Clinical AI in EHR

Thoracic pathologies rarely occur in isolation, yet standard multi-label classifiers rely on shared global descriptors, discarding \emph{where} findings lie and \emph{how} they co-occur. We propose \textbf{C$\mathbf{^2}$A} (Co-occurrence Aware Class Attention), a classification head that explicitly couples spatial evidence with clinical priors. First, C$^2$A casts pooling as an expectation over learned per-class spatial attention maps, yielding localized descriptors for each disease. Second, it couples these descriptors via a learnable graph warm-started from empirical label co-occurrence. A single residual message-passing step shares evidence among related findings, proving to be a bounded perturbation of the identity where co-occurrence enters each logit through an explicit bilinear interaction. On CheXpert, C$^2$A achieves a superior $0.895$ macro-mean AUROC, outperforming advanced context-gating baselines. Crucially, gains concentrate on highly co-occurrent classes with ambiguous spatial evidence (rescuing Atelectasis by $+1.5$ over GCG), demonstrating the prior's regularizing effect with a negligible overhead of one linear projection and a $C\!\times\!C$ edge matrix.

Retinal fundus images frequently exhibit multiple co-occurring pathologies, yet standard deep learning classifiers apply static, identical computation to every image regardless of the underlying disease distribution. We propose a novel architecture that resolves this via sparse conditional computation, pairing a Guided Context Gating (GCG) spatial attention front-end with a sparsely-routed Mixture-of-Experts (MoE) block operating over feature tokens. Crucially, this routing yields an interpretable, data-driven decomposition. Expert allocation is significantly disease-dependent (p < 0.001), with the healthy Normal state and morphologically distinct pathologies (e.g., ERM, AMD) isolating to dedicated experts. On a five-class, patient-disjoint 5-fold cross-validation benchmark, our model achieves 0.912 +/- 0.008 macro AUC and 0.653 +/- 0.014 macro F1. Furthermore, Grad-CAM++ and post-MoE t-SNE visualizations confirm that expert routing aligns with localized lesions and geometrically maps co-occurring cases between their constituent clusters, positioning sparse MoE as an interpretable approach to multi-disease retinal screening.

Reranking medical procedures against patient queries is a critical component of health insurance information retrieval, complicated by a substantial lexical gap between patient language and clinical nomenclature. We present a systematic comparison of two reranking paradigms for this production task: (1) small cross-encoders (MedCPT, MiniLM-L12) fine-tuned with listwise learning-to-rank objectives across layer freezing configurations, and (2) Qwen3-Reranker-4B, a 4B-parameter instruction reranker whose prompt is iteratively refined via an agentic optimization loop driven by GPT-4.1. On a purpose-built dataset of 2,647 queries across 708 insurance services, we find that a 109M-parameter cross-encoder fine-tuned with ListNet outperforms the 4B-parameter model by 2.6 percentage points on NDCG@3 and 13.3 points on Spearman correlation - at 37x fewer parameters. We report practical findings, a scalable LLM based dataset construction pipeline, and deployment trade-offs relevant to production reranking systems. We release our code and a sample dataset to support reproducibility and adaptation to other domains.

Cardiologists interpret electrocardiograms by localizing waveform components, measuring rhythm and interval patterns, and translating these structured observations into diagnostic evidence. Whether this expert reading process can serve as an effective prior for ECG agents remains unclear. To address this question, we introduce LuminaECG, a clinically structured ECG reasoning framework that reformulates ECG interpretation as measurement-grounded visual reading. ECG signals are rendered on standard electrocardiographic grid paper to preserve the spatial and scale cues used in clinical reading. P-wave, QRS-complex, and T-wave boundaries are explicitly delineated, and color-coded segmentation decomposes the waveform into discrete visual measurement primitives. A general 2B vision-language backbone is then trained with low-rank supervised fine-tuning to associate these primitives with diagnostic reasoning, without architectural modification. Across open, proprietary, and ECG-specialist zero-shot baselines, LuminaECG improves both waveform measurement and diagnostic recovery. It reaches a clinically meaningful reader tier on the CODE-test benchmark, transfers across geographically diverse ECG datasets without retraining, and generates reports whose structure contains an emergent prognostic signal. These findings suggest that effective ECG agents require not only larger models, but supervision that preserves the alignment between measurable waveform evidence and clinical knowledge.

Emergency-department (ED) triage requires clinicians to rapidly identify patients who need immediate attention, determine who can safely wait, and prioritize limited clinical resources. At presentation, however, information may be limited to a chief complaint and initial vital signs. Clinically important details, including symptom onset and progression, associated symptoms, medical history, and medication use, are often obtained through focused conversation. Effective triage therefore requires clinicians to identify information gaps, ask appropriate follow-up questions, and update their assessment as new evidence becomes available. Most existing ED benchmarks evaluate acuity prediction from a fixed clinical snapshot. Although this formulation measures predictive performance after patient information has been assembled, it does not capture the interactive process through which triage-relevant evidence is elicited and interpreted. Existing medical dialogue datasets support the study of clinical communication, but dialogue statements are not always linked to temporally ordered events in the electronic health record (EHR). We introduce EHR2Dial-Triage, an agentic conversation-generation framework and benchmark grounded in MIMIC-IV-ED. The framework constructs triage conversations under explicit role-based and temporal information boundaries. Each accepted patient disclosure is linked to its supporting EHR event and the first dialogue turn at which it becomes available. EHR2Dial-Triage enables controlled evaluation of information elicitation, evidence use, five-level Emergency Severity Index prediction, and patient-facing communication across models and patient personas. It provides a structured setting for studying conversational triage as a dynamic process of clinical information acquisition, reasoning, and communication.

Neuroimaging and genetic testing are two important clinical references for nervous system diseases, offering complementary diagnostic information. However, integrating genomic and neuroimaging data for precise disease diagnosis is challenging due to cross-modality heterogeneity. Existing imaging-genetics approaches mainly encode genetic information as hard-coded labels, which lose the local sequence context around disease-associated variants. To address this limitation, we propose GeneFuse, a multimodal learning framework that aligns genetic representations from pre-trained Genomic Language Models (GLMs) with features extracted from images. GeneFuse integrates two components: (1) Genotype-Conditioned Feature Modulation (GCFM), a FiLM-inspired module that uses genomic embeddings to modulate image feature maps; and (2) Uncertainty-aware Genomic Residual Fusion (U-GRF), a fusion strategy that uses imaging-derived predictive uncertainty to gate the contribution of genotypic features. We evaluate GeneFuse on early cognitive decline identification (NC vs. MCI) and dementia screening (NC vs. AD). In the APOE-centered setting, GeneFuse achieves AUROCs of 0.77 and 0.83, outperforming existing imaging-genetics fusion methods. These results indicate that GLM-derived genomic embeddings provide additional information to imaging.

Perioperative risk prediction models are often limited by narrow surgical populations, incomplete intraoperative data, poor calibration, and limited interpretability. We present a domain-structured ensemble framework for perioperative outcome prediction using routinely collected electronic health record (EHR) data. Predictors are organized into patient-related, surgery-related, and anesthetics-related domains. Domain-specific gradient boosting models generate independent risk estimates that are integrated through a logistic regression meta-learner. We demonstrate the framework using postoperative delirium (POD) in a case-control sample of 5,386 surgical encounters (2,693 cases, 2,693 controls) from a statewide health information exchange. POD required both delirium-related ICD codes and a positive Confusion Assessment Method screening within seven postoperative days; patients with preexisting dementia were excluded. The stacked meta-learner achieved AUROC 0.899 (95% CI: 0.891-0.906), precision-recall AUC 0.881, and Brier score 0.126, compared with AUROC 0.849 for the best single-stage model. Domain ablation showed improved discrimination and calibration over a surgery-only model (AUROC 0.879, Brier 0.140). Temporal validation on held-out post-2017 data yielded AUROC 0.915. Calibration was excellent, with intercept -0.006 (95% CI: -0.083 to 0.070) and slope 1.035 (95% CI: 0.982 to 1.088). Decision curve analysis, corrected for case-control sampling, showed positive net benefit across clinically plausible thresholds. The modular framework supports alternative outcomes, extension of predictor domains, and dynamic risk updating, providing a scalable foundation for interpretable, calibration-aware perioperative clinical decision support.

