RubricsTree: Scalable and Evolving Open-Ended Evaluation of Personal Health Agents across Health Memory and Medical Skills

Objective. Clinical AI documentation systems require evaluation methodologies that are clinically valid, economically viable, and sensitive to iterative changes. Methods requiring expert review per scoring instance are too slow and expensive for safe, iterative deployment. We present a case-specific, clinician-authored rubric methodology for clinical AI evaluation and examine whether LLM-generated rubrics can approximate clinician agreement. Materials and Methods. Twenty clinicians authored 1,646 rubrics for 823 clinical cases (736 real-world, 87 synthetic) across primary care, psychiatry, oncology, and behavioral health. Each rubric was validated by confirming that an LLM-based scoring agent consistently scored clinician-preferred outputs higher than rejected ones. Seven versions of an EHR-embedded AI agent for clinicians were evaluated across all cases. Results. Clinician-authored rubrics discriminated effectively between high- and low-quality outputs (median score gap: 82.9%) with high scoring stability (median range: 0.00%). Median scores improved from 84% to 95%. In later experiments, clinician-LLM ranking agreement (tau: 0.42-0.46) matched or exceeded clinician-clinician agreement (tau: 0.38-0.43), attributable to both ceiling compression and LLM rubric improvement. Discussion. This convergence supports incorporating LLM rubrics alongside clinician-authored ones. At roughly 1,000 times lower cost, LLM rubrics enable substantially greater evaluation coverage, while continued clinical authorship grounds evaluation in expert judgment. Ceiling compression poses a methodological challenge for future inter-rater agreement studies. Conclusion. Case-specific rubrics offer a path for clinical AI evaluation that preserves expert judgment while enabling automation at three orders lower cost. Clinician-authored rubrics establish the baseline against which LLM rubrics are validated.

Hallucinations can undermine clinician trust in LLMs, making it important that evaluation methods capture clinically relevant errors. Rubric-based evaluation has become the leading approach for assessing LLMs in medicine, but it is unclear whether rubric scores reflect such errors. We first study this in a controlled setting using MedHallu, finding that more specific rubrics better distinguish correct from hallucinated responses. To test this systematically, we develop a taxonomy of medical hallucination types and a clinician-validated error-injection pipeline that creates matched correct and error-injected responses. Across HealthBench, HealthBench Professional, and LiveMedBench, our clinically relevant hallucinations are missed by rubrics, often leaving scores unchanged. We find that rubrics are most effective when explicitly checking facts, and are less effective for additional or unexpected errors they do not anticipate. A preliminary retrieval-based factuality check recovers some of the rubric-blind errors, suggesting a complementary approach. These findings reveal systematic blind spots in current medical evaluation of LLMs and suggest that rubric scores alone are insufficient to establish clinical reliability, potentially undermining clinician trust and confidence in clinical deployment.

As Large Language Models (LLMs) advance toward open-ended autonomous agents, the mechanisms used to evaluate and guide their behavior must evolve accordingly. This work introduces the rubric as a unifying framework capturing this evolution, characterizing rubrics as a dynamic response to successive LLM paradigm shifts that recurs across otherwise independent efforts in evaluation, reinforcement learning, and safety alignment. We define rubrics as explicit criteria sets that transform complex quality judgments into structured and actionable standards, and demonstrate that their recurrence across these research threads is not coincidental. We systematically organize existing rubric designs, examine their construction and optimization, and analyze their role across evaluation and training. Rubrics manifest at three progressively deeper levels: at the evaluative level, they decompose holistic judgments into verifiable dimensions; at the training level, they serve as dense feedback signals providing process-level guidance where scalar rewards fall short; at the intrinsic level, they emerge dynamically from model behaviors, driving self-improvement. We further assess rubric reliability across generation quality, execution fidelity, theoretical constraints, and security threats, before surveying rubric-based benchmarks across diverse domains. By rendering assessment transparent and decomposable, rubrics translate human value expectations into machine-learnable signals, serving as the enduring bridge between human intentions and machine behavior.