Lillian Sung

Lin Lawrence Guo, Jason Fries, Ethan Steinberg et al.

Foundation models hold promise for transforming AI in healthcare by providing modular components that are easily adaptable to downstream healthcare tasks, making AI development more scalable and cost-effective. Structured EHR foundation models, trained on coded medical records from millions of patients, demonstrated benefits including increased performance with fewer training labels, and improved robustness to distribution shifts. However, questions remain on the feasibility of sharing these models across different hospitals and their performance for local task adaptation. This multi-center study examined the adaptability of a recently released structured EHR foundation model ($FM_{SM}$), trained on longitudinal medical record data from 2.57M Stanford Medicine patients. Experiments were conducted using EHR data at The Hospital for Sick Children and MIMIC-IV. We assessed both adaptability via continued pretraining on local data, and task adaptability compared to baselines of training models from scratch at each site, including a local foundation model. We evaluated the performance of these models on 8 clinical prediction tasks. In both datasets, adapting the off-the-shelf $FM_{SM}$ matched the performance of GBM models locally trained on all data while providing a 13% improvement in settings with few task-specific training labels. With continued pretraining on local data, label efficiency substantially improved, such that $FM_{SM}$ required fewer than 1% of training examples to match the fully trained GBM's performance. Continued pretraining was also 60 to 90% more sample-efficient than training local foundation models from scratch. Our findings show that adapting shared EHR foundation models across hospitals provides improved prediction performance at less cost, underscoring the utility of base foundation models as modular components to streamline the development of healthcare AI.

Lin Lawrence Guo, Santiago Eduardo Arciniegas, Joseph Jihyung Lee et al.

Foundation models for structured electronic health records (EHRs) are pretrained on longitudinal sequences of timestamped clinical events to learn adaptable patient representations. Tokenization -- how these timelines are converted into discrete model inputs -- determines what information is preserved, how efficiently it is encoded, and which relationships must be learned versus precomputed. Yet the impact of tokenization design choices on downstream performance and computational efficiency remains largely unexplored. Here, we pretrained a transformer on pediatric EHR data under a factorial design, varying tokenization along event encoding, time encoding, and workflow annotation. We evaluated area-under-the-receiver-operating-characteristic curve across 74 clinical prediction tasks. Joint event encoding and positional time encoding outperformed their alternatives (73/74 and 71/74 tasks) while requiring 39.5% and 9.6% fewer pretraining floating-point operations, respectively. Targeted ablations traced the joint encoding advantage to local binding efficiency, that is, code-attribute pairs are combined into single tokens, rather than split across tokens that the model must learn to associate during pretraining. External evaluation on an adult intensive care unit cohort demonstrated that this advantage generalizes despite substantial vocabulary mismatch, while temporal and workflow effects remain institution-specific. These results establish tokenization as a tractable lever for improving both the performance and efficiency of EHR foundation models.

Stephen R. Pfohl, Natalie Harris, Chirag Nagpal et al.

Disaggregated evaluation across subgroups is critical for assessing the fairness of machine learning models, but its uncritical use can mislead practitioners. We show that equal performance across subgroups is an unreliable measure of fairness when data are representative of the relevant populations but reflective of real-world disparities. Furthermore, when data are not representative due to selection bias, both disaggregated evaluation and alternative approaches based on conditional independence testing may be invalid without explicit assumptions regarding the bias mechanism. We use causal graphical models to characterize fairness properties and metric stability across subgroups under different data generating processes. Our framework suggests complementing disaggregated evaluations with explicit causal assumptions and analysis to control for confounding and distribution shift, including conditional independence testing and weighted performance estimation. These findings have broad implications for how practitioners design and interpret model assessments given the ubiquity of disaggregated evaluation.

Tina Seto, Lillian Sung, Jose Posada et al.

Flowsheet data presents unique challenges and opportunities for integration into standardized Common Data Models (CDMs) such as the Observational Medical Outcomes Partnership (OMOP) CDM from the Observational Health Data Sciences and Informatics (OHDSI) program. These data are a potentially rich source of detailed curated health outcomes data such as pain scores, vital signs, lines drains and airways (LDA) and other measurements that can be invaluable in building a robust model of patient health journey during an inpatient stay. We present two approaches to integration of flowsheet measures into the OMOP CDM. One approach was computationally straightforward but of potentially limited research utility. The second approach was far more computationally and labor intensive and involved mapping to standardized terms in controlled clinical vocabularies such as Logical Observation Identifiers Names and Codes (LOINC), resulting in a research data set of higher utility to population health studies.