Expert-Guided g-computation with Large Language Models for Estimating Causal Effects on Timings: Applications to Hospital Quality Improvement

Hospital quality improvement (QI) programs routinely face multiple candidate interventions to optimize hospital flow, but existing methods struggle to estimate and rank the causal effects of such interventions. This work focuses on one of the most standard hospital metrics, the average length of stay (LOS), and its causal estimand, the average time saved. To characterize this causal effect, qualitative approaches rely on expert judgment to map patient trajectories, making them susceptible to cognitive biases; quantitative approaches rely on data-driven models, which fail when interventions are hypothetical with no historical data or have complex causal mechanisms that require clinical reasoning rather than data alone. We propose expert-guided g-computation, or egg-computation, which combines the complementary strengths of both approaches by connecting the Gantt charts commonly used to map patient trajectories with the causal DAG literature. We introduce a causal model over Gantt charts and establish identification using a variant of g-computation that seeks expert input only for components unidentifiable from data. To make egg-computation practical, we develop an LLM-assisted pipeline that reliably scales up expert reasoning. In simulations, egg-computation outperforms conventional causal inference methods when patients have diverse causal structures and intervention mechanisms. In a study of eleven candidate QI interventions at an urban safety-net hospital, the LLM pipeline generated graphs and time-saving estimates highly concordant with those of human experts. Beyond healthcare, egg-computation is a broadly applicable framework for estimating the average time saved for candidate interventions whose causal mechanisms can be represented using Gantt charts.

From Fuzzy to Formal: Scaling Hospital Quality Improvement with AI

Hospital Quality Improvement (QI) plays a critical role in optimizing healthcare delivery by translating high-level hospital goals into actionable solutions. A critical step of QI is to identify the key modifiable contributing factors, a process we call QI factor discovery, typically through expert-driven semi-structured qualitative tools like fishbone diagrams, chart reviews, and Lean Healthcare methods. AI has the potential to transform and accelerate QI factor discovery, which is traditionally time- and resource-intensive and limited in reproducibility and auditability. Nevertheless, current AI alignment methods assume the task is well-defined, whereas QI factor discovery is an exploratory, fuzzy, and iterative sense-making process that relies on complex implicit expert judgments. To design an AI pipeline that formalizes the QI process while preserving its exploratory components, we propose viewing the task as learning not only LLM prompts but also the overarching natural-language specifications. In particular, we map QI factor discovery to steps of the classical AI/ML development process (problem formalization, model learning, and model validation) where the specifications are tunable hyperparameters. Domain experts and AI agents iteratively refine both the overarching specifications and AI pipeline until AI extractions are concordant with expert annotations and aligned with clinical objectives. We applied this "Human-AI Spec-Solution Co-optimization" framework at an urban safety-net hospital to identify factors driving prolonged length of stay and unplanned 30-day readmissions. The resulting AI-for-QI pipelines achieved $\ge 70\%$ concordance with expert annotations. Compared to prior manual Lean analyses, the AI pipeline was substantially more efficient, recovered previous findings, surfaced new modifiable factors, and produced auditable reasoning traces.

Human-AI Co-design for Clinical Prediction Models

Developing safe, effective, and practically useful clinical prediction models (CPMs) traditionally requires iterative collaboration between clinical experts, data scientists, and informaticists. This process refines the often small but critical details of the model building process, such as which features/patients to include and how clinical categories should be defined. However, this traditional collaboration process is extremely time- and resource-intensive, resulting in only a small fraction of CPMs reaching clinical practice. This challenge intensifies when teams attempt to incorporate unstructured clinical notes, which can contain an enormous number of concepts. To address this challenge, we introduce HACHI, an iterative human-in-the-loop framework that uses AI agents to accelerate the development of fully interpretable CPMs by enabling the exploration of concepts in clinical notes. HACHI alternates between (i) an AI agent rapidly exploring and evaluating candidate concepts in clinical notes and (ii) clinical and domain experts providing feedback to improve the CPM learning process. HACHI defines concepts as simple yes-no questions that are used in linear models, allowing the clinical AI team to transparently review, refine, and validate the CPM learned in each round. In two real-world prediction tasks (acute kidney injury and traumatic brain injury), HACHI outperforms existing approaches, surfaces new clinically relevant concepts not included in commonly-used CPMs, and improves model generalizability across clinical sites and time periods. Furthermore, HACHI reveals the critical role of the clinical AI team, such as directing the AI agent to explore concepts that it had not previously considered, adjusting the granularity of concepts it considers, changing the objective function to better align with the clinical objectives, and identifying issues of data bias and leakage.

When the Domain Expert Has No Time and the LLM Developer Has No Clinical Expertise: Real-World Lessons from LLM Co-Design in a Safety-Net Hospital

Large language models (LLMs) have the potential to address social and behavioral determinants of health by transforming labor intensive workflows in resource-constrained settings. Creating LLM-based applications that serve the needs of underserved communities requires a deep understanding of their local context, but it is often the case that neither LLMs nor their developers possess this local expertise, and the experts in these communities often face severe time/resource constraints. This creates a disconnect: how can one engage in meaningful co-design of an LLM-based application for an under-resourced community when the communication channel between the LLM developer and domain expert is constrained? We explored this question through a real-world case study, in which our data science team sought to partner with social workers at a safety net hospital to build an LLM application that summarizes patients' social needs. Whereas prior works focus on the challenge of prompt tuning, we found that the most critical challenge in this setting is the careful and precise specification of \what information to surface to providers so that the LLM application is accurate, comprehensive, and verifiable. Here we present a novel co-design framework for settings with limited access to domain experts, in which the summary generation task is first decomposed into individually-optimizable attributes and then each attribute is efficiently refined and validated through a multi-tier cascading approach.