REVIEW 3 major objections 6 minor 89 references
FoMoH: A clinically meaningful foundation model evaluation for structured electronic health records
T0 review · 3 major / 6 minor · reviewed 2026-08-07 · deepseek-v4-flash
Pith's one-line read FoMoH benchmarks six EHR foundation models on 14 clinical tasks and finds their frozen embeddings do not beat supervised baselines where labels are rare.
desk verdict A solid, genuinely useful EHR foundation-model benchmark whose central negative finding is real but specifically about linear probing, not about the models under fine-tuning. read the letter →
The pith
A machine-rendered reading of the paper's core claim, the machinery that carries it, and where it could break.
The reading
What carries the argument
The load-bearing mechanism is the FoMoH evaluation protocol itself: 14 clinically defined tasks with at-risk and case cohorts, a fixed patient split that separates pre-training and evaluation, six models standardized to 768-dimensional embeddings with roughly 120 million parameters, and linear probing — fitting a logistic regression with cross-validated ℓ2 penalty on frozen embeddings — as the common readout. The protocol measures AUROC, Brier score, and maximum subgroup gaps by sex, race, and healthcare utilization, which lets the paper separate discrimination, calibration, and fairness rather than relying on a single rank.
What would settle it
Re-run the same 14 tasks with full fine-tuning of the same six models instead of linear probing; if masked-language-model architectures such as CEHR-BERT or CORE-BEHRT then outperform the best tabular baseline on the rare phenotypes, the paper's negative conclusion would be shown to be an artifact of the probing protocol rather than a property of the representations. An audit of the patient split for pre-training/evaluation overlap would settle whether leakage is present.
Extended reading notes
Core claim
The central claim is that, at least under a frozen-embedding linear-probing evaluation, current EHR foundation models have not yet earned their promise in the settings where labels are scarcest. On common tasks such as readmission the best foundation model wins, but on rarer phenotypes the best supervised baseline frequently has the best calibration and competitive discrimination, and the gap grows in the small-data regime. The paper further claims that models with explicit temporal objectives — predicting time-to-event in MOTOR or time tokens in CEHR-GPT — do better on longer-horizon outcomes, that including laboratory values can hurt rather than help when embedding size is fixed, and that an externally pre-trained model degrades sharply on a new institution's data, partly because tokenizers fail to recognize that institution's codes.
Load-bearing premise
The conclusions depend on the assumption that reading out a foundation model's frozen embedding with a simple linear classifier is a fair test of its usefulness in the clinic, and that evaluation patients were truly excluded from pre-training; if either fails, the negative results are artifacts of the protocol.
Editorial extensions
If this is right
- Frozen embeddings from current EHR foundation models should not be assumed to help where labeled data and outcome prevalence are low; the benchmark finds no conclusive edge over tabular baselines there.
- Future EHR pre-training should invest in explicit temporal objectives such as time-to-event prediction or inter-event time tokens, since these correlate with the best long-horizon results in this evaluation.
- Adding more data sources such as laboratory tests is not automatically beneficial; models trained without labs performed comparably or better under the fixed embedding budget.
- A foundation model trained at one institution can lose much of its value at another unless tokenization and coding practices align, so transportability must be measured, not assumed.
- Evaluations that report only AUROC can miss calibration and fairness tradeoffs; the benchmark's baselines show the largest healthcare-utilization gaps, while pre-trained models are more even across groups.
Reading between the lines
- A plausible reading the authors leave implicit is that masked-language-model architectures might still shine if fine-tuned end-to-end; the paper's own limitation section concedes that fine-tuning could change the rankings, so the negative result should be read as about frozen representations, not about the models' full potential.
- If temporal modeling is the main driver, contrastive or time-aware objectives could be combined with smaller context windows to cut inference cost, a direction the paper does not test.
- The benchmark's cohort definitions are designed to be portable, so re-running FoMoH on other hospital systems would be a direct test of whether rare-condition gaps and transportability failures generalize; the paper only evaluates one center.
- Since baselines show larger fairness gaps by healthcare utilization, pre-training may act as a regularizer on subgroup performance, but this would need confirmation on other datasets before it becomes a design recommendation.
Editorial analysis
A structured set of objections, weighed in public.
