基于系统复杂性及其认识论的中医诊疗决策模式研究
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摘要
诊疗决策模式是医生运用医学知识对疾病演变规律进行推理判断和临床干预的过程。中医与西医由于知识背景、思维方式的差异,形成了迥然不同的认知范式,对于医生而言,了解这些差异非常关键,有助于决定把关注点放在哪里合适。近年来,由于中西医学方法论层面的借鉴和参照,使得临床证据分级、指南制定和决策分析研究在注重标准化的同时,也存在对中医传统经验重视不足的现状。借助可视化方法和路径化的集成策略,有助于发现热点研究之间的相关性,拓展临床观测的维度,为降低医疗成本提供可操作的信息实践模式
本论文是以国家自然基金面上项目“基于系统复杂性的中医诊疗信息集成可视化建模研究(No.81273876)”为依托,从临床决策分析出发,以医学诊疗决策中的热点问题为切入点,系统的阐述了中西医学临床决策原理,并指出中医诊疗决策不是以统计概率作为抉择依据,而是以病象与病机的契合度作为医生经验复现的关键。主体研究借助信息可视化技术,梳理了医学临床决策研究的热点问题和趋势,力图把中医临床思辨与现代医学决策分别加以呈现,拓展同类问题的认识维度。根据国内外文献资料,本研究发现医学决策系统与临床指南模型、临床路径系统研究有紧密的相关性。基于此提出,临床路径信息系统应与循证实践和综合疗效评价相结合,设计了中医临床路径系统研发的建模方案。值得关注的是,医生自媒体形式的报道典型病例,会加快临床路径朝着个性化、实用化的趋势发展。从定性到定量的综合集成法,能为中医经验假设到科学推理的转化过程提供可参证的方法论,综合集成群体研讨厅是目前复杂问题求解的有效形式。群体研讨流程的探索能推动中医领域复杂性问题求解策略的研究,为中医临床决策问题提供一体化平台集成策略。
1.目标
1.1从临床决策分析的视角,研究中医传统诊疗模式的内在规律；
1.2借助信息可视化方法,梳理了医学临床决策研究的热点问题和趋势；
1.3从信息化实践的角度,分析中医临床路径与辅助决策系统研究的结合点；
1.4分析中医诊疗决策演变模式,探讨医学复杂问题求解策略。
2.方法
2.1运用比较分析法,本文试图对中西医学临床决策分析的异同点进行梳理说明,并做出原因分析；
2.2应用聚类分析方法,绘制了医学临床决策研究热点问题的知识图谱;
2.3借助信息可视化技术,识别出临床决策系统研发与临床路径和临床指南模型研发的相关性,发掘信息建模研究的热点问题,为中医临床路径信息化实践和临床决策支持系统的研发提供可参考的素材：
2.4结合从定性到定量的综合集成法,把医生个体和群体层面的决策问题进行分析,指出综合集成群体研讨厅是处理复杂问题求解的有效形式。
3.结果
3.1梳理了中西医学临床决策的内在逻辑结构,结合病机十九条,指出审机求证在中医临床辨证中的重要作用。
3.2应用聚类分析的方法,查找到3172篇目标文献的引文网络,数据分析结果显示,共引网络被分成18个共引聚类,从中可以发现,计算机辅助决策分析研究是近年来学界研究的热点问题。
3.3分析临床路径系统与信息系统研究中的相关性文献,绘制聚类分析视图和时区分析视图,通过列表的形式枚举高影响度的研究文献。在此基础上构建了中医临床路径工作流框架。
3.4在中医学发展过程中,对于决策理论和实践方面的研究,多是从医生个体经验的提升为基点,延伸为不同学术流派的理论体系形成。群体决策经验方面的研究由于受到科学技术发展水平的影响,表现出一定的滞后性和非即时性,分散存在于历代医学著作中。
4.结论
4.1医学实践是以从既往病例中所获取的信息转移到当前和未来为基础的。能够成功应用既往病例信息的关键就在于识别过去与现在病例之间的相似性。决策分析方法就是在寻找相似性的过程中发展起来的。由于文化上的差异,中西医学演变出不同的认识论和决策分析逻辑,西医学的临床决策分析以计算不同机遇点的概率值作为重复参照的依据,中医决策分析是以病机与病象的契合度作为病例复现的内在线索,共同之处在于两者均强调启发性知识在临床决策中的重要作用,随着信息传播方式的多样化,典型病案报告会成为填补决策证据缺失的有效手段。
4.2计算机决策支持系统是近年来临床决策研究的热点问题,与西方发达国家相比,我国的临床决策支持系统的普及率较低。在中医诊疗决策信息集成可视化研究方面,应关注经典著作的引渡触发机制,临床指南的集成可视化和典型病例的报告等议题。将软件功能开发与中医临床疗效评价结合起来,才能在更大范围内促进中医疗效基线的测量和证据知识的应用推广。
4.3中医临床路径实践尚需与辅助决策系统相结合。在思维层面需要的是源头活水,是充满人文气息的理性思考；在组织管理层面,需要的是严谨的方法学设计和流程质量控制；在政策法规方面,有赖于行业规范的调整,让医院有动力去降低医疗成本,推动优势疗法的涌现。同时,在自媒体广泛应用的时代,每一位医生有意识的记录观测指标,治疗效果,患者真实诉求和疾病治疗成本等方面的数据,也会为临床决策提供多元化的解决思路,改变着我们拘谨且日益僵化的认知模式
4.4综合集成法为医生个体与群体并重的决策信息转化提供方法论指导,通过发现问题、确定目标、确定价值准则、拟定方案、分析评价、方案优选、实践方案和普遍实施7个研讨流程梳理,将医生的经验判断与决策模型相结合有助于提升医生对复杂问题的处理能力,降低诊疗误诊率,为中医药领域的决策模式研究提供新的视角。
Diagnosis and treatment decision model reflects the process the doctor use the knowledge to make clinical judgment and intervention. Differences in ways of modes of knowledge background and thinking between TCM and Western medicine, therefore it has formed the far different cognitive paradigm. Knowing what differences within the process are critical to those decisions helps decide where focus are the best placed. As the epistemology and methodology referenced between Chinese and western medicine, it makes the research pay more attention to standardization in terms of clinical evidence grading, guidelines and clinical decision research. But there still exit less attention to the experience in recent years. By using the visualization method and the path integration strategy, it helps to find out the correlation between the hot spot in research and to expand the dimension of clinical observations. That provided information practice model for reduce health care costs.
