Electronic health records (EHRs) support powerful clinical prediction models, but existing methods typically provide coarse, post hoc explanations that offer limited value for patient-level decision making. We introduce a knowledge graph (KG)-guided chain-of-thought (CoT) framework that generates clinically grounded and temporally consistent reasoning for visit-level disease prediction in MIMIC-III. ICD-9 codes are mapped to PrimeKG, from which disease-relevant nodes and multi-hop reasoning paths are extracted and used as scaffolds for CoT generation; only explanations whose conclusions match observed outcomes are retained. Lightweight LLaMA-3.1-Instruct-8B and Gemma-7B models are then fine-tuned on this supervision corpus. Across ten PrimeKG-mapped diseases and limited training cohorts (400 and 1000 cases), KG-guided models outperform strong classical baselines, achieving AUROC values of 0.66 to 0.70 and macro-AUPR values of 0.40 to 0.47. The models also transfer zero-shot to the CRADLE cohort, improving accuracy from approximately 0.40 to 0.51 up to 0.72 to 0.77. A blinded clinician evaluation shows consistent preference for KG-guided CoT explanations in clarity, relevance, and clinical correctness.

Since the COVID-19 pandemic, clinicians have seen a large and sustained influx in patient portal messages, significantly contributing to clinician burnout. To the best of our knowledge, there are no large-scale public patient portal messages corpora researchers can use to build tools to optimize clinician portal workflows. Informed by our ongoing work with a regional hospital, this study introduces an LLM-powered framework for configurable and realistic patient portal message generation. Our approach leverages few-shot grounded text generation, requiring only a small number of de-identified patient portal messages to help LLMs better match the true style and tone of real data. Clinical experts in our team deem this framework as HIPAA-friendly, unlike existing privacy-preserving approaches to synthetic text generation which cannot guarantee all sensitive attributes will be protected. Through extensive quantitative and human evaluation, we show that our framework produces data of higher quality than comparable generation methods as well as all related datasets. We believe this work provides a path forward for (i) the release of large-scale synthetic patient message datasets that are stylistically similar to ground-truth samples and (ii) HIPAA-friendly data generation which requires minimal human de-identification efforts.

A Clinical Decision Support System (CDSS) is designed to enhance clinician decision-making by combining system-generated recommendations with medical expertise. Given the high costs, intensive labor, and time-sensitive nature of medical treatments, there is a pressing need for efficient decision support, especially in complex emergency scenarios. In these scenarios, where information can be limited, an advanced CDSS framework that leverages AI (artificial intelligence) models to effectively reduce diagnostic uncertainty has utility. Such an AI-enabled CDSS framework with quantified uncertainty promises to be practical and beneficial in the demanding context of real-world medical care. In this study, we introduce the concept of Medical Entropy, quantifying uncertainties in patient outcomes predicted by neural machine translation based on the ICD-9 code of procedures. Our experimental results not only show strong correlations between procedure and diagnosis sequences based on the simple ICD-9 code but also demonstrate the promising capacity to model trends of uncertainties during hospitalizations through a data-driven approach.

Large Language Models (LLMs) have demonstrated impressive and diverse abilities that can benefit various domains, such as zero and few-shot information extraction from clinical text without domain-specific training. However, for the ICD coding task, they often hallucinate key details and produce high recall but low precision results due to the high-dimensional and skewed distribution of the ICD codes. Existing LLM-based methods fail to account for the complex and dynamic interactions among the human agents involved in coding, such as patients, physicians, and coders, and they lack interpretability and reliability. In this paper, we present a novel multi-agent method for ICD coding, which mimics the real-world coding process with five agents: a patient agent, a physician agent, a coder agent, a reviewer agent, and an adjuster agent. Each agent has a specific function and uses a LLM-based model to perform it. We evaluate our method on the MIMIC-III dataset and show that our proposed multi-agent coding framework substantially improves performance on both common and rare codes compared to Zero-shot Chain of Thought (CoT) prompting and self-consistency with CoT. The ablation study confirms the proposed agent roles' efficacy. Our method also matches the state-of-the-art ICD coding methods that require pre-training or fine-tuning, in terms of coding accuracy, rare code accuracy, and explainability.

The precipitous rise and adoption of Large Language Models (LLMs) have shattered expectations with the fastest adoption rate of any consumer-facing technology in history. Healthcare, a field that traditionally uses NLP techniques, was bound to be affected by this meteoric rise. In this paper, we gauge the extent of the impact by evaluating the performance of LLMs for the task of medical coding on real-life noisy data. We conducted several experiments on MIMIC III and IV datasets with encoder-based LLMs, such as BERT. Furthermore, we developed Segmented Harmonic Loss, a new loss function to address the extreme class imbalance that we found to prevail in most medical data in a multi-label scenario by segmenting and decoupling co-occurring classes of the dataset with a new segmentation algorithm. We also devised a technique based on embedding similarity to tackle noisy data. Our experimental results show that when trained with the proposed loss, the LLMs achieve significant performance gains even on noisy long-tailed datasets, outperforming the F1 score of the state-of-the-art by over ten percentage points.