Referee Report
Summary. The paper introduces FoMoH, a benchmark for structured-electronic-health-record foundation models using 14 clinically motivated tasks (11 phenotypes and 3 patient outcomes) defined on roughly 5.3 million patients from Columbia University Irving Medical Center, standardized to MEDS and OMOP-compatible formats. It evaluates six foundation models (CEHR-BERT, CEHR-GPT, CORE-BEHRT, LLAMA, MAMBA, MOTOR), a transported Stanford-trained MAMBA, and tabular baselines (FEMR and MEDS-TAB with logistic regression, LightGBM, and XGBoost), all compared through local pre-training followed by linear probing. Metrics include AUROC, Brier score, subgroup fairness gaps, and inference FLOPs. The central findings are that foundation model embeddings do not provide conclusive improvement over supervised baselines for low-data and low-prevalence tasks, that explicit temporal modeling appears more valuable than adding laboratory modalities, and that direct transport of a pre-trained model across institutions degrades performance.
Significance. If the findings hold, FoMoH is a valuable resource: it contributes a standardized, ACES/MEDS-compatible task suite with a fixed patient split aimed at preventing leakage, and it broadens EHR foundation-model evaluation beyond AUROC to calibration, fairness, and computational cost. The negative result on low-data and low-prevalence tasks is an important corrective to the prevailing narrative of EHR foundation model advantage, and the observation that temporal encoding matters more than additional modalities is a concrete, testable design hypothesis. The paper also ships a public benchmark and task definitions, which strengthens reproducibility. The main limitation is that the conclusions are tied to a linear-probing protocol and to several design choices that are not fully isolated, so the strength of the claims needs to be tempered accordingly.
major comments (3)
- [Section 6 / 6.1 / 4.2] The central claim that "foundation models do not provide conclusive improvement over supervised baselines for low-data and low-prevalence tasks" is stated in the abstract and in Section 6 without the qualifier "under linear probing." All foundation model results are obtained by fitting a logistic regression on frozen embeddings (Section 4.2), and Section 6.1 explicitly concedes that "fine-tuning strategies may result in conclusions different from those presented in this work." Because the claimed failure regime is precisely the setting where a frozen linear probe is least likely to exploit task-adapted representations, the headline should either be qualified throughout, or the authors should add a fine-tuning comparison on a subset of low-prevalence tasks (e.g., CLL and celiac disease) to test whether the negative result is an artifact of the probing protocol.
- [Appendix D.1 / Tables 1 and 14] The input code vocabulary is not held constant across models. CEHR-BERT and CEHR-GPT are trained and evaluated on OMOP standard concept codes, whereas the other foundation models and the FEMR/MEDS-TAB baselines operate on MEDS source concept codes such as ICD-9/10. This choice is intended to match the original codebases, but it means that cross-model comparisons, for example the CEHR-GPT versus MAMBA differences reported in Section 5, conflate model design with code representation. The manuscript should state this confound wherever cross-model conclusions are drawn and, ideally, include an ablation with a common code vocabulary for at least one model pair to assess its impact.
- [Section 4 / Appendix F.4 / Table 2] The construction of "Best Baseline" is not defined. Appendix F.4 states that "all previous tables and figures reflect the best performance across these different models," but it does not specify whether the best baseline is selected on the 10% tuning split or on the test set. If selection is based on test-set performance, the baseline is an oracle and the central "no conclusive improvement" claim is biased in favor of the baselines. Please specify the selection procedure, and if test-based selection is used, report each baseline separately and identify the baseline selected on the tuning split.
minor comments (6)
- [Abstract] There is a typo in "across14 clinically relevant tasks"; a space is missing between "across" and "14."
- [Figure 2 caption / Section 4] The Figure 2 caption says the top row reflects the smallest amount of data used for training the linear probing, "i.e., 100 points," while Section 4 states that the training set is capped at 100,000 records. Please clarify whether "100 points" refers to a specific task, to positive examples, or to the smallest task size, and reconcile the numbers.
- [Table 6 / Appendix D.2] The last row of Table 6 is labeled "FEMR" but the surrounding text describes a decoder that uses RoPE and sinusoidal age embeddings; this appears to be a typo for MOTOR. Please correct the label or the accompanying text.
- [Section 3.3] In the CORE-BEHRT paragraph, "Contrarily to CEHR-BEHRT" should read "CEHR-BERT."
