traditional Chinese medicine constitution, resulting in limited accuracy of early warning. Summary of the Invention

[0005] The main technical problem solved by this invention is to provide a smart management platform for grassroots chronic disease screening and prevention centers, which can solve the problems mentioned in the background art.

[0006] To address the aforementioned technical problems, according to one aspect of the present invention, more specifically, a smart management platform for grassroots chronic disease screening and prevention centers, comprising: a multi-disease follow-up management module, a contract-performance-points closed-loop module, a risk assessment and health intervention module, a cross-system data linkage module, a data statistics and evaluation module, and a multi-terminal adaptation and security module. The multi-disease follow-up management module supports joint record-keeping for multiple chronic diseases, generates personalized follow-up plans, and tracks and manages follow-up status; the contract-performance-points closed-loop module supports customized contracted service content, real-time tracking of performance, and the establishment of a points-based correlation mechanism; the risk assessment and health intervention module integrates multi-dimensional data to conduct risk assessments, while also linking follow-up arrangements and outputting targeted intervention suggestions; the cross-system data linkage module achieves data interoperability with external medical systems through standardized interfaces, supporting relevant data import and feedback; the data statistics and evaluation module performs multi-dimensional management data statistics, generates visual results, and provides data export functionality; the multi-terminal adaptation and security module adapts to both medical staff and patients, performs real-time data synchronization across multiple terminals, and ensures data transmission security.

[0007] Furthermore, the multi-disease follow-up management module includes: a record-keeping module, a follow-up plan module, a follow-up status management module, and a follow-up record and update module; Record creation module: Through the joint record creation of common chronic diseases at the primary care level, such as hypertension, diabetes and COPD, multiple chronic disease types can be selected at the same time in the patient's file; Follow-up plan module: Generates personalized follow-up plans based on the rule of "routine follow-up every three months + annual follow-up + complication screening linkage"; Follow-up status management module: Patient follow-up status is marked with different colors, and filtering is supported by disease type, follow-up time, and responsible medical staff. Follow-up Record and Update Module: Supports the entry of clinical events such as patient relocation, death, and refusal to follow up. After entry, the patient's file status is updated, and the file cancellation process is triggered when follow-up is refused.

[0008] Furthermore, the contract signing-performance-points closed-loop module includes: a contract signing service module, a performance tracking module, and a points recording module; Contracted service module: Through customized chronic disease screening packages, traditional Chinese medicine health care packages, and sports and medicine integration packages, service periods, service content, and contract amounts can be set to suit different key groups; The performance tracking module adopts a mechanism of "checking confirmation + electronic signature + performance form printing" to calculate and display the performance completion rate. Performed projects are marked in green, and incomplete projects are marked in yellow for warning. Points Incentive Module: Establish a "Health Behavior - Points Accumulation - Rights Redemption" mechanism. Patients can earn points by completing follow-up visits, self-paid tests, exercise, and renewing service packages. Points can be redeemed for designated free medical services.

[0009] Furthermore, the risk assessment and health intervention module includes: a multi-dimensional risk assessment module, a risk-follow-up linkage module, and a plan generation module; Multi-dimensional risk assessment module: integrates ASCVD atherosclerosis risk assessment, liver fibrosis risk assessment, traditional Chinese medicine constitution identification, and osteoporosis assessment models, and is trained and optimized based on the random forest algorithm; Risk-follow-up linkage module: Generates high / medium / low risk levels based on risk assessment results, shortens follow-up intervals for high-risk patients, and adjusts follow-up plans accordingly; Solution generation module: Based on risk level and chronic disease type, it pushes targeted intervention suggestions on exercise prescriptions and dietary guidance, and generates personalized health care plans after TCM constitution identification.

[0010] Furthermore, the cross-system data linkage module includes: a standardized interface module, a test data import module, and a data feedback module; Standardized interface module: Adopts the HL7 FHIR standardized medical data interface protocol, compatible with HIS system and laboratory testing system; Test data import module: Supports one-click import of test reports, provides photo upload and QR code scan upload methods, and caches data when the server is abnormal; Data feedback module: Feeds back the platform's follow-up data and contract performance data to the external medical system to achieve data exchange between "testing-follow-up-intervention".

[0011] Furthermore, the data statistics and evaluation module includes: a multi-dimensional data statistics module, a chart generation module, and a data export module; Multi-dimensional data statistics module: Statistics on new patients, new follow-up visits, number of signed contracts, contract fulfillment rate, number of people under joint management for hypertension, hyperlipidemia, and hyperglycemia, and number of people screened for complications; supports filtering by time period, unit, and department. Chart generation module: Generates visual statistical charts of management quality, management responsibility, and the proportion of management for each disease type; Data export module: Supports exporting statistical results and follow-up lists to Excel format.

[0012] Furthermore, the multi-terminal adaptation and security module includes: a medical staff module, a patient mobile module, a multi-terminal data synchronization module, and a data transmission security module; Healthcare module: Adapted for PC and mobile devices, supporting real-time entry of follow-up records, uploading of test reports by photo, confirmation of contract performance, and patient information query functions; Patient mobile module: Supports iOS and Android operating systems, providing functions such as follow-up plan query, contract fulfillment progress query, points balance query, and health reminder reception; Multi-device data synchronization module: Enables real-time data synchronization between PC and mobile devices via an encrypted interface, and synchronizes offline operation data after network recovery; Data transmission security module: Employs AES encryption algorithm and OAuth2.0 authentication mechanism to ensure data transmission and storage security.

