傳統(tǒng)隨訪困境重重

Traditional follow-up faces numerous challenges

　　數(shù)據(jù)管理雜亂易錯(cuò)

Data management is messy and prone to errors

　　在中型以上醫(yī)院，每日隨訪數(shù)據(jù)眾多，來源分散，有紙質(zhì)病歷、電話記錄、科室表格等。像某三甲醫(yī)院心內(nèi)科，每月要對 500 多出院患者隨訪，醫(yī)護(hù)手動(dòng)錄入 Excel，不僅耗時(shí)，還常出錯(cuò)，錯(cuò)誤率達(dá) 10% - 15%，影響后續(xù)診斷與患者管理。

In medium-sized and above hospitals, there are numerous daily follow-up data with scattered sources, including paper medical records, telephone records, department forms, etc. For example, in a certain tertiary hospital's cardiology department, more than 500 discharged patients need to be followed up every month. Medical staff manually input the data into Excel, which is not only time-consuming but also prone to errors, with an error rate of 10% -15%, affecting subsequent diagnosis and patient management.

　　醫(yī)患溝通低效不暢

Inefficient and poor communication between doctors and patients

　　傳統(tǒng)隨訪溝通工具多樣，醫(yī)護(hù)需在電話、短信、微信等間切換。社區(qū)衛(wèi)生服務(wù)中心家庭醫(yī)生團(tuán)隊(duì)隨訪慢性病患者時(shí)，常遇患者電話難接通，平均聯(lián)系一位患者需撥打 3 - 5 次。而且因溝通平臺多，信息易遺漏，影響隨訪效果。

Traditional follow-up communication tools are diverse, and medical staff need to switch between phone calls, text messages, WeChat, and other channels. When the family doctor team of the community health service center follows up with chronic disease patients, they often encounter difficulties in connecting the patient's phone, with an average of 3-5 calls required to contact each patient. Moreover, due to the multiple communication platforms, information is prone to omission, which affects the effectiveness of follow-up.

　　病情監(jiān)測反饋滯后

Delayed feedback on disease monitoring

　　傳統(tǒng)隨訪缺乏實(shí)時(shí)監(jiān)測，醫(yī)護(hù)依賴患者反饋，而患者描述可能不準(zhǔn)確。如糖尿病、高血壓患者，兩次復(fù)查間病情變化難以及時(shí)掌握。同時(shí)，傳統(tǒng)方式缺乏數(shù)據(jù)分析，無法為治療調(diào)整提供有力依據(jù)。

Traditional follow-up lacks real-time monitoring, medical staff rely on patient feedback, and patient descriptions may be inaccurate. For example, in patients with diabetes and hypertension, it is difficult to grasp the changes of the condition in time between the two reexaminations. Meanwhile, traditional methods lack data analysis and cannot provide strong evidence for treatment adjustments.

　　智能系統(tǒng)破局有方

Intelligent systems have a way to break through

　　數(shù)據(jù)智能整合管理

Intelligent integration and management of data

　　隨訪一體機(jī)智能系統(tǒng)能與醫(yī)院 HIS、LIS、PACS 等系統(tǒng)對接，自動(dòng)獲取患者醫(yī)療數(shù)據(jù)。番禺區(qū)婦幼保健院引入相關(guān)系統(tǒng)后，患者出院時(shí)數(shù)據(jù)自動(dòng)同步。系統(tǒng)還運(yùn)用 OCR 和自然語言處理技術(shù)，將非結(jié)構(gòu)化病歷數(shù)據(jù)結(jié)構(gòu)化，為患者建立動(dòng)態(tài)電子健康檔案，方便醫(yī)護(hù)隨時(shí)查閱，提升數(shù)據(jù)管理效率與準(zhǔn)確性。

The intelligent follow-up system can be integrated with hospital HIS, LIS, PACS and other systems to automatically obtain patient medical data. After the introduction of relevant systems, Panyu Maternal and Child Health Hospital automatically synchronizes patient data upon discharge. The system also utilizes OCR and natural language processing technology to structure unstructured medical record data, establishing dynamic electronic health records for patients, facilitating medical staff to access them at any time, and improving data management efficiency and accuracy.

