Sunday, March 27, 2022

Difference between Specialty, Service, Level-of-Care, and Location?

Hi fellow CMIOs, CNIOs, and other Applied Clinical Informatics and #HealthIT friends,

In today's post, I thought I'd help answer a common clinical terminology question I sometimes get asked, about information management during inpatient hospitalizations : 

I thought I'd write this post, largely because these very important terms

  1. Specialty / Subspecialty
  2. Service
  3. (Nursing) Level-of-Care
  4. Geographic Location
... can often look alike and sound alike, and so they are sometimes easily confused (or used interchangeably) by both clinical and administrative staff.

Unfortunately, getting this terminology right is essential to good communication, good patient flow, good bed management, and good data reporting - So for clinical educational purposes, I figured I'd write this helpful primer on these terms, what they do, and how to use them. 


Specialty (and subspecialty) is what a Provider is trained to do. While the Association of American Medical Colleges (AAMC) recognized the need to stratify medical training back in 1876, this specialty (and subspecialty) training has since continued to evolve

Today, we recognize a number of :

...which together, gives us some of the physician specialties (and subspecialties) that most people will recognize today : 
  • Select ONE :
  • (  ) INTERNAL MEDICINE (General Internal Medicine)
  • (  ) PEDIATRICS (General Pediatrics)
  • (  ) EMERGENCY MEDICINE (General emergency medicine)
  • (  ) RADIOLOGY (General Radiology)
  • (  ) SURGERY (General Surgery)
  • (  ) NEUROLOGY (General Neurology)
  • (  ) OBGYN (General OBGYN)
  • (  ) PSYCHIATRY (General Psychiatry)
Note : While there may be some occasional variation about how one ended up in a particular subspecialty (e.g. Pediatrics>Emergency Medicine, or Emergency Medicine>Pediatrics), historically - this system of categorization has generally worked fairly well, and gives people a good sense of what training the provider has had
The key take-home point : Specialty/Subspecialty training is what the provider has been clinically trained and licensed to do.


Service is what the provider actually does. It'stypically one-or-more clinical function(s) that they have been assigned to deliver.

Services are commonly categorized as either INPATIENT, ED, or OUTPATIENT services, and again, a provider may function in one or more services

  • Select ALL THAT APPLY : 
  • [  ] OUTPATIENT Internal Medicine (Ambulatory Internal Medicine Clinic)
  • [  ] INPATIENT Hospitalist
  • [  ] INPATIENT Intensivist
  • [  ] INPATIENT Labor and Delivery
  • [  ] OUTPATIENT Psychiatry
  • [  ] INPATIENT Psychiatry
  • [  ] EMERGENCY MEDICINE (Emergency Services)
  • [  ] INPATIENT Neurology
  • [  ] OUTPATIENT Neurology (Ambulatory Neurology Clinic)
  • [  ] INPATIENT Surgery 
  • [  ] OUTPATIENT Surgery (Ambulatory Surgery Clinic)

... and many other clinical services (functions) that have been designed to provide patient care services in various settings

This is where confusion can sometimes arise, especially for scenarios where a provider might have one specialty but two services, e.g. : 

  • SERVICE1 (Primary Service= OUTPATIENT INTERNAL MEDICINE (General Internal Medicine)

Confusing specialty and service can lead to incorrect scheduling of meetings - E.g. Let's say you want to introduce a new outpatient televideo service to your OUTPATIENT INTERNAL MEDICINE docs, then : 

  • [ WRONG WAY ] Mail to SPECIALTY = Internal Medicine ('Please mail this to all Internal Medicine Docs!')
  • [ RIGHT WAY ] Mail to SERVICE = Outpatient Internal Medicine ('Please mail this to all docs who work in the Outpatient Internal Medicine Clinic/Service!')