[0013] Furthermore, the platform uses Vue3+Element Plus to build a responsive front-end interface and uses WebSocket technology to push real-time updates on follow-up status and performance progress.

[0014] The beneficial effects of this invention's intelligent management platform for grassroots chronic disease screening and prevention centers are as follows: Through integrated follow-up management technology for multiple diseases, it can adapt to the common situation of "one person with multiple diseases" at the grassroots level. It not only supports joint record-keeping for multiple chronic diseases and the generation of personalized follow-up plans, but also intelligently merges follow-up tasks and accurately tracks follow-up status, significantly improving the efficiency of medical and nursing operations and providing a more efficient solution for grassroots chronic disease follow-up management; furthermore, through HL7... FHIR's standardized interface and cross-system data linkage technology enable seamless interoperability with external medical systems, breaking down data silos and allowing for real-time sharing of test data without manual entry. This improves data accuracy and management scientificity, enhancing the precision of follow-up decisions and risk assessments. Simultaneously, through a closed-loop mechanism of contract signing, performance evaluation, and points accumulation, along with multi-dimensional risk assessment technology, a full-process management system of "service customization, progress visibility, and positive incentives" has been established. This improves the matching degree of contracted services and patient compliance. Furthermore, multi-dimensional data is integrated to train and optimize the evaluation model, improving the accuracy of complication early warning and pushing targeted intervention suggestions. Combined with multi-terminal adaptation and encryption security technologies, data transmission and storage security and operational convenience are ensured, significantly improving the systematic management level and comprehensive intervention effect of chronic disease screening and prevention at the grassroots level. Attached Figure Description

[0015] The present invention will now be described in further detail with reference to the accompanying drawings and specific implementation methods.

[0016] Figure 1 This is a schematic diagram of the system module architecture. Detailed Implementation

[0017] The present invention will be described in detail below with reference to the accompanying drawings and embodiments. It should be noted that, unless otherwise specified, the embodiments and features described in the present application can be combined with each other.

[0018] According to one aspect of the invention, such as Figure 1 As shown, a smart management platform for primary-level chronic disease screening and prevention centers is provided, including: a multi-disease follow-up management module, which supports joint record-keeping for multiple chronic diseases, generates personalized follow-up plans, and tracks and manages follow-up status. This module includes: Record creation module: Through the joint record creation of common chronic diseases at the primary care level, such as hypertension, diabetes and COPD, multiple chronic disease types can be selected at the same time in the patient's file; Specifically, it supports the joint registration of common chronic diseases that are prevalent in primary care settings, such as hypertension, diabetes, COPD, osteoporosis, coronary heart disease, stroke, and rheumatoid arthritis. When registering, patients can select one or more types of chronic diseases based on their actual condition. The system links the standardized follow-up requirements, clinical treatment guidelines, and personalized management standards for each selected disease. The patient file will integrate core data such as basic information, past medical history, present medical history, test results, medication records, and allergy history. Information such as diagnosis time, disease level, and treatment plan corresponding to each type of chronic disease will be classified, stored, and linked together (for example, when a diabetic patient also selects hypertension, the system will link "diabetic kidney, diabetic heart" and other comorbidity management points). The record-keeping process allows medical staff to upload attachments such as scanned copies of patients' previous medical records and photos of test reports. When patients add or remove chronic disease types later, the system can update the follow-up rules and management dimensions associated with the records without having to recreate the complete records.

[0019] Follow-up plan module: Generates personalized follow-up plans based on the rule of "routine follow-up every three months + annual follow-up + complication screening linkage"; The routine follow-up every three months will include monitoring of core indicators for various chronic diseases (such as blood pressure measurement for hypertensive patients, blood glucose and glycated hemoglobin testing for diabetic patients), medication adherence assessment, medication adjustment recommendations, and lifestyle intervention guidance. The monitoring indicators will be automatically supplemented according to the number of comorbidities of the patient to avoid missing key examination items. Meanwhile, if the routine follow-up time or annual follow-up time for different chronic diseases of the same patient conflict, the system will merge the follow-up tasks and generate a single comprehensive follow-up plan, clearly marking all disease-related follow-up items, examination indicators and communication points that need to be completed. Medical staff can complete the follow-up records for multiple chronic diseases at one time, and patients do not need to make multiple trips. In addition, the annual follow-up will integrate comprehensive physical examination items (such as blood routine, liver and kidney function, blood lipids, electrocardiogram, etc.) and special screening for complications related to various chronic diseases (such as diabetic retinopathy examination and hypertensive kidney damage screening). The follow-up plan will be dynamically adjusted according to the patient's previous risk assessment results. The routine follow-up interval for high-risk patients can be shortened from 3 months to 2 months, and the frequency of complication screening will be increased accordingly.

