随着我国人口老龄化加剧和生活方式的转变，慢性病的发病率持续攀升，已成为威胁全民健康和制约社会经济发展的重大问题。国家为此密集出台政策，推动慢性病管理转型。在这样的背景下，易享随访一体机的出现是响应国家战略、打通基层健康管理的关键载体。

　　With the aggravation of population aging and the change of lifestyle in China, the incidence rate of chronic diseases continues to rise, which has become a major problem threatening the health of the whole people and restricting social and economic development. The government has issued intensive policies to promote the transformation of chronic disease management. In this context, the emergence of the Yixiang follow-up all-in-one machine is a key carrier for responding to national strategies and connecting grassroots health management.

　　PART.01

　　PART.01

　　最新政策

　　Latest policies

　　2025年10月29日，国家卫健委发布《关于加强基层慢性病健康管理服务的指导意见》，提出整合基层慢性病防、筛、诊、治、管、康的全流程服务功能，明确乡镇卫生院、村卫生室等不同机构的角色定位；要求开展慢性病高风险人群早筛、患者分类分级管理、多病共管等5项服务内容，同时从用药保障、数智赋能等方面制定5项保障措施，并设定2027年和2030年阶段性目标。 《指导意见》是一份纲领性文件，它制定了清晰的阶段性任务和规范化、系统化的慢性病健康管理服务内容，推动慢性病防控从零散化、碎片化向制度化、常态化转变。

　　On October 29, 2025, the National Health Commission issued the "Guiding Opinions on Strengthening Grassroots Chronic Disease Health Management Services", proposing to integrate the full process service functions of grassroots chronic disease prevention, screening, diagnosis, treatment, management, and health, and clarify the role positioning of different institutions such as township health centers and village clinics; Five service contents are required to be carried out, including early screening of high-risk populations for chronic diseases, patient classification and grading management, and multi disease co management. At the same time, five guarantee measures are formulated from the aspects of medication guarantee and digital intelligence empowerment, and phased goals are set for 2027 and 2030. The Guiding Opinions is a guiding document that sets clear phased tasks and standardized, systematic content for chronic disease health management services, promoting the transformation of chronic disease prevention and control from fragmented and scattered to institutionalized and normalized.

　　2025年11月20日，国家卫健委发布《关于印发基层慢性病健康管理服务能力建设指引的通知》，明确了两方面核心内容：一是五大重点，包括明确管理服务的核心功能、规划健康服务区与诊疗区的空间布局、整合卫生专业技术团队、基卫配备基础医疗设施设、强调数智化应用与信息数据交汇共享；二是细化基层慢性病服务，从咨询与筛查、诊断与治疗、随访与健康指导三方面，明确11项具体服务内容，全面规范基层健康服务开展。

　　On November 20, 2025, the National Health Commission issued a notice on the issuance of guidelines for the construction of grassroots chronic disease health management service capabilities, which clarified two core contents: first, five key points, including clarifying the core functions of management services, planning the spatial layout of health service areas and diagnosis and treatment areas, integrating health professional technical teams, equipping basic medical facilities for basic health care, and emphasizing the intersection and sharing of digital applications and information data; The second is to refine the services for chronic diseases at the grassroots level, clarifying 11 specific service contents from three aspects: consultation and screening, diagnosis and treatment, follow-up and health guidance, and comprehensively regulating the development of grassroots health services.

　　五大建设核心

　　Five core constructions

　　核心功能：开展辖区慢性病预防、诊疗和健康管理;对接转诊服务;汇总分析流转患者健康信息;引导患者签约家庭医生;

　　Core function: Carry out prevention, diagnosis, treatment, and health management of chronic diseases in the jurisdiction; Coordinate referral services; Summarize and analyze the health information of circulating patients; Guide patients to sign up with family doctors;

　　空间布局：整合现有空间，划分健康服务区负责咨询、筛查等，和诊疗区负责诊断、治疗等，要求分区明确;

　　Space layout: Integrate existing space, divide the health service area for consultation, screening, etc., and the diagnosis and treatment area for diagnosis, treatment, etc., requiring clear zoning;

　　队伍建设：明确由全科医生、中医医师、公共卫生医师、药师、护士等专业人员组成，鼓励吸纳社会工作者、志愿者等;

　　Team building: Clarify the composition of professionals such as general practitioners, traditional Chinese medicine physicians, public health physicians, pharmacists, nurses, etc., and encourage the recruitment of social workers, volunteers, etc;

　　设备配备：要求结合慢性病健康管理需求配备、完善相关设施设备;

　　Equipment configuration: It is required to equip and improve relevant facilities and equipment in accordance with the needs of chronic disease health management;

　　信息化建设：整合电子健康档案、诊疗、体检等数据，强化数智化应用，具备信息交汇功能，支撑全流程健康管理。

　　Informationization construction: Integrate electronic health records, diagnosis and treatment, physical examination and other data, strengthen digital applications, have information exchange functions, and support the entire process of health management.