If you accidentally did mail your announcement to SPECIALTY = Internal Medicine, then half of the recipients might wonder why you contacted them about this new outpatient tool : 

  • [ INTENDED AUDIENCE ] SERVICE = Outpatient Internal Medicine
  • [ UNINTENDED AUDIENCE ] SERVICE = Inpatient Hospitalist

As you can see, it's very easy to get tripped up on this terminology, when it looks so similar

One final note about SERVICE - This is often used during inpatient admissions to describe the "Admitting/Covering Service", as in, who should Nursing call when they identify something that needs a Physician's attention?


The (Nursing) Level-of-Care is an important concept that basically answers the question, "What are the nursing standards that are required for a patient admitted in this hospital bed?" Typically, this is based on patient type and acuity, and is developed in conjunction with both Nursing Leadership and Physician Leadership. From a practical standpoint, this usually needs to include some agreements about : 

  • Patient Acuity - How active are the patient's medical problems, and how much care will they need? (Low/Medium/High?)
  • Standard Frequency of Vitals - How often does a Nurse need to monitor the patient?
  • Standard Nursing Skill Set - What are the Nurses trained/certified to do? Is it general care, or specialty care? On what patient population? Adults? Pediatric? Neonates?
  • Standard Nurse Staffing Ratios - How many patients are Nurses routinely expected to manage concurrently for this Level-of-Care?

Because these are all important to establish a level-of-care, they are commonly laid out in a table that might look something like this : 

So to help standardize care along the needs of the patient (and patient acuity), most admission order sets are aligned along these Nursing Levels-of-Care, with vitals that default to the institutional standards - E.g. :

  • [   ] Vital Signs every 8 hours
  • [   ] Vital Signs every 6 hours
... and ...
  • [   ] Vital Signs every 1 hour
  • [   ] Vital Signs continuously
... and so on. 


Geographic location technically should be the easiest concept to manage - It's just the floor/room (and sometimes bed slot, E.g. Bed A or Bed B) that the patient's bed is geographically located in. Sometimes it also includes a temporary location, such as when a patient is being temporarily located in Radiology for an X-ray :

  • Geographic Location = Room 401 
  • Temporary Location = Radiology
  • Sometimes displayed as "Room 401 (Radiology)"

However, location can occasionally be confused with a (Nursing) Level of Care, especially when naming conventions sometimes combine these concepts, usually intended for convenience purposes. (E.g. "5th Floor Telemetry")

Note that there are two challenges that can sometimes occur when combining these concepts in the naming convention for your geographic locations/floors : 

1. FIRST CHALLENGE : The first of these challenges is boarding - which is when a patient bed needs to be created in a non-standard location, usually for patient flow and/or surge purposes. For example - 

  • If you usually have ten (10) beds on your FOURTH floor, where you commonly care for up to ten (10) Med/Surg patients...
  • One day, you have a patient surge, and need to be able to care for twelve (12) Med/Surg patients...
  • ... then you will need to create two (2) extra Med/Surg beds, maybe on the FIFTH floor

Assuming you are approved to 'surge' your bed capacity like this, and have the Med/Surg nurses available to support those two (2) extra Med/Surg beds on the FIFTH floor, then you can hypothetically create a bed with a defined (Nursing) level-of-care in any geographic location that can support the delivery of the necessary (Nursinglevel-of-care

For example, in an disaster scenario, you could hypothetically make a med/surg bed available in your cafeteria (assuming you had the available resources) : 

  • ADMIT TO = Med/Surg Level-of-care
  • SERVICE = Inpatient Hospitalist

Or, if you are admitting a Med/Surg Patient from the Emergency Room to your FOURTH floor (where you commonly care for Med/Surg patients) - If there is no bed available on the FOURTH floor, you you could hypothetically admit and 'board' the Med/Surg patient (temporarily) in an Emergency Department location : 

  • ADMIT TO = Med/Surg Level-of-Care
  • SERVICE = Inpatient Hospitalist
... and then once the bed becomes available on the FOURTH floor, you could update the status: 

  • ADMIT TO = Med/Surg Level-of-Care
  • GEOGRAPHIC LOCATION = Fourth Floor Bed 401
  • SERVICE = Inpatient Hospitalist

As you can see, keeping this terminology clear and concise is important for the delivery of services. 

