ELICITED: EHR-grounded Longitudinal Interactive Conversations for Information-seeking Triage Evaluation and Decision-making

Emergency-department (ED) triage requires clinicians to rapidly identify patients who need immediate attention, determine who can safely wait, and prioritize limited clinical resources. At presentation, however, information may be limited to a chief complaint and initial vital signs. Clinically important details, including symptom onset and progression, associated symptoms, medical history, and medication use, are often obtained through focused conversation. Effective triage therefore requires clinicians to identify information gaps, ask appropriate follow-up questions, and update their assessment as new evidence becomes available. Most existing ED benchmarks evaluate acuity prediction from a fixed clinical snapshot. Although this formulation measures predictive performance after patient information has been assembled, it does not capture the interactive process through which triage-relevant evidence is elicited and interpreted. Existing medical dialogue datasets support the study of clinical communication, but dialogue statements are not always linked to temporally ordered events in the electronic health record (EHR). We introduce EHR2Dial-Triage, an agentic conversation-generation framework and benchmark grounded in MIMIC-IV-ED. The framework constructs triage conversations under explicit role-based and temporal information boundaries. Each accepted patient disclosure is linked to its supporting EHR event and the first dialogue turn at which it becomes available. EHR2Dial-Triage enables controlled evaluation of information elicitation, evidence use, five-level Emergency Severity Index prediction, and patient-facing communication across models and patient personas. It provides a structured setting for studying conversational triage as a dynamic process of clinical information acquisition, reasoning, and communication.

CRS-Triage: Confidence- and Reliability-Aware Selective Triage under Incomplete Clinical Evidence

Emergency triage requires reliable decisions within a short time period. However, the available electronic health record (EHR) data, including structured data and clinical text, are often incomplete, unreliable, and inconsistent. This makes machine learning (ML)-based triage prediction more challenging, as existing ML models typically rely on complete and reliable EHR data to accurately predict patients' acuity levels. To address this, we propose confidence- and reliability-aware selective triage (CRS-Triage) to predict patients' acuity levels with a confidence score. By comparing the confidence score with a predefined threshold, CRS-Triage can selectively determine whether the model should make the decision or defer the case. Specifically, CRS-Triage separately evaluates the reliability of structured data and clinical text and then jointly considers the consistency between the two modalities to estimate the confidence of each prediction. Moreover, to reduce the risk of missing high-acuity patients, namely under-triage, CRS-Triage prefers to assign patients slightly higher acuity levels, namely over-triage, by penalizing under-triage errors. Experiments on the MIMIC-IV-ED dataset show that CRS-Triage achieves strong predictive performance. It also provides a better risk-coverage trade-off and remains reliable when the available EHR data are incomplete, degraded, or inconsistent across modalities.

The complexities of patient-centred conversational artificial intelligence

Consumer-facing health chatbots powered by large language models (LLMs) are increasingly used for symptom assessment. However, chatbot development and evaluation often rely on cooperative, articulate, simulated patients. We analysed 2,053 real patient-chatbot conversations and found that communication patterns and expression of emotions vary widely across users. We developed a patient simulator that separately models clinical content, emotional state, conversational strategy, and communication style. In a Turing-inspired evaluation of realism with 15 human graders, simulated conversations were nearly indistinguishable from real ones, with human graders achieving an accuracy of 55%. We used five distinct patient personae, across 1,164 clinician-graded cases, to evaluate the performance of four LLMs in urgency assessment. We found that communication style can significantly alter triage outcomes. Patient-centred conversational artificial intelligence must accommodate communication diversity: systems designed for idealised, rather than realistic, interactions risk underperforming and amplifying health disparities when deployed in the real world.

Can LLMs Rank? A Tale of Triads and Triage

From housing allocation for households experiencing homelessness to triage in emergency departments, LLMs are increasingly being considered as judges of consequential decisions that require ranking people for scarce resources. Ranking large groups simultaneously is cognitively demanding and error-prone. A natural solution, drawing on decades of social choice theory, elicits pairwise comparisons and aggregates them into a total order. However, a fundamental question remains when LLMs serve as the pairwise judge: how can a practitioner tell, before committing to a ranking, whether the LLM's judgments are sufficiently consistent to trust the result? We discuss two different ways of identifying consistency. A classical diagnostic, the coefficient of consistency $ζ$, originally developed to measure judge reliability by counting circular triads in tournament graphs, provides a cheap, model-free measure of intra-run consistency. Various standard measures of distance between rankings, for example Kendall's $τ$, can measure inter-run variability. We show, in both theory and practice, that these measures are independently valuable, and advocate for using both to assess reliability of rankings. We demonstrate the practical importance of our results across two high-stakes prioritization tasks: homelessness service allocation and emergency department triage. Three different leading LLMs have considerably different performance profiles across these two axes of consistency. We provide guidelines for how practitioners could think about measuring and assessing consistency before committing to a model for ranking or prioritization.

LLM-Guided Evolution for Medical Decision Pipelines

Adapting large language models (LLMs) to clinical workflows often requires costly fine-tuning or manual prompt and pipeline engineering. We study LLM-guided MAP-Elites evolution as an inference-time alternative for discovering medical decision strategies and provide an implementation repository at https://github.com/univanxx/llm_guided_evo_medical. We formulate urgency triage, interactive consultation, and medical image classification as evolutionary searches over executable artifacts optimized by task-specific fitness functions. Across all three settings, evolution improves over manually designed baselines under practical constraints. In triage, evolved programs increase Semigran accuracy from $77.3\%$ to $87.1\%$ and emergency recall from $0.60$ to $0.97$, while improving safety-weighted held-out MIMIC-ESI performance. In interactive consultation, evolved policies improve the accuracy--cost frontier across Llama-3, Qwen-3.5, and Gemma-4 and transfer to held-out iCRAFTMD. In PneumoniaMNIST, prompt-only evolution improves frozen MedGemma VLMs while preserving strict JSON outputs. Qualitative analysis shows that the gains come from interpretable program-level mechanisms, calibrated triage boundaries, targeted evidence acquisition, selective commitment, and finding-oriented visual decision rules, rather than superficial prompt rewording alone.

Monitoring Agentic Systems Before They're Reliable

Agentic systems entering production typically operate as partially integrated assemblies where structural defects, not task-level errors, dominate the failure landscape. At this maturity level, task-level error detection may be infeasible: structural failure modes mask the signal that task-level monitors are designed to detect.We present a monitoring and triage methodology that decomposes agentic system evaluation into three dimensions (quality, suitability, efficiency) at three monitoring scopes (within-run, cross-run, structural), using variance as a characterization signal. Findings are routed through severity classification adapted from FMEA, concentrating human attention on the subset that warrants investigation. We evaluate on a synthetic testbed of 220 runs across 120 document bundles with controlled error injection.Three results emerge. Monitor scope determines failure type: within-run monitors surface deterministic stage defects (CV = 0.02), cross-run monitors surface stochastic integration consequences (CV = 1.25, 24% at L2), and a structural monitor identifies an integration gap with perfect consistency (CV = 0.00). Injected task-level errors are indistinguishable from clean baselines, confirming structural defects mask task-level signal. Deterministic triage routes 97% of findings to automated tracking, leaving the 2% reflecting variable behavior for human investigation.We propose, on Stage 1 evidence, a maturity-staging model in which monitoring transitions from structural characterization to error detection to reliability tracking as integration defects resolve. The taxonomy, CV-based scope characterization, and severity model transfer architecturally to document-driven, multi-stage agentic workflows in regulated industries; specific calibrations are domain-specific. Deploy monitoring early: the first thing it finds is the most important thing to fix.