A cerebrovascular disease secondary prevention intelligent management system

Abstract

The application discloses a cerebrovascular disease secondary prevention intelligent management system, relates to the medical and health information technology field, and comprises a doctor end and a patient end, both of which are connected through network communication; the patient end is integrated with an Internet of Things device to realize automatic / manual uploading of health data; the doctor end calls a cerebrovascular disease vector knowledge base constructed based on an open source large language model based on medical records, discharge summaries and real-time monitoring data when patients are grouped, generates a personalized management scheme for each patient through a prompt word engineering and retrieval enhancement generation mechanism, and the content covers blood pressure, blood glucose, blood lipid, medication and exercise management; the system forms a closed-loop intervention through a health liaison officer distribution mechanism, message reminders, health clock-in and weekly feedback; the system also supports clinical endpoint event and adverse event reporting, sub-center management and role permission control. The application can effectively improve the compliance of cerebrovascular disease patients in secondary prevention and the standard rate of risk factor control, and reduce the risk of recurrence.

Description

Technical Field

[0001] This application relates to the field of medical and health information technology, and in particular to a smart management system for secondary prevention of cerebrovascular diseases. Background Technology

[0002] Cerebrovascular diseases (such as cerebral infarction and cerebral hemorrhage) are characterized by high recurrence rates, high disability rates, and high mortality rates. The core of secondary prevention lies in the long-term effective control of modifiable risk factors such as hypertension, hyperglycemia, hyperlipidemia, smoking, and unhealthy lifestyle habits. However, in the current medical system, patients lack continuous, timely, and personalized follow-up management after discharge, leading to poor adherence, unmet indicator control, and a persistently high risk of recurrence.

[0003] Current technology has the following shortcomings: (1) Patient self-monitoring relies on paper records or isolated apps, and the data cannot be automatically synchronized to the doctor's end, making it difficult to form an effective basis for intervention; (2) Treatment plans are mostly based on standardized guidelines and lack dynamic and personalized adjustments for individual differences (such as comorbidities, drug tolerance, and lifestyle habits); (3) Lack of intelligent decision support mechanisms that integrate international clinical guidelines, evidence-based medicine, and real-world data; (4) The channels for doctor-patient communication are scattered, and there is no incentive and feedback loop for the execution of follow-up tasks.

[0004] Although some remote health management systems have attempted to integrate wearable devices, a complete closed-loop system has not yet been built, which is centered on secondary prevention of cerebrovascular diseases and integrates AI generative models and IoT monitoring. Summary of the Invention

[0005] The purpose of this application is to provide a smart management system for secondary prevention of cerebrovascular diseases, which can solve technical problems such as poor patient compliance, non-personalized management, data silos, and lack of intervention closed loop.

[0006] To achieve the above objectives, this application provides the following solution: This application provides a smart management system for secondary prevention of cerebrovascular diseases, including: a doctor's terminal and a patient's terminal connected to each other via a network; The patient terminal is used to collect and upload the patient's health data; the health data includes blood pressure, blood sugar, blood lipids, waist circumference, weight, exercise steps and medication records, which are automatically uploaded through IoT devices or manually uploaded by the user. The doctor's terminal is used to receive the health data, establish electronic patient records, and, based on the patient's initial medical record, discharge summary and real-time health data in the electronic records, call the cerebrovascular disease vector knowledge base built on the open source big language model, and generate a personalized secondary prevention management plan for each patient through the retrieval enhancement generation mechanism. The personalized secondary prevention management plan includes blood pressure management goals, blood glucose control strategies, blood lipid intervention measures, medication plans, and exercise recommendations; The patient terminal is further used to automatically generate health check-in tasks based on the personalized secondary prevention management plan, and push reminders for abnormal health data, medication time and check-in tasks through the message reminder module.

[0007] Optionally, the doctor's end specifically includes: The first login module is used to log in to the system using an account and password. The patient management module includes: an intervention group patient unit, a control group patient unit, and a contact person assignment unit. The intervention group patient unit is used for randomized patients to create new patients, fill in basic information, demographic characteristics, hospitalization details, personal history / past medical history / comorbidities, discharge status, and post-discharge management. After successful saving, the entered information is displayed in the intervention group patient list. The control group patient unit is used for randomized patients to create new patients, fill in basic information, demographic characteristics, hospitalization details, personal history / past medical history / comorbidities, discharge status, and post-discharge management. After successful saving, the entered information is displayed in the control group patient list. The contact person assignment unit is used to assign or unassign contact persons to successfully enrolled intervention group patients. Successfully assigned intervention group patients can communicate through their assigned contact persons. The hardware management module includes: a device management unit and a patient device unit; the device management unit is used to view information on IoT devices that have been imported into the system; the patient device unit is used to view patient information and information on IoT devices that have been bound to them. The message management module is used to send short messages to patients who have already been registered at regular intervals; The branch center management module is used to add, delete, modify, and view the branch centers to which doctors belong.

[0008] Optionally, the patient terminal specifically includes: The second login module is used to log in to the mini-program using an account; The health data module includes: blood pressure unit, blood glucose unit, blood lipid unit, waist circumference unit, and exercise unit; The medication management module displays the medication plan and medication information after the doctor has created the patient's file, as well as the medication name, frequency of administration, my pillbox, my additions, and medication record information. It also reminds patients to take their medication through the medication reminder function. The one-click communication module is used to contact liaison officers and help patients schedule doctor appointments; The health check-in module is used to automatically generate check-in tasks that are automatically generated by doctors in the plan management. Patients complete measurement and medication-related tasks through health check-in. The report upload module is used by patients to upload their blood lipid reports. The message notification module is used to display notification messages, health liaison officer messages, friend messages, and messages pushed by doctors in the message management module in the system notifications of the notification messages; My module includes: Personal Information, Health Contact Person, My Appointment, My Device, My Follow-up, My Report, My Management Plan, and more service units. The Personal Information unit displays the patient's name, gender, age, height, weight, waist circumference, mobile phone number, ID number, date of birth, and my QR code, entered during patient registration with the doctor. The Health Contact Person unit displays information about added health contacts and allows viewing their personal information and data. The My Appointment unit displays appointments made by the health contact person for the patient. The system displays the status of doctor appointment requests (in progress, completed, canceled); the "My Devices" section is used to bind and unbind devices and view the names and serial numbers of bound devices; the "My Follow-up" section is used to view the follow-up reports automatically generated after the doctor fills in the follow-up records; the "My Reports" section is used to view weekly blood pressure and blood glucose reports, with the blood pressure report including blood pressure results, blood pressure analysis, and blood pressure target achievement rate, and the blood glucose report including blood glucose results, blood glucose analysis, and blood glucose target achievement rate; and the "My Management Plan" section displays the plan management information filled in by the doctor in the plan management module.

