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Dynamic treatment regimes (DTRs) are critical to precision medicine, optimizing long-term outcomes through personalized, real-time decision making in evolving clinical contexts, but require careful supervision for unsafe treatment risks. Existing efforts rely primarily on clinician prescribed gold standards despite the absence of a known optimal strategy, and predominantly using structured EHR data without extracting valuable insights from clinical notes, limiting their reliability for treatment recommendations. In this work, we introduce SAFER, a calibrated risk-aware tabular-language recommendation framework for DTR that integrates both structured EHR and clinical notes, enabling them to learn from each other, and addresses inherent label uncertainty by assuming ambiguous optimal treatment solution for deceased patients. Moreover, SAFER employs conformal prediction to provide statistical guarantees, ensuring safe treatment recommendations while filtering out uncertain predictions. Experiments on two publicly available sepsis datasets demonstrate that SAFER outperforms state-of-the-art baselines across multiple recommendation metrics and counterfactual mortality rate, while offering robust formal assurances. These findings underscore SAFER’s potential as a trustworthy and theoretically grounded solution for high-stakes DTR applications.
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A Multimodal Transformer: Fusing Clinical Notes with Structured EHR Data for Interpretable In-Hospital Mortality Prediction
Deep-learning-based clinical decision support using structured electronic health records (EHR) has been an active research area for predicting risks of mortality and diseases. Meanwhile, large amounts of narrative clinical notes provide complementary information, but are often not integrated into predictive models. In this paper, we provide a novel multimodal transformer to fuse clinical notes and structured EHR data for better prediction of in-hospital mortality. To improve interpretability, we propose an integrated gradients (IG) method to select important words in clinical notes and discover the critical structured EHR features with Shapley values. These important words and clinical features are visualized to assist with interpretation of the prediction outcomes. We also investigate the significance of domain adaptive pretraining and task adaptive fine-tuning on the Clinical BERT, which is used to learn the representations of clinical notes. Experiments demonstrated that our model outperforms other methods (AUCPR: 0.538, AUCROC: 0.877, F1:0.490).
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- Award ID(s):
- 1909038
- PAR ID:
- 10417488
- Date Published:
- Journal Name:
- AMIA Annual Symposium proceedings
- Format(s):
- Medium: X
- Sponsoring Org:
- National Science Foundation
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The predictive Intensive Care Unit (ICU) scoring system plays an important role in ICU management for its capability of predicting important outcomes, especially mortality. There are many scoring systems that have been developed and used in the ICU. These scoring systems are primarily based on the structured clinical data contained in the electronic health record (EHR), which may suffer the loss of the important clinical information contained in the narratives and images. In this work, we build a deep learning based survival prediction model with multimodality data to predict ICU-mortality. Four sets of features are investigated: (1) physiological measurements of Simplified Acute Physiology Score (SAPS) II, (2) common thorax diseases predefined by radiologists, (3) BERT-based text representations, and (4) chest X-ray image features. We use the Medical Information Mart for Intensive Care IV (MIMIC-IV) dataset to evaluate the proposed model. Our model achieves the average C-index of 0.7847 (95% confidence interval, 0.7625–0.8068), which substantially exceeds that of the baseline with SAPS-II features (0.7477 (0.7238–0.7716)). Ablation studies further demonstrate the contributions of pre-defined labels (2.12%), text features (2.68%), and image features (2.96%). Our model achieves a higher average C-index than the traditional machine learning methods under the same feature fusion setting, which suggests that the deep learning methods can outperform the traditional machine learning methods in ICU-mortality prediction. These results highlight the potential of deep learning models with multimodal information to enhance ICU-mortality prediction. We make our work publicly available at https://github.com/bionlplab/mimic-icu-mortality.more » « less
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Abstract Background Social and behavioral determinants of health (SBDH) are environmental and behavioral factors that often impede disease management and result in sexually transmitted infections. Despite their importance, SBDH are inconsistently documented in electronic health records (EHRs) and typically collected only in an unstructured format. Evidence suggests that structured data elements present in EHRs can contribute further to identify SBDH in the patient record. Objective Explore the automated inference of both the presence of SBDH documentation and individual SBDH risk factors in patient records. Compare the relative ability of clinical notes and structured EHR data, such as laboratory measurements and diagnoses, to support inference. Methods We attempt to infer the presence of SBDH documentation in patient records, as well as patient status of 11 SBDH, including alcohol abuse, homelessness, and sexual orientation. We compare classification performance when considering clinical notes only, structured data only, and notes and structured data together. We perform an error analysis across several SBDH risk factors. Results Classification models inferring the presence of SBDH documentation achieved good performance (F1 score: 92.7–78.7; F1 considered as the primary evaluation metric). Performance was variable for models inferring patient SBDH risk status; results ranged from F1 = 82.7 for LGBT (lesbian, gay, bisexual, and transgender) status to F1 = 28.5 for intravenous drug use. Error analysis demonstrated that lexical diversity and documentation of historical SBDH status challenge inference of patient SBDH status. Three of five classifiers inferring topic-specific SBDH documentation and 10 of 11 patient SBDH status classifiers achieved highest performance when trained using both clinical notes and structured data. Conclusion Our findings suggest that combining clinical free-text notes and structured data provide the best approach in classifying patient SBDH status. Inferring patient SBDH status is most challenging among SBDH with low prevalence and high lexical diversity.more » « less
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Deep neural networks, including the Transformer architecture, have achieved remarkable performance in various time series tasks. However, their effectiveness in handling clinical time series data is hindered by specific challenges: 1) Sparse event sequences collected asynchronously with multivariate time series, and 2) Limited availability of labeled data. To address these challenges, we propose Our code is available at https://github.com/SigmaTsing/TransEHR.git . , a self-supervised Transformer model designed to encode multi-sourced asynchronous sequential data, such as structured Electronic Health Records (EHRs), efficiently. We introduce three pretext tasks for pre-training the Transformer model, utilizing large amounts of unlabeled structured EHR data, followed by fine-tuning on downstream prediction tasks using the limited labeled data. Through extensive experiments on three real-world health datasets, we demonstrate that our model achieves state-of-the-art performance on benchmark clinical tasks, including in-hospital mortality classification, phenotyping, and length-of-stay prediction. Our findings highlight the efficacy of in effectively addressing the challenges associated with clinical time series data, thus contributing to advancements in healthcare analytics.more » « less
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