[0020] Follow-up status management module: Patient follow-up status is marked with different colors, and filtering is supported by disease type, follow-up time, and responsible medical staff. Specifically, patients who have completed their annual physical examination are marked in blue, patients awaiting follow-up (e.g., less than 7 days until the planned follow-up time or those who have exceeded the follow-up period) are marked in red, and lost-to-follow-up patients who have failed to respond to follow-up twice and cannot be contacted are marked in gray. The color markings are prominently displayed in the follow-up list, allowing medical staff to quickly identify key individuals. When filtering by disease type, the follow-up status of a specific chronic disease can be viewed separately (e.g., only diabetes patients). When filtering by follow-up time, fixed time periods such as "last month", "last 3 months", and "this year" can be selected, or a custom start and end time range can be defined for precise filtering. Meanwhile, the follow-up list will simultaneously display the comparison between the number of tests that patients should complete and the number of tests that have been entered. For cases where tests have been completed but data has not been entered, the system will generate a reminder to help medical staff quickly identify and promptly enter the data, avoiding the impact of missing data on follow-up assessment and intervention decisions. It also includes the ability to directly export the screened follow-up list to an Excel file. The exported content by default includes key information such as patient name, gender, age, contact information, combination of chronic disease types, planned follow-up time, actual follow-up time, follow-up status, name and contact information of the responsible medical staff, and reasons for not following up, which makes it convenient for medical staff to remind patients by phone or conduct home visits.

[0021] Follow-up Record and Update Module: Supports the entry of clinical events such as patient relocation, death, and refusal to follow up. After entry, the patient's file status is updated, and the file cancellation process is triggered when follow-up is refused. Clinical event entry is achieved through the system's built-in standardized templates. Medical staff can directly select event types such as "patient relocation," "death," and "refusal to follow up," and then add key details. For example, for patient relocation, the new address and new contact information need to be entered; for death, the time of death and cause of death (e.g., related to or unrelated to chronic diseases) need to be entered; and for refusal to follow up, the patient's core reasons for refusal need to be briefly recorded (e.g., subjective lack of attention, too far away, physical inconvenience, etc.). In addition, after a clinical event is entered, the system will update the patient's file status in real time: after a patient moves, follow-up notices will be automatically sent to the new contact information. Although the follow-up plan includes the function of "adjusting to the nearest service point according to the new address", due to the limited scope of use of the platform's partner hospitals, it is not yet possible to fully realize point-to-point accurate push to the nearest service point. After death information is entered, the file status will be automatically marked as "termination of follow-up", and the system will no longer generate any follow-up plans. The death information will also be synchronized to the multi-dimensional data statistics module and included in the statistics of relevant management indicators. The file cancellation process triggered by the final refusal of follow-up requires two confirmation steps: First, the follow-up medical staff enters the refusal information and uploads the patient's signed written refusal statement (photo upload is supported). Second, the department head reviews and confirms it in the system. After the review is approved, the system officially cancels the patient's follow-up task, and the file is retained as historical data. At the same time, all operation logs of the cancellation process are recorded (such as the operator, operation time, and review comments) to ensure that the process is traceable and to avoid follow-up omissions due to misoperation.

[0022] The contract signing-performance-points closed-loop module supports customized contract service content, real-time tracking of performance progress, and the establishment of a points-based linkage mechanism. This module includes: Contracted service module: Through customized chronic disease screening packages, traditional Chinese medicine health care packages, and sports and medicine integration packages, service periods, service content, and contract amounts can be set to suit different key groups; Specifically, it supports primary healthcare institutions in customizing three types of core service packages and extended service packages based on the health needs of residents in their jurisdiction. The chronic disease screening package can include basic and specialized tests such as blood routine, blood glucose, blood lipids, liver and kidney function, and carotid ultrasound. The traditional Chinese medicine health care package can cover traditional Chinese medicine constitution identification, acupuncture and physiotherapy, traditional Chinese medicine conditioning guidance, and health tea recipes. The sports and medicine integration package can include services such as exercise risk assessment, personalized exercise program development, and exercise effect monitoring. Each service package can freely add or remove specific items. The service period can be set to flexible periods such as 3 months, 6 months, and 1 year. The contract amount can be configured according to the total price of the service package or the unit price of a single service. The system has a built-in price calculation template. After inputting cost parameters, it will automatically generate a suggested price. Once the price is configured in the backend, it cannot be adjusted on-site. Package content can be set through the PC management backend. For different key groups such as the general population, the elderly over 65 years old, patients with chronic diseases such as hypertension / diabetes, patients with multiple diseases, and pregnant women, the system will pre-recommend a single suitable service package. For example, it will recommend a traditional Chinese medicine health care package for patients with multiple diseases and a chronic disease screening package for patients with hypertension. It does not support signing up for multiple service packages in combination. In addition, service packages can be created, edited, and delisted in batches through the PC management platform. When medical staff provide door-to-door services on the mobile app, the details of the service packages (such as a list of items, service frequency, and price) can be directly displayed for residents to choose on-site. After the residents confirm the signing, the system automatically generates an electronic contract, which includes core content such as information of both parties, service content, rights and obligations, and termination clauses, and supports online preview and saving.

[0023] The core feature of this module is its full-process electronic information support. The configuration of the contracted service package, the generation of electronic agreements, the tracking of performance progress, and the calculation and management of points are all digitally processed, eliminating the need for paper-based operations. All data is synchronized to the platform in real time, enabling the completion of statistical analysis related to contract signing and performance. This not only improves process efficiency but also ensures the accuracy and traceability of data, forming a standardized electronic information management closed loop.

