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目的 构建基于“互联网+”及人工智能的关节置换患者全病程管理平台，探索多学科协作的全病程管理模式，提升关节置换患者的诊疗效率、康复效果及长期生活质量。方法 通过整合“互联网+”及人工智能学习技术，组建多学科协作团队，构建关节置换患者全病程管理平台。采用“线上+线下”和“院内+院外”相结合的管理模式，由个案管理师全程介入，覆盖患者从院前准备、住院诊疗、出院准备、双向转诊、远程会诊、智能复诊、出院追踪随访到远程健康管理的全病程。结果 应用全病程管理平台后，完成线上咨询118次、智能复诊94次、远程会诊5次、转诊服务3次；个性化康复指导覆盖率100%，全病程管理平台显著缩短了关节置换患者的会诊等候时长（P<0.001），患者的延续管理满意度97.00%。结论 基于“互联网+”及人工智能技术的全病程管理平台为关节置换患者提供了高效、精准、个性化的全病程管理服务，显著改善了患者的康复效果和生活质量；同时，优化了医疗资源配置，减轻了医护人员的工作负担，实现了医疗资源的高效利用。该模式为关节置换手术的全程管理提供了新的解决方案，具有较高的临床推广价值。
Abstract：Objective To build a whole-course management platform for joint replacement patients based on "Internet+" and artificial intelligence(AI) technology,and to explore a multidisciplinary collaborative whole-course management model to improve the diagnosis and treatment efficiency,rehabilitation effect and long-term quality of life of joint replacement patients.Methods By the integration of "Internet+" and AI learning technology,a multidisciplinary collaborative team was set up,constructed a whole-course management platform for joint replacement patients.It adopted the combination of "online + offline" and "in-hospital + out-of-hospital" management modes,and the case manager intervened in the whole process,covered the whole course of patients' life from pre-hospital preparation,in-hospital diagnosis and treatment,hospital discharge preparation,bidirectional referral,remote consultation,intelligent follow-up,discharge tracking and follow up to remote health management.Results There were 118 online consultations,94 AI-powered follow-up visits,5 consultations of doctors,and 3 referral services.Personalized rehabilitation guidance achieved 100% coverage,and the implementation of the comprehensive disease management platform significantly reduced the consultation waiting time for joint replacement patients(P<0.001) with an overall patient continuity management satisfaction rate of 97.00%.Conclusion The whole-course management platform based on "Internet+" and AI technology provides efficient,accurate and personalized whole-course management services for joint replacement patients,and it significantly improves the recovery effect and quality of life of patients.Meanwhile,it optimizes the allocation of medical resources,alleviates the workload of healthcare professionals and achieves efficient utilization of medical resources.The mode provides a novel solution for the entire process of joint replacement surgery,demonstrates significant clinical value for widespread adoption value.
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基本信息:
中图分类号:R473.6
引用信息:
[1]周阳,郭亚彬,曾必云,等.关节置换患者全病程管理平台的构建与应用研究[J].护理管理杂志,2026,26(02):115-121.
基金信息:
国家卫生健康委医院管理研究所重大项目（2023YFC3605005）; 湖南省重点研发计划项目（2024JK2133）; 湖南省哲学社会科学基金重点项目（23ZDB002）
2026-02-10
2026-02-10