　　三大服务任务

　　Three major service tasks

　　咨询与筛查：1.提供健康咨询、科普、预约挂号及转诊对接服务;2.收集健康信息;3.开展健康自检和慢性病筛查;4.更新电子健康档案并提示健康风险;5.优先安排签约居民分诊，协助家庭医生签约或续约;

　　Consultation and screening: 1. Provide health consultation, science popularization, appointment registration, and referral docking services; 2. Collect health information; 3. Carry out health self-examination and chronic disease screening; 4. Update electronic health records and alert health risks; 5. Prioritize the triage of contracted residents and assist family doctors in signing or renewing contracts;

　　诊断与治疗：6.按规范检查评估，依指南诊断治疗，纳入分类分级管理;7.提供膳食、运动等生活方式指导;8.对超能力诊疗病例，初步处理后启动向上转诊;

　　Diagnosis and treatment: 6. Conduct standardized examinations and evaluations, diagnose and treat according to guidelines, and include them in classification and grading management; 7. Provide lifestyle guidance such as diet and exercise; 8. For cases of superpower diagnosis and treatment, initiate upward referral after initial treatment;

　　随访与健康指导：9.分类分级随访，解读结果、记录信息并预约复诊，动态管理下转患者;10.指导患者监测健康指标，开展膳食、运动等健康指导;11.分析慢性病管理数据，掌握人群特点以优化服务。

　　Follow up and health guidance: 9. Classify and grade follow-up, interpret results, record information, and schedule follow-up appointments, dynamically manage patient referrals; 10. Guide patients to monitor health indicators and provide health guidance such as diet and exercise; 11. Analyze chronic disease management data, grasp population characteristics to optimize services.

　　政策核心聚焦三大变革方向：

　　The policy core focuses on three major directions of change:

　　服务整合化：建立“一站式”健康管理中心，融合防、筛、诊、治、管、康全流程；

　　Service integration: Establish a "one-stop" health management center that integrates the entire process of prevention, screening, diagnosis, treatment, management, and rehabilitation;

　　资源协同化：通过医联体推动专家、药品和技术下沉，实现城乡医疗资源贯通；

　　Resource synergy: Promote the sinking of experts, drugs, and technology through medical consortia, and achieve the integration of urban and rural medical resources;

　　管理数智化：运用AI与大数据实现风险预警、精准随访和个性化干预。

　　Digitalization of Management: Utilizing AI and big data to achieve risk warning, precise follow-up, and personalized intervention.

　　而在这场基层设备升级的浪潮中，易享随访一体机是响应国家战略、打通基层健康管理“最后一公里”的关键载体。

　　In this wave of upgrading grassroots equipment, the Yixiang follow-up all-in-one machine is a key carrier that responds to national strategies and connects the "last mile" of grassroots health management.

　　PART.02

　　PART.02

　　随访一体机

　　Follow up all-in-one machine

　　随访一体机是由易享科技自主研发的智能化健康检测与管理系统。它专为社区卫生服务中心、乡镇卫生院、村卫生室及家庭医生签约服务场景设计。该设备集成了多参数生理指标检测功能，能够检测血压、血糖、血氧、心率、体温、心电图等多项指标。通过一次测量，就能获取多项健康数据，为后续的分析和管理提供全面的信息。

　　The follow-up all-in-one machine is an intelligent health monitoring and management system independently developed by Yixiang Technology. It is designed specifically for community health service centers, township health centers, village clinics, and family doctor contracted service scenarios. This device integrates multi parameter physiological index detection function, which can detect multiple indicators such as blood pressure, blood glucose, blood oxygen, heart rate, body temperature, electrocardiogram, etc. Through one measurement, multiple health data can be obtained, providing comprehensive information for subsequent analysis and management.

　　除了基本的检测功能，易享随访一体机还具备健康评估功能、健康档案自动建档与上传功能、慢病筛查、对接平台以及数据互联互通接口等。这些功能使得它能够真正实现“早发现、早干预、精准管”的目标。

　　In addition to basic testing functions, the Yixiang follow-up all-in-one machine also has health assessment functions, automatic health record creation and upload functions, chronic disease screening, docking platform, and data interconnection interfaces. These functions enable it to truly achieve the goal of "early detection, early intervention, and precise management".

　　政策呼应点：完全契合《建设指引》中提出的“咨询与筛查”环节要求，助力实现“高风险人群早筛”。

　　Policy response point: Fully comply with the requirements of the "consultation and screening" section proposed in the "Construction Guidelines", and help achieve "early screening of high-risk populations".

　　PART.03

　　PART.03

　　赋能基层团队

　　Empowering grassroots teams

　　一体机还有健康随访功能，同时，它支持语音播报健康指导，针对不同人群播放定制化宣教内容。此外，设备内置家庭医生签约服务模块，现场即可完成电子签约、健康评估、预约随访等功能，极大提升了履约率和群众满意度。这不仅是工具的升级，更是一场“服务范式变革”，推动基层医疗从被动接诊转向主动健康管理。

　　The all-in-one machine also has a health follow-up function, and it supports voice broadcasting of health guidance, playing customized educational content for different groups of people. In addition, the device has a built-in family doctor signing service module, which can complete electronic signing, health assessment, appointment follow-up and other functions on-site, greatly improving the compliance rate and public satisfaction. This is not only an upgrade of tools, but also a "service paradigm shift" that promotes the transformation of primary healthcare from passive reception to active health management.

