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. 

A. WHAT IS SPECIALTY (and SUBSPECIALTY)

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 :

• RESIDENCIES (SPECIALTY TRAINING)
• FELLOWSHIPS (SUBSPECIALTY TRAINING)

...which together, gives us some of the physician specialties (and subspecialties) that most people will recognize today : 

• Select ONE :
• (  ) INTERNAL MEDICINE (General Internal Medicine)
• (  ) INTERNAL MEDICINE > CARDIOLOGY
• (  ) INTERNAL MEDICINE > ENDOCRINOLOGY
• (  ) INTERNAL MEDICINE > GASTROENTEROLOGY
• (  ) INTERNAL MEDICINE > RHEUMATOLOGY
• (  ) INTERNAL MEDICINE > GERONTOLOGY (Geriatrics)
• (  ) INTERNAL MEDICINE > PULMONARY/CRITICAL CARE
• (  ) INTERNAL MEDICINE > HEMATOLOGY / ONCOLOGY
• (  ) PEDIATRICS (General Pediatrics)
• (  ) PEDIATRICS > EMERGENCY MEDICINE
• (  ) PEDIATRICS > NEONATOLOGY
• (  ) EMERGENCY MEDICINE (General emergency medicine)
• (  ) EMERGENCY MEDICINE > TRAUMATOLOGY
• (  ) EMERGENCY MEDICINE > TOXICOLOGY
• (  ) RADIOLOGY (General Radiology)
• (  ) RADIOLOGY > INTERVENTIONAL
• (  ) SURGERY (General Surgery)
• (  ) SURGERY > ORTHOPEDICS
• (  ) SURGERY > PLASTIC SURGERY
• (  ) SURGERY > NEUROSURGERY
• (  ) SURGERY > TRANSPLANT
• (  ) SURGERY > GYNECOLOGIC
• (  ) SURGERY > VASCULAR
• (  ) NEUROLOGY (General Neurology)
• (  ) NEUROLOGY > MOVEMENT DISORDERS
• (  ) NEUROLOGY > MULTIPLE SCLEROSIS
• (  ) OBGYN (General OBGYN)
• (  ) OBGYN > MATERNAL FETAL MEDICINE
• (  ) OBGYN > FERTILITY MEDICINE
• (  ) PSYCHIATRY (General Psychiatry)
• (  ) PSYCHIATRY > CHILD AND ADOLESCENT

... and over 135 other specialties/subspecialties currently recognized by the AAMC.

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.

B. WHAT IS A SERVICE?

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. : 

• SPECIALTY/SUBSPECIALTY = INTERNAL MEDICINE (General Internal Medicine)
• SERVICE1 (Primary Service) = OUTPATIENT INTERNAL MEDICINE (General Internal Medicine)
• SERVICE2 (Secondary Service) = INPATIENT HOSPITALIST

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 : 

• SPECIALTY = INTERNAL MEDICINE - Includes both : 
• [ 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?

C. WHAT IS A (Nursing) LEVEL-OF-CARE

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. :

• ADMIT TO ADULT MED/SURG : 
• [   ] Vital Signs every 8 hours
• [   ] Vital Signs every 6 hours

... and ...

• ADMIT TO ADULT ICU
• [   ] Vital Signs every 1 hour
• [   ] Vital Signs continuously

... and so on. 

D. WHAT IS A GEOGRAPHIC LOCATION?

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 (Nursing) level-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
• GEOGRAPHIC LOCATION = CAFETERIA Bed 2
• 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
• GEOGRAPHIC LOCATION = ED Bed 2
• 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 Leader, Bed 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 = ________ (Nursing) Level-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!

What exactly does "Inpatient" mean?

Hi fellow CMIOs, CNIOs, Clinical Operations, HIM, and other Clinical Informatics leaders,

I'm constantly amazed by the complexity of medical terminology. A lot of unnecessary heartache comes from the unappreciated differences in understanding between different parts of the clinical care team and other billing/administrative stakeholders.

