Electronic Health Records (EHRs), comprising diverse clinical data such as diagnoses, medications, and laboratory results, hold great promise for translational research. EHR-derived data have advanced disease prevention, improved clinical trial recruitment, and generated real-world evidence. Synthesizing EHRs across institutions enables large-scale, generalizable studies that capture rare diseases and population diversity, but remains hindered by the heterogeneity of medical codes, institution-specific terminologies, and the absence of standardized data structures. These barriers limit the interpretability, comparability, and scalability of EHR-based analyses, underscoring the need for robust methods to harmonize and extract meaningful insights from distributed, heterogeneous data. To address this, we propose MASH (Multi-source Automated Structured Hierarchy), a fully automated framework that aligns medical codes across institutions using neural optimal transport and constructs hierarchical graphs with learned hyperbolic embeddings. During training, MASH integrates information from pre-trained language models, co-occurrence patterns, textual descriptions, and supervised labels to capture semantic and hierarchical relationships among medical concepts more effectively. Applied to real-world EHR data, including diagnosis, medication, and laboratory codes, MASH produces interpretable hierarchical graphs that facilitate the navigation and understanding of heterogeneous clinical data. Notably, it generates the first automated hierarchies for unstructured local laboratory codes, establishing foundational references for downstream applications.

The adoption of EHRs has expanded opportunities to leverage data-driven algorithms in clinical care and research. A major bottleneck in effectively conducting multi-institutional EHR studies is the data heterogeneity across systems with numerous codes that either do not exist or represent different clinical concepts across institutions. The need for data privacy further limits the feasibility of including multi-institutional patient-level data required to study similarities and differences across patient subgroups. To address these challenges, we developed the GAME algorithm. Tested and validated across 7 institutions and 2 languages, GAME integrates data in several levels: (1) at the institutional level with knowledge graphs to establish relationships between codes and existing knowledge sources, providing the medical context for standard codes and their relationship to each other; (2) between institutions, leveraging language models to determine the relationships between institution-specific codes with established standard codes; and (3) quantifying the strength of the relationships between codes using a graph attention network. Jointly trained embeddings are created using transfer and federated learning to preserve data privacy. In this study, we demonstrate the applicability of GAME in selecting relevant features as inputs for AI-driven algorithms in a range of conditions, e.g., heart failure, rheumatoid arthritis. We then highlight the application of GAME harmonized multi-institutional EHR data in a study of Alzheimer's disease outcomes and suicide risk among patients with mental health disorders, without sharing patient-level data outside individual institutions.

We conduct a scoping review of existing approaches for synthetic EHR data generation, and benchmark major methods with proposed open-source software to offer recommendations for practitioners. We search three academic databases for our scoping review. Methods are benchmarked on open-source EHR datasets, MIMIC-III/IV. Seven existing methods covering major categories and two baseline methods are implemented and compared. Evaluation metrics concern data fidelity, downstream utility, privacy protection, and computational cost. 42 studies are identified and classified into five categories. Seven open-source methods covering all categories are selected, trained on MIMIC-III, and evaluated on MIMIC-III or MIMIC-IV for transportability considerations. Among them, GAN-based methods demonstrate competitive performance in fidelity and utility on MIMIC-III; rule-based methods excel in privacy protection. Similar findings are observed on MIMIC-IV, except that GAN-based methods further outperform the baseline methods in preserving fidelity. A Python package, ``SynthEHRella'', is provided to integrate various choices of approaches and evaluation metrics, enabling more streamlined exploration and evaluation of multiple methods. We found that method choice is governed by the relative importance of the evaluation metrics in downstream use cases. We provide a decision tree to guide the choice among the benchmarked methods. Based on the decision tree, GAN-based methods excel when distributional shifts exist between the training and testing populations. Otherwise, CorGAN and MedGAN are most suitable for association modeling and predictive modeling, respectively. Future research should prioritize enhancing fidelity of the synthetic data while controlling privacy exposure, and comprehensive benchmarking of longitudinal or conditional generation methods.