2. SECOND CHALLENGE : The second challenge that comes from naming conventions that combine concepts (e.g. "FOURTH Floor Med/Surg") is data-reporting. Suppose that when beds are needed - you 

  • sometimes have to board MED/SURG patients on your FIFTH floor, or 
  • sometimes you have to board TELEMETRY patients on your FOURTH floor.

And then one day, you need to know, "How many Med/Surg patients did we see last month?"

  • If you generate a report of 'How many patients were geographically admitted to the FOURTH floor', you may miss any Med/Surg patients who were boarded in other locations, or over-count other telemetry patients who might have been temporarily boarded on the FOURTH floor.
  • If, instead, you generate a report of 'How many patients were admitted with a Level-of-Care=Med/Surg", your report will be accurate and will account for any patients who were temporarily boarded in non-standard locations.
If this all seems confusing, you're not alone. Even seasoned professionals can sometimes confuse/interchange these terms. It's helpful to have an experienced Clinical LeaderBed Manager, HIM/Billing/Coding person, or Applied Clinical Informatics person to help translate/validate, help design your bed management and patient flow strategy, and then help turn that into build/configuration that meets the needs of your patients, Nurses, Physicians, Bed Managers, Billers/Coders, and Data Reporting teams

In conclusion - These terms are all very important, and are the reason most hospital admissions contain the following information : 
  • [ REQUIRED ] ADMIT TO = ________ (NursingLevel-of-care
  • [ REQUIRED ] SERVICE = ___________
  • [ OPTIONAL ] GEOGRAPHIC LOCATION=(Use only if a particular location is necessary, otherwise Nursing may not have any flexibility about where to geographically locate the patient in a surge/boarding scenario.)

... and why it's also helpful to track doctors by both their specialty/subspecialty and also their service(s)

  • SPECIALTY/SUBSPECIALTY = Internal Medicine (General Internal Medicine)
  • SERVICE1 (Primary Service) = Inpatient Hospitalist
  • SERVICE2 (Secondary Service) = Outpatient General Internal Medicine

While this may have been somewhat lengthy, I hope this helps you review and discuss this terminology with your own teams. 

Remember, this blog is for academic/discussion purposes only - Your mileage may vary! Have any patient flow or bed management tips you'd like to share? Have any experiences managing this terminology with your teams, or any other feedback you'd like to share? Leave it in the comments section below!

Saturday, March 19, 2022

What Multicultural, Bilingual Clinical Informaticists Know

Hi fellow CMIOs, CNIOs, Clinical Informaticists, and other HealthIT friends,

Can growing up in a multicultural, bilingual (or polylingual) household help to prepare you for a career in Applied Clinical Informatics? In today's post, I'll explain why I believe the answer to this is "Yes".

Almost all of my Applied Clinical Informatics colleagues that I've met over the years have amazing educational and experiential backgrounds. However, I've noticed that a surprising number of them also come from multicultural backgrounds, where they grew up speaking multiple languages. 

In full disclosure : I don't have great data to support this claim. And I might be biased (or more sensitive) to this issue because I grew up in a polylingual household myself, the son of a German immigrant mother and a polyglot American father, who counted German as one of this favorite and most fluent languages. 

Left : My father during his US military servjce.
Right : My American father and German immigrant mother, circa 1965. 

My father's passion for languages started as a high school student in Yonkers, NY, and would continue to develop until he became a Military Policeman (MP) for the US Army, in Germany, where he also served as a court interpreter. This would also eventually lead him to meet my mother (who had immigrated from Herford, Germany to Westchester County, NY), and to a future career as a high school language teacher at White Plains High School in White Plains, NY.

So with parents like these, I grew up in a multicultural, multilingual household, where we commonly spoke German at home, and then spoke English when other people came to visit our house. Vacations were often spent visiting relatives in Germany, immersed in German language and culture, before returning to America and resuming daily activities in English.

