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Ethan Steinberg

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6 papers

2 author rows

ICLR Conference 2025 Conference Paper

Context Clues: Evaluating Long Context Models for Clinical Prediction Tasks on EHR Data

Michael Wornow
Suhana Bedi
Miguel Angel Fuentes Hernandez
Ethan Steinberg
Jason Alan Fries
Christopher Ré
Sanmi Koyejo
Nigam H. Shah

Foundation Models (FMs) trained on Electronic Health Records (EHRs) have achieved state-of-the-art results on numerous clinical prediction tasks. However, prior EHR FMs typically have context windows of $<$1k tokens, which prevents them from modeling full patient EHRs which can exceed 10k's of events. For making clinical predictions, both model performance and robustness to the unique properties of EHR data are crucial. Recent advancements in subquadratic long-context architectures (e.g. Mamba) offer a promising solution. However, their application to EHR data has not been well-studied. We address this gap by presenting the first systematic evaluation of the effect of context length on modeling EHR data. We find that longer context models improve predictive performance -- our Mamba-based model surpasses the prior state-of-the-art on 9/14 tasks on the EHRSHOT prediction benchmark. Additionally, we measure robustness to three unique, previously underexplored properties of EHR data: (1) the prevalence of ``copy-forwarded" diagnoses which create artificial token repetition in EHR sequences; (2) the irregular time intervals between EHR events which can lead to a wide range of timespans within a context window; and (3) the natural increase in disease complexity over time which makes later tokens in the EHR harder to predict than earlier ones. Stratifying our EHRSHOT results, we find that higher levels of each property correlate negatively with model performance (e.g., a 14% higher Brier loss between the least and most irregular patients), but that longer context models are more robust to more extreme levels of these properties. Our work highlights the potential for using long-context architectures to model EHR data, and offers a case study on how to identify and quantify new challenges in modeling sequential data motivated by domains outside of natural language. We release all of our model checkpoints and code.

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ICLR Conference 2025 Conference Paper

Time-to-Event Pretraining for 3D Medical Imaging

Zepeng Huo
Jason Alan Fries
Alejandro Lozano
Jeya Maria Jose Valanarasu
Ethan Steinberg
Louis Blankemeier
Akshay S. Chaudhari
Curtis Langlotz

With the rise of medical foundation models and the growing availability of imaging data, scalable pretraining techniques offer a promising way to identify imaging biomarkers predictive of future disease risk. While current self-supervised methods for 3D medical imaging models capture local structural features like organ morphology, they fail to link pixel biomarkers with long-term health outcomes due to a missing context problem. Current approaches lack the temporal context necessary to identify biomarkers correlated with disease progression, as they rely on supervision derived only from images and concurrent text descriptions. To address this, we introduce time-to-event pretraining, a pretraining framework for 3D medical imaging models that leverages large-scale temporal supervision from paired, longitudinal electronic health records (EHRs). Using a dataset of 18,945 CT scans (4.2 million 2D images) and time-to-event distributions across thousands of EHR-derived tasks, our method improves outcome prediction, achieving an average AUROC increase of 23.7% and a 29.4% gain in Harrell’s C-index across 8 benchmark tasks. Importantly, these gains are achieved without sacrificing diagnostic classification performance. This study lays the foundation for integrating longitudinal EHR and 3D imaging data to advance clinical risk prediction.

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AAAI Conference 2024 Conference Paper

MedAlign: A Clinician-Generated Dataset for Instruction Following with Electronic Medical Records

Scott L. Fleming
Alejandro Lozano
William J. Haberkorn
Jenelle A. Jindal
Eduardo Reis
Rahul Thapa
Louis Blankemeier
Julian Z. Genkins

The ability of large language models (LLMs) to follow natural language instructions with human-level fluency suggests many opportunities in healthcare to reduce administrative burden and improve quality of care. However, evaluating LLMs on realistic text generation tasks for healthcare remains challenging. Existing question answering datasets for electronic health record (EHR) data fail to capture the complexity of information needs and documentation burdens experienced by clinicians. To address these challenges, we introduce MedAlign, a benchmark dataset of 983 natural language instructions for EHR data. MedAlign is curated by 15 clinicians (7 specialities), includes clinician-written reference responses for 303 instructions, and provides 276 longitudinal EHRs for grounding instruction-response pairs. We used MedAlign to evaluate 6 general domain LLMs, having clinicians rank the accuracy and quality of each LLM response. We found high error rates, ranging from 35% (GPT-4) to 68% (MPT-7B-Instruct), and 8.3% drop in accuracy moving from 32k to 2k context lengths for GPT-4. Finally, we report correlations between clinician rankings and automated natural language generation metrics as a way to rank LLMs without human review. We make MedAlign available under a research data use agreement to enable LLM evaluations on tasks aligned with clinician needs and preferences.

