三高共管三级协同互联网管理系统介绍

Previously, hypertension, diabetes and dyslipidemia (commonly referred to as "three high") were the three major risk factors leading to the rise of cardiovascular and cerebrovascular diseases in China, with a mortality rate of 7 ‰. Every year, 842993 people died of diabetes and complications. At present, there are problems in the diagnosis and treatment management of patients with "three highs": 1. Multiple complications indicators need to be tested, and patients need to repeatedly queue up and travel to multiple different departments to invest more time and energy; 2. Different hospitals, hospitals and families are all information silo of information, which is difficult to achieve accurate diagnosis and treatment and continuous management; 3. The number of doctors and patients is seriously unbalanced, and it is difficult for traditional disease diagnosis and treatment methods to effectively control diabetes.

我国目前已将高血压、糖尿病管理纳入国家基本公共卫生服务，并取得了较明显的成效，但尚未对血脂异常进行管理，成为我国心脑血管疾病防控的“短板”。

At present, China has incorporated the management of hypertension and diabetes into the national basic public health services, and has achieved obvious results. However, it has not yet managed blood lipid abnormalities, which has become a "short board" for the prevention and control of cardiovascular and cerebrovascular diseases in China.

为了解决这一问题，通过三高共管将辖区内的慢病患者纳入平台管理，逐步实现以“治病为中心”向以“健康管理为中心”的转变，创新以家庭医生为核心的“三高共管、三级协同”分级诊疗服务模式。三高共管系统建成将能够辅助基层医生为高血压、糖尿病、高血脂异常的患者提供精细化的共同管理和全程保健。结合我国基本公共卫生规范，及相关慢性病控制规范，对于控制不满意的三高患者能够及时向上级进行转诊，控制理想后，将患者转回基层医疗机构，实现病情信息、评估报告、治疗方案的信息共享，从而提升心脑血管疾病的防控效率，切实为群众提供便捷、优质的医疗卫生和医疗保健。

In order to solve this problem, the chronic disease patients within the jurisdiction will be included in the platform management through the three high co management, gradually realizing the transformation from "disease treatment as the center" to "health management as the center", and innovating the "three high co management, three level collaboration" hierarchical diagnosis and treatment service model with family doctors as the core. The completion of the "three high" co management system will be able to assist grass-roots doctors to provide refined co management and whole process health care for patients with hypertension, diabetes and hyperlipidemia. Based on China's basic public health standards and relevant chronic disease control standards, patients with unsatisfactory control of the "three highs" can be promptly referred to their superiors. After achieving ideal control, patients can be transferred back to grassroots medical institutions to achieve information sharing of disease information, evaluation reports, and treatment plans, thereby improving the prevention and control efficiency of cardiovascular and cerebrovascular diseases and effectively providing convenient and high-quality medical and health care to the public.

如何打造以高血压、糖尿病和高血脂为重点、以家医签约、公卫签约和医保签约合而为一的、一二三级医疗卫生机构协同合作的“三高共管、三级协同”慢病管理服务模式，提高区域慢病管理综合服务能力，赋能基层卫生健康发展,通过综合管理有效遏制心脑血管疾病的高发，早日实现心脑血管疾病下降的拐点,这是目前医疗领域面临的一项十分重要和紧迫的任务。如何利用信息化手段构建三高共管互联网化管理平台，连接高血压和糖尿病专科医师，充分赋能家庭医生，将高血压、糖尿病、血脂异常进行信息化、标准化管理，这是本技术领域亟待解决的技术问题。

How to create a "three high co management, three level coordination" chronic disease management service model focusing on hypertension, diabetes and hyperlipidemia, integrating home doctor signing, public health signing and medical insurance signing, and cooperating with primary, secondary and tertiary medical and health institutions, improve the comprehensive service capacity of regional chronic disease management, enable the healthy development of grassroots health, and effectively curb the high incidence of cardiovascular and cerebrovascular diseases through comprehensive management, Realizing the turning point of the decline in cardiovascular and cerebrovascular diseases as soon as possible is a very important and urgent task currently facing the medical field. How to use information means to build an Internet management platform for three high blood pressure co management, connect hypertension and diabetes specialists, fully empower family doctors, and carry out information and standardized management of hypertension, diabetes, and dyslipidemia is a technical problem that needs to be solved urgently in this technical field.

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