[0009] Optionally, the IoT devices include blood pressure monitors, blood glucose meters, and smart pillboxes; The blood pressure monitor communicates with the patient via the Socket protocol to automatically upload blood pressure data; The blood glucose meter communicates with the patient via the HTTPS protocol to automatically upload blood glucose data; The smart pillbox is used to issue reminders at preset medication times and record the patient's actual medication behavior.

[0010] Optionally, when generating a personalized secondary prevention management plan, the doctor's terminal specifically performs the following steps: (a) Obtain structured health data of patients, including age, sex, height, weight, past medical history, discharge diagnosis, current medication list and initial monitoring index values; (b) Convert the structured health data into a vector representation; (c) Based on the vector representation, several candidate management schemes are retrieved from the pre-constructed cerebrovascular disease vector knowledge base; (d) Input the candidate management scheme and the structured health data into the open-source big language model, and generate the final personalized management scheme based on the search results through the prompt word engineering constraint model.

[0011] Optionally, the cerebrovascular disease vector knowledge base is constructed from the following data: international and domestic clinical guidelines for secondary prevention of cerebrovascular diseases, chapters of authoritative medical textbooks, real doctor-patient Q&A records, and desensitized clinical case data; The vector knowledge base uses a text embedding model to convert text slices into vectors and stores them in a vector database.

[0012] Optionally, the notification message types pushed by the message reminder module include: system notifications, abnormal reminders, check-in notifications, and device status reminders; The abnormal alert is automatically triggered when the patient's uploaded blood pressure or blood sugar value exceeds the individualized target threshold set by the doctor.

[0013] Optionally, the doctor's end also includes: a system management module; the system management module includes: a doctor management unit and a role management unit; the doctor management unit is used to add, delete, modify, and view doctors using the system, and to manage permissions and roles; the role management unit is used to add, delete, modify, and view user role names and permissions.

[0014] Optionally, the "My" module may also include: more service units, used to demonstrate functions related to subsequent development.

[0015] Optionally, during the implementation of the personalized secondary prevention management plan, the system continuously receives new health data and dynamically calls the open-source large language model to update and optimize the original plan based on the new health data, thereby realizing closed-loop iterative personalized intervention.

[0016] According to the specific embodiments provided in this application, this application has the following technical effects: This application provides a smart management system for secondary prevention of cerebrovascular diseases, which has the following significant advantages: Improve adherence: Through smart pillbox reminders, health check-in points incentives, and real-time alerts for abnormal data, significantly improve patient adherence to medication, monitoring, and lifestyle interventions.

[0017] Achieving personalized management: By leveraging AI big data models combined with evidence-based knowledge bases, a personalized management plan is generated and dynamically adjusted for each patient, breaking through the traditional "one-size-fits-all" model.

[0018] Reduce the risk of recurrence: Through continuous monitoring and intelligent early warning, timely detection of uncontrolled risk factors and early intervention can reduce the recurrence rate and disability rate of cerebrovascular diseases.

[0019] Reduce healthcare costs: Reduce unnecessary in-person follow-up visits, optimize the allocation of medical resources, and alleviate the burden on patients and the medical insurance system.

[0020] Build a closed-loop management system: Integrate the entire process of "data collection - AI decision-making - task execution - effect feedback - solution optimization" to form a stable and scalable secondary prevention and intervention model.

[0021] Supports clinical research: The system has built-in control group management, follow-up nodes (90±7 days, 1 year±14 days), and event reporting mechanisms, which are suitable for data collection and management in multi-center clinical trials. Attached Figure Description

[0022] To more clearly illustrate the technical solutions in the embodiments of this application or the prior art, the drawings used in the embodiments will be briefly introduced below. Obviously, the drawings described below are only some embodiments of this application. For those skilled in the art, other drawings can be obtained based on these drawings without creative effort.

[0023] Figure 1 This is a schematic diagram of the structure of a smart management system for secondary prevention of cerebrovascular diseases in one embodiment of this application. Detailed Implementation

[0024] The technical solutions of the embodiments of this application will be clearly and completely described below with reference to the accompanying drawings. Obviously, the described embodiments are only some embodiments of this application, and not all embodiments. Based on the embodiments of this application, all other embodiments obtained by those skilled in the art without creative effort are within the scope of protection of this application.

[0025] To make the above-mentioned objectives, features and advantages of this application more apparent and understandable, the application will be further described in detail below with reference to the accompanying drawings and specific embodiments.

[0026] The occurrence of cerebrovascular disease is associated with multiple risk factors, including hypertension, hyperglycemia, high cholesterol, smoking, poor diet, and lack of exercise. Managing these risk factors is crucial for preventing the disease from worsening, but many patients find it difficult to manage these factors themselves. Existing technologies struggle to model the relationships between multiple risk factors. The IoT monitoring technology for secondary prevention of cerebrovascular disease involved in this application can effectively solve this problem.

[0027] Furthermore, the conditions of cerebrovascular disease patients vary greatly, but traditional treatments are often standardized. The lack of personalized treatment plans may reduce treatment effectiveness. Traditional techniques struggle to match different patient models based on individual differences. This application, through artificial intelligence and big data technology, can generate personalized treatment plans for each individual based on patient differences, thereby effectively solving this problem.