Automatic subphenotyping from electronic health records (EHRs)provides numerous opportunities to understand diseases with unique subgroups and enhance personalized medicine for patients. However, existing machine learning algorithms either focus on specific diseases for better interpretability or produce coarse-grained phenotype topics without considering nuanced disease patterns. In this study, we propose a guided topic model, MixEHR-Nest, to infer sub-phenotype topics from thousands of disease using multi-modal EHR data. Specifically, MixEHR-Nest detects multiple subtopics from each phenotype topic, whose prior is guided by the expert-curated phenotype concepts such as Phenotype Codes (PheCodes) or Clinical Classification Software (CCS) codes. We evaluated MixEHR-Nest on two EHR datasets: (1) the MIMIC-III dataset consisting of over 38 thousand patients from intensive care unit (ICU) from Beth Israel Deaconess Medical Center (BIDMC) in Boston, USA; (2) the healthcare administrative database PopHR, comprising 1.3 million patients from Montreal, Canada. Experimental results demonstrate that MixEHR-Nest can identify subphenotypes with distinct patterns within each phenotype, which are predictive for disease progression and severity. Consequently, MixEHR-Nest distinguishes between type 1 and type 2 diabetes by inferring subphenotypes using CCS codes, which do not differentiate these two subtype concepts. Additionally, MixEHR-Nest not only improved the prediction accuracy of short-term mortality of ICU patients and initial insulin treatment in diabetic patients but also revealed the contributions of subphenotypes. For longitudinal analysis, MixEHR-Nest identified subphenotypes of distinct age prevalence under the same phenotypes, such as asthma, leukemia, epilepsy, and depression. The MixEHR-Nest software is available at GitHub: https://github.com/li-lab-mcgill/MixEHR-Nest.

A large-scale knowledge graph enhances reproducibility in biomedical data discovery by providing a standardized, integrated framework that ensures consistent interpretation across diverse datasets. It improves generalizability by connecting data from various sources, enabling broader applicability of findings across different populations and conditions. Generating reliable knowledge graph, leveraging multi-source information from existing literature, however, is challenging especially with a large number of node sizes and heterogeneous relations. In this paper, we propose a general theoretically guaranteed statistical framework, called RENKI, to enable simultaneous learning of multiple relation types. RENKI generalizes various network models widely used in statistics and computer science. The proposed framework incorporates representation learning output into initial entity embedding of a neural network that approximates the score function for the knowledge graph and continuously trains the model to fit observed facts. We prove nonasymptotic bounds for in-sample and out-of-sample weighted MSEs in relation to the pseudo-dimension of the knowledge graph function class. Additionally, we provide pseudo-dimensions for score functions based on multilayer neural networks with ReLU activation function, in the scenarios when the embedding parameters either fixed or trainable. Finally, we complement our theoretical results with numerical studies and apply the method to learn a comprehensive medical knowledge graph combining a pretrained language model representation with knowledge graph links observed in several medical ontologies. The experiments justify our theoretical findings and demonstrate the effect of weighting in the presence of heterogeneous relations and the benefit of incorporating representation learning in nonparametric models.

Objective For the UK Biobank standardized phenotype codes are associated with patients who have been hospitalized but are missing for many patients who have been treated exclusively in an outpatient setting. We describe a method for phenotype recognition that imputes phenotype codes for all UK Biobank participants. Materials and Methods POPDx (Population-based Objective Phenotyping by Deep Extrapolation) is a bilinear machine learning framework for simultaneously estimating the probabilities of 1,538 phenotype codes. We extracted phenotypic and health-related information of 392,246 individuals from the UK Biobank for POPDx development and evaluation. A total of 12,803 ICD-10 diagnosis codes of the patients were converted to 1,538 Phecodes as gold standard labels. The POPDx framework was evaluated and compared to other available methods on automated multi-phenotype recognition. Results POPDx can predict phenotypes that are rare or even unobserved in training. We demonstrate substantial improvement of automated multi-phenotype recognition across 22 disease categories, and its application in identifying key epidemiological features associated with each phenotype. Conclusions POPDx helps provide well-defined cohorts for downstream studies. It is a general purpose method that can be applied to other biobanks with diverse but incomplete data.

Electronic phenotyping, which is the task of ascertaining whether an individual has a medical condition of interest by analyzing their medical records, is a foundational task in clinical informatics. Increasingly, electronic phenotyping is performed via supervised learning. We investigate the effectiveness of multitask learning for phenotyping using electronic health records (EHR) data. Multitask learning aims to improve model performance on a target task by jointly learning additional auxiliary tasks, and has been used to good effect in disparate areas of machine learning. However, its utility when applied to EHR data has not been established, and prior work suggests that its benefits are inconsistent. Here we present experiments that elucidate when multitask learning with neural networks can improve performance for electronic phenotyping using EHR data relative to well-tuned single task neural networks. We find that multitask networks consistently outperform single task networks for rare phenotypes but underperform for more common phenotypes. The effect size increases as more auxiliary tasks are added.