[0024] The performance tracking module adopts a mechanism of "checking confirmation + electronic signature + performance form printing" to calculate and display the performance completion rate. Performed projects are marked in green, and incomplete projects are marked in yellow for warning. Specifically, after completing a single service, medical staff can find the list of items in the corresponding contracted service package on the PC or mobile app's performance operation interface, check off the completed items one by one, and supplement key service data (such as the duration of TCM physiotherapy and the specific exercise guidance plan) when checking off items. For incomplete items, the reason for non-performance must be filled in (such as the patient having something come up temporarily or the project not being ready to be carried out at the moment). Meanwhile, the electronic signature function allows patients to sign on-site via mobile phone touch screen or have medical staff sign on their behalf and then have the patient confirm with their fingerprint. The signature data is synchronized to the platform in real time and associated with the corresponding performance record. It is tamper-proof. After the performance is completed, the system generates a performance form with electronic signature, service details and performance time. It can be printed out for the patient to keep immediately, or the electronic performance form can be pushed to the patient's mobile device for viewing at any time. Finally, the completion rate is calculated precisely as "number of completed projects / total number of projects in the service package × 100%", rounded to two decimal places (e.g., 93.75%). It is displayed in real time on both the medical staff and patient sides. Completed projects are marked with a green icon and the completion time is displayed. Incomplete projects that are close to the service deadline are marked with a yellow icon and trigger system reminders. Overdue projects are marked in red and a supervision notice is pushed to the responsible medical staff.

[0025] Points Incentive Module: Establish a "Health Behavior - Points Accumulation - Rights Redemption" mechanism. Patients can earn points by completing follow-up visits, self-paid tests, exercise, and renewing service packages. Points can be redeemed for designated free medical services. Specifically, the point allocation rules for various health behaviors are clarified: for example, 10 points are awarded for completing a routine follow-up visit, 30 points for completing an annual follow-up visit, 20 points for completing a glycated hemoglobin test at one's own expense, 40 points for completing a carotid ultrasound at one's own expense, 15 points for achieving the daily exercise target for 30 consecutive days (uploading exercise data via mobile device), and 50 points for renewing a service package for 1 year or more. The point allocation can be flexibly adjusted through the back-end management system. The points are also set to have an expiration period, which is 12 months from the date of earning the points by default. The system will send a reminder to the patient via mobile phone 30 days and 7 days before the points expire. The patient can view the points details (such as the time of earning, the corresponding behavior, and the expiration period), the currently available points and the expired points in the "Points Center" on the mobile app. Furthermore, when redeeming points, patients can select services to redeem on mobile devices or healthcare platforms, including free glycated hemoglobin testing (e.g., 50 points), free blood glucose testing (e.g., 10 points), free traditional Chinese medicine constitution identification (e.g., 30 points), and free exercise program optimization (e.g., 25 points). After redemption, the system generates a redemption voucher, indicating the name of the redeemed service, the validity period, and the location of use. Patients can use the voucher to enjoy the service at the primary chronic disease screening and prevention center. After the service is completed, the system deducts the corresponding points and updates the points balance.

[0026] The risk assessment and health intervention module integrates multi-dimensional data to conduct risk assessments, while also linking follow-up arrangements and providing targeted intervention recommendations. This module includes: Multi-dimensional risk assessment module: integrates ASCVD atherosclerosis risk assessment, liver fibrosis risk assessment, traditional Chinese medicine constitution identification, and osteoporosis assessment models, and is trained and optimized based on the random forest algorithm; The integrated assessment models will share multi-dimensional core patient data, including basic physiological indicators such as age, gender, height, weight, blood pressure, blood sugar, and blood lipids; medical history and course of chronic diseases such as hypertension and diabetes, and medication use; lifestyle data such as smoking history, drinking history, exercise frequency, and dietary habits; family history information such as the chronic disease status of immediate family members; and diagnostic data related to TCM constitution such as tongue coating, pulse, and emotional state, so as to achieve data collection once and reuse of multiple models. The training of the random forest algorithm is based on real diagnosis and treatment big data of patients with chronic diseases at the grassroots level. It extracts key feature variables and optimizes hyperparameters such as the number of decision trees and node splitting threshold through 5-fold cross-validation. It strengthens the weight allocation of comorbidity interaction features for the "one person with multiple diseases" scenario, so that the model can accurately identify the risk of complications under multiple chronic diseases. Meanwhile, by capturing patient follow-up records and cross-system imported test data (such as the four liver fibrosis markers and bone density test results), the system updates the input parameters of the assessment model in real time. No manual input is required from medical staff. The assessment process is completed in the background, and the generated assessment report includes risk level, core risk factors, and risk development trend prediction. Finally, the model supports online iterative updates, adjusting the random forest algorithm parameters quarterly based on new patient data and the latest clinical guidelines. Healthcare professionals can view the model iteration logs and changes in prediction accuracy on a PC (e.g., currently more than 30% higher than the traditional single-dimensional model), and can also manually trigger reassessment of high-risk patients.