[0028] To address the above problems, this application provides a smart management system for secondary prevention of cerebrovascular diseases, see [link to relevant documentation]. Figure 1 This includes: doctor's end and patient's end connected to each other via a network; The patient terminal is used to collect and upload the patient's health data; the health data includes blood pressure, blood sugar, blood lipids, waist circumference, weight, exercise steps and medication records, which are automatically uploaded through IoT devices or manually uploaded by the user. The doctor's end is used to receive the health data, establish electronic patient records, and, based on the patient's initial medical record, discharge summary and real-time health data in the electronic records, call the cerebrovascular disease vector knowledge base built on the open source big language model, and generate a personalized secondary prevention management plan for each patient through the retrieval enhancement generation mechanism. Personalized secondary prevention management plans include blood pressure management goals, blood glucose control strategies, blood lipid intervention measures, medication plans, and exercise recommendations; The patient-side interface is further used to automatically generate health check-in tasks based on the personalized secondary prevention management plan, and to push reminders for abnormal health data, medication time, and check-in tasks through the message reminder module.

[0029] The aforementioned IoT devices include blood pressure monitors, blood glucose meters, and smart pillboxes; The blood pressure monitor communicates with the patient via the Socket protocol to automatically upload blood pressure data; The blood glucose meter communicates with the patient via the HTTPS protocol to automatically upload blood glucose data; The smart pillbox is used to issue reminders at preset medication times and record the patient's actual medication behavior.

[0030] Specifically, the doctor's side includes: the first login module, the patient management module, the hardware management module, the message management module, the branch center management module, and the system management module; The first login module is used to log in to the system using an account and password. Specifically, it is used to log in to the system using a mobile phone number and password. After successfully logging in, users can use the system functions.

[0031] The patient management module includes: intervention group patient unit, control group patient unit, and assignment liaison officer unit; among them, the main function of the intervention group patient unit is to create new patients who are randomly assigned to the intervention group, fill in basic information, demographic characteristics, hospitalization status, personal history / past history / comorbidities, discharge status, and post-discharge management. After successful saving, the filled information will be displayed in the intervention group patient list. The main function of the 90±7 days and 1 year±14 days is to fill in the patient's follow-up questionnaire and view the filled content. The main function of the clinical endpoint event reporting system is to fill out the clinical endpoint event reporting form and view its contents. The main function of the serious adverse event reporting system is to fill out the serious adverse event reporting form and view its contents.

[0032] The main function of the control group patient unit is to allow patients who are randomly assigned to the control group to create a new group, fill in basic information, demographic characteristics, hospitalization status, personal history / past history / comorbidities, discharge status, and post-discharge management. After successful saving, the filled information will be displayed in the control group patient list. The main function of the 90±7 days and 1 year±14 days is to fill in the patient's follow-up questionnaire and view the filled content. The main function of the clinical endpoint event reporting system is to fill out the clinical endpoint event reporting form and view its contents. The main function of the serious adverse event reporting system is to fill out the serious adverse event reporting form and view its contents.

[0033] The main function of the assigned liaison officer unit is to assign or unbind health liaison officers to intervention groups that have been successfully enrolled. After successful assignment, intervention group patients can communicate with their health liaison officers through a one-click communication module in the patient's app.

[0034] The hardware management module specifically includes: the device management unit and the patient device unit; The device management unit is used to view information about IoT devices (blood pressure monitors, blood glucose meters, smart pillboxes, etc.) that have been imported into the system. The patient device unit is used to view patient information and information about the linked IoT devices.

[0035] The message management module is used to send short messages to patients who have already been registered.

[0036] The branch center management module is used to add, delete, modify, and view the branch centers to which doctors belong.

[0037] The system management module includes: a doctor management unit and a role management unit; The doctor management unit is used to add, delete, modify, and view doctors using the system, and to manage permissions and roles. The role management unit is used to add, delete, modify, and view user role names and permissions.

[0038] When generating a personalized secondary prevention management plan, the doctor performs the following steps: (a) Obtain structured health data of patients, including age, sex, height, weight, past medical history, discharge diagnosis, current medication list and initial monitoring index values; (b) Convert the structured health data into a vector representation; (c) Based on the vector representation, several candidate management schemes are retrieved from the pre-constructed cerebrovascular disease vector knowledge base; (d) Input the candidate management scheme and the structured health data into the open-source big language model, and generate the final personalized management scheme based on the search results through the prompt word engineering constraint model.

[0039] The patient-side module includes: a second login module, a health data module, a medication management module, a one-click communication module, a health check-in module, a report upload module, a message reminder module, and a "My" module. The second login module is used to log in to the mini-program with an account; specifically, it logs in to the mini-program by obtaining a mobile phone number from WeChat. After successful login, the mini-program's functions can be used.

[0040] The health data module includes: blood pressure unit, blood glucose unit, blood lipid unit, waist circumference unit, and exercise unit; The main functions of the blood pressure unit are to display the device binding status and process, and to display health monitoring information such as blood pressure data uploaded or manually uploaded by the patient's blood pressure monitor. After the blood pressure monitor is bound through the "My Devices" submodule, the server receives and displays the blood pressure data obtained from the blood pressure monitor via the socket protocol. The page functions include manual upload, automatic upload, latest data, blood pressure trend graph, heart rate trend graph, and historical data. In the latest data, systolic blood pressure of 130-140 mmHg is displayed as the critical value and marked in yellow. When the blood pressure exceeds the maximum target blood pressure value in the patient's record, it is displayed as systolic blood pressure and marked in red with an upward arrow and a "danger" symbol. Doctors can view the uploaded data through the health data submodule of the doctor's terminal system. Both patients and doctors can understand the blood pressure change trend and health status through this blood pressure data.

[0041] The main function of the blood glucose unit is to display the device binding status and process, and to display health monitoring information such as blood glucose data uploaded or manually uploaded by the blood glucose meter used daily. After binding the blood glucose meter through the "My Devices" module, the server receives and displays the blood glucose data obtained from the blood glucose meter through the HTTPS protocol. The page functions include manual upload, automatic upload, latest data, blood glucose data type, fasting blood glucose trend chart, postprandial two-hour blood glucose trend chart, and historical data. In the latest data, blood glucose values ​​that are higher or lower than the target blood glucose value in the patient's record will be marked in red. Doctors can view the uploaded data through the health data sub-module of the doctor's terminal system. Both patients and doctors can understand the blood glucose trend and health status through this blood glucose data. The main function of the blood lipid unit is to display blood lipid information that is manually uploaded or filled in during the registration process. The page functions include manual upload, latest data, blood lipid trend chart, and historical data. Through this blood lipid data, you can understand the trend of blood lipid changes and health status. Doctors can also view the uploaded data through the health data sub-module of the doctor's terminal system.

