Research on an integrated community-based chronic disease management model driven by massive databases

Minna Cheng; Sheng Zhang; Mengyun Sui; Yang Zheng; Kai GU; Yuheng Wang; Qinghua Yan; Yanyun LI; Xiaohua Ying; Yan Shi; Chen FU

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Research on an integrated community-based chronic disease management model driven by massive databases

VernacularTitle:信息化支撑的整合式社区慢性病健康管理模式探索
Author: Minna CHENG ¹ ; Sheng ZHANG ¹ ; Mengyun SUI ¹ ; Yang ZHENG ¹ ; Kai GU ¹ ; Yuheng WANG ¹ ; Qinghua YAN ¹ ; Yanyun LI ¹ ; Xiaohua YING ² ; Yan SHI ¹ ; Chen FU ¹
Author Information

1. Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, China
2. School of Public Health, Fudan University, Shanghai 200032, China
Publication Type:Journal Article
Keywords: chronic disease; health management model; community-based; informatization
From: Shanghai Journal of Preventive Medicine 2022;34(11):1079-1084
CountryChina
Language:Chinese
Abstract: China’s chronic disease management suffers from problems such as unclear institutional function， insufficient information technology application， and weak regulation support. On the basis of current chronic disease management condition in China， this paper proposes to apply the concept of “people-centered” integrated health management to community chronic disease management and discusses the content and procedure of establishing an integrated community-based chronic disease management model driven by massive databases. The model innovatively combines technology integration， data integration and service integration， and can accurately and efficiently realize the "people-centered" full-course health management of various chronic diseases. Shanghai has provided integrated community-based chronic disease management service for 1.98 million citizens through applying this model. The model warrants further effectiveness and economic evaluation. This study provides precious experience for the development of chronic disease prevention and treatment in China.