[0027] Risk-follow-up linkage module: Generates high / medium / low risk levels based on risk assessment results, shortens follow-up intervals for high-risk patients, and adjusts follow-up plans accordingly; Specifically, the risk level classification adopts a quantitative scoring mechanism. For example, the total score is 100 points, with 80 points and above being high risk, 60-79 points being medium risk, and 59 points and below being low risk. The scoring criteria are formulated with reference to the chronic disease prevention and control guidelines and combined with the characteristics of primary comorbidity management. For example, the risk score of patients with diabetes and hypertension is increased by 20 points, and patients with a smoking history of more than 10 years are given an additional 15 points. The routine follow-up interval for high-risk patients has been shortened from 3 months to 2 months, while the annual follow-up remains unchanged. However, a special screening program for complications has been added (e.g., coronary CTA examination for high-risk ASCVD patients and liver elasticity test for high-risk liver fibrosis patients). The follow-up plan is clearly marked with the "high-risk focus" label, and follow-up resources are given priority. For patients at medium risk, routine follow-up every 3 months and annual follow-up are maintained. The follow-up content is strengthened with the evaluation of the intervention effect of risk factors (such as changes in blood lipids after dietary adjustment and changes in weight after exercise intervention), and the intervention plan is dynamically adjusted according to the evaluation results. In addition, low-risk patients can extend the regular follow-up interval to 6 months, retain the core physical examination items in the annual follow-up, and the system will push a health self-test reminder every 2 months (such as home blood pressure and blood sugar monitoring). After patients upload data through their mobile devices, the system will automatically review the risk level. If the data is abnormal, the follow-up interval will be shortened.

[0028] Solution generation module: Based on risk level and chronic disease type, it pushes targeted intervention suggestions on exercise prescriptions and dietary guidance, and generates personalized health care plans after TCM constitution identification; Specifically, the exercise prescription is generated based on the patient's chronic disease type, risk level, age, and physical condition (e.g., assessed through a 6-minute walk test during follow-up). For high-risk hypertension patients, "30 minutes of moderate-intensity aerobic exercise daily (e.g., brisk walking, Tai Chi), 5 times a week, avoiding strenuous exercise" is recommended. For patients with diabetes and osteoporosis, "resistance training (e.g., dumbbell exercises, resistance band training) + balance training (e.g., single-leg standing), 3 times a week, 20 minutes each time, with blood glucose monitoring before and after exercise" is recommended. The prescription clearly specifies the type, duration, frequency, intensity, and precautions for exercise. It also includes dietary guidance that combines the patient's chronic disease combination, metabolic indicators (such as blood lipids and uric acid), and dietary habits. For example, patients with hyperglycemia are recommended to "eat a low-sugar, high-fiber diet, replace staple foods with whole grains (such as oats and brown rice), and control daily carbohydrate intake to 200-300 grams, divided into 5-6 meals." Patients at high risk of liver fibrosis are recommended to "eat a low-fat, high-protein diet, avoid spicy, stimulating, and greasy foods, and calculate daily protein intake at 1.2-1.5g / kg body weight." After TCM constitution identification, patients with Yin deficiency constitution are given a health regimen of "eating more Yin-nourishing foods such as white fungus, lily bulbs, and goji berries, avoiding staying up late, and drinking goji berry and chrysanthemum tea as a substitute for tea." Patients with phlegm-dampness constitution are given a regimen of "eating more dampness-removing foods such as barley, red beans, and winter melon, reducing the intake of sweets and raw and cold foods, and moxibustion on the Zusanli acupoint daily." The regimen supports the import of TCM diagnosis and treatment data (such as Chinese medicine prescriptions and acupuncture records) from the past 3 months for automatic updates.

[0029] The cross-system data linkage module enables data exchange with external medical systems through standardized interfaces, supporting relevant data import and feedback. This module includes: Standardized interface module: Adopts the HL7 FHIR standardized medical data interface protocol, compatible with HIS system and laboratory testing system; Specifically, the interface is developed based on the HL7 FHIRR4 version protocol, with built-in standardized mapping relationships for medical data elements, which can be directly adapted to mainstream brand HIS systems and testing laboratory systems without the need for secondary development and modification of external systems. It also supports dynamic configuration of interface parameters. Medical staff can set data interaction fields, transmission frequency, and synchronization priority through the PC backend. For example, they can set the "real-time synchronization" priority for emergency laboratory data and the "synchronization every 30 minutes" priority for general outpatient laboratory data to adapt to different data transmission needs at the grassroots level.

[0030] Test data import module: Supports one-click import of test reports, provides photo upload and QR code scan upload methods, and caches data when the server is abnormal; Specifically, the one-click import function directly reads test data from external systems through a standardized interface, covering commonly used test items at the grassroots level such as complete blood count, blood glucose, blood lipids, liver and kidney function, glycated hemoglobin, four liver fibrosis items, and bone density test. When importing, it automatically matches the patient's unique identifier (such as ID card number or medical card number) and accurately associates it with the patient's file on the platform, without the need for manual matching. Simultaneously, the system supports medical staff to take photos of the original test reports using their mobile phones (e.g., supporting JPG and PNG formats). The system is equipped with an OCR text recognition algorithm to extract core data from the report, such as patient information, test items, result values, reference ranges, and test times. After extraction, manual correction of errors is supported. Furthermore, QR code scanning upload can directly scan the exclusive QR code on the inspection report to quickly obtain electronic inspection data and synchronize it to the platform. When the remote server encounters abnormal situations such as 502 errors or network interruptions, the data is cached to the local device (e.g., cached to the local hard drive on the PC and cached to the local storage space on the mobile phone). The cached data is stored in encrypted form, and the synchronization mechanism is triggered after the network is restored to ensure that the data is not lost.