[0042] The main function of the waist circumference unit is to display manually uploaded waist circumference and weight information. The page functions include manual upload, latest data, waist circumference trend chart, and historical data. After updating waist circumference or weight information, the system will automatically calculate the BMI data and display it in the BMI sub-module of the doctor's terminal system. Doctors can view it by using the health data sub-module of the doctor's terminal system.

[0043] The main functions of the exercise unit are exercise-related information, and the page functions include exercise steps, doctor's suggestions, historical data, and manual upload. Doctors can view the uploaded data through the health data sub-module of the doctor's terminal system.

[0044] The main functions of the medication management module are to display the medication plans and medication information displayed after the doctor has created the patient's file, as well as the medication name, frequency of administration, my pillbox, my additions, and medication record information. The medication reminder function reminds patients to take their medication.

[0045] The main function of the one-click communication module is to allow doctors to assign health liaison officer information to patients in the patient pool, which can facilitate quick and easy communication with the liaison officer and help patients make appointments with doctors.

[0046] The main function of the health check-in module is to automatically generate check-in tasks in the doctor's plan management. Patients can easily complete related tasks such as measurement and medication through health check-in.

[0047] The main function of the report upload module is to allow patients to upload their blood lipid reports. The message notification module is used to display notification messages, health liaison officer messages, friend messages, and messages pushed by doctors in the message management module in the system notifications of the notification messages; among them, notification messages include: system notifications, abnormal reminders, check-in notifications, and device management.

[0048] My modules include: Personal Information, Health Contact Person, My Appointment, My Device, My Follow-up, My Reports, My Management Plan, and more service modules; The personal information unit is used to display the patient's name, gender, age, height, weight, waist circumference, mobile phone number, ID number, date of birth, and my QR code, which were filled in by the patient when creating a medical record on the doctor's end. The Health Contact Unit is used to display information on health contacts that have been added, and allows users to view the personal information and data of these health contacts. My Appointment section is used to display the status information of the application for a doctor appointment that the health liaison officer helped the patient to make, including whether it is in progress, completed, or canceled. My device unit is used to bind devices, unbind devices, and view the names and serial numbers of bound devices. My follow-up unit is used to view the follow-up report information automatically generated after the doctor fills in the follow-up record; My report unit is used to view weekly blood pressure reports and weekly blood glucose reports. The weekly blood pressure report includes: blood pressure results, blood pressure analysis, and blood pressure target achievement rate. The weekly blood glucose report includes: blood glucose results, blood glucose analysis, and blood glucose target achievement rate. My Management Plan unit is used to display the plan management information that doctors fill in in the plan management module.

[0049] More service units are used to showcase features related to future development.

[0050] Specifically, the patient management module on the doctor's side is connected to the second login module, health data, and medication management module on the patient's side; the patient management module on the doctor's side is connected to the health check-in module on the patient's side; the patient management module on the doctor's side is connected to the one-click communication module; and the message management module on the doctor's side is connected to the message reminder module on the patient's side. The patient's second login module, health data module, and medication management module are connected to the doctor's "My Patient Management" module. The patient's health check-in module is connected to the doctor's patient management module. The patient's message reminder module is connected to the doctor's message management module.

[0051] The technical solution of this application will be further explained and illustrated below with a specific example: Patient side: I. Login Login method: WeChat login Instructions: Open WeChat - Enter the mini program - Get your phone number - Enter the mini program homepage.

[0052] II. Health Data 2.1 Blood Pressure The homepage displays the blood pressure tab by default when you click on health data.

[0053] 2.1.1 My Devices: Displays the device binding status. If the device is bound, a "Bind Now" button will be displayed. Clicking "Bind Now" will initiate the binding process. If there are already bound devices, the name and SN code of the bound devices will be displayed directly. 2.1.2 Latest Data Displays target blood pressure, latest data, and data upload methods; Target blood pressure: This is derived from the target blood pressure value for blood pressure management from the enrollment questionnaire completed by the researchers. If the researchers change the target blood pressure, this data will be updated. Blood pressure data: Displays the latest data uploaded manually or by the device, including time, systolic blood pressure, diastolic blood pressure and heart rate. Systolic blood pressure of 130-140 mmHg is displayed as the critical value and marked in yellow. Blood pressure exceeding 140 mmHg is displayed as high blood pressure and marked in red with an up arrow and a "danger" symbol. Manual upload: Enter the manual upload page, fill in the blood pressure data, and after successful saving, the blood pressure data will be displayed in the latest data, blood pressure trend chart and historical data; Automatic upload: Click to enter the tutorial page on how to measure blood pressure using a blood pressure monitor.

