A Patient World Model for Early Forecasting of Digital Health Campaign Outcomes: Capabilities and Limits

Digital medicine now captures data that traces individual health trajectories and reveals population health dynamics through electronic health records, claims, remote monitoring, wearable devices, mobile devices, social sensing data, medical images, etc. But much of its modeling still centers on task-specific, outcome-specific, and prediction-specific estimation. The next frontier is not simply better prediction, but action in an evolving health world shaped by multiple decision-makers, heterogeneous populations, resource constraints, and feedback in care delivery. This is why digital medicine now needs world models: not only to estimate what will happen, but to represent how actions change what can happen next -- whom to prioritize, how to allocate scarce resources, how to adapt care across subgroups, and how interventions reshape future health trajectories and population dynamics. We call such a model population health world model (PHWM): a more foundational representation of an evolving health world in which health states, individual trajectories, population health dynamics, interventions, constraints, and feedback are intrinsically coupled. Building a PHWM endows three unmet structural gaps in current digital medicine: dynamic health-state modeling, population-level intervention intelligence, and validation, equity, and governance for action-oriented use. We argue that addressing these gaps requires three minimal capabilities: representation learning under action-dependent observation, multi-scale intervention intelligence, and validation with explicit decision boundaries, while highlighting the importance of social, contextual, and public-health sensing data for action-oriented digital medicine.

Patient world models are increasingly proposed for longitudinal prediction, intervention-aware reasoning, and clinical-trial simulation. Causal or clinical intervention validity is distinct from predictive generalization and reliability; before making stronger claims, the underlying predictive state should generalize across patients, survive realistic shifts and missing observations, and expose failure through meaningful reliability signals. We evaluate these prerequisites in a deliberately narrow setting: short-horizon digital-biomarker forecasting from PhysioNet GaitPDB, comprising 165 participants, 306 recordings, and 51,129 context-future pairs. Using persistence, ridge, MLP, GRU, Transformer, and a compact JEPA-style predictor, we build an evaluation ladder that progressively removes raw temporal overlap, same-recording familiarity, and same-patient familiarity before testing unseen-patient generalization. For GRU, NMSE rises from 0.1227 under random-window splitting to 0.1393 after eliminating raw train-test overlap and to 0.1961 under patient holdout. Among 54 participants with repeated recordings, exposure to a different recording from the same patient improves GRU NMSE from 0.2177 to 0.1556, while a recording-excluded identity hypothesis is not supported at the participant level. Under participant-held-out evaluation, MLP and Transformer are statistically indistinguishable. Study shift, a four-times-longer prediction gap, and partial observation further degrade performance; under 50% temporal masking, Transformer NMSE rises to 0.611 while MC-dropout predictive variance falls. We do not claim a longitudinal or intervention-aware simulator. Instead, the results support a prerequisite evaluation stack of patient separation, repeated-measure controls, shift, missingness, and uncertainty validation before stronger patient-world-model claims are trusted.

Longitudinal models forecast how a patient's imaging state evolves, but accuracy does not show whether the patient's observed trajectory drives the prediction. A population-average forecast may be useful but cannot establish a patient-specific world-model claim. We introduce Patient, Place, Prior (P$^3$), an audit asking whether a forecast benefits from the patient's longitudinal imaging history (Patient), benefits from patient-matched externally supplied spatial support (Place), and gains predictive value beyond a population-average prediction under matched support and context (Prior). We also propose Cancer JEPA, a one-step model that forecasts frozen representations of future breast dynamic contrast-enhanced MRI examinations during neoadjuvant therapy. It adds a lesion-constrained neural correction, trained with an occlusion-based latent objective, to a patient-conditioned low-complexity reduced-rank regression baseline. This factorization permits a post-hoc P$^3$ audit of the frozen model. In a validation cohort previously used in development, forecast error is lower when the neural correction receives the patient's history rather than another patient's and patient-matched lesion occupancy maps rather than substituted maps. However, the descriptive 95% interval comparing the correction computed from patient history with the population-average neural correction includes zero. P$^3$ thus separates input use from evidence of patient-specific predictive value beyond a population-level pattern.