[0031] Data feedback module: Feeds back platform follow-up data and contract performance data to external medical systems to achieve data exchange between "testing-follow-up-intervention"; Specifically, the feedback data includes patient follow-up records (such as follow-up time, vital signs data, medication adjustment suggestions, and health intervention content), contracted service information (such as service package type, contract time, and expiration reminder), performance status (such as performance items, completion rate, and electronic signature information), and points incentive data (such as points acquisition and redemption records). The data format is uniformly converted to the HL7 FHIR standard format to ensure that external systems can directly parse and use it. Furthermore, a feedback log is generated after the data is fed back, recording the data sending time, the name of the receiving system, the number of data entries, and the feedback status (e.g., success / failure). If the feedback fails, the system will retry within a certain period of time (e.g., 15 minutes). If the retry fails multiple times (e.g., 3 times), an early warning notification will be pushed to the system administrator. At the same time, the failed data will be retained for manual intervention, forming a closed-loop control of "sending-confirmation-retry-early warning".

[0032] The data statistics and evaluation module performs multi-dimensional data statistics management, generates visualization results, and provides data export functionality. This module includes: Multi-dimensional data statistics module: Statistics on new patients, new follow-up visits, number of signed contracts, contract fulfillment rate, number of people under joint management for hypertension, hyperlipidemia, and hyperglycemia, and number of people screened for complications; supports filtering by time period, unit, and department. Specifically, the statistical indicators cover the core dimensions of the entire process of chronic disease management at the grassroots level. The number of new patients is subdivided into "new patients with a single chronic disease", "new patients with multiple coexisting diseases", and "the proportion of new patients with each disease". The number of new follow-up visits is divided into "the number of routine follow-up visits completed", "the number of annual follow-up visits completed", "the number of lost to follow-up visits", and "the number of follow-up visits". The completion rate of the contract is accurate to the completion rate of a single service package and a single contract item. The number of people under the management of the three highs is counted as the existing number and the number of new patients with hypertension, diabetes and hyperlipidemia. The number of people screened for complications is subdivided into specific screening types such as "the number of fundus screenings", "the number of kidney injury screenings", and "the number of vascular ultrasound screenings". Meanwhile, the filtering function supports multi-condition combination queries. By time period, users can select "last 7 days", "last 30 days", "last 90 days", "this year", or "custom date range". By unit, users can filter for a single township health center, community health service center, or joint statistics of multiple units. By department, users can accurately filter for specific implementing departments such as internal medicine, chronic disease management, and traditional Chinese medicine. After filtering, the data is updated in real time, and the statistical results calculate the year-on-year (e.g., the same period last year) and month-on-month (e.g., the same month last year) growth rates, intuitively displaying the changing trends of management effectiveness.

[0033] Chart generation module: Generates visual statistical charts of management quality, management responsibility, and the proportion of management for each disease type; The management quality indicators are generated into bar charts, covering indicators such as "follow-up completion rate", "fulfillment rate", and "number of follow-ups". The horizontal axis represents the statistical period (e.g., day / week / month / quarter / year), and the vertical axis represents the specific values. Different indicators are distinguished by different colors, and the legend can be clicked to hide / show the corresponding indicator data. The management responsibility index generates a line chart, which includes dimensions such as "number of people who should be followed up", "number of people actually followed up", "follow-up coverage rate of key populations" and "intervention rate of high-risk patients". It can intuitively present the responsibility change curve and support mouse hover to view specific values ​​and the reasons for fluctuations (e.g., the decline in responsibility at a certain time period is due to the impact of the epidemic). In addition, pie charts and donut charts are generated based on the proportion of each disease management indicator. The pie chart shows the proportion of patients with all chronic diseases, and the donut chart shows the proportion of each disease combination among patients with multiple coexisting diseases (such as the proportion of the "hypertension + diabetes" combination). The charts support zooming in, zooming out, and rotating. Detailed statistics for the corresponding disease can be accessed by clicking on the chart section (for example, clicking on the diabetes proportion section will automatically display the follow-up, contract signing, and contract fulfillment details for diabetic patients).

[0034] Data export module: Supports exporting statistical results and follow-up lists to Excel format; Specifically, the export format is Excel, and the export content can be customized. For example, when exporting statistical results, you can choose "Chart data only", "Chart data + year-on-year and month-on-month data", or "Full detailed data". When exporting the follow-up list, you can choose whether to include sensitive information such as patient contact information, detailed chronic disease type, and risk level. It also supports batch export, allowing you to select multiple statistical dimensions and multiple time periods at once to package and export the results. The exported files are automatically named (for example, in the format "statistical type-statistical time period-export time"). AES encryption is used during the export process to prevent data leakage during the export stage. The exported file contains built-in data verification formulas to verify numerical consistency (e.g., follow-up completion rate = actual number of follow-ups / number of follow-ups to be conducted), and indicates the data source (e.g., "data comes from the platform's follow-up module + cross-system linkage module"), which is convenient for grassroots organizations to use for assessment reporting and data auditing. The exported data also supports seamless integration with the statistical system of higher-level health management departments without the need for secondary format conversion.