[0054] 2.1.3 Blood Pressure Trend Chart: Displayed in two dimensions: day and week. Day: All blood pressure measurements within a day. Week: The latest blood pressure measurements for each day within a week (including manually uploaded and automatically measured data). 2.1.4 Heart Rate Trend Chart: Displayed in two dimensions: day and week. Day: All heart rate measurements within a day. Week: The latest heart rate measurements for each day within a week (including manually uploaded and automatically measured data). 2.1.5 Historical Records: Displays the three most recent historical data points, including the specific blood pressure measurement time and data. Systolic blood pressure of 130-140 mmHg is displayed as the critical value and marked in yellow. Blood pressure exceeding 140 mmHg is displayed as high blood pressure and marked in red. Systolic blood pressure of 85-90 mmHg is displayed as the critical value and marked in yellow. Blood pressure exceeding 90 mmHg is displayed in red. 2.1.6 More: By default, all measurement data for the day is displayed. If no measurement is performed on the day, a message will be displayed: "No test was performed today." If measurement data is available on the day, the blood pressure measurement time and measurement data will be displayed. Measurement data for any day can be viewed in the calendar (data display is the same as historical data). 2.1.7 Liaison Officer: Clicking this will redirect you to the Health Liaison Officer page. 2.2 Blood glucose Click "Homepage > Health Data" to switch to the Blood Glucose tab; 2.2.1 My Devices: Displays the device binding status. If the device is bound, a "Bind Now" button will be displayed. Clicking "Bind Now" will initiate the binding process. If there are already bound devices, the name and SN code of the bound devices will be displayed directly. 2.2.2 Latest Data Displays target blood glucose level, latest data, and data upload methods; Target blood glucose: This is derived from the target blood glucose value for blood glucose management from the enrollment questionnaire completed by the researchers. If the researchers change the target blood glucose, this data will be updated. Blood glucose data: Displays the latest data uploaded manually or by the device, including time, blood glucose data, and a button to select measurement type. Click to select type, and a type drop-down box will pop up at the bottom. After successful selection, the selected measurement type will be displayed. Fasting blood glucose: above 7 mmol / L is marked in red, and below 3.9 mmol / L is marked in red. 2-hour postprandial blood glucose (after breakfast, lunch, and dinner): above 10 mmol / L is marked in red, and below 3.9 mmol / L is marked in red. Manual upload: Enter the manual upload page, fill in the blood glucose data, and after successful saving, the entered blood glucose data will be displayed in the latest data and the corresponding blood glucose trend chart and historical data; Automatic upload: Click to enter the tutorial page for measuring blood pressure using a blood glucose meter; 2.2.3 Fasting Blood Glucose Trend Chart: Displayed in two dimensions: day and week. Day: Measurement of fasting blood glucose within a day. Week: The latest fasting blood glucose measurement for each day of the week (including manually uploaded and automatically measured data). 2.2.4 Postprandial 2-hour blood glucose trend chart: Displayed in two dimensions: day and week. Day: Measurement of postprandial 2-hour blood glucose within a day. Week: The latest postprandial 2-hour blood glucose measurement for each day of the week (including manually uploaded and automatically measured data); 2.2.5 Historical Data: Displays the three most recent historical data points, including the specific blood glucose measurement time, measurement data, and measurement type. Fasting blood glucose: values ​​above 7 mmol / L are marked in red, and values ​​below 3.9 mmol / L are also marked in red. Postprandial 2-hour blood glucose (after breakfast, lunch, and dinner): values ​​above 10 mmol / L are marked in red, and values ​​below 3.9 mmol / L are also marked in red. Normal blood glucose is displayed in blue. 2.2.6 More: The More Data page displays all measurement data for the day by default. If no measurement was performed that day, a message will appear saying "No test was performed today." If measurement data was performed that day, the page will display the blood glucose measurement time, measurement data, and measurement type. Measurement data for any day can be viewed in the calendar (data display is the same as historical data). 2.2.7 Liaison Officer: Clicking this will redirect you to the Health Liaison Officer page. 2.3 Blood lipids Click on the homepage, then click on Health Data, and switch to the Blood Lipids tab. 2.3.1 Latest Data: Displaying and manually uploaded blood lipid data or data filled in by researchers in the enrollment questionnaire or management protocol; 2.3.2 Manual Upload: Click to enter the blood lipid data for the current day or a previous day. Once saved, the data will be displayed in the latest data. 2.3.3 Blood Lipid Trend Chart: Displays the seven most recent uploaded blood lipid data entries; 2.3.4 Historical Records: Displays the three most recent historical data points, including the time and blood lipid data. 2.3.5 More: The More Data page displays all data for the day by default. If no measurements were taken that day, a message will appear saying "No test was performed today." If measurements were taken that day, blood lipid information will be displayed. Data for any day can be viewed in the calendar. 2.3.6 Liaison Officer: Clicking this will redirect you to the Health Liaison Officer page; 2.4 Waist circumference Click "Homepage," then click "Health Data" to switch to the "Services" tab. 2.4.1 Latest Data: Displays manually uploaded data for waist circumference and weight; 2.4.2 Manual Upload: Enter the manual upload page, which displays the measurement time and type. After successful saving, the data will be displayed in the corresponding latest data. 2.4.3 Waist circumference trend chart: 2.4.4 Weight Trend Chart: Displays the seven most recent weight data points; 2.4.5 Historical Records: Displays the three most recent historical data entries, specifically showing the time, waist circumference, and weight data; 2.4.6 More: The More Data page displays all data for the day by default. If no measurements were taken that day, a message will appear saying "No test was performed today." If measurements were taken that day, blood lipid information will be displayed. Data for any day can be viewed in the calendar. 2.4.7 Liaison Officer: Clicking this will redirect you to the Health Liaison Officer page; 2.5 exercise Click "Homepage," then click "Health Data" to switch to the "Services" tab. 2.5.1 Current Steps: Retrieves the number of steps taken via WeChat Sports after enabling WeChat Sports; 2.5.2 Doctor's suggestions: The exercise that the doctor sets for the patient in the "Exercise Management" of "Patient Record" or "Management Plan" through the doctor's terminal will be displayed to the patient's terminal. 