The paper roots in the project "The information integration visualized modeling study of TCM diagnosis and treatment base on system complexity' which is supported by National Nature Science Fund(grant No.81273876). The article is backed by clinical decision analysis, begin with the hot spot in the field, systematically describes the clinical decision principle of Chinese and western medicine and point out that the clinical decision in TCM is not based on statistical probability, but based on the goodness of fit between pathogenesis and symptom as doctors experience repetition key. On the strength of information visualization technology, It's a research that combs the medical clinical decision research hot issues and trends, strives to discuss each category between the traditional clinical thinking and modern medical decision, and expands the understanding of the similar problem dimensions. According to the relevant domestic and international literature, the study found that medical decision-making system, clinical guidelines model and clinical pathway system research have close correlation. Based on this, put forward some new ideas that the clinical pathway system should be combined with evidence-based practice and comprehensive curative effect evaluation. The study design the development of clinical pathway of traditional Chinese medicine system modeling scheme. What should be of concern is that the doctor reports typical cases by we-media, which will accelerate the development of clinical pathway on the way to personalized and practical development. The metasynthesis can provides the complement methodology to the transformation process from the experience of TCM hypothesis to scientific reasoning. HWME is an effective tool to solve the problem of complex problem. Group discussion process exploration can promote complexity problem solving strategies in the field of research in TCM,which can provides integrated platform integration strategy to TCM clinical decision problems.
1.objectives
1.1to study the inherent law of traditional Chinese medicine diagnosis and treatment pattern from clinical decision analysis perspective;
1.2to comb the medical clinical decision research hot issues and trends by information visualization method;
1.3to analysis the joint point between the clinical pathway of traditional Chinese medicine research and decision support system from the information practice perspective;
1.4to analysis the evolution of the diagnosis and treatment decision-making model in TCM, and to discuss medical complex problem solving strategies.
2.methods
2.1Using comparison analysis method, this article attempts to point clinical decision analysis to sort out differences and similarities between TCM and western medicine;
2.2Using clustering method, this study develops a knowledge map of the hot spot of medicine;
2.3On the strength of information visualization technology, this article identified the the correlation between the clinical decision supported system and the clinical pathway, explored information modeling research hot spot problems. Which can provide material for the clinical pathway of TCM information practice and the clinical decision support system development;
2.4With regard to the metasynthesis, the paper analyses the decision making problems from the perspective of individual and group decision and found out that HWME is an effective tool to solve the problem of complex problem.
3Results
3.1The intrinsic logic structure of Chinese and western medicine clinical decision was combed out. Combining with "pathogenesis article19", it was very important that syndrome differentiation and disease differentiation should be combined.
