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智慧慢病管理模式及发展策略研究
Smart Chronic-Disease Management Models and Development Strategies
人口老龄化和生活方式的转变导致慢性病（慢病）的发病率持续上升，已经成为我国公共健康和社会经济发展面临的严峻挑战。为实现“健康中国”的战略目标，迫切需要加快构建适应我国国情的慢病管理策略，通过借助新一代信息技术，完善我国智慧慢病管理的创新解决方案。本文系统论述了国外慢病管理的现行主要模式及先进技术赋能的慢病管理新趋势，分析了我国智慧慢病管理面临的挑战，包括资源分配不均、信息化建设迟缓、患者依从性不足；在此基础上，结合我国现有卫生管理体系，提出了以患者为中心的“国家、县市、基层三级垂直管理”“医、患、管多端协同运作”“全流程智能技术辅助”的智慧慢病管理总体策略，以及策略的全面实现路径；通过剖析“医患管”协同的高血压智能管理和“人工+智能”协同心电判读两个代表性案例，验证提出策略的实践应用价值。未来，建议持续推进构建以区域为核心的整合智慧慢病防控模式，制定支持智慧慢病管理的中长期规划，优化智慧慢病互补产业链结构，以促进基层慢病管理服务体系的智能化和高效化，从而为全民健康提供更为坚实的保障。
With population aging and lifestyle changes, the incidence of chronic diseases is on the rise, posing a significant challenge for public health and socio-economic development in China. To advance the Healthy China initiative, it is urgent to accelerate the establishment of chronic disease management strategies tailored to China and leverage cutting-edge information technologies to create innovative solutions for smart chronic-disease management. This study offers a comprehensive analysis of the current models and emerging trends of chronic disease management enabled by advanced technologies, and identifies challenges faced by China in smart chronic-disease management, including uneven resource allocation, slow progress in information technology infrastructure, and insufficient patient compliance. Based on these insights and aligned with the current healthcare management system in China, this study proposes an overall strategy for smart chronic-disease management that is patient-centered and characterized by a "three-tier vertical management at national, county, and community levels", "multi-end collaboration among healthcare providers, patients, and management agencies", and "intelligent technological assistance throughout the management process". Additionally, it outlines a comprehensive path for the realization of this strategy. The study illustrates the practical utility of the proposed strategy by examining two emblematic cases: the intelligent management of hypertension via physician-patient-administration collaboration and the integrative electrocardiograph interpretation employing a human-intelligence hybrid approach. In the future, it is recommended to develop a region-based integrated chronic-disease prevention and control model, formulate long-term plans for smart chronic-disease management, and optimize the industry chain to enhance the intelligence and efficiency of the community-level chronic-disease management services, thereby providing stronger safeguards for public health.
智慧医疗 / 慢病管理 / 人工智能 / 三级垂直管理 / 多端协同 / 智能辅助
smart healthcare / chronic disease management / artificial intelligence / three-tier vertical management / multi-end collaboration / intelligent technological assistance
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