2.5.3 Manual Upload: Click to enter and fill in your exercise record for the current day or a previous day. After successful saving, it will be displayed in the historical data. 2.5.4 Historical Records: Displays the three most recent historical data entries, specifically showing the upload time, exercise time, and exercise type; 2.5.5 More: The More Data page displays all data for the day by default. If no measurements were taken that day, a message will appear saying "No test was performed today." If measurements were taken that day, blood lipid information will be displayed. Data for any day can be viewed in the calendar. 2.5.6 Liaison Officer: Clicking this will redirect you to the Health Liaison Officer page; III. Medication Management 3.1 My Pillbox: Displays the name of the medication, the frequency of medication use, and the information source is the medication set by the doctor for the patient through the doctor's terminal in the "Medication Management" of "Patient Record" or "Management Plan". The latest medication set is displayed on the patient's terminal. 3.2 Adding Medicines: Two methods are available: search for medicines and manually take a photo and upload it. Successfully added medicines will be displayed in "My Additions". 3.3 Medication Reminders: After binding the pillbox, you can set medication reminders. The pillbox will remind you at the set time if the reminder is successfully set. If you have not bound a pillbox, you need to bind it first. 3.4 Medication Records: Manually upload and fill in medication information. After successful saving, the medication records will be displayed. Click "More" to view historical medication records. IV. One-click communication 4.1 Health Liaison Officer Click "One-Click Communication" to enter the Health Liaison Officer tab; 4.1.1 Health Liaison Officer List: The backend will assign a health liaison officer to each patient, displaying the name and avatar of the assigned health liaison officer; 4.1.2 Appointment: Schedule an appointment with a doctor through the health liaison, leave a message with the health liaison officer, or call the health liaison officer directly. 4.2 My Doctor Click "One-Click Communication" to enter the "My Doctor" tab; 4.2.1 My Doctors List: Information on the doctors who created the patient's medical record; 4.2.2 View: View doctor information, dietary recommendations, exercise recommendations, and recommended frequency of blood pressure measurements; V. Health Check-in 5.1 Check-in Points: You will receive random points for each completed check-in; 5.2 Exercise Tasks: Exercise tasks are automatically generated by doctors in the backend management plan; 5.3 Blood Pressure Tasks: Doctors manage blood pressure in the backend system, automatically generating blood pressure measurement tasks; 5.4 Blood Glucose Tasks: Blood glucose management in the backend management plan automatically generates blood measurement tasks; 5.5 Completed check-in: A completion indicator appears; 5.6 Historical Check-in Records: View historical check-in records; VI. Upload Report 6.1 Click "Upload Report" to select the report type. After successful upload, a list of uploaded reports will be displayed. VII. Message Notifications 7.1 Notification Messages Includes system notifications, anomaly alerts, attendance tracking notifications, and device management; 7.1.1 System Notifications: Receive messages sent by doctors to patients in the background; 7.1.2 Abnormal Alerts: Receive alerts related to abnormal blood pressure / blood glucose data; 7.1.3 Check-in Notification: Receive reminders for blood pressure / blood sugar check-in messages; 7.1.4 Device Management: Receives status alerts for hardware devices; 7.2 Health Liaison Officer Message 7.2.1 Appointment Notification: Message reminders related to appointments; 7.2.2 Message Notification: Message notifications related to reminding people of new messages; 7.2.3 Assign Health Liaison Officer Messages: Assign Health Liaison Officer message reminders; 7.3 Messages from friends A notification message indicating successful addition of a health guardian; VIII. My 8.1 Personal Information Display personal information, lifestyle habits, and past medical history (information is brought out from the past medical history module filled out by the patient when registering). 8.2 Health Guardian 8.2.1 List of health guardians, displaying names and photos, and allowing users to view detailed information about health contacts; 8.2.2 Add a health guardian: Search for a health contact by mobile phone number and select to add them to become each other's health guardians; 8.3 My Appointment 8.3.1 In Progress: Shows the appointment being initiated with the health liaison officer; 8.3.2 In Progress: Appointments that have already begun (health liaison officers have made appointments with doctors and are awaiting appointments). 8.3.3 Completed: Reservations that have already been completed; 8.3.4 Cancelled: Appointments cancelled by the user or by the health liaison officer; 8.4 My Device Displays a list of already bound hardware devices; users can choose to unbind or bind devices. 8.5 My Follow-up A follow-up report is generated after each follow-up visit, and patients can view the details of the follow-up report. 8.6 My Report 8.6.1 Blood Pressure Weekly Report: The previous week's blood pressure weekly report is automatically generated every Monday at 8:00 AM, displaying the time and a view button. If the number of blood pressure measurements in the previous week was less than four, clicking "View" will bring up a prompt: "The number of measurements in the past week was less than 4, and there is no report information available." If the number of blood pressure measurements in the previous week was four or more, clicking "View" will take you to the blood pressure report details page. 8.6.2 Weekly Blood Glucose Report: The weekly blood glucose report for the previous week is automatically generated every Monday at 8:00 AM, displaying the time and a view button. If the number of blood glucose measurements in the previous week was less than four, clicking "View" will bring up a prompt: "The number of measurements in the past week was less than 4, and there is no report information available." If the number of blood glucose measurements in the previous week was greater than or equal to four, clicking "View" will take you to the blood glucose report details page. 8.7 My Management Plan Displays the latest data on the management plans that doctors fill out for patients on the doctor's end; Doctor's side: I. Login Login method: Login with account and password. After successful login, you will be taken to the homepage.