Imaging device downtime is a major barrier to healthcare delivery in low- and middle-income countries (LMICs), often driven by limited access to specialized biomedical engineering support. We present a multi-modality medical equipment maintenance question-answering (QA) framework and demonstrate the fine-tuning of a medical foundation model for specialized technical troubleshooting tasks. Guided by a multi-country survey across nine LMICs, we curated technical manuals from MRI and ultrasound systems to generate the INGENZI_DatasetV1, containing 10,294 high-quality, filtered QA-context pairs. Using QLoRA-based parameter-efficient fine-tuning, we adapted the MedGemma-4b-it model to interpret system error logs and generate step-by-step equipment repair instructions. Compared to the baseline model, the fine-tuned system achieved substantial improvements across metrics, including F1 score (0.22 to 0.38), ROUGE-2 (0.18 to 0.41), and BERTScore F1 (0.86 to 0.91). These metric gains demonstrate that the model generates significantly more precise and procedurally accurate technical responses to new troubleshooting queries. This work establishes a reliable foundation for AI-assisted diagnostic and maintenance tools in resource-constrained settings.

Many modern AI systems analyze conversational traces to infer aspects of human interaction and state, implicitly assuming that such information is recoverable from conversation. We study observability: whether a target is recoverable from conversational transcripts alone. Observability is difficult to assess because transcripts may provide only a partial view of many targets, and large-scale analysis requires model-based annotation, making true limits of the conversational signal hard to distinguish from annotator error. We therefore study clinical encounters, where patient-reported outcome measures (PROMs) provide an external anchor for patient state, and visits follow broadly structured patterns. We study observability of patient state and conversational phase structure using 439 real-world clinical encounter transcripts spanning 134 hours, including 245 ENT transcripts paired with 273 PROM surveys. We operationalize patient state using PROM scores for voice, cough, and swallowing; phase structure using conversational phase segmentation. To make these analyses credible at scale, we use a PHI-compliant GPT-5 deployment for transcript annotation and conduct 40 hours of manual validation, reducing the risk that apparent limits of observability simply reflect annotator error. Our core finding is an observability asymmetry: phase structure is observable and useful for characterizing clinical encounter organization, while patient state is only partially observable, even in a setting designed to elicit patient symptoms and experiences, cautioning against transcript-only inference of human state.

Objective. Healthcare IT is usually organized by the technologies it adopts. We instead organize it by the unit of information a system makes computable, and describe a computational layer whose object is patient-specific clinical intent. Approach. We give criteria for a computational layer, derive three (record, clinical state, and a proposed layer of intent), and formalize the Actionable Clinical Record (ACR) as the atomic object of the third layer. Discussion. The framework distinguishes prescribed, observed, and intended process; existing standards represent intent once it is structured but do not recover it from natural communication, the capability we localize. The ACR is complementary to FHIR workflow resources, guidelines, and process mining; a companion feasibility study illustrates tractability for one narrow subproblem. Conclusion. Computable clinical intent is a coherent research direction; the ACR, its readiness ladder, and an executable-correctness evaluation framework are reusable constructs for subsequent work to extend, evaluate, or falsify.

Prospective daily symptom tracking is central to premenstrual health assessment, but repeated ordinal forms impose substantial response burden. We formulate conversational administration as an ordinal label-recovery problem: the system actively elicits a small set of symptom clusters and maps each response to the original severity labels. We used 3,320 complete participant-days from the mcPHASES dataset, covering cramps, mood swing, fatigue, sleep issues, stress, and bloating on a six-level scale. Six participants were reserved for development and 36 for a frozen evaluation comprising 360 participant-days and 2,160 item labels. A ModernBERT evidence gate detected whether a symptom was expressed, and Qwen2.5-1.5B-Instruct produced deterministic structured severity scores. Fixed six-item questioning achieved a quadratic weighted kappa of 0.976, whereas three joint symptom-cluster questions achieved 0.913, 97.45% agreement within one severity level, and 80.94% recall for moderate-or-higher symptoms while reducing questions by 50%. Open-first adaptive policies required 3.92-5.98 questions and produced lower agreement than the corresponding fixed policies. Participant-cluster bootstrap analysis estimated a kappa difference of -0.062 (95% CI -0.076 to -0.048) between the three-cluster and six-item strategies. Active cluster-level elicitation provides a direct, local-model route from natural conversation to reusable daily symptom labels.

Reinforcement learning (RL) seeks to optimize sequential decisions to maximize population-level benefits over time. However, when deployed in high-stakes settings such as healthcare, RL decisions might systematically restrict some subpopulation's access to valuable services in a manner contrary to the values and goals of stakeholders. Counterfactual fairness (CF) offers a promising framework to address this problem based on causal reasoning. This paper develops a data preprocessing algorithm that, when used in tandem with policy learning, enables CF in RL. Our algorithm relies on a novel quantile distribution mapping method for sequentially estimating the counterfactual states and rewards in the data preprocessing step, subsuming common additivity assumptions used for counterfactual prediction as a special case. We theoretically prove that the per-step level of counterfactual unfairness and infinite-horizon suboptimality gap can be bounded under mild regularity conditions. We also empirically test our algorithm in numerical experiments as well as in application to a real-world interventional digital health dataset.

Despite significant advances in Medical Report Generation (MRG), the reliability remains constrained by the prevalence of factual errors. While Direct Preference Optimization (DPO) has emerged as a promising post-training paradigm to enhance the performance of Supervised Fine-Tuned (SFT) MRG models, existing DPO-based MRG methods typically adopt a naive preference construction that directly pairs model-generated reports with ground truth reports. This strategy inadvertently entangles critical clinical findings with clinically irrelevant linguistic characteristics, and fundamentally lacks explicit vision-language alignment. To address these challenges, we propose DPO-Clin, a novel post-training framework that focuses preference optimization on clinical findings and cross-modal alignment. First, we introduce the Entity-level Clinical Diagnostic (ECD) module to perform a precise entity-level factual diagnosis. ECD guides the generation of linguistically-aligned report preference pairs, isolating clinical discrepancies from linguistic variations. Second, to achieve fine-grained cross-modal alignment, we develop M2DPO, a retrieval-augmented multi-modal DPO variant that enforces textual preference inversion triggered by visual context switches. Third, we locate correct yet highly uncertain predicted entities and apply counterfactual modifications to construct targeted preference data for latent risk mitigation, thereby further enhancing the model reliability. Extensive experiments on two public chest X-ray datasets (MIMIC-CXR and IU X-Ray) and an in-house endoscopy dataset demonstrate that DPO-Clin significantly improves the SFT baselines on clinical-aware metrics. Furthermore, it achieves superior performance over existing DPO-based MRG methods, exhibiting robust generalizability across distinct baseline architectures and diverse medical imaging modalities.

Medical Visual Question Answering (VQA) requires aligning subtle visual evidence, including lesion texture, boundary sharpness, and diffuse density changes, with clinical language. Existing multimodal fusion approaches operating in the spatial domain may not fully exploit complementary frequency information present in visual and textual representations. We introduce a dual-branch frequency-domain fusion module that conditions spectral filtering on the input question, enabling adaptive selection of global low-frequency structure and fine-grained high-frequency detail before reconstructing the spatial representation for answer generation. To provide a richer spectrum for filtering, we extract complementary features from early texture-sensitive and final semantic layers of a frozen BiomedCLIP encoder and align both with the question representation using a symmetric InfoNCE objective prior to staged joint training with a BioBART decoder. We pretrain the proposed model on PMC-VQA and fine-tune it on the VQA-RAD and SLAKE benchmarks, demonstrating that frequency-aware multimodal fusion improves medical VQA performance while maintaining a lightweight and efficient architecture.

General-purpose wearable foundation models are pretrained on broad sensor streams and populations, but their representations are not organized around women's health. FemWear is a women's wearable foundation model, obtained by parameter-efficiently repurposing a pretrained general multimodal wearable backbone into a specialized representation for women's health. It keeps the pretrained patch projection and Transformer encoder frozen and trains 239,236 encoder parameters - 1.11% of a 21.54M-parameter encoder - through low-rank residual adapters and causal task-family heads, producing one shared longitudinal representation for menstrual, symptom, affective, sleep/recovery, autonomic, activity, and pregnancy outcomes. We evaluate six cohorts with 63 comparable primary metrics, 33 from women's-health cohorts, while retaining the 32-task OpenMHC ability-retention benchmark. On a fixed participant split over three seeds, FemWear improved cycle-phase macro-F1 by 8.15% and reduced mean absolute error for cramps, mood symptoms, and sleep problems by 9.32%, 5.80%, and 9.43%; 24-hour onset AUPRC decreased by 3.40%. A stricter 42-participant nested leave-one-participant-out audit retained positive changes for 24-hour onset (+2.87%), 72-hour onset (+6.35%), and cramps (+2.19%), while phase, mood, and sleep changes were neutral or negative and no endpoint had a strictly positive corrected confidence interval. Capacity-matched experiments beat a latest-day multilayer perceptron but not shared-GRU or multi-gate mixture-of-experts baselines. Train-only calibration reduced onset expected calibration error by 84.2-88.2% with zero temporal-nesting violations. FemWear is therefore a women's wearable foundation model: a reproducible, parameter-efficient specialization delivering targeted transfer across women's-health tasks and coherent probability outputs.

