# Reinforcement Learning enhanced Online Adaptive Clinical Decision Support via Digital Twin powered Policy and Treatment Effect optimized Reward

arXiv: https://arxiv.org/abs/2508.17212 · HTML: https://mlsanity.com/paper/2508.17212/

## Key facts

- No citing papers in the map yet (data through 14 Oct 2026).
- Placed in RL for clinical treatment and surgery, one of 15 directions in Deep reinforcement learning methods.
- Builds on 4 of its 18 references that are in the map.
- First posted on arXiv 24 Aug 2025.

## Placed in

- Deep reinforcement learning methods / [RL for clinical treatment and surgery](https://mlsanity.com/deeprl/rl-for-clinical-treatment-and-surgery/)

## Builds on (most cited first, 4 of 4)

- [Efficient Memory Management for Large Language Model Serving with PagedAttention](https://mlsanity.com/paper/2309.06180/) (2023)
- [Large Language Models Encode Clinical Knowledge](https://mlsanity.com/paper/2212.13138/) (2022)
- [Conservative Q-Learning for Offline Reinforcement Learning](https://mlsanity.com/paper/2006.04779/) (2020)
- [Deep Reinforcement Learning with Double Q-learning](https://mlsanity.com/paper/1509.06461/) (2015)

## Abstract (arXiv)

Clinical decision support must adapt online under safety constraints. We present an online adaptive tool where reinforcement learning provides the policy, a patient digital twin provides the environment, and treatment effect defines the reward. The system initializes a batch-constrained policy from retrospective data and then runs a streaming loop that selects actions, checks safety, and queries experts only when uncertainty is high. Uncertainty comes from a compact ensemble of five Q-networks via the coefficient of variation of action values with a tanh compression. The digital twin updates the patient state with a bounded residual rule. The outcome model estimates immediate clinical effect, and the reward is the treatment effect relative to a conservative reference with a fixed z-score normalization from the training split. Online updates operate on recent data with short runs and exponential moving averages. A rule-based safety gate enforces vital ranges and contraindications before any action is applied. Experiments in a synthetic clinical simulator show low latency, stable throughput, a low expert query rate at fixed safety, and improved return against standard value-based baselines. The design turns an offline policy into a continuous, clinician-supervised system with clear controls and fast adaptation.