public health follow-up and refined model synergy of chronic disease
Use a unified path to connect public health follow-up, chronic disease management and in-hospital specialist collaboration.
Six core issues, corresponding to six groups of delivery capabilities
primary care public health services Data authenticity and traceability
From on-device collection, device access, code scanning verification to platform quality control, manual filling deviation is reduced.
primary care Large-scale paperless public health Physical examination
Support on-site physical examinations of multiple devices, multiple positions, and multiple groups of people, forming automatic collection and automatic aggregation.
primary care AI large model empowerment for diagnosis and treatment capabilities
Embed risk reminders, auxiliary screening and superior collaboration into the primary care service process.
Accurate prediction and interception of major chronic disease complications
Incorporate abnormal identification, review reminders and continuous intervention into the same management closed loop.
Business sharing and efficient collaboration in the four-level medical system
Support multi-level roles in cities, counties, townships, and villages to share information, coordinate processing, and supervise tracking.
regional collaborative chronic disease solution architecture
Using the regional platform as a hub, it connects Health Commission supervision, lead hospital collaboration, primary healthcare institutions execution and resident health data collection to form a closed-loop management capability from screening, quality control, early warning, referral to follow-up intervention.
WiGroup full-stack self-developed edge computing network
WiGroup combines years of industry experience and rigorous health economics evaluation to understand the core pain points of primary healthcare institutions. Adhere to full-stack self-research and in-depth industry adaptation of software and hardware to overcome the problems of data collection and traceability of scattered equipment in the hospital. With the help of independent and controllable advanced AI capabilities, the platform deeply empowers a full-link digital closed loop from "data collection, sensorless uploading, real-time anti-counterfeiting quality control to intelligent analysis of the entire disease process", truly using technology to make high-quality primary care medical services within reach.
From the collection site to regional supervision, a closed data loop is formed
Through intelligent collection, edge quality control, platform aggregation, risk warning and collaborative processing, primary care helps primary care transform screening results into manageable and traceable business actions.
Product positioning
Take the primary care screening and prevention center as the fulcrum to build a solid base for the chronic disease early screening and early tube
Primary Care Chronic Disease Screening and Prevention Center is suitable for areas that already have a basic public health system, regional medical platform or integrated county healthcare network collaborative foundation. The positioning of WiGroup is not to simply add a software entrance, but to organize equipment collection, resident documentation, complication screening, risk assessment, hierarchical intervention and superior collaboration into a set of operational centralized capabilities around the real service scenario of primary care.
Service objects: community health service centers, township health centers, primary care integrated county healthcare network units
Business boundaries: Mainly hypertension, diabetes, and hyperlipidemia, supporting expansion of COPD, atrial fibrillation, tumors, etc.
Delivery goal: Make screening results collectible, quality controlable, manageable, and traceable
Policy and construction basis
Guided by people's livelihood issues, the primary care model of joint prevention and joint management of multiple diseases has been formed.
Jiangsu Province has continuously incorporated the construction of Primary Care Chronic Disease Screening and Prevention Center into the provincial government’s livelihood projects, and promoted primary care to form a unified, standardized, simple and easy-to-implement integrated chronic disease screening and prevention management strategy focusing on infrastructure, equipment purchase, personnel training, construction standards and participation of social forces.
The construction focuses on the "three highs" of high blood pressure, diabetes, and hyperlipidemia, and gradually includes high-risk groups and patients such as COPD, osteoporosis, atrial fibrillation, and tumors through the "3+N" model, and promotes secondary and above hospitals to participate in chronic disease services through visits, training, teaching, expert studios, and joint wards.
continuous constructionContinuously included in the provincial government’s people’s livelihood matters in 2024 and 2025
Standard towingConstrain space, equipment, personnel and service processes with construction standards
Three-high condominiumHypertension, diabetes, and hyperlipidemia are the main lines of primary care screening and prevention
3+N extensionExpand screening targets for COPD, atrial fibrillation, tumors, etc. according to regional capabilities
what problem to solve
primary care It’s not a lack of tasks, but a lack of a screening and prevention organization method that can be implemented stably
public health physical examination, outpatient discovery, disease-specific care follow-up and in-hospital referral operate independently, making it difficult to form a continuous identification portal.
