Paulius Mui

Aaryan Shah, Andrew Hines, Alexia Downs et al.

Objective. Clinical AI documentation systems require evaluation methodologies that are clinically valid, economically viable, and sensitive to iterative changes. Methods requiring expert review per scoring instance are too slow and expensive for safe, iterative deployment. We present a case-specific, clinician-authored rubric methodology for clinical AI evaluation and examine whether LLM-generated rubrics can approximate clinician agreement. Materials and Methods. Twenty clinicians authored 1,646 rubrics for 823 clinical cases (736 real-world, 87 synthetic) across primary care, psychiatry, oncology, and behavioral health. Each rubric was validated by confirming that an LLM-based scoring agent consistently scored clinician-preferred outputs higher than rejected ones. Seven versions of an EHR-embedded AI agent for clinicians were evaluated across all cases. Results. Clinician-authored rubrics discriminated effectively between high- and low-quality outputs (median score gap: 82.9%) with high scoring stability (median range: 0.00%). Median scores improved from 84% to 95%. In later experiments, clinician-LLM ranking agreement (tau: 0.42-0.46) matched or exceeded clinician-clinician agreement (tau: 0.38-0.43), attributable to both ceiling compression and LLM rubric improvement. Discussion. This convergence supports incorporating LLM rubrics alongside clinician-authored ones. At roughly 1,000 times lower cost, LLM rubrics enable substantially greater evaluation coverage, while continued clinical authorship grounds evaluation in expert judgment. Ceiling compression poses a methodological challenge for future inter-rater agreement studies. Conclusion. Case-specific rubrics offer a path for clinical AI evaluation that preserves expert judgment while enabling automation at three orders lower cost. Clinician-authored rubrics establish the baseline against which LLM rubrics are validated.

Aaryan Shah, Andrew Hines, Alexia Downs et al.

Clinical AI systems require not just point-in-time evaluation but continuous governance: the ongoing practice of monitoring, evaluating, iterating, and re-evaluating performance throughout deployment. We present an end-to-end framework of governance that integrates rubric validation, live deployment feedback, technical performance monitoring, and cost tracking, with controlled experimentation gating system changes before deployment. Applied to Hyperscribe, an EHR-embedded agent that converts ambient audio into structured chart updates, twenty clinicians authored 1,646 validated rubrics across 823 cases. Seven Hyperscribe versions were evaluated through controlled experiments, with median scores improving from 84% to 95%. Analysis of 107 live feedback entries over three months showed feedback composition shifting from 79% error reports and 14% positive observations to 30% errors and 45% positive observations as engineering interventions resolved failures. Median processing time per audio segment was 8.1 seconds with a 99.6% effective completion rate after retry mechanisms absorbed transient model errors. These results demonstrate that continuous, multi-channel governance of deployed clinical AI is both achievable and effective.

Xuhai Xu, Haoyu Hu, Haoran Zhang et al.

Artificial intelligence (AI) is increasingly permeating healthcare, from physician assistants to consumer applications. Since AI algorithm's opacity challenges human interaction, explainable AI (XAI) addresses this by providing AI decision-making insight, but evidence suggests XAI can paradoxically induce over-reliance or bias. We present results from two large-scale experiments (623 lay people; 153 primary care physicians, PCPs) combining a fairness-based diagnosis AI model and different XAI explanations to examine how XAI assistance, particularly multimodal large language models (LLMs), influences diagnostic performance. AI assistance balanced across skin tones improved accuracy and reduced diagnostic disparities. However, LLM explanations yielded divergent effects: lay users showed higher automation bias - accuracy boosted when AI was correct, reduced when AI erred - while experienced PCPs remained resilient, benefiting irrespective of AI accuracy. Presenting AI suggestions first also led to worse outcomes when the AI was incorrect for both groups. These findings highlight XAI's varying impact based on expertise and timing, underscoring LLMs as a "double-edged sword" in medical AI and informing future human-AI collaborative system design.