[0035] A multi-device adaptation and security module adapts to both healthcare and patient operations, enabling real-time data synchronization across multiple devices and ensuring secure data transmission. This module includes: Healthcare module: Adapted for PC and mobile devices, supporting real-time entry of follow-up records, uploading of test reports by photo, confirmation of contract performance, and patient information query functions; Specifically, the PC version adopts a large-screen responsive interface, with a layout of "module partitioning + quick access". The left side is the function navigation bar (including all core module access), the middle is the main operation interface, and the right side is the data preview panel, which supports simultaneous operation of multiple tabs (such as opening patient files, follow-up records, and statistical reports at the same time). Meanwhile, the mobile app features a lightweight design, focusing on the core scenario of home follow-up visits. Follow-up record entry supports voice input to text conversion and quick selection of frequently used phrases (such as "blood pressure is under stable control" and "medication adherence is good"). Uploading test reports by photo supports cropping and filter optimization (such as improving OCR recognition accuracy). Contract signing and performance confirmation supports offline operation and synchronization after network recovery.

[0036] Patient mobile module: Supports iOS and Android operating systems, providing functions such as follow-up plan query, contract fulfillment progress query, points balance query, and health reminder reception; Specifically, to support mobile devices such as smartphones and tablets, elderly users can enable "Senior Mode," which enlarges the font size (e.g., by 20%), enhances color contrast, enlarges operation buttons, and adds voice prompts for key functions.

[0037] Multi-device data synchronization module: Enables real-time data synchronization between PC and mobile devices via an encrypted interface, and synchronizes offline operation data after network recovery; The encrypted interface uses AES-256 symmetric encryption algorithm + OAuth2.0 authentication. Before data transmission, sensitive fields (such as patient ID number and test results) are anonymized (e.g., the middle 8 digits of the ID number are hidden, and only the numerical value and reference range of the test results are displayed). Then, the data is transmitted through an encrypted channel. The authentication process requires verification of device identification, user account password, and dynamic verification code to prevent unauthorized devices from accessing the network. In addition, real-time synchronization is based on WebSocket technology. Operation data on PC and mobile devices (such as medical staff entering follow-up records and patients querying points) are pushed to each other's terminals in real time. The synchronization status is displayed in the upper right corner of the interface with "Synchronizing" or "Synchronized" icons. If synchronization fails, it will be retried (for example, the retry interval is 5 seconds, and the maximum number of retryes is 5). Meanwhile, when the network is interrupted, the operation data on the PC is cached to the local MySQL database, and the data on the mobile device is cached to the local sandbox directory. The cached data is stored using AES encryption. Synchronization is triggered after the network is restored (network connection is detected). During synchronization, the data is sorted according to the priority of "timestamp + data type" (for example, key data such as follow-up records and performance confirmations are synchronized first). If data conflicts occur (for example, both ends modify the same patient's file at the same time), the rule of "later operation overwrites earlier operation + operation log is retained" is followed. The log records the original content of the conflicting data, the person who made the modification, and the modification time.

[0038] Data transmission security module: Employs AES encryption algorithm and OAuth2.0 authentication mechanism to ensure data transmission and storage security; Specifically, the AES encryption algorithm uses a 256-bit key, which is updated periodically by the cloud server (e.g., every 7 days) and distributed to authenticated terminals through an encrypted channel. The key update process does not affect normal data transmission. The encryption scope covers all transmitted data (including user operation instructions, patient records, test reports, points data, etc.). Data storage adopts "encrypted storage + access control". Sensitive data in the MySQL database is stored in encrypted form, and Redis cached data only retains non-sensitive fields (e.g., follow-up plan time, points balance). It also includes OAuth2.0 authentication support for "password mode + client mode". Medical staff login uses password mode (e.g., account password + dynamic verification code), while device binding uses client mode (the device needs to be reviewed and authorized by the administrator when it is first connected). Unbinding a device requires operation in the PC backend and verification of the administrator password. At the same time, an operation log audit mechanism is established to record all terminal login, data query, modification and deletion operations. The log includes the operator, operation time, operation content, device identifier and IP address. It supports filtering and querying by time period, operator and operation type, which meets the requirements of medical data security audit.

[0039] Of course, the above description is not a limitation of the present invention, and the present invention is not limited to the examples given above. Any changes, modifications, additions or substitutions made by those skilled in the art within the scope of the present invention are also within the protection scope of the present invention.

Claims

1. A smart management platform for grassroots chronic disease screening and prevention centers, characterized in that, include: The system comprises four modules: a multi-disease follow-up management module, a contract-performance-points closed-loop module, a risk assessment and health intervention module, a cross-system data linkage module, a data statistics and evaluation module, and a multi-terminal adaptation and security module. The multi-disease follow-up management module supports joint record-keeping for multiple chronic diseases, generates personalized follow-up plans, and tracks and manages follow-up status. The contract-performance-points closed-loop module supports customized contracted service content, real-time tracking of performance, and the establishment of a points-based linkage mechanism. The risk assessment and health intervention module integrates multi-dimensional data to conduct risk assessments, while also linking follow-up arrangements and outputting targeted intervention suggestions. The cross-system data linkage module achieves data interoperability with external medical systems through standardized interfaces, supporting relevant data import and feedback. The data statistics and evaluation module performs multi-dimensional management data statistics, generates visualized results, and provides data export functionality. The multi-terminal adaptation and security module adapts to both healthcare and patient operations, performs real-time data synchronization across multiple terminals, and ensures secure data transmission.