Large language models perform strongly on medical knowledge benchmarks, but reliable clinical deployment requires agents to conduct defensible investigations over heterogeneous, longitudinal records: determining what evidence is needed, retrieving and reconciling structured and free-text data, grounding conclusions in verifiable evidence, and deferring cases that cannot be resolved reliably. We introduce CliniCARE-Bench (Clinical Calibrated Audit of Medical Reasoning in EHR), a benchmark for retrospective clinical audit: 25 clinician-validated scenarios instantiated as 750 patient-specific cases over real-patient-derived MIMIC-IV data. Systems investigate each case through a governed, logged tool environment for record retrieval, computation, and policy access, and return one of four verdicts---Yes, No, Indeterminate: Lack of Data, or Indeterminate: Medically Ambiguous---the last two separating missing evidence from residual medical ambiguity. Beyond verdict accuracy, we score patient-evidence and policy grounding, process adherence, calibrated abstention, reliability, and efficiency against case-level reference verdicts produced by independent multi-model adjudication and calibrated against Clinical Board review. Every retrieval, computation, and report is replayable, so the investigation trace is inspectable and scorable. To our knowledge, CliniCARE-Bench is the first deployment-oriented clinical-agent benchmark to jointly evaluate real longitudinal EHR investigation, claim-level evidence grounding, governing-policy use, process adherence, and calibrated abstention within a common patient-level adjudication framework. Across 16 agentic systems, four-way accuracy spans 65.3-76.1%, but raw accuracy overstates investigation quality. Defect-free accuracy, which credits a verdict only when correct and free of prohibited shortcuts, is 4.8-14.8 points lower and reorders the leaderboard.

Clinical foundation models trained on large-scale patient data are increasingly used for decision support, screening, and public health planning. As deployment expands, privacy risk arises from model-mediated leakage, yet its prevalence and severity remain poorly quantified. Models can disclose sensitive training artifacts, enabling patient re-identification in ways not captured by data-handling controls alone. As a result, existing frameworks, including HIPAA and GDPR, offer limited protection against assessing and addressing. We propose a practical framework for assessing privacy risk in clinical foundation models, illustrate realistic leakage scenarios across deployment settings, map them to legal regimes, and outline complementary technical and legal mitigations. Our analysis provides a context-aware risk assessment grounded in realistic usage to preserve the value of medical foundation models while rigorously safeguarding patient privacy.

In medical education, physicians convert academic knowledge into clinical expertise through residency: years of training across thousands of encounters, with diverse sources of feedback and progressively greater autonomy. Much of clinical reasoning relies on the patient encounter, a dialogue in which a clinician elicits history, refines diagnostic hypotheses, and decides management under uncertainty. While large language models (LLMs) excel on static medical benchmarks, methods to optimize the full sequence of clinical decisions remain underdeveloped. We present ResidencyRL, a reinforcement learning (RL) method for training clinical artificial intelligence (AI) agents through simulated multi-turn clinical encounters (up to 60 dialogue turns and 8 tool calls per trajectory). ResidencyRL pairs the policy agent with LLM simulators capable of complex, adversarial behaviors, training against a structured reward aligned to diagnostic accuracy, management quality, communication, documentation, and safety. On held-out evaluations, the ResidencyRL agent improves diagnostic accuracy by 7.0% under adversarial conditions (88.0% vs. 81.0%) and reduces missed red flag rates by 31%, demonstrating rigorous mitigation of premature closure. Blinded expert clinicians validated these gains, preferring the trained agent in 87.6% of side-by-side comparisons. The procedural competencies transfer to unseen benchmarks: the agent outperforms the base model across all six clinical axes of the AMIE multi-visit benchmark, and shows consistent directional improvements on AgentClinic and CRAFT-MD. Our findings demonstrate that sequential clinical decision-making can be effectively learned through multi-turn RL in simulation, yielding robust, generalizable capabilities, paving the way towards clinical mastery. Prospective validation with real-world workflows remains necessary to establish clinical utility.

Foundation models have shown strong transferability in cardiac MRI (CMR), but their effectiveness for heterogeneous multi-view and multi-sequence CMR analysis remains unclear. In this work, we explore the effectiveness of fine-tuning and combining different CMR foundation models for the Universal Multi-Sequence, Multi-Center and Multi-View CMR Segmentation (CMR-Multi) Challenge. CineMA was fine-tuned for cine and late gadolinium enhancement (LGE) segmentation across short-axis and long-axis views. For direct left-ventricular ejection fraction (LVEF) estimation, we used two recent frozen CMR foundation models to extract embedding vectors that were then combined using attention-based multiple-instance learning for LVEF regression. In the challenge validation set, cine segmentation achieved Dice scores of 0.862, 0.883, and 0.902 for short-axis, two-chamber and four-chamber cine MRI, respectively. LGE segmentation achieved Dice scores between 0.621 and 0.846 across views. The direct LVEF regression model achieved an MAE of 4.96 percentage points and a Pearson correlation of 0.91. These results indicate that foundation models can be effectively adapted and combined for multi-view CMR analysis, while accurate LGE scar segmentation remains a challenging task.

Systematic reviews of Randomised Controlled Trials (RCTs) are routinely used as evidence for clinical care guidelines. Such evidence has to meet high research integrity standards to prevent low quality or false research outputs influencing the clinical care. However, assessing research integrity of published RCTs is a complex process requiring manual effort, and potentially resulting in diverse opinions of the human assessors. This paper describes INSPECT-AI, an LLM-based interactive tool that assists human reviewers with research integrity assessments of published RCTs based on the community approved INSPECT-SR framework, and the Research Integrity Provenance and Evidence ontology (RIPE-O) for documenting the provenance of the assessment process. In addition, we present the Research Integrity Provenance and Evidence knowledge graph (RIPE-KG), an initial set of 140 expert research integrity assessments of 95 RCT publications generated by INSPECT-AI and described using RIPE-O.

Hospitals are racing to embed AI, while coping with the surge in adaptation of the technology in other industries, into the triage management, documentation, scheduling, and revenue-cycle workflows, yet most deployments remain as fragmented pilots that stall at the edge of production, exposing patients and institutions to operational fragility, ungoverned risk, and mounting technical debt. At the same time, the global AI-in-healthcare market is projected to exceed nearly USD 1 trillion by 2034, according to the report of Fortune Business Insights, amplifying the financial consequences of architectural missteps and failed scaling strategies. This research proposes a compliance-first Agentic AI pattern catalogue and orchestration framework, purposely built for HIMS, moving beyond the single LLM chatbots and towards a governed ecosystem of autonomous and semi-autonomous agents. The framework extends by adding (i) a taxonomy of Agentic roles, (ii) a formal risk-stratification model that maps each pattern to risk tiers, human-in-the-loop checkpoints, and governance hooks, and (iii) a unified orchestration runtime capable of coordinating multi-agent workflows across EHR/HIMS landscapes such as Epic, Cerner, and MEDITECH. Technically the framework combines vLLM-based inference, optimized paging memory, confidential computing, and MCP based on-premise deployment, enforcing end-to-end encryption and policy-as-code controls aligned with HIPAA, GDPR, the EU AI Act, India's DPDP and DISHA Acts, ISO 27001, ISO 27002, ISO 14971 and IEC 62304. We exhibit how the proposed architecture is capable and efficient to reduce the documentation time, integration effort, and AI pilot attrition while constricting the governance and auditability, offering hospital leaders and governing authorities an urgently needed blueprint to convert AI investment into sustainable clinical, operational, and financial ROI

Electronic health record (EHR) feature engineering is a major bottleneck in clinical research and AI, accounting for 39-45% of data scientists' workload. This is especially pronounced in heart failure, which affects an estimated 6.7 million U.S. adults and requires integrating fragmented EHR data with disease-specific, guideline-based clinical reasoning. Existing rule-based and large language model (LLM)-based approaches offer only partial automation with limited maintainability and evidence traceability. We developed the Nimblemind Multi-Agent System (nMAS), an evidence-linked, rubric-grounded pipeline for automated heart-failure feature engineering, and evaluated it on 500 dummy patient records from nine EHR source tables. nMAS generated 132 structured and 70 rubric-scored aggregated features, verified for structural integrity, rubric compliance, and provenance, and audited by a restricted LLM. Adding the aggregated features improved held-out AUROC from 0.895 to 0.963 for HFrEF and 0.870 to 0.910 for HFpEF phenotyping, and an independent LLM-based rubric assessment of evidence support and methodological soundness scored the features at 81.5% of maximum points. These results demonstrate the feasibility of automated, auditable feature engineering for complex cardiovascular EHR data, though evaluation was limited to a single-institution cohort and external validation is needed.