- [Section 5] The sentence "In our analysis of available data sources (Appendix C), we find that lab tests are, on average, more prevalent" is confusing; the surrounding argument is that lab tests are not informative. Consider rewording to "more numerous but not more informative" or similar.
- [Section 4 / Appendix B] Because the low-prevalence argument is central to the paper, consider reporting the prevalence and cohort size for every task in the main text rather than only in the appendix, so that readers can gauge the reliability of the AUROC and Brier estimates for rare phenotypes.
Circularity Check
No significant circularity: the benchmark evaluates held-out downstream tasks with linear probing against independent baselines, and the acknowledged scope limitation is not a circular reduction.
full rationale
This paper is an empirical benchmark rather than a derivation, so there is no chain in which a fitted parameter is renamed as a prediction or in which a result reduces by construction to an input. Downstream evaluation uses a fixed patient split (60% train, 10% tuning, 30% evaluation), linear probing with cross-validated lambda selection, and bootstrapped confidence intervals. All foundation models, including the authors' own CEHR-BERT and CEHR-GPT, are retrained locally on CUMC data and compared against independent tabular baselines (FEMR, MEDS-TAB) and external architectures (LLAMA, MAMBA, MOTOR), so the central comparison is externally grounded rather than forced by any fitted value. The paper's statement that 'fine-tuning strategies may result in conclusions different from those presented in this work' (Section 6.1) is an explicit scope restriction on the linear-probing protocol, not a hidden circular step; it qualifies the claim but does not make the claim equivalent to its inputs. The use of same-institution models is a standard benchmarking choice and does not constitute self-citation load-bearing evidence, because the models' performance is measured on held-out outcomes rather than inferred from the cited papers. No specific equation or definition is found that reduces to itself, so the appropriate finding is no significant circularity.
Assumptions & free parameters
free parameters (5)
- Context length coverage threshold =
99%
- Linear probing training cap =
100,000 records
- Evaluation set cap =
50,000 records
- Phenotype prediction window =
1 year
- Healthcare utilization tertiles =
Empirical tertiles of encounters per year
assumptions (5)
- domain assumption EHR data in OMOP CDM and MEDS faithfully represent patient health trajectories.
- domain assumption Phenotype algorithms from OHDSI, PheKB, and clinical risk factors are valid proxies for ground-truth disease status.
- domain assumption ICD-9 to ICD-10 mapping via GEM is adequate for harmonizing diagnoses.
- ad hoc to paper Linear probing of frozen embeddings reflects downstream clinical utility.
- ad hoc to paper Two years of observation before prediction time is sufficient baseline history.
Cite this review
Pith. "Pith review of FoMoH: A clinically meaningful foundation model evaluation for structured electronic health records." pith.science (2026). https://pith.science/paper/4BOOTXZC
@misc{pith2026250516941,
author = {Pith},
title = {Pith review of: FoMoH: A clinically meaningful foundation model evaluation for structured electronic health records},
year = {2026},
howpublished = {\url{https://pith.science/paper/4BOOTXZC}},
note = {Machine review of arXiv:2505.16941}
}
read the original abstract
Foundation models hold significant promise in healthcare, given their capacity to extract meaningful representations independent of downstream tasks. This property has enabled state-of-the-art performance across several clinical applications trained on structured electronic health record (EHR) data, even in settings with limited labeled data, a prevalent challenge in healthcare. However, there is little consensus on these models' potential for clinical utility due to the lack of desiderata of comprehensive and meaningful tasks and sufficiently diverse evaluations to characterize the benefit over conventional supervised learning. To address this gap, we propose a suite of clinically meaningful tasks spanning patient outcomes, early prediction of acute and chronic conditions, including desiderata for robust evaluations. We evaluate state-of-the-art foundation models on EHR data consisting of 5 million patients from Columbia University Irving Medical Center (CUMC), a large urban academic medical center in New York City, across 14 clinically relevant tasks. We measure overall accuracy, calibration, and subpopulation performance to surface tradeoffs based on the choice of pre-training, tokenization, and data representation strategies. Our study aims to advance the empirical evaluation of structured EHR foundation models and guide the development of future healthcare foundation models.
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URL https://doi.org/10.1146/ annurev-biodatasci-092820-114757
doi: 10.1146/annurev-biodatasci-092820-114757. URL https://doi.org/10.1146/ annurev-biodatasci-092820-114757
Reviewed August 7, 2026 · model on record in the stance chip above.
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