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中文摘要: 目的 探讨EHR对骨质疏松分级诊疗管理模式的临床效果。方法 以上海市某社区慢性病管理团队为例，依托瑞金-卢湾医联体“全-专门诊”进行分级诊疗，介绍该区域医联体内专科与全科医生团队如何开展区域医联体特色的家庭医生“1+1+1”签约服务，建立个人EHR，通过调阅区、市两级EHR查阅患者区域内就诊信息，对签约骨质疏松患者进行管理，分析管理效果。结果 研究对象疼痛症状、身体机能、社会适应能力和精神心理功能较一年前得分均有下降(P＜0.05)；骨代谢指标β-CTX、PICP、PTH和BGP明显下降(P＜0.05)，维生素D升高(P＜0.001)；L1～3、股骨颈、wards三角、大粗隆和total髋的骨密度有提高(P＜0.05)。结论 EHR对骨质疏松分级诊疗，实施区域医联体特色的签约服务，建立个人EHR等方案可改善骨质疏松患者生活质量，值得推广。
中文关键词: 关键词 个人电子健康档案 分级诊疗 区域医联体 家庭医生签约
Abstract:OBJECTIVE To explore the effect of graded diagnosis and treatment management mode on the basis of electronic health record in osteoporosis chronic disease.METHODS Take a chronic disease management team in a community in Shanghai as an example, relying on the "full-specialized diagnosis" of Ruijin-Luwan Medical Association to introduce how to carry out the family doctors with characteristics of regional medical union "1 + 1 + 1" contract service, establish personal EHR, check the information of the patients in the patient area through the EHR in the reading area and the city, manage the contracted osteoporosis patients, and analyze the management effect.RESULTS The subjects' pain symptom, physical function, social adaptability, mental and psychological function, and their scores were all decreased compared with one year ago(P＜0.05); bone metabolism indexes β-CTX, PICP, PTH, BGP were significantly decreased(P＜0.05), Vitamin D increased (P＜0.001); Bone density of L1-3, femoral neck, wards triangle, gross trochanter, and total hip increased (P＜0.05). CONCLUSION EHR is used for the diagnosis and treatment of osteoporosis. The implementation of the regional medical consortium signature service and the establishment of personal EHR and otEHR programs can improve the quality of life of osteoporosis patients and are worthy of promotion.
keywords: key words EHR Graded diagnosis and treatment Regional medicine consortium Family doctor contract
文章编号：3202007010 中图分类号：R681 文献标志码：
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