Cardiac arrest remains one of the most lethal conditions encountered in intensive care units. Despite the growing availability of electronic health record data, existing mortality prediction studies in this population largely depend on static summaries derived from early admission. Such approaches ignore the temporal progression of physiological deterioration and recovery that unfolds throughout a patient's ICU stay. To address this limitation, we introduce QuanTiMedAI, a quantum-agentic framework developed for cardiac arrest mortality prediction using agentic AI guided quantum enhancement time series model. The proposed system combines an agentic large language model (LLM) for clinically informed feature discovery with a compact quantum recurrent network for temporality aware mortality prediction. Our findings demonstrate that agentic LLM-guided feature selection consistently outperforms conventional feature selection approaches, and the proposed quantum architecture achieves competitive predictive performance through nonlinear feature enhancement while keeping the number of parameters very low. Through extensive experimentation on a MIMIC-IV cohort of cardiac arrest patients, QuanTiMedAI's quantum-enhanced architecture attains an AUROC of 0.852 using only 605 parameters, an improvement of approximately 2.9% over a current state-of-the-art baseline for this task. A structured ablation study systematically validates the contribution of each architectural design choice. These results show that quantum-enhanced sequential modeling can exceed classical recurrent networks while using substantially fewer parameters.

Oral health issues affect billions globally, but the cost and limited access to professional dental care hinder preventive oral healthcare. Research relies on clinical-grade radiographs or intraoral camera images, unavailable for public self-screening. This study introduces a tooth localisation and numbering model for smartphone photographs. We developed a customised Mask Region-based Convolutional Neural Network (Mask R-CNN) pipeline trained on 1,272 annotated smartphone images. To address variability in patient-generated health data, the pipeline incorporates two domain-informed mechanisms: a masked gray-world white-balancing algorithm to mitigate artificial colour casts and an anatomically constrained detection layer to enforce structural validity and suppress false positives. Evaluation comprised four stages: internal held-out testing, independent external testing, a descriptive ablation study, and fold-based training stability analysis using the same internal test set. On the internal test set, the model achieved an instance-mask AP@50 of 0.818, class-aware PQ of 0.780, and operational F1 of 0.884. Training stability showed limited between-model variation: across ten runs, instance-mask AP@50 had a standard deviation of 0.009. On the external dataset, the model achieved an instance-mask AP@50 of 0.901, class-aware PQ of 0.832, and operational F1 of 0.928 despite differences in population, sensors, and acquisition protocols. The inference pipeline is available as an open-source, containerised API. These results demonstrate that consumer-grade smartphone imagery can support automated tooth-level anatomical mapping, offering a scalable, potentially low-cost foundation for remote screening and tele-dentistry in resource-constrained environments.

Metabolomics knowledge is distributed across heterogeneous resources and remains difficult to translate into predictive representations. We developed MetaboLLM, a metabolomics-specialized large language model adapted through continual pretraining, supervised fine-tuning, and structured retrieval, together with MetaboLLM-GIN, which converts generated biochemical descriptions into metabolite graphs for patient-level prediction using a graph isomorphism network. Across four backbone families, MetaboLLM outperformed corresponding base and medically adapted models on metabolomics knowledge, relational, and description tasks, and transferred to an external public benchmark. MetaboLLM-GIN achieved the highest AUC for stress hyperglycemia prediction after coronary artery bypass grafting (0.8616) and postmenopausal hormone-regimen classification (0.8123), outperforming conventional models, alternative graph constructions, and graphs generated from unadapted or non-retrieval LLM configurations. Model interpretation further produced biologically meaningful findings in both applications. These results show that domain-specialized language models can organize heterogeneous biochemical knowledge into predictive and interpretable metabolite graph representations.

We present a schema-based framework for extracting complex, structured information from unstructured text documents using generative AI, followed by automated semantic evaluation of the extracted information against a gold standard. The schema, serving as an information model encoding domain knowledge, provides a unified, systematic, and consistent framework for extraction of hierarchical, nested information, with attributes of variable cardinality, and subsequent evaluation of the results. Information extraction from a document is performed in a single call to the model, in zero-shot mode. In the evaluation step, we introduce a path-based semantic matching algorithm to align the nested, variable-cardinality attributes in the extracted results with those in the gold standard. We use generative AI for semantic comparison of the extracted and gold standard values of an attribute, and introduce a rubric to classify the result of the comparison, according to domain-specific considerations, as an exact, semantic, useful, or non-match. We were able to extract 12 out of 14 attributes with an F1 score of $>$90% from documents published by the health technology assessment organisation NICE, using the generative AI model Claude Opus 3. The time needed to extract the attributes from a document was $\sim$30 times lower than the time taken by a human domain expert. We further demonstrate generalisability of this framework across different generative AI models and transferability across different HTA organisations and languages.

An adequate diagnostic quality of radiographs is essential for reliable diagnoses and treatment planning. The patient's pose during radiography is one of the most important factors determining the diagnostic quality. Since patient positioning is difficult and not standardized, an automated AI-based approach using depth images to automatically assess the patient's pose before the radiograph has been taken would be helpful. Due to regulatory hurdles, however, it is difficult in practice to acquire the required depth images and corresponding radiographs. In this paper, we present a framework that can generate such training data synthetically from Computed Tomography scans. We further show that by pretraining on our generated synthetic dataset consisting of 3077 image pairs of upper ankle joints, the pose assessment of real upper ankle joints can be improved by up to 11 percentage points.

Hospitals are rapidly adopting artificial intelligence for triage, imaging, scheduling etc., yet most deployments remain isolated point solutions locked inside departmental silos, resulting in duplicated effort, hidden risks, and unrealized enterprise value. Despite explosive growth of AI in healthcare market and accelerating investment, an estimated 70-80% of healthcare AI pilots fail to scale, largely due to governance gaps, fragmented data, and missing integration blueprints. This research proposes a hospital-specific, compliance-first, Agentic AI architecture with multiple interoperable layers, extending existing hospital AI platform models with: (i) an Agent Orchestration Layer for multi-agent workflows across clinical, operational, and financial domains, (ii) a Compliance and Policy Layer that centralizes policy-as-code for HIPAA, GDPR, the EU AI Act, DISHA Act, India's DPDP Act, and ISO/IEC security and safety standards, and (iii) a Privacy-Preserving Data Fabric that plugs federated learning, differential privacy, and secure enclaves into real-world Hospital Information Management System (HIMS) flows. Using a synthetic but structurally realistic hospital dataset and an open, ready-to-deploy prototype implementation, this study demonstrates the end-to-end orchestration of triage risk prediction, workflow optimization, and compliance logging, achieving substantial simulated reductions in task turnaround times and manual documentation effort while maintaining policy-guarded data access. The resulting architecture offers hospital leaders a pragmatic blueprint to move from ad hoc tools to a governed, globally compliant, ROI-focused AI platform that can be tailored to on-premise, hybrid and cloud-native deployments.

This paper presents ECHO (Enhanced Care & Health Observer), a locally-deployable conversational health assistant for long-term chronic care management. ECHO integrates three complementary software modules developed under shared supervision as a unified system. The core module is an agentic chatbot built on a ReAct loop orchestrated via LangGraph, equipped with 17 clinical tools and a temporal knowledge graph for persistent cross-session memory; it achieves a 94.9% tool-execution pass rate across a 59-scenario benchmark with GPT-5 Mini. A two-stage hybrid safety layer intercepts all incoming queries: a rule-based layer handles explicit crisis signals and jailbreak attempts in under 1ms, while a signed graph neural network (GNN) with APPNP-style propagation classifies boundary cases by clinical intent, achieving 88.8% accuracy and 90.6% unsafe recall on a 2,537-query annotated Turkish health dataset while outperforming zero-shot LLM baselines including Llama 3.3 70B. A multimodal speech assessment module combining Whisper acoustic encoding and BERT text encoding with cross-attention fusion estimates emotion, depression, and pain, reaching a mean macro F1 of 0.652. The full system is implemented as a web application that can run entirely on consumer hardware, with no patient data transmitted to external services, supporting compliance with GDPR and KVKK.

Much clinical value is conveyed not through structured records but through communication: exchanges in which patients describe symptoms, clinicians reason and give instructions, ambulances hand over to emergency departments, and nurses pass on a shift. Such language differs from tabular data because meaning depends on speaker role, intent, causality, uncertainty, omission, and channel noise. Healthcare natural language processing must therefore interpret information as conveyed rather than coded. This requires well-annotated corpora, which are scarce because authentic exchanges are private, fragmented, and costly to annotate. Large language models offer a way forward by transforming clinical sources, such as records, diagnostic labels, symptom lists, or care plans, into written and transcribed communication for downstream models. We present a structured narrative survey organized by source representation, communication form and participants, generation method, and downstream task, complemented by thirteen novel case studies. These build clinical NLP systems for communication channels and languages without labeled real-world data, including EMS pre-arrival reports, field-radio casualty documentation, nurse handoffs, patient-portal triage, and low-resource discharge communication. They show that synthetic communication can bootstrap such systems. Findings include the competitiveness of fine-tuned encoder models over evaluated zero-shot baselines and the value of deliberately degraded communication for robustness. The main limitation is that most studies evaluate on held-out synthetic communication, while train-on-synthetic, test-on-authentic evidence remains limited. We conclude that syn-thetic clinical communication is becoming a practical research resource; establishing it as reusable clinical infrastructure will require authentic-data transfer, safety and external validation.