On-site collection of multiple devices and positions relies on manual registration, and data authenticity, integrity and efficiency are easily affected.
Screening for fundus, foot, kidney, blood vessel and other complications is not embedded in the primary care process, making it difficult for risk groups to intervene early.
There is a lack of traceable data links and unified processing closed loops between higher-level hospitals, primary healthcare institutions and regional supervision.
How to build
Focusing on "Two Screenings and Three Prevention Measures" and standardized processes, on-site services become data closed loops
Two Screenings and Three Prevention Measures: Move screening forward and layer prevention
With Primary Care Chronic Disease Screening and Prevention Center as the hub, the chronic disease early identification portal is first established through wide-coverage screening, and then high-risk groups are identified through complication screening, and finally enters the primary, secondary, and tertiary prevention management paths, forming a post-screening closed loop.
Standardized process: traceable service chain from document creation to target
Taking archiving, admissions, screening, assessment, management and compliance as the main lines, it connects resident entrance, health records, consultation information, high-risk screening, disease diagnosis, complication screening, risk assessment, standardized management and target inspection.
Construction preparation: software, hardware, network and personnel are synchronized in place
Pictures of hardware to be supplemented: subsequent supplementary screening equipment, mobile follow-up package, edge gateway and on-site deployment photos.
Specific equipment can be configured in stages according to regional construction goals. The core principle is to allow on-site inspection data to be automatically collected, uploaded, and quality controlled as much as possible to reduce primary care repeated entry and subsequent supplementary entry.
Basic physical examination equipment: blood pressure, blood sugar, height and weight, waist circumference, urine test, biochemistry, etc.
Complication screening equipment: fundus, sole, kidney disease-related testing, ECG, ultrasound, etc.
On-site execution equipment: scanning terminal, mobile follow-up package, ID card verification, printing and calling equipment
Data access capabilities: edge gateway, device interface, network environment, platform account and permission system
Personnel organization ability: primary care clinicians training, superior hospital guidance, quality control rules and abnormal handling mechanism
Construction indicators
Indicators not only look at the number of completed projects, but also look at screening, discovery, management and compliance.
The introduction page does not expand the project acceptance details, but it is necessary to let customers see the direction of the construction goals: after the center is completed, it should be able to support population screening, risk discovery, complication screening, classified registration, standardized management, follow-up intervention and superior coordination.
Taking the public construction results of Jiangsu Province as a reference, in 2024, relying on the 60 Primary Care Chronic Disease Screening and Prevention Centers that have been built, a total of 830,000 residents were screened, and 320,000 people at high risk of chronic diseases were found, 36,521 newly diagnosed patients with hypertension, and 27,270 patients with diabetes.
screening coverageTarget population archiving, physical examination and screening coverage
risk discoveryIdentification, classification registration and tracking of high-risk groups
Complication screeningFundus, kidney, foot, blood vessel and other key risk screenings
Data quality controlEquipment collection, identity verification, result upload and quality verification
Standardized managementStratified intervention, follow-up plan, service package signing and compliance assessment
collaborative supportTeaching, referral, consultation and expert resources sinking in higher-level hospitals
Product screenshots
Consolidate primary care on-site services into manageable system capabilities
personal health record
Centering on resident identity, basic information, physical examination records, chronic disease tags and historical service records, a unified data portal for primary care screening and prevention work is formed to provide a basis for subsequent risk assessment and follow-up management.
integrated in-hospital and post-discharge care Health Management Center
Let health management move from report delivery to continuous services inside and outside the hospital
The platform is oriented to hospital health management center, outpatient, inpatient, specialist and out-of-hospital follow-up scenarios. It integrates physical examination, out-patient, in-patient, examination and patient self-assessment data into continuous health files to support risk identification, hierarchical management, specialist collaboration, out-of-hospital follow-up and effect evaluation.
Product positioning: Hospital-level collaborative operation platform for hospital health management centers
Core value: solidify hospital-level authorization, specialist resources and follow-up operations into executable task paths
Delivery closed loop: continuous advancement of in-hospital discovery, out-of-hospital extension, primary care linkage and long-term intervention
Continuous service path inside and outside the hospital
IN
Admission assessment and documentation
Risk assessment, health record establishment, patient tag initialization.
