Mapping the Ictal-Interictal-Injury Continuum Using Interpretable Machine Learning

IMPORTANCE: An interpretable machine learning model can provide faithful explanations of each prediction and yet maintain higher performance than its black box counterpart. OBJECTIVE: To design an interpretable machine learning model which accurately predicts EEG protopatterns while providing an explanation of its predictions with assistance of a specialized GUI. To map the cEEG latent features to a 2D space in order to visualize the ictal-interictal-injury continuum and gain insight into its high-dimensional structure. DESIGN, SETTING, AND PARTICIPANTS: 50,697 50-second cEEG samples from 2,711 ICU patients collected between July 2006 and March 2020 at Massachusetts General Hospital. Samples were labeled as one of 6 EEG activities by domain experts, with 124 different experts providing annotations. MAIN OUTCOMES AND MEASURES: Our neural network is interpretable because it uses case-based reasoning: it compares a new EEG reading to a set of learned prototypical EEG samples from the training dataset. Interpretability was measured with task-specific neighborhood agreement statistics. Discriminatory performance was evaluated with AUROC and AUPRC. RESULTS: The model achieves AUROCs of 0.87, 0.93, 0.96, 0.92, 0.93, 0.80 for classes Seizure, LPD, GPD, LRDA, GRDA, Other respectively. This performance is statistically significantly higher than that of the corresponding uninterpretable (black box) model with p<0.0001. Videos of the ictal-interictal-injury continuum are provided. CONCLUSION AND RELEVANCE: Our interpretable model and GUI can act as a reference for practitioners who work with cEEG patterns. We can now better understand the relationships between different types of cEEG patterns. In the future, this system may allow for targeted intervention and training in clinical settings. It could also be used for re-confirming or providing additional information for diagnostics.

Why Interpretable Causal Inference is Important for High-Stakes Decision Making for Critically Ill Patients and How To Do It

Many fundamental problems affecting the care of critically ill patients lead to similar analytical challenges: physicians cannot easily estimate the effects of at-risk medical conditions or treatments because the causal effects of medical conditions and drugs are entangled. They also cannot easily perform studies: there are not enough high-quality data for high-dimensional observational causal inference, and RCTs often cannot ethically be conducted. However, mechanistic knowledge is available, including how drugs are absorbed into the body, and the combination of this knowledge with the limited data could potentially suffice -- if we knew how to combine them. In this work, we present a framework for interpretable estimation of causal effects for critically ill patients under exactly these complex conditions: interactions between drugs and observations over time, patient data sets that are not large, and mechanistic knowledge that can substitute for lack of data. We apply this framework to an extremely important problem affecting critically ill patients, namely the effect of seizures and other potentially harmful electrical events in the brain (called epileptiform activity -- EA) on outcomes. Given the high stakes involved and the high noise in the data, interpretability is critical for troubleshooting such complex problems. Interpretability of our matched groups allowed neurologists to perform chart reviews to verify the quality of our causal analysis. For instance, our work indicates that a patient who experiences a high level of seizure-like activity (75% high EA burden) and is untreated for a six-hour window, has, on average, a 16.7% increased chance of adverse outcomes such as severe brain damage, lifetime disability, or death. We find that patients with mild but long-lasting EA (average EA burden >= 50%) have their risk of an adverse outcome increased by 11.2%.

Using Deep Learning to Identify Patients with Cognitive Impairment in Electronic Health Records

Dementia is a neurodegenerative disorder that causes cognitive decline and affects more than 50 million people worldwide. Dementia is under-diagnosed by healthcare professionals - only one in four people who suffer from dementia are diagnosed. Even when a diagnosis is made, it may not be entered as a structured International Classification of Diseases (ICD) diagnosis code in a patient's charts. Information relevant to cognitive impairment (CI) is often found within electronic health records (EHR), but manual review of clinician notes by experts is both time consuming and often prone to errors. Automated mining of these notes presents an opportunity to label patients with cognitive impairment in EHR data. We developed natural language processing (NLP) tools to identify patients with cognitive impairment and demonstrate that linguistic context enhances performance for the cognitive impairment classification task. We fine-tuned our attention based deep learning model, which can learn from complex language structures, and substantially improved accuracy (0.93) relative to a baseline NLP model (0.84). Further, we show that deep learning NLP can successfully identify dementia patients without dementia-related ICD codes or medications.

Natural Language Processing to Detect Cognitive Concerns in Electronic Health Records Using Deep Learning

Dementia is under-recognized in the community, under-diagnosed by healthcare professionals, and under-coded in claims data. Information on cognitive dysfunction, however, is often found in unstructured clinician notes within medical records but manual review by experts is time consuming and often prone to errors. Automated mining of these notes presents a potential opportunity to label patients with cognitive concerns who could benefit from an evaluation or be referred to specialist care. In order to identify patients with cognitive concerns in electronic medical records, we applied natural language processing (NLP) algorithms and compared model performance to a baseline model that used structured diagnosis codes and medication data only. An attention-based deep learning model outperformed the baseline model and other simpler models.