Inadequate target--disease linkage accounts for 40--50% of PhaseII efficacy failures, so anticipating which programmes will advance would let sponsors back the hypotheses most likely to reach patients. What a programme can be judged on is the evidence that supported its linkage \emph{when it entered the clinic}. No existing biomedical knowledge graph allows that evidence profile to be assembled as of a past date. We present the Temporal Heterogeneous Biomedical Knowledge Graph (THBKG), which describes and predicts therapeutic target--disease links through time: 110,396 entities and 11.1M edges across nineteen relation types, each edge carrying the year its evidence changed, so a pair's profile can be recovered as it stood when its own decision fell due. On this graph we define a decision-aligned benchmark that predicts, for a target--disease pair entering PhaseII, whether it advances to Phase~III on evidence datable before that decision. Graph propagation over the THBKG outranks every direct-evidence reference scored under the same decision-aligned protocol, reaching a relative success of 4.3--4.5 at the top ten pairs per therapeutic area. The gain concentrates on the 72.8% of pairs with no direct target--disease evidence at their decision point, where a direct-edge model has nothing to read: the encoders still rank five- to sixfold above chance, recovering the signal by propagating over the intervening biology. Adapting a path-based explainer to the decision-time subgraph decomposes each prediction into the evidence landscape behind the hypothesis for explainable prediction. We release the THBKG as a continually updated substrate for studying therapeutic target hypotheses by retrospective validation.

Medical images are routinely de-identified---names, dates, and other metadata removed---and then shared for research, teaching, and public benchmarks under the assumption that this renders them anonymous. Such de-identification protects the metadata but not the pixels, and---apart from scans that directly contain facial structures---whether the image content itself identifies the patient has received little scrutiny. We investigate this question by learning a cycle-consistent correspondence between a cross-sectional medical image and a non-medical, patient-identifying image, using a pair of coupled, cycle-consistent variational autoencoders. From a held-out scan, the model recovers a recognisable likeness of the patient (identity-region MAE = 0.163); conversely, it synthesises a scan from such an image. These results indicate that a de-identified medical scan remains identifying---it is, in effect, a photograph of the patient---and that imaging data should be governed as biometric data rather than as anonymisable records. To support reproducibility, the code and trained models are shared at https://github.com/attilasimko/public-repository.

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.

Computed tomography (CT) is widely used for clinical diagnosis and longitudinal follow-up, yet automatically generating accurate and complete radiology reports from three-dimensional (3D) CT remains challenging. Existing methods improve fine-grained correspondence between images and text by modeling anatomical regions, but remain centered on the current examination. Consequently, patient-specific longitudinal changes within individual regions remain insufficiently modeled. Meanwhile, interval changes are often distributed across multiple anatomical regions, complicating a coherent assessment of the overall longitudinal state. We propose Anatomically Localized Temporal Evidence Representation (ALTER) to address these limitations. Global Prior Integration (GPI) incorporates the prior CT and report to establish historical context for the current examination. Regional Proxy Differencing (RPD) enables each current anatomical region to retrieve a historical proxy from a single shared encoding of the prior volume and to derive localized interval evidence. Interval Change Fusion (ICF) further combines current abnormality states with region-distributed differences, converting their joint representation into change-aware soft prompts that guide report generation. ALTER achieves state-of-the-art results on most evaluation metrics across the RadGenome-ChestCT validation and CTRG-Chest-548K test sets. Code and data preprocessing details are available at https://github.com/peytonkarlie/ALTER/tree/main.

As large language models (LLMs) enter high-stakes domains such as healthcare, understanding their moral reasoning becomes essential. Decisions about scarce medical resources often hinge on judgments of responsibility, particularly when patients' own actions contribute to illness. We investigate how LLMs reason about responsibility and its consequences, tracing their judgments across successive levels, from the behavior, to the resulting illness, to the denial of care. We evaluate a wide range of LLMs, spanning different model families and capability levels, on various clinical vignettes adapted from prior studies. Our results identify a judgment-consequence gap: LLMs largely agree with humans that patients bear responsibility for health-harming behaviors, yet overwhelmingly refuse to let that judgment influence how they allocate scarce resources. Specifically, LLMs default to random allocation, whereas humans consistently favor the less-culpable patient. Compared to humans, LLMs also place greater emphasis on access to information, reducing responsibility judgments when health-risk knowledge is unavailable. These findings reveal that LLMs apply a systematically different moral framework than humans when responsibility and resource scarcity intersect, surprisingly often amplifying normative disagreement with humans as reasoning capability increases.

Learning from Electronic Health Records (EHRs) has gained significant attention due to its potential to improve clinical prediction. However, effective learning remains challenging because EHRs encode heterogeneous, temporally ordered clinical interactions. In particular, EHRs contain: (i) heterogeneous clinical entities, including patients, visits, diagnoses, prescriptions, and procedures, together with their heterogeneous interactions, (ii) longitudinal patient trajectories across hospital visits and (iii) shared statistical dependencies across related clinical prediction tasks. Existing EHR learning methods capture only a subset of these properties. To bridge this gap, we propose Multi-task Graph transformer for Heterogeneous Temporal EHRs (MiGHT-EHR), which jointly models all three within a unified representation learning method. MiGHT-EHR constructs a heterogeneous graph from EHRs in which nodes represent clinical entities and edges connect statistically associated entities identified via normalized point-wise mutual information. Across MIMIC-III and MIMIC-IV datasets, MiGHT-EHR outperforms state-of-the-art methods on average across four tasks: drug recommendation, prediction of length-of-stay, mortality, and readmission, with particularly strong improvements in mortality and readmission prediction. Furthermore, a post-hoc analysis of the learned representations reveals that patient neighborhoods are organized by clinical outcomes, salient medical concepts are recoverable as linear directions in the representation space, and task probabilities are well calibrated. Collectively, these findings demonstrate that MiGHT-EHR representations support diverse prediction tasks while preserving clinically interpretable structure.

CASCADE is an agentic framework that predicts downstream transcriptional effects of gene perturbation from precomputed ARACNe regulatory networks, exposed via MCP. Prior work validates such tools by checking whether predicted genes are known cancer genes (membership); we instead test whether the predicted direction of change matches reality, using focal-gene copy-number amplification as a dosage-based proxy for the inverse of knockdown against real TCGA patient tumor data. For MYC, CASCADE's predicted knockdown targets show strong concordance with real amplified-vs-non-amplified tumor expression across three cancer types (BRCA: 90.0%, COAD: 72.0%, STAD: 85.7%; all p<0.0013), well above permutation baselines, surviving a PAM50 subtype control and replicating in an independent cohort (METABRIC, 87.2%). Compared against curated MSigDB gene-set baselines via Fisher's exact test, CASCADE's accuracy is not shown to exceed existing public knowledge of MYC- or E2F-driven biology, though its gene-specific direction-calling clearly outperforms a naive uniform guess. Extending to fifteen additional genes, validation proves gene-specific rather than universal: proliferation-machinery regulators mostly replicate, while lineage-identity transcription factors and one cyclin-D paralog (CCND2) consistently fail, a pattern we discuss as a hedged, post-hoc hypothesis. We separately benchmark whether an LLM-based agent correctly grounds natural-language requests into CASCADE's real MCP tool calls. Across 35 queries, a documented local model reaches 71.4% exact match (85.7% for a larger model); schema and gene-alias failures are resolved by scale or server-side correction, but both models confidently default to the wrong perturbation type on ambiguous queries, a failure a targeted fix could not resolve because its trigger condition never occurs.

Synthetic generation of Cognitive Behavioral Therapy (CBT) sessions is challenged by two competing demands: adhering to strict therapeutic structure while modeling the resistant, unpredictable behavior of real patients. Existing script-based methods fail to capture dynamic therapeutic interactions, while multi-agent approaches struggle to adhere to CBT's sequential structure; both suffer from sycophancy, producing overly compliant patients that misrepresent real clinical settings. In this work we introduce ODRA, a novel framework for synthesizing therapy dialogues through a Chain-of-Thought (CoT) strategy grounded in foundational CBT guidelines (Beck, 2020). ODRA further incorporates a resistance orchestrator to solve patient sycophancy, which employs steering techniques to elicit behaviors aligned with their resistance level. Automated and expert evaluations show that ODRA significantly outperforms existing methods across therapeutic skills, CBT alignment, and patient behavioral fidelity, with licensed psychologists preferring ODRA sessions across 12 of 13 clinical metrics. Furthermore, models fine-tuned on our dataset demonstrate superior therapeutic performance against both cooperative and resistant patients, validating that explicit resistance modeling in synthetic training data directly translates to downstream clinical robustness.