[0055] II. Patient Management 2.1 Intervention group patients 2.1.1 Create a new enrollment: Click "Create a new enrollment" to enter the enrollment questionnaire. The enrollment questionnaire includes: basic information, demographic characteristics, hospitalization status, personal history / past history / comorbidities, discharge status, and post-discharge management. After successful temporary saving, the enrollment information will be displayed in the patient list. The enrollment information indicator will be yellow and editable. Alternatively, you can save it directly, and the enrollment information indicator will turn green and editable. 2.1.2 90±7 days: Click the gray icon to enter the 90±7 day follow-up form. After successful completion, it will be temporarily saved and displayed in yellow and can be edited. Alternatively, you can save it directly and the form color will turn green so that it can be edited again. 2.1.3 1 year ± 14 days: Click the gray icon to enter the 1 year ± 14 days follow-up form. After successful completion, it will be temporarily saved and displayed in yellow, and can be viewed and edited. Alternatively, you can save it directly, and the form color will turn green, allowing you to view and edit it. 2.1.4 Clinical endpoint event reporting: Click to enter the clinical key event reporting list page, click Add to enter the clinical endpoint event table. After successful saving, the saved form will be displayed on the list page. Click to view the saved form information. 2.1.5 Reporting of serious adverse events: Click to enter the serious adverse event reporting list page, click Add to enter the serious adverse event table, and after successful saving, the saved form will be displayed on the list page. Click View to view the saved form information; 2.1.6 Health Data: Click the Health Data button to view the patient's basic information, including blood pressure, blood sugar, blood lipids, BMI, medication, and exercise. The basic information displayed is derived from the enrollment questionnaire filled out by the researchers. The blood pressure page displays blood pressure records, blood pressure trend graphs, and historical blood pressure data. If the blood pressure exceeds the target value, a "hypertension" label will be displayed in the historical records. The system displays blood glucose records, postprandial blood glucose trend charts, and historical blood glucose data. If the blood glucose level exceeds the target value, a "high blood glucose" label will be displayed in the historical records. Blood lipid data includes a trend chart and records. The BMI trend chart is displayed. The first BMI is generated by filling in the waist circumference and height information in the enrollment questionnaire and displayed on the trend chart. Patients fill in their waist circumference and height information in the mini-program and the BMI is automatically calculated. My Fitness page displays a fitness trend chart (step count records obtained from the mini-program), fitness plans, and fitness records. The fitness plans are derived from the fitness management information filled in during the enrollment questionnaire. When the fitness plan is changed, it is updated synchronously. The medication page displays medication plans, patient additions, medication records, and medication plans sourced from the medication management information filled in during the enrollment questionnaire. When a medication plan is changed, it is updated synchronously. The patient addition page displays the medication information added by the patient in the mini-program, which is synchronized. 2.1.7 Protocol Management: Click the Protocol Management button to enter the Protocol Management list. Fill in or edit the post-discharge management (blood pressure management, blood glucose management, blood lipid management, discharge medication, exercise management) in the enrollment questionnaire. The system will automatically generate and add a management protocol. Click Add to enter the page for adding a management protocol (blood pressure management, blood glucose management, blood lipid management, discharge medication, exercise management). The system will display patient information and management protocol questionnaire. After successful saving, the saved questionnaire information will be displayed on the list page. Click View to view the management protocol details. 2.2 Control group patients 2.2.1 Create a new enrollment: Click "Create a new enrollment" to enter the enrollment questionnaire. The enrollment questionnaire includes: basic information, demographic characteristics, hospitalization status, personal history / past history / comorbidities, discharge status, and post-discharge management. After successful temporary saving, the enrollment information will be displayed in the patient list. The enrollment information indicator will be yellow and editable. Alternatively, you can save it directly, and the enrollment information indicator will turn green and editable. 2.2.2 90±7 days: Click the gray icon to enter the 90±7 day follow-up form. After successful completion, it will be temporarily saved and displayed in yellow and can be edited. Alternatively, you can save it directly and the form color will turn green so that it can be edited again. 2.2.3 1 year ± 14 days: Click the gray icon to enter the 1 year ± 14 days follow-up form. After successful completion, it will be temporarily saved and displayed in yellow, and can be viewed and edited. Alternatively, you can save it directly, and the form color will turn green, allowing you to view and edit it. 2.2.4 Reporting of Clinical Endpoint Events: Click to enter the list page of key clinical events, click Add to enter the clinical endpoint event table. After successful saving, the saved form will be displayed on the list page. Click to view the saved form information. 2.2.5 Reporting of Serious Adverse Events: Click to enter the serious adverse event reporting list page, click Add to enter the serious adverse event table, and after successful saving, the saved form will be displayed on the list page. Click View to view the saved form information; 2.3 Assigning Liaison Officers Showcasing patients who have been successfully enrolled in the intervention group; Clicking the patient assignment button displays the users whose health liaison officer roles have been added by the system. After successful assignment, the "liaison officer" section displays the name of the assigned health liaison officer, the "Assign liaison officer?" status changes from "unassigned" to "assigned", and the assignment button is grayed out. After successful assignment, the assignment button will be grayed out. Clicking the unbind button will bring up a confirmation pop-up. After confirming, the health liaison officer will be successfully unbound. The health liaison officer's name will not be displayed in the "liaison officer" section. The "Assign a liaison officer?" status will change from "Assigned" to "Unassigned", and the assignment button will be grayed out. III. Hardware Management 3.1 Equipment Management Displays a list of added devices, allowing users to import devices and view device information; 3.2 Patient Equipment Displays patient information for bound devices. Click to view basic patient information and the patient's bound device status. Message Management Click to enter the message push list, which displays: message type, push type, notification type, and notification time; Click "Add" to enter the "Add Message Push" page. The push methods are global push and specified push. Global push sends a message to all patients using the mini program, while specified push sends a message to a selected group of patients. The push time is divided into scheduled push and custom time. Scheduled push sends a message at a fixed time, while custom time push sends a message over a specific period of time. After confirmation, the pushed messages will be displayed in the list. Click the "Edit" button to enter the message push details. After successfully modifying the push message, the modified push message will be displayed on the list page, and pushes will be made according to the modified push message. Clicking "Delete" will bring up a second confirmation pop-up. After confirming, the push message will be removed from the list and will no longer be pushed. V. Branch Center Management The sub-center list displays the sub-center name, sub-center type, and sub-center region. Users can add, modify, and delete sub-centers, and assign doctors to sub-centers. Click "Add" to enter the new sub-center management page, fill in the sub-center information, and after successful addition, the added sub-center will be displayed in the list. When adding or modifying, assign doctors who do not have sub-centers to the sub-center. After confirming the assignment, the doctor belongs to the sub-center. Click the "Edit" button to enter the sub-center management page. After successfully modifying the information, the modified sub-center information will be displayed on the list page. Clicking the delete button will bring up a second pop-up window. After successful deletion, the deleted sub-center will not be displayed in the sub-center list page. VI. System Management 6.1 Physician Management The doctor list displays the doctor's name, phone number, department, institution, and creation date, and allows users to add, modify, and delete doctor information. Click "Add" to enter the "Add User" page. After filling in the information, the newly added doctor's information will be displayed in the list. Click "Edit" to enter the user editing page. After successfully modifying the information, the modified doctor information will be displayed in the list page. Clicking the delete button will bring up a second pop-up window. After successful deletion, the deleted doctor will not be displayed in the doctor list page. 6.2 Role Management Click to expand the role categories, where you can add, delete, and modify roles, and assign permissions to roles; The technical features of the above embodiments can be combined in any way. For the sake of brevity, not all possible combinations of the technical features in the above embodiments are described. However, as long as there is no contradiction in the combination of these technical features, they should be considered to be within the scope of this specification.