3.2By cluster analysis method.3172target paper was founded and drawn into citation network. The data result shows that the citation network were divided into18clustering, from which we can find that computer aided decision analysis research is a hot problem in recent years.
3.3Articles had close correlation with the clinical pathway system and information system were selected, clustering analysis view and time zone analysis view were drawn, the high levels of research literature was enumerated as the list of forms. And on this basis we create the clinical pathway of traditional Chinese medicine workflow framework.
3.4The formation mode and development mode of TCM traditional decision theory of diagnosis and treatment are mostly on the basis of promotion of individual doctor's experience leading to the formation of different theoretical system of academic schools. The group decision experience, scattering in medical works in all ages, shows up some hysteresis and non-real-time quality because the influence of the level of science and technology.
4. Conclusions
4.1Medical practice bottoms upon transferred the case information transfer mode from the past to the future. The key to success used the case information is to identify the similarities between past and present cases. Decision analysis method is developed in the process of looking for similarities. Because of the difference of culture, Chinese and Western medicine have evolved different epistemology logic and decision analysis. Western clinical decision analysis is the basis calculation of the value of different opportunities. The clinical decision in TCM is based on the goodness of fit between pathogenesis and symptom as doctors experience repetition key. The common ground between the two is that both emphasize the important role of heuristic knowledge in clinical decision making. With the diversification of information dissemination, the typical medical record will be an effective means for filling the evidence missing.
4.2Computer decision support system is a hot problem in the study on clinical decision in recent years. Compared with western developed countries, the apply of the decision support system in our country is less. In the aspect of the TCM decision-making information integrated visualization study, classic extradition triggering mechanism should be concerned. Meanwhile Clinical guidelines for the integration of visualization and typical case report also be paid more attention, combined with the development of software function and the clinical efficacy evaluation of TCM, Similar studies are possible in a wider range to promote the effect of baseline measurement and the application of Evidence knowledge.
4.3In the practice of clinical pathway, origin and reasonable thinking with humanity flavor are needed at thinking level, rigorous methodological design and process quality control are needed at organization level, and adjustment of medical standards, reduction of medical cost and emergence of advantage therapies are needed at policy and regulation level.
4.4Metasynthesis method provides a methodological guidance for the translation of decision information laying equal stress on doctor individual and group. The doctor's experience and judgment were combined with decision mode through clearing7processes including finding problems, defining goal, confirming value disciplines, and preparing, analyzing, optimizing, practicing and spreading scheme. The study will be benefit to improve doctors'ability to solve complex problems, defining goal, confirming value disciplines, and preparing, analyzing, optimizing, practicing and spreading scheme. The study will be benefit to improve doctors' ability to solve complex problems and reduce misdiagnosis rate.
本论文是以国家自然基金面上项目“基于系统复杂性的中医诊疗信息集成可视化建模研究(No.81273876)”为依托,从临床决策分析出发,以医学诊疗决策中的热点问题为切入点,系统的阐述了中西医学临床决策原理,并指出中医诊疗决策不是以统计概率作为抉择依据,而是以病象与病机的契合度作为医生经验复现的关键。主体研究借助信息可视化技术,梳理了医学临床决策研究的热点问题和趋势,力图把中医临床思辨与现代医学决策分别加以呈现,拓展同类问题的认识维度。根据国内外文献资料,本研究发现医学决策系统与临床指南模型、临床路径系统研究有紧密的相关性。基于此提出,临床路径信息系统应与循证实践和综合疗效评价相结合,设计了中医临床路径系统研发的建模方案。值得关注的是,医生自媒体形式的报道典型病例,会加快临床路径朝着个性化、实用化的趋势发展。从定性到定量的综合集成法,能为中医经验假设到科学推理的转化过程提供可参证的方法论,综合集成群体研讨厅是目前复杂问题求解的有效形式。群体研讨流程的探索能推动中医领域复杂性问题求解策略的研究,为中医临床决策问题提供一体化平台集成策略。
1.目标
1.1从临床决策分析的视角,研究中医传统诊疗模式的内在规律；
1.2借助信息可视化方法,梳理了医学临床决策研究的热点问题和趋势；
1.3从信息化实践的角度,分析中医临床路径与辅助决策系统研究的结合点；
