The three high co management three-level collaborative chronic disease management platform is characterized in that it includes a data source, a user system, and a cloud platform, wherein the data source, the user system, and the cloud platform are communicated and connected;
The cloud platform comprises a service layer, an evaluation report engine, a logical framework layer, and a storage layer;
The evaluation report engine is used to access health information from the data source and health information from the user system. The evaluation report engine is used to clean, transform, and merge the accessed health information;
The storage layer includes a basic database, a patient database, and a referral information database. The basic database is used to store the health information. The service layer interacts with the storage layer through the logical framework layer. The service layer includes a population screening system, a disease assessment system, a hierarchical grading system, a report display system, a bidirectional consultation system, a disease trend system, and a green channel system;
The population screening system is used to screen the health information from the basic database, identify the health information related to the three highs, and integrate and store it in the patient database;
The disease assessment system is used to input disease assessment information through a user system. The storage layer is equipped with a disease assessment experience database, which stores disease assessment experience data. The disease assessment system is used to generate disease assessment information based on the disease assessment experience data and health information, The disease assessment system is used to integrate the disease assessment information into the health information located in the basic database and the patient database;
The hierarchical grading system is used to divide the population according to the three high risk levels based on the health information in the patient database, and generate corresponding risk information. The risk information includes high risk, medium risk, low risk, susceptible, and normal. The hierarchical grading system is used to integrate and store the risk information into the health information located in the basic database and the patient database;
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