The invention discloses a hierarchical
chronic disease management and
referral system based on
artificial intelligence, and belongs to the technical field of intelligent
medical treatment, and the
system comprises the steps: setting upstream and downstream
referral paths composed of diagnosis and treatment institutions, binding responsible doctors corresponding to chronic diseases for the diagnosis and treatment institutions of each level, and forming a
referral relation mapping table; predicting a
chronic disease dynamic risk based on the multi-source and multi-
modal data of the target crowd, classifying the target crowd, generating a
chronic disease management suggestion for each type of crowd, and pushing the chronic
disease management suggestion to a chronic
disease doctor for contract signing management; generating referral suggestions based on the chronic
disease dynamic risk changes of each type of people and pushing the referral suggestions to chronic disease doctors, and the chronic disease doctors determining the referral suggestions, setting referral information based on upstream and downstream referral paths and a referral relation mapping table and synchronously notifying target diagnosis and treatment institutions and patients; performance excitation is performed on whether a chronic disease doctor completes contract signing of a chronic
disease patient, implementation of graded referral treatment and medical cost saving, so that the medical service precision can be improved, the diagnosis and treatment efficiency is improved, and medical cost throttling is promoted.