健康管理随访系统应用有哪些？

随访是医院治疗的一个重要组成环节。随访是指医院对曾在医院就诊的患者以通讯或其他方式，定期了解患者病情变化和指导患者康复的一种观察方法，与诊治后的患者保持联系或要求患者定期来医院复查，对患者的疾病疗效和发展状况继续进行追踪观察所做的工作。传统的随访方式主要有术后病房随访、电话随访、门诊面访和家庭随访等。随着病患数量的增多和医院精细化管理水平的提升，需要采集的信息也随之增加，但由于医护人员精力有限，这些内容的梳理工作难以落实。传统的随访模式已经无法满足当前医院运营管理的需求。

Follow up is an important component of hospital treatment. Follow up refers to a method of observation in which hospitals regularly understand changes in the patient's condition and guide their recovery through communication or other means for patients who have previously visited the hospital. It involves maintaining contact with patients after diagnosis and treatment or requesting patients to come to the hospital for regular follow-up, and continuing to track and observe the patient's disease efficacy and development status. The traditional follow-up methods mainly include postoperative ward follow-up, telephone follow-up, outpatient face-to-face visits, and home follow-up. With the increase in the number of patients and the improvement of hospital refined management level, the amount of information that needs to be collected also increases. However, due to the limited energy of medical staff, it is difficult to implement the sorting work of these contents. The traditional follow-up model can no longer meet the current needs of hospital operation and management.

平台利用云随访系统推行院前、院中、院后的一体化医疗服务模式，可以将医疗服务延伸至院后和家庭，使住院患者的院外康复和继续治疗能得到科学、专业、便捷的技术服务和指导是必然趋势。

The platform utilizes a cloud follow-up system to promote an integrated medical service model for pre hospital, in hospital, and post hospital care. This can extend medical services to both post hospital and home settings, enabling inpatients to receive scientific, professional, and convenient technical services and guidance for their external rehabilitation and continued treatment. This is an inevitable trend.

一、云随访系统的设计应以医生为主体，以服务患者为中心，坚持系统性、实用性和安全性原则。具体来说，功能模块的具体设计包括管理服务器、医生客户端和患者客户端。通过功能嵌入、用户体系对接等方式。

1、 The design of the cloud follow-up system should focus on doctors as the main body, serve patients as the center, and adhere to the principles of systematicity, practicality, and safety. Specifically, the specific design of functional modules includes management servers, doctor clients, and patient clients. Through functional embedding, user system integration, and other methods.

1.管理服务器

1. Manage servers

操作系统启动后管理服务器便可启动运行。云随访系统的建设和应用与医院信息系统（HIS）、电子病历（EMR）、实验室信息管理系统（LIS）等密不可分，因此必须通过接口将相关数据从以上系统提取到云随访系统中，才能方便随访人员查看和利用相关信息。

After the operating system starts, the management server can start running. The construction and application of cloud follow-up systems are closely related to hospital information systems (HIS), electronic medical records (EMR), laboratory information management systems (LIS), etc. Therefore, relevant data must be extracted from the above systems through interfaces into the cloud follow-up system in order to facilitate follow-up personnel to view and utilize relevant information.

不论采取何种系统技术架构，都应当格外注意数据安全。可以采取独立第三方安全应用超文本传输安全协议，对数据开放过程中全程加密，以在一个安全的网络环境中建立云服务器的访问，保证数据的安全性。

Regardless of the system technology architecture adopted, special attention should be paid to data security. An independent third-party secure application hypertext transmission security protocol can be adopted to encrypt the entire process of data opening, in order to establish access to cloud servers in a secure network environment and ensure data security.

2.医生客户端

2. Doctor client

医生客户端主要包括用户登录、患者管理、随访管理、健康宣教、随访库管理、知识库管理、信息发布、系统管理等功能模块。

The doctor client mainly includes functional modules such as user login, patient management, follow-up management, health education, follow-up database management, knowledge base management, information publishing, and system management.

3.患者客户端

3. Patient client

患者客户端主要包括用户登录、我的病历、我的随访、线上咨询、用药指导、医院活动、医学知识等功能模块。

The patient client mainly includes functional modules such as user login, my medical record, my follow-up, online consultation, medication guidance, hospital activities, medical knowledge, etc.

二、平台云随访系统应用都有哪些？

2、 What are the applications of the platform cloud follow-up system?

