Chronic Disease Management “Internet Plus” Mobile Health Tiered Diagnosis and Treatment
江苏现代医院管理研究中心课题（JSY32016082）
慢性病已成为威胁中国居民致残和致死的头号杀手。多年来以基层医疗卫生机构为重心的防治模式，并没有有效降低慢性病的患病率和死亡率，而移动互联网技术的实时性、针对性、互动性和经济性等诸多特点，为开展慢性病线上管理带来可能。作者研究苏北某三甲医院将“互联网+”用于慢性病管理的尝试。通过借鉴国家大力推行的临床路径做法，依据慢性病防治权威性指南，设计符合医疗规范的慢性病病种管理路径，采取以时间轴为核心，以事件为驱动的病种管理路径，指导合作公司开展“网络平台”建设，为慢性病管理搭建规范性、可控性、直观性的管理工具，为新医改下探索分级诊疗提供新思路。
Chronic diseases have become the biggest killer of people in China. The pattern of preventive and control based on primary health care，which did not achieve the purpose of reducing morbidity and mortality rate. The characteristics of mobile Internet are as follows：real-time，pertinence，interactive，economical ，and so on，which made the management of chronic diseases online possible. The emphasis was introduction to the practice of management in chronic diseases using ‘Internet plus’ in this paper. On the basis of clinical pathway which were vigorously implemented in China，time-centered，event-driven，the hospital cooperated with the company to develop the “network platform”，to set up normative，controllable and intuitive management tool. The practice would provide new ideas for exploring the system of tiered diagnosis and treatment service on the background of the new healthcare reform.