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To support the "people-centered" chronic disease health management work, Shanghai has developed a community chronic disease health management information system. This system provides an efficient tool for achieving integrated medical care and disease prevention, as well as collaborative management between doctors and patients, through functions such as information registration and management, risk assessment, chronic disease screening, patient evaluation, and categorized follow-up. It delivers comprehensive, precise, and high-quality health management services for various chronic diseases, effectively promoting the implementation of comprehensive chronic disease prevention and control strategies and the transformative development of chronic disease health management services. However, the system currently requires the inclusion of a broader range of chronic diseases and the enhancement of interactive integration between clinic-based doctor follow-ups and home-based self-management. Future improvements may include the integration of additional disease types and the fusion of complex interaction scenarios to continuously adapt to the new situations and challenges in chronic disease prevention and control.