In modern healthcare, there are a few words which can trigger a special level of confusion, and surprisingly one of them is the word "inpatient". It is one of the most context-sensitive, role-dependent words that I can think of, commonly used across the table in healthcare operational and workflow discussions. 

What exactly does it mean, how does it work, and how can it be misunderstood?

1. THE HISTORY      
While I'm not an expert medical historian, the history of the word "inpatient" likely derives from the 200-or-so-year history of healthcare. Most hospitals were not really hospitals like we think of them today - They were charity and alms houses, often with beds, with nuns, nurses, and practitioners/physicians tending to sick and dying patients in them.

In a local nearby community hospital, where I once worked, I once interviewed some older nurses who volunteered in our coffee shop - Just to ask them what they remember about the history of the hospital. (For those of you who are lucky enough, ask some older nurses about the history of healthcare - The stories they tell are unbelievable!)

What I found out is that our hospital was once, back in the late 1800s, a simple house, on a hill, donated by a local farmer to help tend to the sick in our area. "It was a place where old and sick farmers came to die," they explained to me. "And then, one day, penicillin arrived - And suddenly, the farmers didn't die, but actually felt better and wanted to go home." And voila - The discharge process was born. 

Taking care of these patients, 24/7, inside the 'house' took a lot of work and attention. Unfortunately, the local community physicians weren't available 24/7 (many had families!), so how exactly did they care for patients 24/7 when there were no physicians available?

In most academic hospitals, there were younger student doctors, who as part of their training agreed to basically live "in" the house - Hence, the name "Residents", since during training they were basically committed to living inside the house, while the Attending providers went home at night to their families.  

Meanwhile, in many community hospitals, this was probably a complex situation for the nurses, who fought heroic battles to keep their patients alive and comfortable until the morning, when the community providers would return and do morning rounds in the hospital. Remember, it was the 1990s when Hospitalist medicine was born, so before that - I can only imagine it must have been a difficult situation for nurses who fought for their sickest patients. (If you know any nurses from this era, make sure you appreciate them.)

In any case, from this era of healthcare, came two important concepts : 

• "Inpatient" - Patients INSIDE the 'house'/hospital
• "Outpatient" - Patients OUTSIDE  the 'house'/hospital

During this era, this terminology was probably somewhat helpful in judging patient acuity, e.g.:

• If you were sick enough to need to be in a hospital --> INPATIENT
• If you weren't, and could walk around --> OUTPATIENT

And so, healthcare appears to have made it through the 1960s-1970s with those terms mostly intact. 

2. THE LEVELS-OF-CARE     

In the 1960s and 1970s, with increased technology, specialization, and standards, the price of healthcare increased. Eventually payment reform became necessary to help control the costs of this care. 

So to help better understand patient acuity and care needs, two terms became important - Taken from https://casemanagementstudyguide.com/ccm-knowledge-domains/healthcare-management-delivery/levels-of-care/ is this : 

• "LEVEL OF CARE" - The intensity of effort required to diagnose, treat, preserve, or maintain an individual's physical or emotional status
• "LEVEL OF SERVICE" - Based on the patient's condition and the needed level of care, used to identify and verify that the patient is receiving care at the appropriate level.

So these terms were stratified to help better organize our healthcare system. In general : 

Looking at the above list, one might ask, "Why is the Emergency Department considered an outpatient level-of-care/acuity? Don't they have really sick patients?" The answer is yes, they often do have sick patients - But :

• because the modern-day Emergency Department grew (circa 1960s-1970s) out of what was once a combination of primary care, urgent care, and the historical "Accident Room" in most hospitals, AND
• because many of the patients seen in an Emergency room are treated, fixed, and sent home
• because patients in the ED are usually waiting to be admitted to inpatient levels-of-care/locations

... the Emergency Department is kind of an unusual hybrid patient care location, staffed with critical care-trained doctors and nurses, but is still considered an outpatient patient care location (even when they have patients with inpatient acuity needing an inpatient level-of-care).

And with regard to nurse training and staffing? Generally, nurses train and staff uniquely in each of these levels-of-care. (Interesting note : Staffing usually depends on the routine vitals!)

And finally, with regard to "bed" management? 

