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.

通過慢管通全院慢病智慧管理平臺，融合目前市面成熟的AI智能隨訪技術，可實現(xiàn)慢病管理過程中高頻、核心慢病隨訪業(yè)務的智能化、人性化，提升患者的依從性。

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.

自動化隨訪管理

Automated follow-up management

可根據(jù)科室、病種或者患者健康為中心建立標準化隨訪路徑，例如：醫(yī)生確認患者為高尿酸患者，系統(tǒng)自動啟動高尿酸患者隨訪模板，為該患者生成隨訪計劃。根據(jù)計劃，系統(tǒng)定時提醒醫(yī)護人員，并將該患者信息綜合回報給醫(yī)護人員，結合移動應用管理，將部分隨訪反饋給院外患者，真正做到高效便捷。同時自動篩選出脫訪的患者，支持對脫訪患者進行提醒。

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.

標準化兼顧個性化

Standardization and personalization

系統(tǒng)內置豐富的隨訪模板，支持同一類患者匹配同樣的隨訪方案，確保隨訪數(shù)據(jù)的統(tǒng)一性，以便后續(xù)的統(tǒng)計分析；同時系統(tǒng)還賦予了用戶更多的主動權，可根據(jù)工作需要自定義模板或計劃，增加隨訪的針對性、個性化，提高隨訪質量。

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.

多維度統(tǒng)計分析

Multidimensional statistical analysis

系統(tǒng)可針對不同類別的隨訪數(shù)據(jù)，并形成可視化的統(tǒng)計報表（如隨訪工作統(tǒng)計、患者隨訪統(tǒng)計），便于醫(yī)院全局審視自身醫(yī)療服務品質，量化管理評價指標，深度挖掘隨訪大數(shù)據(jù)應用價值，為院方高層的科學決策提供全維度、立體化的數(shù)據(jù)支撐。

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.

多樣化的隨訪路徑

Diversified follow-up pathways

除了常規(guī)電話隨訪，該系統(tǒng)還能夠結合短信、語音外呼、院外患者端等形式對患者推送用藥提醒、復診提醒等，使得用戶不再局限于單一集中式的人工撥打模式，不再受限于時空限制。幫助用戶建立與患者更緊密的溝通與服務關系，多方位服務患者，體現(xiàn)醫(yī)院關懷，減少患者流失率，提高患者滿意度和忠誠度，構建和諧醫(yī)患關系。

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.

隨著全院慢病智慧管理平臺的應用，能更好地了解隨訪患者的康復情況、心理狀態(tài)及需求，及時準確地給予健康指導，提高患者自我護理能力及生活質量，促進患者的身心康復。

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.

同時也降低了醫(yī)院回訪的人力成本和時間成本，提高隨訪工作效率和質量，使各類調查數(shù)據(jù)和統(tǒng)計數(shù)據(jù)更加精準，幫助醫(yī)護或者醫(yī)院從繁重無序的隨訪工作中解放出來，壓縮出的時間用于深度挖掘數(shù)據(jù)和投身科研，增強科室及醫(yī)院競爭力。

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?？茖２〉娜郝」芾斫鉀Q方案

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

基于專科專病的全院慢病管理解決方案，結合了現(xiàn)代醫(yī)院及科室實際工作場景和管理痛點，采用最新人工智能（AI）技術，以“人工智能+醫(yī)院+互聯(lián)網(wǎng)+?？铺厣?rdquo;為核心，實現(xiàn)醫(yī)院的慢病全流程閉環(huán)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.

現(xiàn)在，基于?？茖２〉娜郝」芾斫鉀Q方案已在四川大學華西醫(yī)院、河北醫(yī)科大學第四醫(yī)院等一批醫(yī)院成功落地并取得顯著成效。未來，慢管通將繼續(xù)秉持著“人人需要健康，讓智慧健康管理成為一種生活方式”的核心價值主張，幫助醫(yī)護更智能、更高效的實現(xiàn)慢性病的治療與管理，讓國民少生病、不生病，不竭余力地推進健康中國偉大宏圖建設。

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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