基于数智平台的心血管病立体联动管控的理论框架与实践路径

Theoretical framework and practical pathway of integrated multidimensional management for cardiovascular diseases based on an intelligent digital platform

摘要

随着心血管病(CVDs)发病率持续上升,其高致残、高死亡率特征已对我国公共健康体系构成严重挑战。在医疗资源区域分布不均、院后管理机制薄弱、基层防治能力不足等现实背景下,探索系统化、智能化的防控路径已成为当务之急。本文立足我国医疗体系现状,结合人工智能(AI)与信息化手段,构建了一个以“医疗质量提升—院后服务延伸—基层能力强化”为核心的CVDs立体联动管控理论框架,并依托统一数智平台开展实践应用。平台集成多源异构数据,建立涵盖医疗质量管控、医院管理与科研数据服务、院后全周期管理、基层慢病管理的四大功能模块,形成智能化服务模式,开展多维度成效评估,并结合国内外CVDs防控经验提出推广对策。本研究旨在为构建面向未来的CVDs全流程智能管控体系提供理论支撑与实践路径,推动我国慢病管理模式向高效协同、智能融合方向转型,为“健康中国”战略目标的实现提供可持续保障。

Abstract

With the continuous rise in the incidence of cardiovascular diseases (CVDs), their high disability and mortality rates pose a significant challenge to China's public health system. Against the backdrop of uneven regional distribution of medical resources, weak post-discharge management, and limited primary care capacity, exploring systematic and intelligent approaches for prevention and control has become imperative. In view of the current healthcare system in China, this study integrates artificial intelligence (AI) and information technology to construct a theoretical framework for multi-level, integrated CVDs management, centered on medical quality improvement, extension of post-discharge services, and strengthening of primary care capacity. A unified digital intelligence platform was developed to support practical implementation, integrating heterogeneous multi-source data and encompassing four core functional modules: medical quality control, hospital management and research data services, full-cycle post-discharge management, and primary care chronic disease management. The platform enables an intelligent service model and supports multi-dimensional effectiveness evaluation. Drawing on both domestic and international CVDs prevention and control experiences, corresponding strategies for wider implementation are proposed. This study aims to provide theoretical support and practical pathways for building a full-process, intelligent CVDs management system, promoting the transformation of chronic disease management in China toward efficient coordination and intelligent integration, and offering sustainable solutions for achieving the objectives of the Healthy China strategy.

关键词

心血管病(CVDs)防治 / 人工智能(AI) / 信息技术 / 医院管理 / 创新实践

Key words

prevention and control of cardiovascular diseases (CVDs) / artificial intelligence (AI) / information technology / hospital management / innovative practice

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基金资助

国家自然科学基金面上项目(72374216)

心血管病高危人群早期筛查与综合干预项目(信息中心平台2025-8)