Previously, hypertension, diabetes and dyslipidemia (commonly referred to as "three high") were the three major risk factors leading to the rise of cardiovascular and cerebrovascular diseases in China, with a mortality rate of 7 ‰. Every year, 842993 people died of diabetes and complications. At present, there are problems in the diagnosis and treatment management of patients with "three highs": 1. Multiple complications indicators need to be tested, and patients need to repeatedly queue up and travel to multiple different departments to invest more time and energy; 2. Different hospitals, hospitals and families are all information silo of information, which is difficult to achieve accurate diagnosis and treatment and continuous management; 3. The number of doctors and patients is seriously unbalanced, and it is difficult for traditional disease diagnosis and treatment methods to effectively control diabetes.

我國目前已將高血壓、糖尿病管理納入國家基本公共衛(wèi)生服務，并取得了較明顯的成效，但尚未對血脂異常進行管理，成為我國心腦血管疾病防控的“短板”。

At present, China has incorporated the management of hypertension and diabetes into the national basic public health services, and has achieved obvious results. However, it has not yet managed blood lipid abnormalities, which has become a "short board" for the prevention and control of cardiovascular and cerebrovascular diseases in China.

為了解決這一問題，通過三高共管將轄區(qū)內的慢病患者納入平臺管理，逐步實現以“治病為中心”向以“健康管理為中心”的轉變，創(chuàng)新以家庭醫(yī)生為核心的“三高共管、三級協同”分級診療服務模式。三高共管系統建成將能夠輔助基層醫(yī)生為高血壓、糖尿病、高血脂異常的患者提供精細化的共同管理和全程保健。結合我國基本公共衛(wèi)生規(guī)范，及相關慢性病控制規(guī)范，對于控制不滿意的三高患者能夠及時向上級進行轉診，控制理想后，將患者轉回基層醫(yī)療機構，實現病情信息、評估報告、治療方案的信息共享，從而提升心腦血管疾病的防控效率，切實為群眾提供便捷、優(yōu)質的醫(yī)療衛(wèi)生和醫(yī)療保健。

In order to solve this problem, the chronic disease patients within the jurisdiction will be included in the platform management through the three high co management, gradually realizing the transformation from "disease treatment as the center" to "health management as the center", and innovating the "three high co management, three level collaboration" hierarchical diagnosis and treatment service model with family doctors as the core. The completion of the "three high" co management system will be able to assist grass-roots doctors to provide refined co management and whole process health care for patients with hypertension, diabetes and hyperlipidemia. Based on China's basic public health standards and relevant chronic disease control standards, patients with unsatisfactory control of the "three highs" can be promptly referred to their superiors. After achieving ideal control, patients can be transferred back to grassroots medical institutions to achieve information sharing of disease information, evaluation reports, and treatment plans, thereby improving the prevention and control efficiency of cardiovascular and cerebrovascular diseases and effectively providing convenient and high-quality medical and health care to the public.

如何打造以高血壓、糖尿病和高血脂為重點、以家醫(yī)簽約、公衛(wèi)簽約和醫(yī)保簽約合而為一的、一二三級醫(yī)療衛(wèi)生機構協同合作的“三高共管、三級協同”慢病管理服務模式，提高區(qū)域慢病管理綜合服務能力，賦能基層衛(wèi)生健康發(fā)展,通過綜合管理有效遏制心腦血管疾病的高發(fā)，早日實現心腦血管疾病下降的拐點,這是目前醫(yī)療領域面臨的一項十分重要和緊迫的任務。如何利用信息化手段構建三高共管互聯網化管理平臺，連接高血壓和糖尿病專科醫(yī)師，充分賦能家庭醫(yī)生，將高血壓、糖尿病、血脂異常進行信息化、標準化管理，這是本技術領域亟待解決的技術問題。

How to create a "three high co management, three level coordination" chronic disease management service model focusing on hypertension, diabetes and hyperlipidemia, integrating home doctor signing, public health signing and medical insurance signing, and cooperating with primary, secondary and tertiary medical and health institutions, improve the comprehensive service capacity of regional chronic disease management, enable the healthy development of grassroots health, and effectively curb the high incidence of cardiovascular and cerebrovascular diseases through comprehensive management, Realizing the turning point of the decline in cardiovascular and cerebrovascular diseases as soon as possible is a very important and urgent task currently facing the medical field. How to use information means to build an Internet management platform for three high blood pressure co management, connect hypertension and diabetes specialists, fully empower family doctors, and carry out information and standardized management of hypertension, diabetes, and dyslipidemia is a technical problem that needs to be solved urgently in this technical field.

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