关键词: 糖尿病, 信息系统, 健康管理, 家庭医学, 家庭医生签约

Abstract: Background　With the increasing prevalence of diabetes and the number of diabetic patients，diabetes management in primary care is becoming increasingly arduous.How to further give play to the role of information technology，raise working efficiency，promoting standardized management and management quality has become the aim and objective of diabetes management information construction.Objective　To explore the application of diabetes management module in Electronic Contracted Family Doctors Services Management （ECFDSPM） platform in Wuhou District，Chengdu；to provide basis for further optimizing health management information system，by which type 2 diabetes management procedure in primary care can be standardized and the management quality and efficiency can be improved.Methods　From November to December 2017，a total of 52 family doctor teams with 170 members were selected by random sampling from 13 community health centers in Wuhou District，Chengdu.They received an online survey with a self-designed questionnaire named as Application of Diabetes Health Management Information System，consisting of knowledge，belief and practice （total 6 items） of "health management service specification for type 2 diabetic patients in Wuhou District" and "health management service technical specification for type 2 diabetic patients in Wuhou District"（hereinafter referred to as "Specification"），intention of using diabetes management module （1 item），optimizing requirements of the diabetes management module （1 item for overall optimizing requirement，5 items for clinical path management optimizing requirement，3 items for intelligent decision function optimizing requirement），and subjective selection of health workers responsible for the application of specific diabetes management submodules （total 6 items） in the ECFDSPM system.Results　The survey achieved a response rate of 97.6%（166/170）.Of the respondents，the ratio of general practitioners（GPs） to physician assistants，health promoters and other assistant members was about 4∶4∶1∶1.The rate of knowing the contents of the Specification was 97.0%（161/166），but only 39.2%（65/161） of them thought that the diabetes management module in the ECFDSPM platform was the same as the management pathway in the Specification，and 57.8%（96/166） thought that the module could effectively manage diabetes patients effectively in a standardized way.The rate of intending to use the available diabetes management module was 59.6%（99/166）.In terms of the submodules in the available diabetes management module，90.4%（150/166） reported that they needed diabetes diagnosis submodule （diagnosis，diabetes duration and complication），67.5%（112/166） needed the thyroid palpation submodule，88.0%（148/166） needed the submodule for examining foot pain，temperature and vibration，92.8%（154/166） thought that the evaluation submodules for diabetic complications should be integrated into one，89.2%（148/166） needed the referral submodule，97.6%（162/166）proposed to develop a submodule including the target objectives（glucose，glycosylated hemoglobin，lipid and blood pressure） which could be generated automatically based on the evaluation results of each patient's pervious information，and all of them proposed to develop a comprehensive evaluation submodule，and 99.4%（165/166） proposed to develop a personalized health guidance submodule（dietary，exercise，weight loss，smoking cessation and alcohol limitation prescriptions），generated automatically based on the evaluation results of each patient's pervious information.In terms of healthcare providers responsible for using specific submodules of the diabetes management module，physician assistants were thought to be principal responsible persons for basic information collection by 66.9%（111/166） of the respondents，GPs were thought to be principal responsible persons for disease information collection，health assessment，development of individualized control objectives and individualized health instruction by 56.6%（94/166），79.5% （133/166），85.5%（142/166） and 57.2%（95/166） of the respondents，respectively，and nurses were thought to be principal responsible persons for follow-up services by 72.3%（120/166） of the respondents.The selection of major responsible persons for basic information collection and disease information collection submodules among physician assistants，health promoters and other assistant members were significantly different（P<0.05）.Conclusion　The family doctor teams in Wuhou District generally think that the existing diabetes health management module in ECFDSPM system has certain guiding significance for clinical practice，but it still needs further optimization.And the systematic functions expected to be optimized first are clinical management path and intelligent decision making.

Key words: Diabetes mellitus, Information systems, Health management, Family practice, Family doctor contract