慢病随访管理工作化繁为简

In the past, follow-up of patients was operated by nurses from various departments. Due to the large number of patients, large workload, and limited human resources, follow-up work gradually became a formality, which not only wasted time and labor costs, but also made it difficult to analyze data and provide effective reference for improving medical service levels. The ability of each department to complete 100% of follow-up tasks as required is also influenced by various factors.

通过慢管通全院慢病智慧管理平台，融合目前市面成熟的AI智能随访技术，可实现慢病管理过程中高频、核心慢病随访业务的智能化、人性化，提升患者的依从性。

By integrating the mature AI intelligent follow-up technology on the market through the slow management platform of the entire hospital, the intelligent and humanized high-frequency and core slow disease follow-up business in the slow disease management process can be achieved, improving patient compliance.

自动化随访管理

Automated follow-up management

可根据科室、病种或者患者健康为中心建立标准化随访路径，例如：医生确认患者为高尿酸患者，系统自动启动高尿酸患者随访模板，为该患者生成随访计划。根据计划，系统定时提醒医护人员，并将该患者信息综合回报给医护人员，结合移动应用管理，将部分随访反馈给院外患者，真正做到高效便捷。同时自动筛选出脱访的患者，支持对脱访患者进行提醒。

A standardized follow-up path can be established based on the department, disease type, or patient's health as the center. For example, if the doctor confirms that the patient is a high uric acid patient, the system automatically launches a high uric acid patient follow-up template to generate a follow-up plan for the patient. According to the plan, the system regularly reminds medical staff and comprehensively reports the patient's information to them. Combined with mobile application management, it provides partial follow-up feedback to patients outside the hospital, truly achieving efficiency and convenience. At the same time, automatically screen out patients who have left the interview, and support reminders for patients who have left the interview.

标准化兼顾个性化

Standardization and personalization

系统内置丰富的随访模板，支持同一类患者匹配同样的随访方案，确保随访数据的统一性，以便后续的统计分析；同时系统还赋予了用户更多的主动权，可根据工作需要自定义模板或计划，增加随访的针对性、个性化，提高随访质量。

The system is equipped with rich follow-up templates that support matching the same follow-up plan for the same type of patients, ensuring the consistency of follow-up data for subsequent statistical analysis; At the same time, the system also gives users more initiative, allowing them to customize templates or plans according to work needs, increasing the targeted and personalized follow-up, and improving the quality of follow-up.

多维度统计分析

Multidimensional statistical analysis

系统可针对不同类别的随访数据，并形成可视化的统计报表（如随访工作统计、患者随访统计），便于医院全局审视自身医疗服务品质，量化管理评价指标，深度挖掘随访大数据应用价值，为院方高层的科学决策提供全维度、立体化的数据支撑。

The system can target different types of follow-up data and form visual statistical reports (such as follow-up work statistics and patient follow-up statistics), facilitating the hospital to comprehensively examine its own medical service quality, quantify management evaluation indicators, deeply explore the application value of follow-up big data, and provide comprehensive and three-dimensional data support for scientific decision-making by the hospital's senior management.

多样化的随访路径

Diversified follow-up pathways

除了常规电话随访，该系统还能够结合短信、语音外呼、院外患者端等形式对患者推送用药提醒、复诊提醒等，使得用户不再局限于单一集中式的人工拨打模式，不再受限于时空限制。帮助用户建立与患者更紧密的沟通与服务关系，多方位服务患者，体现医院关怀，减少患者流失率，提高患者满意度和忠诚度，构建和谐医患关系。

In addition to regular phone follow-up, the system can also combine forms such as text messages, voice calls, and out of hospital patient terminals to push medication reminders, follow-up reminders, etc. to patients, so that users are no longer limited to a single centralized manual dialing mode and are no longer limited by time and space constraints. Help users establish closer communication and service relationships with patients, provide comprehensive services to patients, reflect hospital care, reduce patient turnover rate, improve patient satisfaction and loyalty, and build a harmonious doctor-patient relationship.

随着全院慢病智慧管理平台的应用，能更好地了解随访患者的康复情况、心理状态及需求，及时准确地给予健康指导，提高患者自我护理能力及生活质量，促进患者的身心康复。

With the application of the intelligent management platform for chronic diseases throughout the hospital, it is possible to better understand the rehabilitation status, psychological status, and needs of follow-up patients, provide timely and accurate health guidance, improve patients' self-care ability and quality of life, and promote their physical and mental recovery.

同时也降低了医院回访的人力成本和时间成本，提高随访工作效率和质量，使各类调查数据和统计数据更加精准，帮助医护或者医院从繁重无序的随访工作中解放出来，压缩出的时间用于深度挖掘数据和投身科研，增强科室及医院竞争力。

At the same time, it also reduces the labor and time costs of hospital follow-up, improves the efficiency and quality of follow-up work, makes various survey and statistical data more accurate, helps medical staff or hospitals free from the heavy and disorderly follow-up work, and compresses the time for deep data mining and scientific research, enhancing the competitiveness of departments and hospitals.

基于专科专病的全院慢病管理解决方案

A Solution for Hospital wide Chronic Disease Management Based on Specialized Diseases

基于专科专病的全院慢病管理解决方案，结合了现代医院及科室实际工作场景和管理痛点，采用最新人工智能（AI）技术，以“人工智能+医院+互联网+专科特色”为核心，实现医院的慢病全流程闭环管理。

The hospital wide chronic disease management solution based on specialized diseases, combined with the actual working scenes and management pain points of modern hospitals and departments, adopts the latest artificial intelligence (AI) technology, and takes "AI+hospital+Internet plus+specialty features" as the core to realize the closed-loop management of the whole process of chronic diseases in hospitals.

现在，基于专科专病的全院慢病管理解决方案已在四川大学华西医院、河北医科大学第四医院等一批医院成功落地并取得显著成效。未来，慢管通将继续秉持着“人人需要健康，让智慧健康管理成为一种生活方式”的核心价值主张，帮助医护更智能、更高效的实现慢性病的治疗与管理，让国民少生病、不生病，不竭余力地推进健康中国伟大宏图建设。

Now, the hospital wide chronic disease management solution based on specialized diseases has been successfully implemented and achieved significant results in a number of hospitals, including West China Hospital of Sichuan University and the Fourth Hospital of Hebei Medical University. In the future, Manguantong will continue to uphold the core value proposition of "everyone needs health, making intelligent health management a way of life", helping healthcare professionals to achieve more intelligent and efficient treatment and management of chronic diseases, reducing and avoiding illness among the people, and tirelessly promoting the great construction of a healthy China.

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