Loud or Silent? A Reusable Framework for Per-Modality Failure Analysis in Multimodal Clinical AI

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Summary

This paper presents a model-agnostic framework for per-modality failure analysis in multimodal clinical AI, distinguishing loud vs silent failures when a modality is dropped. Validated on planted ground truth and applied to EchoJEPA and HuBERT-ECG embeddings for LVEF prediction, it shows that dropping echo nearly doubles error.

Multimodal clinical models are usually judged on accuracy with every modality present, but deployment removes modalities; an echocardiogram is often unavailable where an ECG is routine. Two questions then matter beyond the size of the accuracy loss: which modality was responsible, and whether the model fails loudly or silently once that modality is dropped. The distinction is per-example and modality-level, and is separate from post-hoc feature attribution (e.g. SHAP). Models are replaced often; the evaluation that answers these questions is reused. We present a model-agnostic modality-failure framework: given N modality embeddings, any mask-aware probe, and labels, it returns a per-example failure taxonomy, a per-modality complementarity matrix that attributes error to modalities, and a loud-vs-silent dropout profile separating monitorable failures from those that pass unflagged far from the decision boundary, using only deployment-observable signals. We release it as a small, unit-tested harness and validate it against planted ground truth. Across seeds it recovers that planted modality dominance and complementary subset, reports per-modality loud-vs-silent rates, and scales to a three-modality complementarity matrix; because the planted structure is known by construction, this validates recovery of per-example attribution rather than clinical performance. We then instantiate the framework on frozen EchoJEPA and HuBERT-ECG embeddings for LVEF and the EF <= 40% HFrEF gate over a paired MIMIC-IV cohort, where on the held-out test split (n = 245) dropping echo nearly doubles error. The narrow echo-to-ECG overlap that bounds cohort size is itself a deployment finding for cardiac foundation models. All of our work can be found at https://github.com/criticaldata/PRIMED-AI.
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Abstract

Multimodalclinicalmodelsareusuallyjudgedonaccuracywitheverymodalitypresent,butdeploymentremovesmodalities;anechocardiogramisoftenunavailablewhereanECGisroutine.Twoquestionsthenmatterbeyondthesizeoftheaccuracyloss:whichmodalitywasresponsible,andwhetherthemodelfailsloudlyorsilentlyoncethatmodalityisdropped.Thedistinctionisper-exampleandmodality-level,andisseparatefrompost-hocfeatureattribution(e.g.SHAP).Modelsarereplacedoften;theevaluationthatanswersthesequestionsisreused.Wepresentamodel-agnosticmodality-failureframework:givenNmodalityembeddings,anymask-awareprobe,andlabels,itreturnsaper-examplefailuretaxonomy,aper-modalitycomplementaritymatrixthatattributeserrortomodalities,andaloud-vs-silentdropoutprofileseparatingmonitorablefailuresfromthosethatpassunflaggedfarfromthedecisionboundary,usingonlydeployment-observablesignals.Wereleaseitasasmall,unit-testedharnessandvalidateitagainstplantedgroundtruth.Acrossseedsitrecoversthatplantedmodalitydominanceandcomplementarysubset,reportsper-modalityloud-vs-silentrates,andscalestoathree-modalitycomplementaritymatrix;becausetheplantedstructureisknownbyconstruction,thisvalidatesrecoveryofper-exampleattributionratherthanclinicalperformance.WetheninstantiatetheframeworkonfrozenEchoJEPAandHuBERT-ECGembeddingsforLVEFandtheEF<=40%HFrEFgateoverapairedMIMIC-IVcohort,whereontheheld-outtestsplit(n=245)droppingechonearlydoubleserror.Thenarrowecho-to-ECGoverlapthatboundscohortsizeisitselfadeploymentfindingforcardiacfoundationmodels.Allofourworkcanbefoundathttps://github.com/criticaldata/PRIMED-AI.

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