1.4分析中医诊疗决策演变模式,探讨医学复杂问题求解策略。
2.方法
2.1运用比较分析法,本文试图对中西医学临床决策分析的异同点进行梳理说明,并做出原因分析；
2.2应用聚类分析方法,绘制了医学临床决策研究热点问题的知识图谱;
2.3借助信息可视化技术,识别出临床决策系统研发与临床路径和临床指南模型研发的相关性,发掘信息建模研究的热点问题,为中医临床路径信息化实践和临床决策支持系统的研发提供可参考的素材：
2.4结合从定性到定量的综合集成法,把医生个体和群体层面的决策问题进行分析,指出综合集成群体研讨厅是处理复杂问题求解的有效形式。
3.结果
3.1梳理了中西医学临床决策的内在逻辑结构,结合病机十九条,指出审机求证在中医临床辨证中的重要作用。
3.2应用聚类分析的方法,查找到3172篇目标文献的引文网络,数据分析结果显示,共引网络被分成18个共引聚类,从中可以发现,计算机辅助决策分析研究是近年来学界研究的热点问题。
3.3分析临床路径系统与信息系统研究中的相关性文献,绘制聚类分析视图和时区分析视图,通过列表的形式枚举高影响度的研究文献。在此基础上构建了中医临床路径工作流框架。
3.4在中医学发展过程中,对于决策理论和实践方面的研究,多是从医生个体经验的提升为基点,延伸为不同学术流派的理论体系形成。群体决策经验方面的研究由于受到科学技术发展水平的影响,表现出一定的滞后性和非即时性,分散存在于历代医学著作中。
4.结论
4.1医学实践是以从既往病例中所获取的信息转移到当前和未来为基础的。能够成功应用既往病例信息的关键就在于识别过去与现在病例之间的相似性。决策分析方法就是在寻找相似性的过程中发展起来的。由于文化上的差异,中西医学演变出不同的认识论和决策分析逻辑,西医学的临床决策分析以计算不同机遇点的概率值作为重复参照的依据,中医决策分析是以病机与病象的契合度作为病例复现的内在线索,共同之处在于两者均强调启发性知识在临床决策中的重要作用,随着信息传播方式的多样化,典型病案报告会成为填补决策证据缺失的有效手段。
4.2计算机决策支持系统是近年来临床决策研究的热点问题,与西方发达国家相比,我国的临床决策支持系统的普及率较低。在中医诊疗决策信息集成可视化研究方面,应关注经典著作的引渡触发机制,临床指南的集成可视化和典型病例的报告等议题。将软件功能开发与中医临床疗效评价结合起来,才能在更大范围内促进中医疗效基线的测量和证据知识的应用推广。
4.3中医临床路径实践尚需与辅助决策系统相结合。在思维层面需要的是源头活水,是充满人文气息的理性思考；在组织管理层面,需要的是严谨的方法学设计和流程质量控制；在政策法规方面,有赖于行业规范的调整,让医院有动力去降低医疗成本,推动优势疗法的涌现。同时,在自媒体广泛应用的时代,每一位医生有意识的记录观测指标,治疗效果,患者真实诉求和疾病治疗成本等方面的数据,也会为临床决策提供多元化的解决思路,改变着我们拘谨且日益僵化的认知模式
4.4综合集成法为医生个体与群体并重的决策信息转化提供方法论指导,通过发现问题、确定目标、确定价值准则、拟定方案、分析评价、方案优选、实践方案和普遍实施7个研讨流程梳理,将医生的经验判断与决策模型相结合有助于提升医生对复杂问题的处理能力,降低诊疗误诊率,为中医药领域的决策模式研究提供新的视角。
Diagnosis and treatment decision model reflects the process the doctor use the knowledge to make clinical judgment and intervention. Differences in ways of modes of knowledge background and thinking between TCM and Western medicine, therefore it has formed the far different cognitive paradigm. Knowing what differences within the process are critical to those decisions helps decide where focus are the best placed. As the epistemology and methodology referenced between Chinese and western medicine, it makes the research pay more attention to standardization in terms of clinical evidence grading, guidelines and clinical decision research. But there still exit less attention to the experience in recent years. By using the visualization method and the path integration strategy, it helps to find out the correlation between the hot spot in research and to expand the dimension of clinical observations. That provided information practice model for reduce health care costs.
The paper roots in the project "The information integration visualized modeling study of TCM diagnosis and treatment base on system complexity' which is supported by National Nature Science Fund(grant No.81273876). The article is backed by clinical decision analysis, begin with the hot spot in the field, systematically describes the clinical decision principle of Chinese and western medicine and point out that the clinical decision in TCM is not based on statistical probability, but based on the goodness of fit between pathogenesis and symptom as doctors experience repetition key. On the strength of information visualization technology, It's a research that combs the medical clinical decision research hot issues and trends, strives to discuss each category between the traditional clinical thinking and modern medical decision, and expands the understanding of the similar problem dimensions. According to the relevant domestic and international literature, the study found that medical decision-making system, clinical guidelines model and clinical pathway system research have close correlation. Based on this, put forward some new ideas that the clinical pathway system should be combined with evidence-based practice and comprehensive curative effect evaluation. The study design the development of clinical pathway of traditional Chinese medicine system modeling scheme. What should be of concern is that the doctor reports typical cases by we-media, which will accelerate the development of clinical pathway on the way to personalized and practical development. The metasynthesis can provides the complement methodology to the transformation process from the experience of TCM hypothesis to scientific reasoning. HWME is an effective tool to solve the problem of complex problem. Group discussion process exploration can promote complexity problem solving strategies in the field of research in TCM,which can provides integrated platform integration strategy to TCM clinical decision problems.