Background: Respiratory specialty care requires multimodal interpretation, longitudinal risk assessment, guideline-concordant intervention, and whole-course management, which are poorly represented by examination-oriented medical benchmarks. Objective: To develop RESPClinBench, a real-world scenario-based benchmark for respiratory clinical decision-making, and evaluate seven contemporary large language models across AECOPD-PIM and PNBIM. Methods: RESPClinBench cases were adapted from de-identified respiratory clinical data. Three attending-level respiratory physicians revised cases, reference answers, and atomic clinical-action points, while one senior respiratory specialist performed cross-review and final adjudication. AECOPD-PIM comprised 427 open-ended COPD cases, and PNBIM comprised 196 multimodal pulmonary nodule cases combining chest CT with structured clinical information. Seven models generated 4,361 responses through standardized API inference with temperature 0 and a maximum output length of 8192 tokens. An automated framework calculated the final score as the arithmetic mean of atomic-action recall and rubric-based LLM-as-a-Judge assessment. Results: Across 623 cases, the mean final score was 68.58. Qwen3.6-27B ranked first overall at 71.22, Qwen3.5-397B-A17B led PNBIM at 72.48, and Qwen3.6-27B led AECOPD-PIM at 71.11. Imaging hallucination and serious medical risk occurred in 31.85% and 8.16% of PNBIM responses; medication-safety risk and serious medical risk occurred in 26.93% and 1.44% of AECOPD-PIM responses. Conclusions: RESPClinBench identifies task-specific limitations in multimodal pulmonary nodule assessment and longitudinal COPD management. Combining explicit clinical-action coverage, holistic evaluation, and independent safety flags provides a clinically grounded basis for model selection and prospective validation.

Memory-efficient matrix optimizers such as Sinkhorn gradient descent remove most AdamW optimizer state for dense Transformer matrices, but direct application to Mixture-of-Experts (MoE) training is unreliable. We study this failure in a controlled 110M-parameter nanowhale DeepSeek-style MoE pretraining setting. A SAGE/Sinkhorn hybrid reduces optimizer state from 0.883GB to 0.331GB but degrades evaluation loss to 3.8265, far above the AdamW baselines observed in the same setup (3.58--3.64 across the seeds we study). We show that routed MoE expert matrices are the dominant failure point: their gradients are conditional, temporally varying, and poorly served by stateless Sinkhorn normalization. We propose MESH, a hidden-momentum Sinkhorn update for MoE experts. MESH restores a temporal first-moment signal through the gradient-buffer lifecycle, without storing the expert first moment as optimizer state. MESH is an optional block-preconditioned variant that adds a coarse neuron/block inverse-RMS multiplier. Across ablations, temporal smoothing before matrix normalization is the primary causal ingredient; block/neuron preconditioning can improve the memory-quality frontier, but is not established as universally necessary. In two additional seeds, MESH and MESH-B reduce optimizer-state memory by 62.5% and peak PyTorch CUDA allocation by about 12.6% relative to AdamW, with a modest evaluation-loss gap. Full-state diagnostic variants recover AdamW-like performance in ablations, supporting the conclusion that MoE experts need temporal smoothing, but not necessarily full coordinate-wise AdamW state.

Language models (LMs) offer strong textual representations for electronic health records (EHRs), but they encode patient sequences in isolation and provide limited explainability. Graph neural networks (GNNs) complement LMs by incorporating inter-patient relationships and enabling reference-patient attribution, yet they rely on high-quality patient representations. We propose Patients-like-me (PLM), a unified LM--GNN framework that integrates local patient semantics with global cohort structure. To train PLM efficiently, we introduce a Variational Expectation-Maximization algorithm that alternates LM and GNN updates under a supervised variational objective. Extensive experiments on MIMIC-III and MIMIC-IV show that PLM consistently outperforms state-of-the-art methods, with improvements generalizing across encoder-only and decoder-only LM backbones. These gains are achieved with only modest additional computational overhead. PLM also provides reference-patient explanations by retrieving influential similar patients, while edge-masking experiments confirm that the highest-ranked references have the greatest impact on model predictions.

Feature selection is a critical step in electronic health record (EHR)-based predictive modeling, where input variables are often high-dimensional, sparse, noisy, and redundant. Large feature sets not only increase computational burden and overfitting risk, but also make model interpretation difficult, leading to limited usefulness in clinical settings. In this study, we focus on diagnosis-related features and compare five feature selection paradigms for opioid use disorder (OUD) prediction: recurrence enrichment, NTK-motivated early gradient sensitivity, LightGBM-SHAP, Elastic Net, and large language model (LLM)-guided semantic selection. We use a unified preprocessing and evaluation framework and assess each method by downstream predictive performance, resampling stability, and representation of infrequent diagnosis codes. Our results demonstrate that performance improves with larger feature budgets with diminishing returns beyond a moderate size. NTK sensitivity provides the best overall balance of accuracy and stability, and LLM-guided selection contributes complementary clinically meaningful signals despite lower standalone performance.

Emergency triage requires reliable decisions within a short time period. However, the available electronic health record (EHR) data, including structured data and clinical text, are often incomplete, unreliable, and inconsistent. This makes machine learning (ML)-based triage prediction more challenging, as existing ML models typically rely on complete and reliable EHR data to accurately predict patients' acuity levels. To address this, we propose confidence- and reliability-aware selective triage (CRS-Triage) to predict patients' acuity levels with a confidence score. By comparing the confidence score with a predefined threshold, CRS-Triage can selectively determine whether the model should make the decision or defer the case. Specifically, CRS-Triage separately evaluates the reliability of structured data and clinical text and then jointly considers the consistency between the two modalities to estimate the confidence of each prediction. Moreover, to reduce the risk of missing high-acuity patients, namely under-triage, CRS-Triage prefers to assign patients slightly higher acuity levels, namely over-triage, by penalizing under-triage errors. Experiments on the MIMIC-IV-ED dataset show that CRS-Triage achieves strong predictive performance. It also provides a better risk-coverage trade-off and remains reliable when the available EHR data are incomplete, degraded, or inconsistent across modalities.

Skin lesion classification plays an important role in supporting the early diagnosis of skin cancer. However, automated analysis remains challenging due to class imbalance, inter-class similarity, and intra-class variability in dermoscopic images. This paper proposes a multimodal classification framework that combines Swin Transformer-based image features with structured clinical metadata to improve diagnostic performance through integrated visual-context learning. Experiments on a publicly available dataset show that the proposed model achieves a test accuracy of 92.55% and a macro F1-score of 91.33%, with strong performance across minority classes. Temperature scaling is applied as a post-hoc calibration method, resulting in a reduction in expected calibration error and improving prediction reliability, while uncertainty estimation is incorporated to further assess the confidence of model predictions. Qualitative explainability analysis further shows that the model focuses on lesion regions during inference. Therefore, the results demonstrate that multimodal fusion, combined with calibration and interpretability analysis, provides an effective and trustworthy approach for automated skin lesion classification.

Clinical decision support is moving toward committees of language-model agents deliberating on a shared workspace. We ask whether such committees can be gamed by shortcuts, cues a benchmark rewards but a clinician would ignore. Across seven cohorts on six public datasets spanning text (MedQA-USMLE, MedMCQA, MIMIC-CXR reports), imaging (NIH ChestX-ray14, MIMIC-CXR-JPG, CheXpert) and tabular ICU records (SUPPORT2), Gemini committees resist these cues in isolation (flip 5-16%), yet a socially plausible shortcut spreads: when two peers assert the same wrong answer, the holdout under test adopts it in 38% of cases, as does a false "pre-screen" system flag, on both capability tiers. Of three oversight agents, a gate cannot separate adoption from honest agreement (false-positive rate 100%); a same-lineage judge reading only the transcript flags adoption on text (precision 100%, recall 93%) but collapses onto the gate in imaging; a referee that privately re-queries the holdout transfers to imaging (77-88% precision, 13-21% false-positive rate). Tripling a cue's visual salience does not move contagion, whereas a second peer voice raises it by half again. Gaming a hidden rubric is near-silent: only 1/10 text and 1/134 imaging drifters name the rubric they moved toward. What games a committee is social plausibility, and only a referee independent of self-report catches it. Code: https://github.com/criticaldata/benchmaxxing

Patient-facing medical LLMs and agents increasingly answer symptom questions before clinician contact, where the key safety question is what action the user should take next. We introduce CARE-Bench, a source-grounded benchmark that evaluates sequential patient-facing triage as a four-label per-turn current-action task. CARE-Bench contains 500 cases and 1,059 evaluated patient-disclosure prefixes reconstructed from medical dialogue, consultation, and follow-up-question sources. We evaluate 11 models on 269 held-out rounds under unprompted and minimally prompted open-ended protocols, using a fixed GPT-5.5 mapper to code each response into the four-label action space. Unprompted macro-F1 remains low, ranging from 31.2 to 50.4. Prompting improves 10 of 11 models, with prompted macro-F1 ranging from 46.9 to 63.4, but substantial threshold errors remain. Prompted models often recommend care before needed clarification is obtained; when the correct action was to ask for more information, only 33.5% of prompted outputs preserved the step. The persistence of these errors after prompting suggests that patient-facing triage is not a simple prompting problem and supports explicit evaluation of action timing before deployment.