2. The intelligent management platform for a primary-level chronic disease screening and prevention center according to claim 1, characterized in that: The multi-disease follow-up management module includes: a record-keeping module, a follow-up plan module, a follow-up status management module, and a follow-up record and update module; Record creation module: Through the joint record creation of common chronic diseases at the primary care level, such as hypertension, diabetes and COPD, multiple chronic disease types can be selected at the same time in the patient's file; Follow-up plan module: Generates personalized follow-up plans based on the rule of "routine follow-up every three months + annual follow-up + complication screening linkage"; Follow-up status management module: Patient follow-up status is marked with different colors, and filtering is supported by disease type, follow-up time, and responsible medical staff. Follow-up Record and Update Module: Supports the entry of clinical events such as patient relocation, death, and refusal to follow up. After entry, the patient's file status is updated, and the file cancellation process is triggered when follow-up is refused.

3. The intelligent management platform for a primary-level chronic disease screening and prevention center according to claim 1, characterized in that: The contract signing-performance-points closed-loop module includes: a contract signing service module, a performance tracking module, and a points recording module; Contracted service module: Through customized chronic disease screening packages, traditional Chinese medicine health care packages, and sports and medicine integration packages, service periods, service content, and contract amounts can be set to suit different key groups; The performance tracking module adopts a "check confirmation + electronic signature + performance form printing" mechanism to calculate and display the performance completion rate, with performed items marked in green and incomplete items marked in yellow for warning. Points Incentive Module: Establish a "Health Behavior - Points Accumulation - Rights Redemption" mechanism. Patients can earn points by completing follow-up visits, self-paid tests, exercise, and renewing service packages. Points can be redeemed for designated free medical services.

4. The intelligent management platform for a primary-level chronic disease screening and prevention center according to claim 1, characterized in that: The risk assessment and health intervention module includes: a multi-dimensional risk assessment module, a risk-follow-up linkage module, and a plan generation module; Multi-dimensional risk assessment module: integrates ASCVD atherosclerosis risk assessment, liver fibrosis risk assessment, traditional Chinese medicine constitution identification, and osteoporosis assessment models, and is trained and optimized based on the random forest algorithm; Risk-follow-up linkage module: Generates high / medium / low risk levels based on risk assessment results, shortens follow-up intervals for high-risk patients, and adjusts follow-up plans accordingly; Solution generation module: Based on risk level and chronic disease type, it pushes targeted intervention suggestions on exercise prescriptions and dietary guidance, and generates personalized health care plans after TCM constitution identification.

5. The intelligent management platform for a primary-level chronic disease screening and prevention center according to claim 1, characterized in that: The cross-system data linkage module includes: a standardized interface module, a test data import module, and a data feedback module; Standardized interface module: Adopts the HL7 FHIR standardized medical data interface protocol, compatible with HIS system and laboratory testing system; Test data import module: Supports one-click import of test reports, provides photo upload and QR code scan upload methods, and caches data when the server is abnormal; Data feedback module: Feeds back the platform's follow-up data and contract performance data to the external medical system to achieve data exchange between "testing-follow-up-intervention".

6. The intelligent management platform for a primary-level chronic disease screening and prevention center according to claim 1, characterized in that: The data statistics and evaluation module includes: a multi-dimensional data statistics module, a chart generation module, and a data export module; Multi-dimensional data statistics module: Statistics on new patients, new follow-up visits, number of signed contracts, contract fulfillment rate, number of people under joint management for hypertension, hyperlipidemia, and hyperglycemia, and number of people screened for complications; supports filtering by time period, unit, and department. Chart generation module: Generates visual statistical charts of management quality, management responsibility, and the proportion of management for each disease type; Data export module: Supports exporting statistical results and follow-up lists to Excel format.

7. The intelligent management platform for a primary-level chronic disease screening and prevention center according to claim 1, characterized in that: The multi-terminal adaptation and security module includes: a medical staff module, a patient mobile module, a multi-terminal data synchronization module, and a data transmission security module; Healthcare module: Adapted for PC and mobile devices, supporting real-time entry of follow-up records, uploading of test reports by photo, confirmation of contract performance, and patient information query functions; Patient mobile module: Supports iOS and Android operating systems, providing functions such as follow-up plan query, contract fulfillment progress query, points balance query, and health reminder reception; Multi-device data synchronization module: Enables real-time data synchronization between PC and mobile devices via an encrypted interface, and synchronizes offline operation data after network recovery; Data transmission security module: Employs AES encryption algorithm and OAuth2.0 authentication mechanism to ensure data transmission and storage security.

8. The intelligent management platform for a primary-level chronic disease screening and prevention center according to claim 1, characterized in that: The platform uses Vue3+Element Plus to build a responsive front-end interface and uses WebSocket technology to push real-time updates on follow-up status and performance progress.

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