Generating Faithful and Complete Hospital-Course Summaries from the Electronic Health Record

The rapid adoption of Electronic Health Records (EHRs) has been instrumental in streamlining administrative tasks, increasing transparency, and enabling continuity of care across providers. An unintended consequence of the increased documentation burden, however, has been reduced face-time with patients and, concomitantly, a dramatic rise in clinician burnout. In this thesis, we pinpoint a particularly time-intensive, yet critical, documentation task: generating a summary of a patient's hospital admissions, and propose and evaluate automated solutions. In Chapter 2, we construct a dataset based on 109,000 hospitalizations (2M source notes) and perform exploratory analyses to motivate future work on modeling and evaluation [NAACL 2021]. In Chapter 3, we address faithfulness from a modeling perspective by revising noisy references [EMNLP 2022] and, to reduce the reliance on references, directly calibrating model outputs to metrics [ACL 2023]. These works relied heavily on automatic metrics as human annotations were limited. To fill this gap, in Chapter 4, we conduct a fine-grained expert annotation of system errors in order to meta-evaluate existing metrics and better understand task-specific issues of domain adaptation and source-summary alignments. To learn a metric less correlated to extractiveness (copy-and-paste), we derive noisy faithfulness labels from an ensemble of existing metrics and train a faithfulness classifier on these pseudo labels [MLHC 2023]. Finally, in Chapter 5, we demonstrate that fine-tuned LLMs (Mistral and Zephyr) are highly prone to entity hallucinations and cover fewer salient entities. We improve both coverage and faithfulness by performing sentence-level entity planning based on a set of pre-computed salient entities from the source text, which extends our work on entity-guided news summarization [ACL, 2023], [EMNLP, 2023].

SPEER: Sentence-Level Planning of Long Clinical Summaries via Embedded Entity Retrieval

Clinician must write a lengthy summary each time a patient is discharged from the hospital. This task is time-consuming due to the sheer number of unique clinical concepts covered in the admission. Identifying and covering salient entities is vital for the summary to be clinically useful. We fine-tune open-source LLMs (Mistral-7B-Instruct and Zephyr-7B-\b{eta}) on the task and find that they generate incomplete and unfaithful summaries. To increase entity coverage, we train a smaller, encoder-only model to predict salient entities, which are treated as content-plans to guide the LLM. To encourage the LLM to focus on specific mentions in the source notes, we propose SPEER: Sentence-level Planning via Embedded Entity Retrieval. Specifically, we mark each salient entity span with special "{{ }}" boundary tags and instruct the LLM to retrieve marked spans before generating each sentence. Sentence-level planning acts as a form of state tracking in that the model is explicitly recording the entities it uses. We fine-tune Mistral and Zephyr variants on a large-scale, diverse dataset of ~167k in-patient hospital admissions and evaluate on 3 datasets. SPEER shows gains in both coverage and faithfulness metrics over non-guided and guided baselines.

From Sparse to Dense: GPT-4 Summarization with Chain of Density Prompting

Selecting the ``right'' amount of information to include in a summary is a difficult task. A good summary should be detailed and entity-centric without being overly dense and hard to follow. To better understand this tradeoff, we solicit increasingly dense GPT-4 summaries with what we refer to as a ``Chain of Density'' (CoD) prompt. Specifically, GPT-4 generates an initial entity-sparse summary before iteratively incorporating missing salient entities without increasing the length. Summaries generated by CoD are more abstractive, exhibit more fusion, and have less of a lead bias than GPT-4 summaries generated by a vanilla prompt. We conduct a human preference study on 100 CNN DailyMail articles and find that that humans prefer GPT-4 summaries that are more dense than those generated by a vanilla prompt and almost as dense as human written summaries. Qualitative analysis supports the notion that there exists a tradeoff between informativeness and readability. 500 annotated CoD summaries, as well as an extra 5,000 unannotated summaries, are freely available on HuggingFace (https://huggingface.co/datasets/griffin/chain_of_density).