　　多渠道溝通提效

Multi channel communication improves efficiency

　　智能隨訪系統(tǒng)整合電話、微信、APP 等溝通渠道，依患者偏好自動(dòng)選擇溝通方式。年輕患者優(yōu)先微信推送隨訪問卷，老年患者安排電話隨訪并配智能語音導(dǎo)航。溝通內(nèi)容支持圖文、視頻等，患者能拍照、語音反饋病情，提升溝通效率與信息傳達(dá)準(zhǔn)確性。

The intelligent follow-up system integrates communication channels such as phone, WeChat, and APP, and automatically selects communication methods based on patient preferences. Young patients are given priority in receiving follow-up questionnaires through WeChat, while elderly patients are arranged for telephone follow-up with intelligent voice navigation. Communication content supports text, images, videos, etc. Patients can take photos and provide voice feedback on their condition, improving communication efficiency and accuracy of information dissemination.

　　實(shí)時(shí)監(jiān)測精準(zhǔn)分析

Real time monitoring and precise analysis

　　一體機(jī)搭配智能手環(huán)、便攜式血糖儀等設(shè)備，實(shí)時(shí)監(jiān)測患者生理參數(shù)并傳輸至系統(tǒng)。系統(tǒng)利用大數(shù)據(jù)、機(jī)器學(xué)習(xí)算法分析數(shù)據(jù)，識別異常并預(yù)警。如心臟病患者心率異常時(shí)系統(tǒng)及時(shí)通知醫(yī)護(hù)。還能預(yù)測病情，像分析糖尿病患者數(shù)據(jù)，預(yù)測并發(fā)癥風(fēng)險(xiǎn)，助力醫(yī)護(hù)提前干預(yù)。

The all-in-one machine is equipped with smart wristbands, portable blood glucose meters and other devices to monitor patients' physiological parameters in real time and transmit them to the system. The system utilizes big data and machine learning algorithms to analyze data, identify anomalies, and issue warnings. If the heart rate of a patient with heart disease is abnormal, the system will promptly notify the medical staff. It can also predict the condition, such as analyzing the data of diabetes patients, predicting the risk of complications, and helping doctors and nurses to intervene in advance.

　　康策醫(yī)院智能隨訪系統(tǒng)以 AI 和大數(shù)據(jù)為核心，構(gòu)建全周期患者管理體系。通過多渠道觸達(dá)患者，降低護(hù)士 / 醫(yī)生人工操作量 60%，危急值患者 30 分鐘內(nèi)響應(yīng)預(yù)警。整合多系統(tǒng)數(shù)據(jù)構(gòu)建患者畫像，自動(dòng)解析醫(yī)患對話，生成隨訪分析報(bào)告，為臨床決策提供數(shù)據(jù)支撐。

Kangce Hospital's intelligent follow-up system is based on AI and big data, building a full cycle patient management system. By reaching patients through multiple channels, the workload of nurses/doctors can be reduced by 60%, and critical patients can respond to warnings within 30 minutes. Integrating multiple system data to construct patient profiles, automatically parsing doctor-patient conversations, generating follow-up analysis reports, and providing data support for clinical decision-making.

　　傳統(tǒng)隨訪在數(shù)據(jù)管理、醫(yī)患溝通、病情監(jiān)測上問題突出，隨訪一體機(jī)及智能系統(tǒng)憑借智能管理、高效溝通、實(shí)時(shí)監(jiān)測分析等功能解決難題，推動(dòng)醫(yī)療服務(wù)向精準(zhǔn)、高效發(fā)展，守護(hù)患者健康 。

Traditional follow-up has prominent problems in data management, doctor-patient communication, and disease monitoring. The follow-up all-in-one machine and intelligent system solve these problems with intelligent management, efficient communication, real-time monitoring and analysis, and promote the development of medical services towards precision and efficiency, safeguarding patient health.

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