AdaPCLA: Adaptive Prior-Calibrated Logit Adjustment for Long-Tailed Longitudinal EHR Generation

Autoregressive foundation models for electronic health records (EHRs) typically inherit pretraining methods from language modeling, where patient trajectories are concatenated into a single token stream and windows are sampled from that stream. In EHR data, this choice is consequential: windows may mix multiple patients, and patients with longer records contribute more optimization updates, potentially introducing bias. We propose Patient Sampling, a pretraining sequence-construction method that allows us to control how training signal is distributed across patients. We compare this method to the standard approach, which we refer to as Global Stream. We show that stochastic Patient Sampling with controllable weighting improves performance on real-world EHR data. Across downstream clinical tasks on MIMIC-IV v2.2 and v3.1, Patient Sampling improves Macro AUROC and AUPRC over the Global Stream baseline. These results identify training and validation sequence construction as important and underexplored design choices for autoregressive EHR foundation models.

The generation of high-fidelity synthetic Electronic Health Records (EHR) is crucial for advancing medical research while preserving patient privacy. However, head-to-head comparison of existing generative models is hindered by disjointed codebases, incompatible data loaders, conflicting library dependencies, and inconsistent evaluation protocols. To address these gaps, we introduce a lightweight, end-to-end benchmarking framework for reproducible synthetic EHR evaluation, organized as a unified pipeline spanning data ingestion, standardized model training, and architecture-agnostic evaluation. Our current implementation targets the generation of longitudinal ICD diagnosis codes -- the most commonly studied modality in this literature -- and is built on the community-maintained PyHealth library. We reimplement and unify strong baselines (MedGAN, CorGAN, PromptEHR, HALO) under full ICD-9 vocabulary granularity, and add a lightweight GPT-2 baseline from the general-purpose sequence-modeling literature. We contribute a rigorous, architecture-agnostic privacy-utility evaluation suite that applies identically to GAN- and transformer-based generators, and report bootstrapped confidence intervals across all metrics. We further analyze the poor long-tailed performance of existing models and discuss the extensibility of our framework beyond diagnosis codes. By lowering the engineering barrier to running, extending, and evaluating under a single pipeline, we introduce a starting point for community-driven reproducibility and benchmarking synthetic EHR models.

Synthetic Electronic Health Record (EHR) generation provides a promising avenue for data augmentation and cross-hospital modeling in privacy-constrained healthcare settings. However, most existing EHR generative models are centralized and require pooling data across hospitals, which is often infeasible when real-world data sharing is restricted. While federated EHR generation offers a natural solution, direct federated modeling often collapses or diverges due to the high dimensionality, sparsity, and cross-hospital heterogeneity of EHR data. In this work, we propose FedEHR-Gen, the first federated framework for synthetic time-series EHR generation across distributed hospitals. FedEHR-Gen uses a two-stage learning paradigm. First, we introduce a federated autoencoder that projects high-dimensional and sparse EHR features onto a compact latent space. To ensure semantic consistency across hospitals, we develop a layer-wise matching aggregation mechanism that aligns local encoders into a unified global latent space. Second, operating on this aligned latent space, we train a federated temporal conditional variational autoencoder (TCVAE) with distribution-aware aggregation, enabling stable temporal generative modeling under severe cross-hospital heterogeneity. Extensive experiments on the eICU and MIMIC-III datasets demonstrate that FedEHR-Gen achieves generation fidelity, downstream utility, and privacy risk comparable to centralized training, while consistently outperforming the standard federated baseline.