中国卫生信息管理杂志

慢性病已成为我国最主要的疾病负担。本文就2018—2022年期间开展的4轮调查和2020年开展的一次专题小组访谈资料，结合文献梳理我国县域医疗机构慢病管理系统的应用现状、建设意愿和需求等。在此基础上，提出基层慢病管理系统的建设思路、系统架构和主要功能，并探讨落地应用需要达成的条件，以期为推进慢病管理系统的功能完善和应用推广提供参考。

Chronic diseases have become the major disease burden in China. Based on four surveys during 2018-2022 and a special panel interview in 2020, combined with relevant literature, this paper sorted out current application status, construction willingness and special needs of chronic disease management systems of county-level health institutions in China. On this basis, the construction ideas, system architecture and main functions of the county-level chronic disease management system are proposed, and the necessary conditions required for system application were discussed, so as to provide reference for advancement of the function improvement and promotion of application of the chronic disease management system.