RAG-TRACE: Tracing Measurement Evidence and Diagnostic Completeness in AI-Generated ECG Reports

Electrocardiography (ECG) is one of the most widely used non-invasive tools for diagnosing cardiovascular disease, but transforming multi-lead ECG recordings into reliable clinical reports remains challenging. Automating ECG report generation could reduce clinicians' interpretive workload, improve diagnostic efficiency, and expand access to cardiac assessment in underserved communities. Unlike image-based report-generation tasks, ECG interpretation requires the analysis of subtle temporal morphologies, followed by coherent diagnostic reasoning expressed in dense clinical terminology. Existing systems predominantly focus on classification, while current report-generation methods often produce outputs that remain inadequate for practical clinical use. To address these challenges, we propose ECG-LENS, an end-to-end ECG report-generation framework that jointly integrates multi-lead signal modeling, diagnosis-aware representations, and clinically grounded text generation. ECG-LENS combines lead-wise encoders that preserve localized waveform morphology with a global encoder that captures inter-lead dependencies. To guide report generation, we fuse signal representations with clinically enriched textual prompts that condition a GPT-2 decoder. We further introduce an ECG-specific report-preprocessing strategy that helps the model focus on clinically meaningful findings. Finally, because lexical metrics may under- or overestimate report quality, we propose F1-ECGBERT, a BERT-based, ECG-specific metric that measures agreement between diagnostic labels extracted from generated and reference reports. In-domain experiments on PTB-XL and cross-domain evaluation on MIMIC-IV-ECG show that ECG-LENS consistently outperforms state-of-the-art methods, with absolute gains of 4.0%, 6.3%, and 11.5% in METEOR, ROUGE-L, and F1-ECGBERT, respectively, over the strongest baselines.

Retrieval-augmented generation is an attractive way to improve chest X-ray reporting, because reports from similar prior studies supply clinical context a general vision-language model lacks. We show the same mechanism is a reliable source of clinical error. Over 100 MIMIC-CXR studies with a frozen LLaVA-1.5 generator and BioMedCLIP retrieval, CheXbert clinical F1 doubles under relevant retrieval (0.201 to 0.402) and collapses to 0.043 under clinically mismatched retrieval, a fifth of the image-only score; the retrieval-induced hallucination rate, counting only unsupported findings traceable to retrieved evidence, rises from 0.00 to 0.76 and 0.98. To show this is not an artefact of evidence-set coverage, we introduce a coincidental-overlap control that scores image-only generations against evidence they never saw, placing the chance base rate at 0.18, four to five times below the observed rates. The generator does not merely acquire findings, it transcribes text: 95% of reports produced under relevant retrieval contain an eight-word span occurring verbatim in the retrieved evidence but absent from the reference, against 0% without retrieval. We then explain the mechanism: a normal chest X-ray retrieves at least one abnormal precedent in 24 of 28 cases, because medical image-embedding similarity is dominated by anatomy and acquisition rather than by the presence of disease. This has a direct design consequence. Retrieval similarity does not predict harm (RIH rates 0.80/0.80/0.60/0.84 across similarity quartiles), so relevance gates conditioned on embedding similarity cannot work; gating on predicted pathology agreement removes 61% of unsupported evidence at no cost to useful coverage. We argue that retrieval-augmented clinical systems must be evaluated under retrieval failure, not only under retrieval success.

Existing ECG report generation is tightly coupled -- interpretation and reporting fused end-to-end, so errors propagate without stage-level recourse -- while agent-based systems decouple tasks but remain single-pass, never revisiting earlier outputs. Clinical ECG reporting instead unfolds iteratively, requiring progressive context integration and bidirectional editing. We present ATRIA, a multi-agent ECG reporting system that mirrors the clinician's iterative workflow: it binds every report claim to its supporting evidence, flags statements unsupported by that evidence, incorporates additional context mid-session, and lets clinicians verify and revise individual findings rather than accept one opaque output. Because its agents use ECG analysis models already in clinical use, the underlying findings are clinically trustworthy; and as a cloud-based web service, ATRIA is ready for immediate deployment. We demonstrate ATRIA through four interaction cases, with a live demo and video available.