Given my father's interpreter experiences, he always took languages and translation very seriously. Growing up outside of NYC in the 1970s and 1980s, he would occasionally take me into the city to the United Nations, to learn about and watch the famous UN Interpreter pool at work. Over our dinner table, we would often discuss the inseparable bond between culture and language, the real responsibilities of professional interpreters, and the occasional fallibility of both written and spoken words. 

This sort of cross-cultural upbringing led me to some frequent challenges, that most multicultural people can probably relate to

  • Having to explain "American things" to my German family.
  • Having to explain "German things" to my American friends.
  • Occasionally having to do real-time interpretation of English-to-German, and German-to-English, to facilitate discussions between my German family and American friends.

I didn't fully appreciate this sort of multicultural upbringing until I was older, and learned that not everyone struggled with (or learned to manage) these types of issues. 

One of the things you learn from this sort of cross-cultural upbringing is that communication is actually much more frail and fragile than you might imagine. Success often depends on a number of factors helping you achieve a desired comprehension rate

For most routine, practical, day-to-day communications, about 75%-80% comprehension is just fine. Typically, your brain fills in the gaps (without your awareness), and you usually don't even notice the small details you might have missed. It still gets you to work, gets you to dinner on time, lets you order food at restaurants, and lets you manage your typical day-to-day activities. Informally, I personally refer to this as "Kitchen Language", since it's what you'd typically hear in a kitchen when people are making dinner and talking about their day. Failures sometimes happen, but when they do - they usually only result in some brief confusion, a wrong or forgotten birthday gift, or an impromptu discussion about 'ineffective communication' from a loved one. After a little more discussion - The error or conflict usually gets resolved. Failure is usually pretty well-tolerated.

And then there is another standard, which I informally call "High Risk Language". This is where failure is NOT well-tolerated, and so additional work and terminology are commonly required to help ensure a higher accuracy rate, typically >90-95%. Political, industrial, and clinical discussions all fall into this range. Successfully navigating High-Risk Language often requires additional analysis/planning, work, and often even new terminology that both sides (separately) agree to and understand, to help align concepts for effective cross-cultural communication.

*Interesting historical side-note : 
Ever wonder about the June 1961 Cuban Missile summit between Kennedy and Kruschev? Viktor Sukhodrev was the interpreter in between them - Talk about responsibility for ensuring both accurate translation and comprehension!

Don't believe me that age is an important factor in effective communication, even in the same language? Check out this Saturday Night Live skit, "Gen Z Hospital" - Your appreciation of this skit will largely depend on the year you were born. Similarly, different upbringings, experiences, education, and culture can also quietly degrade comprehension rates, sometimes to the point of failure. (Applied Clinical Informaticists often see this cultural boundary when translating across clinical and administrative realms, which both have their own culture and terminology.)

So to overcome these differences across different languages - for both Kitchen Language and High-Risk Language scenarios - good interpreters need to know how different people speak and write. They need to know different cultures and subcultures, and the specific context and nuances of the language they use in each culture

I think this may be why I notice a lot of multicultural, polylingual people in Applied Clinical Informatics. Even in English, this sort of cross-cultural interpretation requires an understanding of two different cultures - Both Clinical, and Information Technology (IT) : 

And then once you have mastered the art of interpreting the culture and language of both sides - you can then become even more helpful when you add clinical architecture to your repertoire, developing new terminology and documented 'blueprints' that meet the needs of both sides

So in closing - I'd say a bilingual (or polylingual), multicultural upbringing can serve as an excellent model for the same interpretation functions that Applied Clinical Informaticists provide in their daily work. It would be interesting to do some formal research into these concepts, to help confirm the value of this sort of early training.

Remember, this blog is for education and discussion only - Your mileage may vary!

Have any thoughts or feedback about this post? Did you grow up in a multicultural household, and do you speak multiple languages? Do you find these experiences helped you in your career in Applied Clinical Informatics? If so, please feel free to leave a comment in the comments box below!