基于跨境医疗数据整合的粤港澳大湾区社区医院智慧慢性病管理系统的构建与优化

基于跨境医疗数据整合的粤港澳大湾区社区医院智慧慢性病管理系统的构建与优化

Construction and Optimization of a Smart Chronic Disease ManagementSystem for Community Hospitals in the Guangdong - Hong Kong - MacaoGreater Bay Area Based on Cross-Border Medical Data Integration

作者：徐劲飞 蓝炜 梁宝滢 任怡霖(1.珠海复旦创新研究院双碳创新中心，广东珠海，519000;2.庆应义塾大学，神奈川县横滨市，日本，223-8526;3.暨南大学珠海校区，广东珠海，519070)

摘 要：粤港澳大湾区医疗卫生一体化进程中，港澳居民跨境就医需求持续增长，但受限于三地制度势差与法域壁垒，基层社区医院在慢性病管理上面临数据孤岛化、标准碎片化及协同治理缺失等深层困境。对此，本研究融合慢性病管理模型(CCM)与跨境数据治理理论，探索基于跨境医疗数据整合的智慧慢性病管理系统的构建与优化路径。以“医疗数据空间”技术架构为底座构建可信数据流通机制，创新性地设计跨境患者主索引与多维字典动态映射规则，实现了多源异构HIS数据的同质化清洗与合规流转，完成了从碎片化诊疗记录到标准化跨境健康档案的逻辑重构。针对系统实施中的挑战，进一步提出涵盖治理协同、数据流通、技术架构与服务创新的“四层协同”优化策略。研究表明，该系统的构建与优化有效破解了健康画像割裂与重复医疗难题，显著提升了跨域慢性病管理的连续性与精准性，为大湾区乃至同类跨制度区域的基层医疗数字化转型与一体化建设提供了可借鉴的“湾区范本”。

关键词：跨境医疗数据;智慧慢性病管理;粤港澳大湾区;社区医院;数据治理

Abstract:In the process of healthcare integration in the Guangdong -Hong Kong -Macao GreaterBay Area, the demand for cross-border medical services among Hong Kong and Macao residentshas continued to grow. However, constrained by institutional disparities and jurisdictionalbarriers among the three regions, primary community hospitals face profound challenges inchronic disease management, including data silos, fragmented standards, and the absence ofcollaborative govemance. In response, this study integrates the Chronic Care Model (CCM) withcross-border data governance theory to explore the construction and optimization pathways of asmart chronic disease management system based on cross-border medical data integration. Usingthe technical architecture of a "medical data space" as the foundation, the study establishes atrusted mechanism for data circulation and innovatively designs a cross-border patient masterindex together with dynamic multidimensional dictionary mapping rules. This enables thehomogeneous cleansing and compliant circulation of multi-source heterogeneous HIS data,thereby achieving a logical reconstruction from fragmented diagnostic and treatment records tostandardized cross-border health records. To address challenges arising during systemimplementation, the study further proposes a "four-layer synergy" optimization strategyencompassing governance coordination, data circulation, technical architecture, and serviceinnovation. The findings indicate that the construction and optimization of this system effectivelyresolve the problems of fragmented health profiling and duplicate medical services, significantlyenhancing the continuity and precision of cross-regional chronic disease management. The studythus provides a replicable "Greater Bay Area model" for the digital transformation and integrateddevelopment of primary healthcare in the Greater Bay Area and other regions characterized bycross-institutional systems.

Keywords:cross-border medical data; smart chronic disease management; Guangdong-HongKong-Macao Greater Bay Area; community hospitals; data governance

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