Point-of-care cardiac devices such as smartwatches and handheld ECG recorders typically capture 1--2 leads, yet existing ECG foundation models are architecturally constrained to fixed 12-lead inputs, degrading or failing under these reduced configurations. We introduce LAEF (Lead-Agnostic ECG Foundation), a 7M-parameter ECG foundation model that can natively process any lead subset without zero-padding or architectural modification. LAEF represents ECGs as variable-size spatiotemporal graphs with physiologically motivated intra- and inter-lead connectivity, processed by a Graph Attention Network that scales naturally with active lead count.Pre-trained on 9.2M 12-lead ECGs via masked node modelling with stochastic lead sampling, LAEF learns representations robust to lead configuration. Across 18 downstream datasets, LAEF is on par with specialized 12-lead baselines over 12$\times$ larger at full lead availability. Under direct point-of-care-oriented diagnostics (1--2 leads), it outperforms all zero-padded alternatives on 17 out of 18 datasets with with a single randomly sampled lead and on 14 out of 18 with 2 leads, with an average AUROC gain of +3.2 points. Representation analysis links this advantage to architectural lead-agnosticism, and a lead-importance study across 164 cardiovascular conditions shows population-level performance is stable across single standard input leads while still recovering established clinically lead-condition associations.

Citation excerpts can be used to increase the reliability of generated outputs and their faithfulness to cited sources, which is especially important in high-stakes domains such as human and veterinary medicine. However, this does not guarantee that generated claims are faithful to the provided excerpts. We present VetScore, a multi-step evaluation method for veterinary long-form question answering, designed to assess how well are generated claims supported by the provided excerpts, weighing this information by each claim's harm potential. VetScore first segments the output and decomposes it into individual claims, then scores each claim with respect to its harm potential and evaluates its faithfulness to source excerpts, and finally calculates the overall risk-adjusted score. We collect an expert-annotated meta-evaluation dataset, evaluate our approach with a range of judge models, and show that it achieves high correlations with veterinary experts even with small judge models, while offering explainability across multiple dimensions.

Causal diagnostic models must explain how conclusions follow from evidence because diagnoses guide repairs and treatments. Yet serious cases are scarce, records rarely contain reasoning paths, and data transfer poorly across configurations, complicating local deployment. We present DiagLoop, a counterfactual data flywheel that converts codified physical relations or clinical guidelines, authored once per mechanism family, into training supervision beyond recorded cases. A training-only teacher proposes counterfactual worlds by varying causes, contexts, and observations, while an independent hybrid checker admits only valid worlds. The student reasons through symptom abstraction, causal-chain construction, and root-cause attribution. Stage-specific criteria identify its earliest failure. For nonterminal failures, a bounded repair probes downstream competence, and the resulting weakness profile guides subsequent data generation. Stage-localized reinforcement learning updates only the model-generated continuation, while replay and preservation reduce forgetting. The same criteria govern admission, attribution, reward, and regeneration through checks separate from the proposer. Using only synthesized scenarios and no case-level expert reasoning annotations, the resulting 8B model improves strict path correctness over the strongest conventional baseline. Gains are 11.6 points across eight industrial systems and 5.5 points across ten disease categories. Gains over a deranged-routing control are 3.9 and 2.3 points, respectively. The model also exceeds the evaluated proprietary references in both domains, even when they receive few-shot examples or the specification in context.

Adaptive conformal prediction can recover clinically important heartbeat classes missed by a point classifier, but delayed feedback makes its decisions sensitive to event order. We introduce ConformalShift, a bounded event-reordering attack that suppresses the ventricular class for rescued events without modifying ECG waveforms, labels, classifier scores, or the event multiset. ConformalShift searches for feasible permutations of authentic preceding events that lower the ventricular threshold before a selected target is evaluated. On disjoint MIT--BIH confirmation records, the attack suppressed 66.7% of eligible targets for Extra Trees and 60.0% for HistGradientBoosting, compared with random-schedule rates of 4.4% and 12.0%, respectively. Transferred configurations also outperformed random scheduling on INCART, while reducing the displacement budget weakened the attack on both datasets. These results show that adaptive monitors in healthcare can be compromised through the timing of authentic information, even when waveforms, labels, classifier outputs, and event contents remain unchanged.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with increased risks of stroke, heart failure, and mortality. Recent ECG foundation models offer transferable representations for automated AF detection. However, their relative effectiveness remains unclear because existing studies use different datasets, preprocessing procedures, classifiers, and validation protocols. This study presents FOUND-AF, a unified, leakage-controlled, and deployment-oriented benchmarking framework that evaluates the quality of pretrained ECG representations under identical experimental conditions. Nine publicly available foundation models from five families, including HuBERT-ECG, CLEF, ST-MEM, ECG-JEPA, and ECGFounder, were evaluated across four heterogeneous ECG datasets, namely AFDB, CinC2017, CPSC2021, and LTAFDB. All models were used as frozen feature extractors with standardized preprocessing, model-native resampling, a fixed XGBoost classifier, and recording-level grouped cross-validation. The evaluation included classification metrics, receiver operating characteristic analysis, paired recording-level bootstrap comparisons with Holm correction, embedding-space visualization, and computational efficiency profiling. The ECGFounder model consistently achieved the strongest overall performance across datasets while offering a favorable trade-off between accuracy, model size, inference time, and memory usage. FOUND-AF therefore provides a reproducible framework for selecting ECG foundation models and demonstrates that compact, clinically pretrained encoders can support robust and computationally efficient AF detection across heterogeneous acquisition settings.

Federated Learning (FL) enables collaborative model training across distributed healthcare institutions without centralising sensitive patient data. However, real-world healthcare federations are often characterised not only by non-IID data, but also by heterogeneous clinical objectives and partially overlapping feature spaces. Different hospitals may optimise distinct and potentially conflicting objectives, such as mortality risk prediction, readmission reduction, or length-of-stay estimation, while also retaining institution-specific clinical features that cannot be shared with other participants. Existing personalised FL methods mainly address statistical heterogeneity, whereas multi-objective FL approaches typically learn a shared global model without explicit client-level adaptation. To address these limitations, we propose \textbf{FedCARE}, a multi-objective personalised FL framework for smart healthcare services. FedCARE follows a two-stage training strategy. First, it learns a shared global backbone from common clinical features using Pareto-driven multi-objective federated optimisation. Second, each client independently fine-tunes the shared backbone using its private features and local clinical objectives, enabling institution-specific personalisation without additional communication overhead. We implement FedCARE in a cloud-based client-server federated deployment on the Melbourne Research Cloud and evaluate it on two real-world healthcare datasets, MIMIC-III and Diabetes 130-US Hospitals. Experimental results show that FedCARE consistently outperforms standard FL, multi-objective FL, and personalised FL baselines, achieving up to 12.5% AUROC improvement and 32.0% MAE reduction over FedAvg.

Medical visual grounding connects free-form clinical queries to spatial evidence in medical images and is an important component of interpretable medical artificial intelligence. However, general-purpose grounding models are predominantly trained on natural images, while existing medical localization resources remain fragmented across imaging modalities, datasets, and task formulations. To address this gap, we construct LocAnyMed-200K, a multimodal medical visual grounding dataset containing approximately 200K image-query-answer examples across computed tomography, optical medical imaging, ultrasound, and X-ray. We harmonize heterogeneous detection and localization resources into a unified free-form instruction format that supports one or multiple bounding boxes, point coordinates, and no-target outputs for negative queries. Full-parameter fine-tuning of LocateAnything-3B on LocAnyMed-200K improves F1@IoU 0.50 from 10.64 to 85.59 on a held-out evaluation split, demonstrating that large-scale domain-specific supervision can equip a general grounding model with effective medical localization capabilities. Beyond spatial coordinates, a clinically interpretable grounding system should also communicate the evidence supporting its prediction. We therefore derive LocAnyMed-CoT-20K, a rationale-augmented subset that connects anatomical context, visual observations, and spatial conclusions through structured reasoning and further improves cross-source generalization through fine-tuning. Together, these resources provide a unified foundation for studying both localization accuracy and rationale quality across heterogeneous medical imaging modalities. The code is publicly available at https://github.com/MiliLab/LocAnyMed.