　　PART.04

　　PART.04

　　数智赋能治理

　　Empowering Governance with Digital Intelligence

　　《指导意见》强调要“强化数智化应用，推进信息交汇共享”。易享随访一体机正是这一理念的技术载体。采用本地存储和加密传输的方式，保障了患者隐私安全。可以对接县域医共体平台、基本公卫系统等，实现区域内信息的流通和共享。

　　The Guiding Opinions emphasize the need to "strengthen the application of digital intelligence and promote information exchange and sharing". The Yixiang follow-up all-in-one machine is the technical carrier of this concept. The use of local storage and encrypted transmission ensures patient privacy and security. It can connect with county-level medical community platforms, basic public health systems, etc., to achieve the circulation and sharing of information within the region.

　　PART.05

　　PART.05

　　客户案例

　　Customer Case

　　易享随访一体机SH-T18集成了多项核心检测功能，覆盖基础体征、慢病筛查、中医体质辨识等多维度健康数据：

　　The SH-T18 follow-up all-in-one machine integrates multiple core detection functions, covering multi-dimensional health data such as basic physical signs, chronic disease screening, and traditional Chinese medicine constitution identification

　　1、基础检测：身高、体重、BMI、腰臀比、体温、血氧饱和度；

　　1. Basic tests: height, weight BMI、 Waist to hip ratio, body temperature, and blood oxygen saturation;

　　2、慢病管理：血压、血糖、尿酸、胆固醇、血脂四项、血红蛋白；

　　2. Chronic disease management: blood pressure, blood glucose, uric acid, cholesterol, blood lipids, hemoglobin;

　　3、专项筛查：十二导联心电图、尿液分析；

　　3. Special screening: Twelve lead electrocardiogram, urine analysis;

　　4、特色服务：中医体质辨识（9种体质分析）、视力检测、心理评估量表；

　　4. Featured services: Traditional Chinese Medicine constitution identification (9 constitution analyses), vision testing, psychological assessment scales;

　　5、便捷输出：A4打印机，现场生成个性化健康报告。

　　5. Convenient output: A4 printer, on-site generation of personalized health reports.

　　设备优势：

　　Equipment advantages:

　　全自动化操作：居民通过身份证或人脸识别登录，系统引导完成检测，减少人工误差；

　　Fully automated operation: Residents log in through ID cards or facial recognition, and the system guides the detection process to reduce manual errors;

　　数据实时上传：检测结果自动同步至医院公共卫生（公卫）系统，支持电子健康档案动态更新；

　　Real time data upload: The test results are automatically synchronized to the hospital's public health system, which supports dynamic updates of electronic health records;

　　PART.06

　　PART.06

　　让科技有温度，让健康可及

　　Make technology warm and accessible to health

　　慢性病防控是一场持久战，也是一场系统工程。国家政策已经指明方向，下一步的关键在于“抓落实、强执行、重实效”。 易享随访一体机，正以其集成化、智能化、标准化、普惠化的特点，慢慢成为基层慢性病管理体系建设中的“新基建”和“新动能”。

　　Chronic disease prevention and control is a long-term battle and a systematic project. The national policy has already indicated the direction, and the key to the next step is to "implement, strengthen execution, and focus on practical results". The Yixiang follow-up all-in-one machine is gradually becoming a "new infrastructure" and "new driving force" in the construction of grassroots chronic disease management system due to its integrated, intelligent, standardized, and inclusive characteristics.

　　它不只是一个机器，而是：

　　It is not just a machine, but:

　　一位永不疲倦的“健康守门人”

　　A tireless' health gatekeeper '

　　一座连接城乡医疗资源的“数字桥梁”

　　A 'digital bridge' connecting urban and rural medical resources

　　一套覆盖“筛-防-管-治-康”的闭环解决方案

　　A closed-loop solution covering "screening prevention management treatment health"

　　未来，随着人工智能、大模型预测的发展，易享将持续迭代升级，探索更多创新场景…… 我们相信，在科技与人文的交汇处，必将生长出更加公平、高效、温暖的中国健康服务体系。 易享所行之路，正是健康中国的微光汇聚之处。 关注我们，了解更多智慧医疗前沿实践与政策解读。

　　In the future, with the development of artificial intelligence and large model prediction, Yixiang will continue to iterate and upgrade, exploring more innovative scenarios... We believe that at the intersection of technology and humanities, a more fair, efficient, and warm Chinese health service system will grow. The path taken by Yi Xiang is where the faint light of a healthy China gathers. Follow us to learn more about cutting-edge practices and policy interpretations in smart healthcare.

　　本文由  随访一体机  友情奉献.更多有关的知识请点击  http://www.yixiangyiliao.com/   真诚的态度.为您提供为全面的服务.更多有关的知识我们将会陆续向大家奉献.敬请期待.

　　This article is a friendly contribution from the follow-up all-in-one machine For more related knowledge, please click http://www.yixiangyiliao.com/ Sincere attitude To provide you with comprehensive services We will gradually contribute more relevant knowledge to everyone Stay tuned