JMIR Publications

ABSTRACT

Background:

In recent years, China has been vigorously promoting health management of communities chronic diseases and exploring intelligent digital active health management models. However, due to the fact that most medical information systems in China were built separately and there was no information sharing available, it is difficult to achieve interconnectivity between community residents' self testing information, community health care institution information and hospital health information, and the digital chronic disease management has not been fully promoted in China .

Objective:

The primary objective of this study was to build a shared and intelligent active health information platform, and comprehensively improve the effectiveness of community chronic disease full cycle management through digital active health management.

Methods:

The methodology for this study was a single-arm pre-post intervention study, which involved an information interconnected active health information platform was built, which included the interconnected "i active health" applet for residents, the active health information system (cardio cerebral Vascular disease risk management system) for medical teams, the community health service center information system and the regional hospital information system. A digital active health management model for residents was carried out, which included: built intelligent health streets, carried out Internet assisted full cycle active health services for residents, implemented “Internet-based” community refined management for hypertension and diabetes in community, carried out real-time quantitative assessment and hierarchical management of residents' risk of cardio cerebral vascular disease. The management effectiveness of the residents was evaluated after2- years intervention.

Results:

An active health information platform with interconnected health information was constructed, and an intelligent digital active health management model was successfully implemented. After 2-year intervention, the two-way referral between community health care institutions and hospitals in the experimental streets has significantly increased; The residents' Health literacy increased from 30.6% in 2020 to 49.92% in 2022, in which residents' health knowledge, health behavior and health skills were significantly improved. The risk of cardio cerebral vascular disease in residents decreased significantly. The community elderly health management rate, hypertension standardized management rate and diabetes standardized management rate increased from 52.81%, 82.12%, 79.73% to 79.19%, 85.52% and 85.52% respectively. The control rate of blood pressure and blood sugar in patients with hypertension and diabetes increased from 51.7% and 42.0% to 81.2% and 72.99% respectively. The patient's BMI, waist circumference, blood uric acid, and LDL levels have significantly improved; The drug compliance of patients with hypertension and diabetes increased from 33.6% and 36.0% to 73.30% and 75.8%; There was a statistical difference (P<0.05). The diet behavior, exercise behavior and drinking behavior of hypertensive and diabetes patients were significantly improved (P<0.05) compared with that of before intervention.

Conclusions:

The active health information platform we have built can effectively achieve the interconnection and exchange of multiple health information. The digital active health management carried out with the assistance of this platform effectively improved the effectiveness of community chronic disease management. This practice is worth promoting and applying.