Purpose/Significance To develop a patient-oriented specialized disease management platform that aligns with patients’ healthcare needs, in order to facilitate the transition of medical services from treatment-focused to whole-cycle health management.Method/Process The system integrates existing hospital business systems via the WeCom platform, based on patient records, health files, and follow-up feedback data to create a specialized disease management plan. Patient profiling and health data analysis are used to track health status in real-time, offering personalized health guidance.Result/Conclusion The platform implements a new patient-centered digital specialized disease management model, which enhances the accessibility of patient-oriented services and demonstrates comprehensive application value in improving management efficiency, optimizing service experience, and facilitating physician-patient interaction, etc.