Generating EDU Extracts for Plan-Guided Summary Re-Ranking

Two-step approaches, in which summary candidates are generated-then-reranked to return a single summary, can improve ROUGE scores over the standard single-step approach. Yet, standard decoding methods (i.e., beam search, nucleus sampling, and diverse beam search) produce candidates with redundant, and often low quality, content. In this paper, we design a novel method to generate candidates for re-ranking that addresses these issues. We ground each candidate abstract on its own unique content plan and generate distinct plan-guided abstracts using a model's top beam. More concretely, a standard language model (a BART LM) auto-regressively generates elemental discourse unit (EDU) content plans with an extractive copy mechanism. The top K beams from the content plan generator are then used to guide a separate LM, which produces a single abstractive candidate for each distinct plan. We apply an existing re-ranker (BRIO) to abstractive candidates generated from our method, as well as baseline decoding methods. We show large relevance improvements over previously published methods on widely used single document news article corpora, with ROUGE-2 F1 gains of 0.88, 2.01, and 0.38 on CNN / Dailymail, NYT, and Xsum, respectively. A human evaluation on CNN / DM validates these results. Similarly, on 1k samples from CNN / DM, we show that prompting GPT-3 to follow EDU plans outperforms sampling-based methods by 1.05 ROUGE-2 F1 points. Code to generate and realize plans is available at https://github.com/griff4692/edu-sum.

What are the Desired Characteristics of Calibration Sets? Identifying Correlates on Long Form Scientific Summarization

Summarization models often generate text that is poorly calibrated to quality metrics because they are trained to maximize the likelihood of a single reference (MLE). To address this, recent work has added a calibration step, which exposes a model to its own ranked outputs to improve relevance or, in a separate line of work, contrasts positive and negative sets to improve faithfulness. While effective, much of this work has focused on how to generate and optimize these sets. Less is known about why one setup is more effective than another. In this work, we uncover the underlying characteristics of effective sets. For each training instance, we form a large, diverse pool of candidates and systematically vary the subsets used for calibration fine-tuning. Each selection strategy targets distinct aspects of the sets, such as lexical diversity or the size of the gap between positive and negatives. On three diverse scientific long-form summarization datasets (spanning biomedical, clinical, and chemical domains), we find, among others, that faithfulness calibration is optimal when the negative sets are extractive and more likely to be generated, whereas for relevance calibration, the metric margin between candidates should be maximized and surprise--the disagreement between model and metric defined candidate rankings--minimized. Code to create, select, and optimize calibration sets is available at https://github.com/griff4692/calibrating-summaries

A Meta-Evaluation of Faithfulness Metrics for Long-Form Hospital-Course Summarization

Long-form clinical summarization of hospital admissions has real-world significance because of its potential to help both clinicians and patients. The faithfulness of summaries is critical to their safe usage in clinical settings. To better understand the limitations of abstractive systems, as well as the suitability of existing evaluation metrics, we benchmark faithfulness metrics against fine-grained human annotations for model-generated summaries of a patient's Brief Hospital Course. We create a corpus of patient hospital admissions and summaries for a cohort of HIV patients, each with complex medical histories. Annotators are presented with summaries and source notes, and asked to categorize manually highlighted summary elements (clinical entities like conditions and medications as well as actions like "following up") into one of three categories: ``Incorrect,'' ``Missing,'' and ``Not in Notes.'' We meta-evaluate a broad set of proposed faithfulness metrics and, across metrics, explore the importance of domain adaptation (e.g. the impact of in-domain pre-training and metric fine-tuning), the use of source-summary alignments, and the effects of distilling a single metric from an ensemble of pre-existing metrics. Off-the-shelf metrics with no exposure to clinical text correlate well yet overly rely on summary extractiveness. As a practical guide to long-form clinical narrative summarization, we find that most metrics correlate best to human judgments when provided with one summary sentence at a time and a minimal set of relevant source context.