[0056] This document uses specific examples to illustrate the principles and implementation methods of this application. The descriptions of the above embodiments are only for the purpose of helping to understand the methods and core ideas of this application. Furthermore, those skilled in the art will recognize that, based on the ideas of this application, there will be changes in the specific implementation methods and application scope. Therefore, the content of this specification should not be construed as a limitation of this application.

Claims

1. A smart management system for secondary prevention of cerebrovascular diseases, characterized in that, The intelligent management system for secondary prevention of cerebrovascular diseases includes: doctor terminals and patient terminals connected to each other via a network; The patient terminal is used to collect and upload the patient's health data; the health data includes blood pressure, blood sugar, blood lipids, waist circumference, weight, exercise steps and medication records, which are automatically uploaded through IoT devices or manually uploaded by the user. The doctor's terminal is used to receive the health data, establish electronic patient records, and, based on the patient's initial medical record, discharge summary and real-time health data in the electronic records, call the cerebrovascular disease vector knowledge base built on the open source big language model, and generate a personalized secondary prevention management plan for each patient through the retrieval enhancement generation mechanism. The personalized secondary prevention management plan includes blood pressure management goals, blood glucose control strategies, blood lipid intervention measures, medication plans, and exercise recommendations; The patient terminal is further used to automatically generate health check-in tasks based on the personalized secondary prevention management plan, and push reminders for abnormal health data, medication time and check-in tasks through the message reminder module.

2. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 1, characterized in that, The doctor's end specifically includes: The first login module is used to log in to the system using an account and password. The patient management module includes: an intervention group patient unit, a control group patient unit, and a contact person assignment unit. The intervention group patient unit is used for randomized patients to create new patients, fill in basic information, demographic characteristics, hospitalization details, personal history / past medical history / comorbidities, discharge status, and post-discharge management. After successful saving, the entered information is displayed in the intervention group patient list. The control group patient unit is used for randomized patients to create new patients, fill in basic information, demographic characteristics, hospitalization details, personal history / past medical history / comorbidities, discharge status, and post-discharge management. After successful saving, the entered information is displayed in the control group patient list. The contact person assignment unit is used to assign or unassign contact persons to successfully enrolled intervention group patients. Successfully assigned intervention group patients can communicate through their assigned contact persons. The hardware management module includes: a device management unit and a patient device unit; the device management unit is used to view information on IoT devices that have been imported into the system; the patient device unit is used to view patient information and information on IoT devices that have been bound to them. The message management module is used to send short messages to patients who have already been registered at regular intervals; The branch center management module is used to add, delete, modify, and view the branch centers to which doctors belong.

3. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 1, characterized in that, The patient terminal specifically includes: The second login module is used to log in to the mini-program using an account; The health data module includes: blood pressure unit, blood glucose unit, blood lipid unit, waist circumference unit, and exercise unit; The medication management module displays the medication plan and medication information after the doctor has created the patient's file, as well as the medication name, frequency of administration, my pillbox, my additions, and medication record information. It also reminds patients to take their medication through the medication reminder function. The one-click communication module is used to contact liaison officers and help patients schedule doctor appointments; The health check-in module is used to automatically generate check-in tasks that are automatically generated by doctors in the plan management. Patients complete measurement and medication-related tasks through health check-ins. The report upload module is used by patients to upload their blood lipid reports. The message notification module is used to display notification messages, health liaison officer messages, friend messages, and messages pushed by doctors in the message management module in the system notifications of the notification messages; My module includes: Personal Information, Health Contact Person, My Appointment, My Device, My Follow-up, My Report, and My Management Plan. The Personal Information unit displays the patient's name, gender, age, height, weight, waist circumference, mobile phone number, ID number, date of birth, and my QR code, entered during patient registration with the doctor. The Health Contact Person unit displays information on health contacts already added and allows viewing their personal information and data. The My Appointment unit displays the status of appointments made by health contacts for patients, including pending, in progress, completed, and canceled applications. The My Device unit allows binding and unbinding devices and viewing the names and serial numbers of bound devices. The My Follow-up unit displays automatically generated follow-up reports based on follow-up information entered by the doctor in the follow-up records. The My Report unit displays weekly blood pressure and blood glucose reports; the blood pressure report includes blood pressure results, blood pressure analysis, and blood pressure target achievement rate, and the blood glucose report includes blood glucose results, blood glucose analysis, and blood glucose target achievement rate. The My Management Plan unit displays the plan management information entered by the doctor in the plan management module.

4. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 1, characterized in that, The IoT devices include blood pressure monitors, blood glucose meters, and smart pillboxes; The blood pressure monitor communicates with the patient via the Socket protocol to automatically upload blood pressure data; The blood glucose meter communicates with the patient via the HTTPS protocol to automatically upload blood glucose data; The smart pillbox is used to issue reminders at preset medication times and record the patient's actual medication behavior.

5. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 1, characterized in that, When generating a personalized secondary prevention management plan, the doctor's terminal performs the following steps: (a) Obtain structured health data of patients, including age, sex, height, weight, medical history, discharge diagnosis, current medication list and initial monitoring index values; (b) Convert the structured health data into a vector representation; (c) Based on the vector representation, several candidate management schemes are retrieved from the pre-constructed cerebrovascular disease vector knowledge base; (d) Input the candidate management scheme and the structured health data into the open-source big language model, and generate the final personalized management scheme based on the search results through the prompt word engineering constraint model.

6. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 1, characterized in that, The cerebrovascular disease vector knowledge base is constructed from the following data: international and domestic clinical guidelines for secondary prevention of cerebrovascular diseases, chapters of authoritative medical textbooks, real doctor-patient Q&A records, and desensitized clinical case data; The vector knowledge base uses a text embedding model to convert text slices into vectors and stores them in a vector database.

7. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 3, characterized in that, The notification message types pushed by the message reminder module include: system notifications, abnormal reminders, check-in notifications, and device status reminders; The abnormal alert is automatically triggered when the patient's uploaded blood pressure or blood sugar value exceeds the individualized target threshold set by the doctor.

8. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 1, characterized in that, The doctor's end also includes: a system management module; the system management module includes: a doctor management unit and a role management unit; the doctor management unit is used to add, delete, modify, and view doctors using the system, and to manage permissions and roles; the role management unit is used to add, delete, modify, and view user role names and permissions.

9. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 3, characterized in that, My module also includes: more service units, used to demonstrate functions related to subsequent development.

10. The intelligent management system for secondary prevention of cerebrovascular diseases according to claim 1, characterized in that, During the implementation of the personalized secondary prevention management plan, the system continuously receives new health data and dynamically calls the open-source large language model to update and optimize the original plan based on the new health data, thereby realizing closed-loop iterative personalized intervention.

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