Multimodal learning has significantly advanced survival prediction by integrating pathology images with genomic data. However, clinical information, despite its critical role in reflecting a patient' s overall health, remains underutilized due to its discrete, sparse, and low-dimensional nature. Furthermore, the inherent heterogeneity across these modalities pose significant challenges in modeling cross-modal interactions. In this paper, we propose CIGTSurv, a Clinical Information Guided Tri-modal framework for Survival prediction. Specifically, we first design a holistic text template and use pretrained foundation models to transform clinical tabular data into high-dimensional tokenized embeddings. Using clinical information as an anchor, we then introduce a dual-level interaction mechanism: 1) a local prototype association (LPA) module based on cross-attention to explicitly learn token-level correspondences between different modalities, and 2) a global feature alignment (GFA) loss based on Maximum Mean Discrepancy (MMD) to implicitly enhance cross-modal distribution consistency. Extensive experiments on five TCGA cancer cohorts demonstrate that CIGTSurv achieves state-of-the-art (SOTA) survival prediction performance. Our source code is publicly available at https://github.com/Daijing-ai/CIGT-Surv.git.

Human-interpretable computer-aided diagnosis is crucial for clinical decision making. Concept-based models excel by providing transparent reasoning and enabling post-hoc, clinician-in-the-loop interventions. However, their rigid dataset-specific adaptation inherently restricts cross-site generalization. Applying them across diverse modalities, such as dermoscopic and clinical photographs, is challenging due to heterogeneous concept taxonomies varying in availability, granularity, and semantics across cohorts. Consequently, adapting Foundation Vision-Language Models (FVLMs) demands costly label engineering and repeated post-training. Existing intervention mechanisms remain rigidly tied to predefined concepts, lacking adaptability and hindering scalable dermatology CAD deployment. To address these bottlenecks, we propose UniCon, an open-linguistic unified concept learning framework for multimodal interpretable vision-language diagnosis. UniCon resolves these challenges through three contributions: (1) A shared semantic representation space via a unified concept prototype codebook, seamlessly coordinating heterogeneous concept systems across modalities without dataset-specific retraining. (2) Open-linguistic based multi-faceted semantic specifications to overcome sparse textual label limitations, improving boundary sensitivity in uncertain clinical contexts. (3) A robust, cross-site adjustable intervention interface powered by reliability-gated bottleneck aggregation, enabling consistent reasoning and transferable clinician corrections. Extensive experiments demonstrate that beyond securing top-tier diagnostic accuracy, UniCon successfully bridges disparate clinical taxonomies, unlocking unprecedented cross-site intervention capabilities. Code is available at https://github.com/wuchengyu123/UniCon.

Neuro-oncology decisions require coordinated interpretation of serial MRI, pathology, molecular markers, treatment history, performance status, and evolving guidelines. We present TumorBoard, a multi-agent decision-support system built around a shared longitudinal case state and an auditable claim-evidence ledger. Specialist agents for radiology, neuropathology, molecular diagnosis, guidelines, and therapy planning produce atomic claims with provenance. An adversarial critic exposes contradictions, and a safety governor releases, qualifies, or defers recommendations according to evidence sufficiency and temporal validity. On a 360-case hidden benchmark at a matched token budget, TumorBoard achieved an action F1 of 0.772 and evidence entailment of 0.914. It exceeded the strongest typed-council baseline by 3.1 percentage points (95% CI: 1.6 to 4.7, adjusted p = 0.0012), while recommendation-to-evidence coverage reached 0.927. Under evidence deletion, the system deferred 84.2% of unsafe cases and limited harmful recommendations to 5.8%. The safety governor reduced harmful release by 7.8 percentage points at a false-deferral cost of 4.3 percentage points. Ablation studies of the ledger, critic, and governor produced the predicted failure patterns, establishing structured coordination as the source of the measured multi-agent advantage.

Multimodal medical large language models remain structurally weak for neuro-oncology because volumetric evidence is compressed into generic visual tokens and diagnostic conclusions often lack an auditable link to MRI regions. We present NeuroMosaic, a 3D multimodal language model that converts multi-sequence brain MRI into anatomy-indexed regional tokens, aligns them with clinical narrative and molecular concepts, and generates evidence-linked outputs. The architecture combines a multi-resolution volumetric tokenizer, a neuroanatomical graph router, a molecular concept memory, and selective risk control. Across four glioma cohorts, NeuroMosaic achieved an internal subtype macro-F1 of 0.827 and external macro-F1 values of 0.784, 0.761, and 0.742. On UPenn-GBM, it improved over the strongest matched-input baseline by 3.6 percentage points (95% CI: 1.8 to 5.4, adjusted p = 0.0018), with IDH, 1p/19q, and MGMT AUROCs of 0.918, 0.861, and 0.781. Evidence pointing accuracy reached 0.703, and targeted evidence deletion reduced correct-answer probability by 0.187, compared with 0.046 for random deletion. These results establish anatomy-indexed routing as a measurable mechanism for accurate, grounded, and calibrated volumetric medical-language reasoning.

Artificial intelligence (AI) is increasingly integrated into medical decision-making, yet its liability implications remain complex, particularly when physicians differ in diagnostic skills and their quality is unobservable. This paper develops a principal-agent model in which a social planner designs medical liability to regulate a physician with private quality information who chooses between a standard treatment, a personalized judgment-based treatment, or following an imperfect AI recommendation. Our analysis yields several novel insights. First, we show that the optimal mechanism under asymmetric information is surprisingly simple: a uniform, one-size-fits-all liability level for all physician types who deviate from the standard of care. Despite physician heterogeneity, this simple policy often achieves the full-information first-best outcome, particularly when standard care is reliable or AI is highly accurate. Second, the relationship between AI accuracy and optimal liability is non-monotonic. Contrary to common intuition, better AI does not always imply more relaxed liability. As AI accuracy increases, the optimal liability either decreases monotonically or follows an inverted-U pattern, depending on the uncertainty of the standard treatment. Third, asymmetric information does not universally reduce social welfare. Welfare loss arises only when standard care is unreliable and AI accuracy is too low; even then, its magnitude follows an inverted U-shape, initially increasing as AI complicates the regulatory problem, but declining as more accurate AI helps mitigate it. Finally, we find that information asymmetry is a double-edged sword in the presence of AI, and greater transparency does not benefit all stakeholders equally.

Multimodal large language models have demonstrated strong defect recognition capability in industrial anomaly detection. However, in lithography review, merely determining whether an image contains a defect is insufficient for engineering inspection; models must also understand defect morphology, spatial location, and the potential causes supported by visible evidence. To this end, this paper proposes LDU-Bench, a multi-task multimodal benchmark for lithography defect understanding. Constructed from real lithography and integrated-circuit review images, LDU-Bench decomposes the review workflow into four independent tasks: defect triage, morphology recognition, coarse localization, and image-conditioned cause analysis. It systematically evaluates models using task-level metrics, diagnostic readouts, and the Lithography Closure Score (LCS). Experimental results show that although existing MLLMs can perform defect triage relatively reliably, this ability does not stably transfer to downstream review stages. Morphology alignment, effective localization, and evidence-to-cause mapping remain the major bottlenecks. Further diagnostics indicate that this capability break is not a fluctuation of a single metric, but reflects insufficient structured understanding across semantic levels. Overall, LDU-Bench provides a quantifiable and diagnostic unified platform for evaluating the usability, failure points, and capability boundaries of industrial MLLMs in lithography review chains.

Electronic health record foundation models are limited by institutionally siloed data and substantial performance degradation under cross-site transfer. We evaluated federated training of tokenized generative event models (GEMs) across 122,251 intensive care hospitalizations from three independent health systems harmonized to the Common Longitudinal ICU Data Format. Models were assessed on 12 post-24-hour clinical prediction tasks using within-site, cross-site, centralized, and federated training configurations. GEMs achieved the highest mean within-site and cross-site ROC-AUC and were substantially more transportable than conventional supervised models: their average cross-site penalties were 0.025 ROC-AUC and 0.027 PR-AUC, compared with 0.079 and 0.089 for LightGBM. Federated Learning (FedAvg and FedAvgM) approached the performance of centralized GEM training, with most gains obtained within 5-10 communication rounds. However, centralized multi-site training provided only modest improvements over complete local training. Multi-site models were most useful when local training data were limited, with their advantage narrowing as institutional data accumulated. These findings show that federated GEM training is technically feasible and preserves most centralized performance, but that the main open challenge is learning transportable representations to translate larger, but heterogeneous data from multiple health systems into a reliable target-site benefit.