1.objectives
1.1to study the inherent law of traditional Chinese medicine diagnosis and treatment pattern from clinical decision analysis perspective;
1.2to comb the medical clinical decision research hot issues and trends by information visualization method;
1.3to analysis the joint point between the clinical pathway of traditional Chinese medicine research and decision support system from the information practice perspective;
1.4to analysis the evolution of the diagnosis and treatment decision-making model in TCM, and to discuss medical complex problem solving strategies.
2.methods
2.1Using comparison analysis method, this article attempts to point clinical decision analysis to sort out differences and similarities between TCM and western medicine;
2.2Using clustering method, this study develops a knowledge map of the hot spot of medicine;
2.3On the strength of information visualization technology, this article identified the the correlation between the clinical decision supported system and the clinical pathway, explored information modeling research hot spot problems. Which can provide material for the clinical pathway of TCM information practice and the clinical decision support system development;
2.4With regard to the metasynthesis, the paper analyses the decision making problems from the perspective of individual and group decision and found out that HWME is an effective tool to solve the problem of complex problem.
3Results
3.1The intrinsic logic structure of Chinese and western medicine clinical decision was combed out. Combining with "pathogenesis article19", it was very important that syndrome differentiation and disease differentiation should be combined.
3.2By cluster analysis method.3172target paper was founded and drawn into citation network. The data result shows that the citation network were divided into18clustering, from which we can find that computer aided decision analysis research is a hot problem in recent years.
3.3Articles had close correlation with the clinical pathway system and information system were selected, clustering analysis view and time zone analysis view were drawn, the high levels of research literature was enumerated as the list of forms. And on this basis we create the clinical pathway of traditional Chinese medicine workflow framework.
3.4The formation mode and development mode of TCM traditional decision theory of diagnosis and treatment are mostly on the basis of promotion of individual doctor's experience leading to the formation of different theoretical system of academic schools. The group decision experience, scattering in medical works in all ages, shows up some hysteresis and non-real-time quality because the influence of the level of science and technology.
4. Conclusions
4.1Medical practice bottoms upon transferred the case information transfer mode from the past to the future. The key to success used the case information is to identify the similarities between past and present cases. Decision analysis method is developed in the process of looking for similarities. Because of the difference of culture, Chinese and Western medicine have evolved different epistemology logic and decision analysis. Western clinical decision analysis is the basis calculation of the value of different opportunities. The clinical decision in TCM is based on the goodness of fit between pathogenesis and symptom as doctors experience repetition key. The common ground between the two is that both emphasize the important role of heuristic knowledge in clinical decision making. With the diversification of information dissemination, the typical medical record will be an effective means for filling the evidence missing.
4.2Computer decision support system is a hot problem in the study on clinical decision in recent years. Compared with western developed countries, the apply of the decision support system in our country is less. In the aspect of the TCM decision-making information integrated visualization study, classic extradition triggering mechanism should be concerned. Meanwhile Clinical guidelines for the integration of visualization and typical case report also be paid more attention, combined with the development of software function and the clinical efficacy evaluation of TCM, Similar studies are possible in a wider range to promote the effect of baseline measurement and the application of Evidence knowledge.
4.3In the practice of clinical pathway, origin and reasonable thinking with humanity flavor are needed at thinking level, rigorous methodological design and process quality control are needed at organization level, and adjustment of medical standards, reduction of medical cost and emergence of advantage therapies are needed at policy and regulation level.
4.4Metasynthesis method provides a methodological guidance for the translation of decision information laying equal stress on doctor individual and group. The doctor's experience and judgment were combined with decision mode through clearing7processes including finding problems, defining goal, confirming value disciplines, and preparing, analyzing, optimizing, practicing and spreading scheme. The study will be benefit to improve doctors'ability to solve complex problems, defining goal, confirming value disciplines, and preparing, analyzing, optimizing, practicing and spreading scheme. The study will be benefit to improve doctors' ability to solve complex problems and reduce misdiagnosis rate.
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