We introduce a dataset for evidence/rationale extraction on an extreme multi-label classification task over long medical documents. One such task is Computer-Assisted Coding (CAC) which has improved significantly in recent years, thanks to advances in machine learning technologies. Yet simply predicting a set of final codes for a patient encounter is insufficient as CAC systems are required to provide supporting textual evidence to justify the billing codes. A model able to produce accurate and reliable supporting evidence for each code would be a tremendous benefit. However, a human annotated code evidence corpus is extremely difficult to create because it requires specialized knowledge. In this paper, we introduce MDACE, the first publicly available code evidence dataset, which is built on a subset of the MIMIC-III clinical records. The dataset -- annotated by professional medical coders -- consists of 302 Inpatient charts with 3,934 evidence spans and 52 Profee charts with 5,563 evidence spans. We implemented several evidence extraction methods based on the EffectiveCAN model (Liu et al., 2021) to establish baseline performance on this dataset. MDACE can be used to evaluate code evidence extraction methods for CAC systems, as well as the accuracy and interpretability of deep learning models for multi-label classification. We believe that the release of MDACE will greatly improve the understanding and application of deep learning technologies for medical coding and document classification.

Deep neural networks (DNNs) have been broadly adopted in health risk prediction to provide healthcare diagnoses and treatments. To evaluate their robustness, existing research conducts adversarial attacks in the white/gray-box setting where model parameters are accessible. However, a more realistic black-box adversarial attack is ignored even though most real-world models are trained with private data and released as black-box services on the cloud. To fill this gap, we propose the first black-box adversarial attack method against health risk prediction models named MedAttacker to investigate their vulnerability. MedAttacker addresses the challenges brought by EHR data via two steps: hierarchical position selection which selects the attacked positions in a reinforcement learning (RL) framework and substitute selection which identifies substitute with a score-based principle. Particularly, by considering the temporal context inside EHRs, it initializes its RL position selection policy by using the contribution score of each visit and the saliency score of each code, which can be well integrated with the deterministic substitute selection process decided by the score changes. In experiments, MedAttacker consistently achieves the highest average success rate and even outperforms a recent white-box EHR adversarial attack technique in certain cases when attacking three advanced health risk prediction models in the black-box setting across multiple real-world datasets. In addition, based on the experiment results we include a discussion on defending EHR adversarial attacks.

Multi-label learning predicts a subset of labels from a given label set for an unseen instance while considering label correlations. A known challenge with multi-label classification is the long-tailed distribution of labels. Many studies focus on improving the overall predictions of the model and thus do not prioritise tail-end labels. Improving the tail-end label predictions in multi-label classifications of medical text enables the potential to understand patients better and improve care. The knowledge gained by one or more infrequent labels can impact the cause of medical decisions and treatment plans. This research presents variations of concatenated domain-specific language models, including multi-BioMed-Transformers, to achieve two primary goals. First, to improve F1 scores of infrequent labels across multi-label problems, especially with long-tail labels; second, to handle long medical text and multi-sourced electronic health records (EHRs), a challenging task for standard transformers designed to work on short input sequences. A vital contribution of this research is new state-of-the-art (SOTA) results obtained using TransformerXL for predicting medical codes. A variety of experiments are performed on the Medical Information Mart for Intensive Care (MIMIC-III) database. Results show that concatenated BioMed-Transformers outperform standard transformers in terms of overall micro and macro F1 scores and individual F1 scores of tail-end labels, while incurring lower training times than existing transformer-based solutions for long input sequences.

Clinical notes are unstructured text generated by clinicians during patient encounters. Clinical notes are usually accompanied by a set of metadata codes from the international classification of diseases (ICD). ICD code is an important code used in a variety of operations, including insurance, reimbursement, medical diagnosis, etc. Therefore, it is important to classify ICD codes quickly and accurately. However, annotating these codes is costly and time-consuming. So we propose a model based on bidirectional encoder representations from transformer (BERT) using the sequence attention method for automatic ICD code assignment. We evaluate our ap-proach on the MIMIC-III benchmark dataset. Our model achieved performance of Macro-aver-aged F1: 0.62898 and Micro-averaged F1: 0.68555, and is performing better than a performance of the previous state-of-the-art model. The contribution of this study proposes a method of using BERT that can be applied to documents and a sequence attention method that can capture im-portant sequence information appearing in documents.

Clinical coding is currently a labour-intensive, error-prone, but critical administrative process whereby hospital patient episodes are manually assigned codes by qualified staff from large, standardised taxonomic hierarchies of codes. Automating clinical coding has a long history in NLP research and has recently seen novel developments setting new state of the art results. A popular dataset used in this task is MIMIC-III, a large intensive care database that includes clinical free text notes and associated codes. We argue for the reconsideration of the validity MIMIC-III's assigned codes that are often treated as gold-standard, especially when MIMIC-III has not undergone secondary validation. This work presents an open-source, reproducible experimental methodology for assessing the validity of codes derived from EHR discharge summaries. We exemplify the methodology with MIMIC-III discharge summaries and show the most frequently assigned codes in MIMIC-III are under-coded up to 35%.