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ICLR Conference 2024 Conference Paper

MOTOR: A Time-to-Event Foundation Model For Structured Medical Records

Ethan Steinberg
Jason Alan Fries
Yizhe Xu
Nigam H. Shah

We present a self-supervised, time-to-event (TTE) foundation model called MOTOR (Many Outcome Time Oriented Representations) which is pretrained on timestamped sequences of events in electronic health records (EHR) and health insurance claims. TTE models are used for estimating the probability distribution of the time until a specific event occurs, which is an important task in medical settings. TTE models provide many advantages over classification using fixed time horizons, including naturally handling censored observations, but are challenging to train with limited labeled data. MOTOR addresses this challenge by pretraining on up to 55M patient records (9B clinical events). We evaluate MOTOR's transfer learning performance on 19 tasks, across 3 patient databases (a private EHR system, MIMIC-IV, and Merative claims data). Task-specific models adapted from MOTOR improve time-dependent C statistics by 4.6\% over state-of-the-art, improve label efficiency by up to 95\%, and are more robust to temporal distributional shifts. We further evaluate cross-site portability by adapting our MOTOR foundation model for six prediction tasks on the MIMIC-IV dataset, where it outperforms all baselines. MOTOR is the first foundation model for medical TTE predictions and we release a 143M parameter pretrained model for research use at https://huggingface.co/StanfordShahLab/motor-t-base.

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NeurIPS Conference 2023 Conference Paper

EHRSHOT: An EHR Benchmark for Few-Shot Evaluation of Foundation Models

Michael Wornow
Rahul Thapa
Ethan Steinberg
Jason Fries
Nigam Shah

While the general machine learning (ML) community has benefited from public datasets, tasks, and models, the progress of ML in healthcare has been hampered by a lack of such shared assets. The success of foundation models creates new challenges for healthcare ML by requiring access to shared pretrained models to validate performance benefits. We help address these challenges through three contributions. First, we publish a new dataset, EHRSHOT, which contains de-identified structured data from the electronic health records (EHRs) of 6, 739 patients from Stanford Medicine. Unlike MIMIC-III/IV and other popular EHR datasets, EHRSHOT is longitudinal and not restricted to ICU/ED patients. Second, we publish the weights of CLMBR-T-base, a 141M parameter clinical foundation model pretrained on the structured EHR data of 2. 57M patients. We are one of the first to fully release such a model for coded EHR data; in contrast, most prior models released for clinical data (e. g. GatorTron, ClinicalBERT) only work with unstructured text and cannot process the rich, structured data within an EHR. We provide an end-to-end pipeline for the community to validate and build upon its performance. Third, we define 15 few-shot clinical prediction tasks, enabling evaluation of foundation models on benefits such as sample efficiency and task adaptation. Our model and dataset are available via a research data use agreement from here: https: //stanfordaimi. azurewebsites. net/. Code to reproduce our results is available here: https: //github. com/som-shahlab/ehrshot-benchmark.

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NeurIPS Conference 2023 Conference Paper

INSPECT: A Multimodal Dataset for Patient Outcome Prediction of Pulmonary Embolisms

Shih-Cheng Huang
Zepeng Huo
Ethan Steinberg
Chia-Chun Chiang
Curtis Langlotz
Matthew Lungren
Serena Yeung
Nigam Shah

Synthesizing information from various data sources plays a crucial role in the practice of modern medicine. Current applications of artificial intelligence in medicine often focus on single-modality data due to a lack of publicly available, multimodal medical datasets. To address this limitation, we introduce INSPECT, which contains de-identified longitudinal records from a large cohort of pulmonary embolism (PE) patients, along with ground truth labels for multiple outcomes. INSPECT contains data from 19, 402 patients, including CT images, sections of radiology reports, and structured electronic health record (EHR) data (including demographics, diagnoses, procedures, and vitals). Using our provided dataset, we develop and release a benchmark for evaluating several baseline modeling approaches on a variety of important PE related tasks. We evaluate image-only, EHR-only, and fused models. Trained models and the de-identified dataset are made available for non-commercial use under a data use agreement. To the best our knowledge, INSPECT is the largest multimodal dataset for enabling reproducible research on strategies for integrating 3D medical imaging and EHR data.

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