1.随访服务

1. Follow up services

在对患者进行随访时，通过记录患者反馈建立随访大数据，以帮助后续完善诊疗方案和开展临床科研分析，可极大降低医护人员的工作量。通过语音直接拨打患者电话，询问并记录患者随访数据。对于未完成随访的患者直接推送随访问卷到患者微信、短信等移动端，剩余仍未完成的患者，则采用人工电话随访的方式进行，以此实现多层次、多模式的随访。

When following up patients, establishing follow-up big data by recording patient feedback can help improve diagnosis and treatment plans and conduct clinical research analysis, which can greatly reduce the workload of medical staff. Directly dial the patient's phone number through voice, inquire and record patient follow-up data. For patients who have not completed follow-up, follow-up questionnaires are directly pushed to their mobile devices such as WeChat and SMS. For the remaining patients who have not completed follow-up, manual telephone follow-up is used to achieve multi-level and multi-mode follow-up.

2.健康宣教

2. Health education

云随访系统以专业的健康宣教知识库为基础，实现多种场景下的健康宣教工作。当患者在门诊就诊时，医生根据患者情况，可通过医生客户端的健康宣教模块，实现个性化健康宣教。当患者门诊就诊完毕或出院时，通过预先设置好的程序，根据患者的疾病等基础条件，实现批量自动化宣教推送。同时根据患者医嘱及处方信息，自动推送用药宣教，保证患者用药安全性。

The cloud follow-up system is based on a professional health education knowledge base and realizes health education work in various scenarios. When patients visit the outpatient department, doctors can achieve personalized health education through the health education module of the doctor client based on the patient's condition. When the patient's outpatient visit is completed or discharged, a pre-set program is used to achieve batch automated education push based on the patient's basic conditions such as illness. At the same time, according to the patient's medical advice and prescription information, medication education is automatically pushed to ensure the safety of patient medication.

3.健康监测

3. Health monitoring

对于特殊或慢病人群来说，可穿戴式设备和物联网与随访系统的结合为其提供了一个智能自我管理工具。患者可通过患者移动端，直接采集血压计、血糖仪及心电等设备的健康监测数据，数据直接上传到医生端，医生可随时查看，实现院外健康数据和院内医疗数据的连贯性。当异常情况发生时，系统即可根据预先设置的提醒规则，既提示患者，又可以推送给相应的医生，及时进行远程诊疗。

For special or chronic patient groups, the combination of wearable devices and the Internet of Things with follow-up systems provides an intelligent self-management tool. Patients can directly collect health monitoring data from devices such as blood pressure monitors, blood glucose meters, and electrocardiograms through the patient's mobile device. The data is uploaded directly to the doctor's end, and the doctor can view it at any time, achieving consistency between external health data and internal medical data. When abnormal situations occur, the system can remind patients according to pre-set reminder rules and push them to the corresponding doctors for timely remote diagnosis and treatment.

4.医患沟通

4. doctor-patient communication

云随访系统还为医患提供了突破时空限制的沟通通道。通过系统上设置的沟通途径，患者可以在患者端发起咨询，医护人员可通过网页端和医护端移动端与患者进行一对一指导咨询，具体可采用文字、图片、语音、小视频、视频等形式进行沟通，拉近医患距离，更好地服务患者。

The cloud follow-up system also provides a communication channel for doctors and patients to break through time and space limitations. Through the communication channels set up on the system, patients can initiate consultations on the patient end. Medical staff can provide one-on-one guidance and consultation with patients through web pages and mobile medical devices. Specific forms of communication can be used, such as text, images, voice, short videos, and videos, to shorten the distance between doctors and patients and better serve patients.

平台云随访系统是结合大数据、物联网以及人工智能等先进技术，以专业的随访知识库为基础，提供以院后随访、健康宣教、健康监测和医患沟通为核心服务的平台。平台云随访系统希望真正成为每个医院的医生健康助手，降低医院随访成本，成倍提高医务人员工作效率，实现AI在医疗领域的深度融合和创新应用，实现医疗机构技术信息化能力与服务效率的双提升。

The platform cloud follow-up system is a platform that combines advanced technologies such as big data, the Internet of Things, and artificial intelligence. Based on a professional follow-up knowledge base, it provides core services such as post hospital follow-up, health education, health monitoring, and doctor-patient communication. The platform's cloud follow-up system aims to truly become a doctor's health assistant for every hospital, reduce hospital follow-up costs, exponentially improve the work efficiency of medical personnel, achieve deep integration and innovative application of AI in the medical field, and achieve dual improvement of medical institution's technological informatization ability and service efficiency.