STAY
In-hospital diagnosis, treatment and nursing management
Diagnosis and treatment records, nursing pathways, process monitoring and education.
OUT
Discharge planning and medication guidance
Discharge summary, medication reminders, follow-up plans and health education.
HOME
Out-of-hospital follow-up and re-diagnosis intervention
Follow-up management, follow-up reminders, risk reminders and long-term intervention.
health recordFollow-up tasksrisk intervention
What the health management center needs to complement is a closed loop of continuous services
The practical difficulty is not only the lack of system tools, but also that service value, hospital-level authorization, specialty collaboration and data processes are not organized into the same set of executable paths.
It is difficult to rely solely on medical insurance payment for prevention and long-term health management. The willingness of patients and commercial insurance to pay needs to be gradually established by clarifying the value of services.
If the health management center is just a physical examination department, it will be difficult to coordinate outpatient clinic numbers, specialists, nursing follow-up, examination reviews, and operational resources.
Abnormal physical examination, chronic disease risks and postoperative recovery tend to remain at the level of recommendations, lacking referral, review, return of opinions and continuous management paths.
Physical examination, outpatient, hospitalization, examination and examination, follow-up and patient self-evaluation data are scattered, making it difficult to support risk stratification, task allocation and effect evaluation.
Hospital-level health management collaborative system
Health management is not a single department project, but a hospital-level collaborative project. The platform uses the health management center as the operational entrance to connect medical standards, specialist capabilities, nursing follow-up, information systems and performance mechanisms.
From opportunistic screening to long-term intervention, forming a closed loop of platform capabilities
The platform does not replace the hospital's organizational capabilities, but instead precipitates cross-department collaboration into rules, paths and tasks, allowing the health management center to continue operating, tracking and reviewing.
Found in the hospitalPhysical examination, outpatient and hospitalization abnormality identification
risk stratificationPopulation labeling and intervention priority
Specialty collaborationNumber source, review, feedback of opinions
path executionNutrition, exercise, medication, follow-up consultation
patient accessMini programs, text messages, follow-up tasks
primary care linkageDistrict follow-up and long-term management
Effect evaluationIndicator compliance and service review
Start with high-value diseases to make the closed-loop service visible
Prediabetes and Diabetes Management
Identify abnormal groups such as blood sugar, glycosylated hemoglobin, BMI, and blood lipids from physical examination, outpatient, hospitalization, and test results, automatically complete risk stratification, and generate nutrition, exercise, review, medication reminder, and specialist referral tasks.
- Blood sugar abnormality identification
- Pre-diabetic/diabetic stratification
- Endocrinology Specialty Collaboration
- 1, 3, 6 month review
Hypertension risk management
Integrate physical blood pressure examination, outpatient diagnosis, home blood pressure monitoring and combined risk factors, establish a stratified follow-up path, and link specialist resources such as cardiology, nephrology, and neurology.
- Blood pressure abnormality identification
- risk factor assessment
- Low, medium and high risk stratification
- Compliance evaluation and long-term follow-up
Pulmonary nodule management
Undertake low-dose CT results, combine nodule size, density, number, boundary, previous imaging and personal risk factors, link the imaging department, respiratory department, thoracic surgery and MDT to avoid leakage and excessive intervention.
- CT revealed pulmonary nodules
- Image structured assessment
- Risk stratification and review
- Return of professional opinions
Use task-oriented interface to carry health management operations
The following is a page-level product capability preview, which can be replaced with real system screenshots later.
continuous health recordPhysical examination · outpatient service · hospitalization · out-of-hospital
patient labelPrediabetic risk/high BMI/family history of hypertension
key indicatorsHbA1c 6.2% · LDL-C 3.8 · BP 148/92
Recent tasksNutritional assessment, review reminders, endocrinology clinic appointments
continuous health record
Unify physical examination, outpatient, hospitalization, examination and out-of-hospital follow-up data from the patient's perspective to form a health file that can be used for risk identification and long-term management.