• INPATIENT BEDS = A bed with a patient assigned to one of the inpatient levels-of-care, usually (but not always!) geographically located in an inpatient area*
• OUTPATIENT BEDS = A bed with a patient assigned to one of the outpatient levels-of-care, usually (but not always!) geographically located in an outpatient area*

* NOTE - In "bed overflow" situations, it's entirely possible to "make" an "Inpatient" bed in a geographically "outpatient" location - E.g. A patient waiting for an inpatient intermediate/cardiac bed might be physically lying in a bed in an outpatient/ED location, but if they are admitted to the inpatient intermediate/cardiac level-of-care, they are still considered to be an inpatient, in an inpatient bed, "boarding" in the ED/outpatient location.

So this level-of-care index was at least a little more helpful in roughly estimating a patient's acuity, and for planning the kind of care that would need to be delivered in these locations.

3. THE PHYSICIANS     

With these newer, better-defined levels-of-care, some providers started to distinguish themselves and their clinical practices : 

• "I do inpatient medicine."
• "I do outpatient medicine."
• "I do inpatient neurology."
• "I do outpatient neurology."
• "I do inpatient hospitalist work."
• "I do inpatient pulmonary and critical care."
• Etc...

And so physicians started to define and stratify themselves - again with the curious hybrid of the Emergency Department, where modern ED providers have critical care training but are still considered to be working in an outpatient location, hence, are technically outpatient providers.

4. THE BILLING STATUS     

Once upon a time, the terminology was pretty simple : 

• ADMITTED = Admitted to an inpatient level-of-care / location
• NOT ADMITTED = Not admitted to an inpatient level-of-care / location

But as the price of healthcare continued to rise in the 1980s, this was too granular a concept, and some payors started to question whether everyone in the hospital really needed to be admitted to the hospital - Did they all need to be inpatients? (Were they all really that sick?)

So again, new terminology was developed, to help distinguish : 

• "INPATIENT" - Patients who are admitted to an inpatient level-of-care/location, and sick enough to need to stay in the hospital for at least two midnights (E.g. The "sick" sepsis patient with multiple organ failure)
• "OBSERVATION/OUTPATIENT" - Patients who are admitted to an inpatient level-of-care/location, but not sick enough to require a stay in the hospital for more than two midnights. (E.g. the long-distance runner who got dehydrated and dizzy, and just needed a night of IV fluids and observation before being sent home)

Unfortunately, the use of the billing status "INPATIENT" can be easily confused with the level-of-care/location "INPATIENT".

5. THE SUMMARY       

So it's entirely possible to have : 

• An admitted inpatient with 
• a CMS billing status = OBSERVATION/OUTPATIENT
• being cared for in BED/LEVEL-OF-CARE = INPATIENT(MED/SURG),
• temporarily boarded in a LOCATION = OUTPATIENT(ED),
• until they arrive in their final LOCATION = INPATIENT(MED/SURG UNIT),
• being routinely cared for by their INPATIENT HOSPITALIST or
• being emergently cared for their OUTPATIENT ED PROVIDER (e.g. during a code?)

And during that emergency code, the OUTPATIENT ED PROVIDER may come to work on the INPATIENT (currently in OBSERVATION status) in an INPATIENT LEVEL-OF-CARE/ACUITY and in an INPATIENT LOCATION, along with nurses trained to deliver inpatient care. 

And after the code, if the patient is sick and is estimated to require more than 2 midnights of care in the hospital - the INPATIENT HOSPITALIST may ask the Case Manager to change their CMS Billing Status from OBSERVATION/OUTPATIENT to INPATIENT. 

Makes perfect sense, right? It can be complicated! Unfortunately, our healthcare system is somewhat limited by the lack of terminology development, so I thought I'd summarize it here : 

Hope this helps! Need help interpreting or translating during discussions? Ask your own Clinical Informatics, Health Information Management, or other Clinical Operational leadership for help!

Remember, this blog is for educational purposes only - Your mileage may vary. Have any stories to share about translating this terminology? Have ideas of how to simplify? Feel free to leave in the comments below!