Auditable Clinical Timeline Reconstruction with Provenance-Aware Evidence Graphs

Clinical language models increasingly operate over electronic health records (EHRs), yet patient records are not stored as temporally grounded trajectories. Clinical notes describe symptoms, assessments, and disease progression, but often compress or narratively reorder events. Structured EHR rows provide timestamps for labs, medications, vitals, and procedures, but capture only part of the clinical story. We formulate clinical timeline reconstruction as retrieval-augmented temporal grounding: constructing a patient trajectory by using narrative text for event semantics and structured rows as partial temporal evidence. We introduce a scaffolded workflow that extracts central narrative events, builds an initial temporal scaffold, attaches non-central events, and calibrates timestamps using retrieved structured EHR rows. We evaluate on 40 discharge summaries, including 15 i2b2-derived and 25 MIMIC-IV summaries, each with manual gold-standard timelines and aligned structured EHR data. Across models, multimodal calibration left event match rates largely unchanged and generally improved temporal performance: mean paired case-level multimodal-unimodal differences were positive in 7 of 12 model-metric comparisons across concordance and AULTC, with none negative. However, uncertainty was substantial given the 40-case sample; paired case-level bootstrap intervals excluded zero only for the DeepSeek V3.2 AULTC improvement. A gap analysis shows that 35.1% of text-derived events have no structured counterpart. These findings support treating structured EHR data as partial temporal evidence for narrative-derived patient trajectories.

Clinical timelines support treatment-window analysis and leakage-free modeling, but discharge summaries often obscure chronology and structured EHR tables describe only part of the patient course. We present a UID-preserving framework that links each narrative event occurrence to its source span and retains that identity through text-only estimation, structured-evidence retrieval, timestamped source-row grounding, and joint revision. We also present GAVEL, an LLM judge that compares two UID-aligned timelines against the narrative and structured record, to augment prior matching and temporal assessments. Across six open-weight models and 40 mixed-critical-care summaries, the GLM 5.2 multimodal revision, as compared to its text-only variant, improved temporal agreement without reducing event recovery and performed competitively with clinician annotations, while other model revisions showed smaller gains and lower overall performance. Ablations showed that UIDs primarily preserve event retention, whereas source-row linkage supports temporal placement. Blinded human review upheld most GAVEL findings, and controlled adjudication favored multimodal over text-only GLM 5.2 but did not for DeepSeek V3.2. In developing the UID and judge pipeline, we are able to demonstrate 43% increased event recovery, a framework competitive with clinician annotations, and a system with occurrence-level provenance for both reconstruction and evaluation.

Frontier large language models generate clinically accurate outputs, but their citations are often fabricated. We term this the Provenance Gap. We tested five frontier LLMs across 36 clinician-validated scenarios for three rare neuromuscular disease pairs. No model produced a clinically relevant PubMed identifier without prompting. When explicitly asked to cite, the best model achieved 15.3% relevant PMIDs; the majority resolved to real publications in unrelated fields. We present HEG-TKG (Hierarchical Evidence-Grounded Temporal Knowledge Graphs), a system that grounds clinical claims in temporal knowledge graphs built from 4,512 PubMed records and curated sources with quality-tier stratification and 1,280 disease-trajectory milestones. In a controlled three-arm comparison using the same synthesis model, HEG-TKG matches baseline clinical feature coverage while achieving 100% evidence verifiability with 203 inline citations. Guideline-RAG, given overlapping source documents as raw text, produces zero verifiable citations. LLM judges cannot distinguish fabricated from verified citations without PubMed audit data. Independent clinician evaluation confirms the verifiability advantage (Cohen's d = 1.81, p < 0.001) with no degradation on safety or completeness. A counterfactual experiment shows 80% resistance to injected clinical errors with 100% detectability via citation trace. The system deploys on-premise via open-source models so patient data never leaves institutional infrastructure.