Learning to Revise References for Faithful Summarization

In many real-world scenarios with naturally occurring datasets, reference summaries are noisy and contain information that cannot be inferred from the source text. On large news corpora, removing low quality samples has been shown to reduce model hallucinations. Yet, this method is largely untested for smaller, noisier corpora. To improve reference quality while retaining all data, we propose a new approach: to revise--not remove--unsupported reference content. Without ground-truth supervision, we construct synthetic unsupported alternatives to supported sentences and use contrastive learning to discourage/encourage (un)faithful revisions. At inference, we vary style codes to over-generate revisions of unsupported reference sentences and select a final revision which balances faithfulness and abstraction. We extract a small corpus from a noisy source--the Electronic Health Record (EHR)--for the task of summarizing a hospital admission from multiple notes. Training models on original, filtered, and revised references, we find (1) learning from revised references reduces the hallucination rate substantially more than filtering (18.4\% vs 3.8\%), (2) learning from abstractive (vs extractive) revisions improves coherence, relevance, and faithfulness, (3) beyond redress of noisy data, the revision task has standalone value for the task: as a pre-training objective and as a post-hoc editor.

Investigating Crowdsourcing Protocols for Evaluating the Factual Consistency of Summaries

Current pre-trained models applied to summarization are prone to factual inconsistencies which either misrepresent the source text or introduce extraneous information. Thus, comparing the factual consistency of summaries is necessary as we develop improved models. However, the optimal human evaluation setup for factual consistency has not been standardized. To address this issue, we crowdsourced evaluations for factual consistency using the rating-based Likert scale and ranking-based Best-Worst Scaling protocols, on 100 articles from each of the CNN-Daily Mail and XSum datasets over four state-of-the-art models, to determine the most reliable evaluation framework. We find that ranking-based protocols offer a more reliable measure of summary quality across datasets, while the reliability of Likert ratings depends on the target dataset and the evaluation design. Our crowdsourcing templates and summary evaluations will be publicly available to facilitate future research on factual consistency in summarization.

What's in a Summary? Laying the Groundwork for Advances in Hospital-Course Summarization

Summarization of clinical narratives is a long-standing research problem. Here, we introduce the task of hospital-course summarization. Given the documentation authored throughout a patient's hospitalization, generate a paragraph that tells the story of the patient admission. We construct an English, text-to-text dataset of 109,000 hospitalizations (2M source notes) and their corresponding summary proxy: the clinician-authored "Brief Hospital Course" paragraph written as part of a discharge note. Exploratory analyses reveal that the BHC paragraphs are highly abstractive with some long extracted fragments; are concise yet comprehensive; differ in style and content organization from the source notes; exhibit minimal lexical cohesion; and represent silver-standard references. Our analysis identifies multiple implications for modeling this complex, multi-document summarization task.

Resolving Implicit Coordination in Multi-Agent Deep Reinforcement Learning with Deep Q-Networks & Game Theory

We address two major challenges of implicit coordination in multi-agent deep reinforcement learning: non-stationarity and exponential growth of state-action space, by combining Deep-Q Networks for policy learning with Nash equilibrium for action selection. Q-values proxy as payoffs in Nash settings, and mutual best responses define joint action selection. Coordination is implicit because multiple/no Nash equilibria are resolved deterministically. We demonstrate that knowledge of game type leads to an assumption of mirrored best responses and faster convergence than Nash-Q. Specifically, the Friend-or-Foe algorithm demonstrates signs of convergence to a Set Controller which jointly chooses actions for two agents. This encouraging given the highly unstable nature of decentralized coordination over joint actions. Inspired by the dueling network architecture, which decouples the Q-function into state and advantage streams, as well as residual networks, we learn both a single and joint agent representation, and merge them via element-wise addition. This simplifies coordination by recasting it is as learning a residual function. We also draw high level comparative insights on key MADRL and game theoretic variables: competitive vs. cooperative, asynchronous vs. parallel learning, greedy versus socially optimal Nash equilibria tie breaking, and strategies for the no Nash equilibrium case. We evaluate on 3 custom environments written in Python using OpenAI Gym: a Predator Prey environment, an alternating Warehouse environment, and a Synchronization environment. Each environment requires successively more coordination to achieve positive rewards.