Visit vs place of service

[MPhilofsky]

@kDarko,

PCP at the out-patient clinic had subsequent encounters at Cardiology (care site?/place of service?), Endocrinology(care site?/place of service?)

You can use the care_site_id and care_site_name field in the care_site table to represent the PCP, Cardiology, and Endocrinology. All will have the same place_of_service_id to represent Emory hospital. And most likely the same location_id, but it could be different depending on the granularity of your address/location data. Care_site_id is:

not useful for standardized analytics.

but it may be useful for your internal purposes. If it isn't, not sure you want to create a bunch of care_site_ids (and extra work) for your data.

[Dymshyts]

Actually, I have doubts:
CARE_SITE
place_of_service_concept_id describes type of the clinic, i.e. Rural Clinic, Mental asylum, etc.

VISIT_OCCURRENCE
Visit_concept_id describes type of visit: in or out-patient, ER

So you suggest to populate place_of_service_concept_id and Visit_concept_id with the same concept, say place_of_service_concept_id = "Inpatient Psychiatric Facility"
Visit_concept_id = "Inpatient Psychiatric Facility"

instead of
place_of_service_concept_id = "Inpatient Psychiatric Facility"
Visit_concept_id = "Inpatient "
?

Can this change be confusing for the people used to "in- or out-patient, ER" visit IDs?

[Christian_Reich]

Friends:

I think we are bumping here into a problem that came up the other day in the Atlanta hackathon discussion: place of service really denote two things:

1. A type of service, like surgery, psych assessment, emergency, etc. (which is adequate for Visit).
2. A type of provider organization, like Assisted Living Facility, Outpatient NEC, Inpatient Psychiatric Facility etc. (which is adequate for Care Site).

The Visit seems to need 1), not 2). So, from that perspective we need not combine them. Instead, we need to think of more granular service concepts.

[Gowtham_Rao]

I think we need to answer the question: why do we need the domain_id "Place of Service". Why can't it be "Visit".

I don't think we need "Place of Service" domain_id, because we are mapping the standard Concept's in that domain to standard concepts in "Visit" domain.

[Christian_Reich]

@Gowtham_Rao:

Because Place of Service doesn't denote something that further qualifies a Visit, but a Care Site where the visit happened. And for that we have the table CARE_SITE.

[cukarthik]

I think it is needed for care site. Should this then be changed to a “care site” domain?

For an ambulatory surgery, how would one code the visit and care site?

[Gowtham_Rao]

Should this then be changed to a “care site” domain?

Yes, if we change the field name from place_of_service_concept_id to caresite_source_concept_id and caresite_concept_id. This is obviously not backwards compatible, but will be consistent with Omop CDM conventions. Maybe done for CDM 6.x

@christian_reich , why did place_of_service_concept_id break out of the visit table into care_site table when we moved from CDM 4 to 5?

[Gowtham_Rao]

For an ambulatory surgery, how would one code the visit and care site?

Is ambulatory surgery, an
1. Attribute of the physical place where care is provided.
2. Attribute of the business/administrative entity for billing or documentation purpose i.e. the same physical entity can take on many place_of_service.
3. Attribute of the (service) visit like a condition, procedure is an attribute of a visit.

[Gowtham_Rao]

Can this change be confusing for the people used to "in- or out-patient, ER" visit IDs?

All change can cause confusion, but the risk in this case should be very low because we are not deprecating existing concepts. Further, our proposal will have robust ancestor mapping - and the changed concepts will be child if the existing concepts.

A data partner may map to any any level of the hierarchy, and we can go up or down the hierarchy

[cukarthik]

Is ambulatory surgery, an 1. Attribute of the physical place where care is provided. 2. Attribute of the business/administrative entity for billing or documentation purpose i.e. the same physical entity can take on many place_of_service.3. Attribute of the (service) visit like a condition, procedure is an attribute of a visit.

I would say it's more #3 and maybe #1. Right now, we classify ambulatory surgeries as outpatient visits since patients do not have a room; however, there are cases when the procedure might not go as expected and a patient has to be admitted. If we want to look at all procedures that might have this transition, it's a little unclear to me. I can see going the #1 route and classifying a care site using OMOP code 8883 (Ambulatory Surgical Center), but I would think it would be nice to also have a new visit type for ambulatory surgery for easier analysis since from a practical point listing locations and their services can be difficult. I am curious to see what others think.

[Gowtham_Rao]

I would say it's more #3

If we want to look at all procedures that might have this transition, it's a little unclear to me.

it would be nice to also have a new visit type for ambulatory surgery

You hit the nail on the head @cukarthik ; the problem is that in most data sources, although it is called 'place of service' - it is not an attribute of the place, but it is an attribute of the service itself. In US health care, care-site is not a 'credentialing' information, but a 'claim'. e.g. place of service information comes in every claim on CMS 1500 form.

[Christian_Reich]

why did place_of_service_concept_id break out of the visit table into care_site table when we moved from CDM 4 to 5

That's not what happened. In 4, we had ORGANIZATION and CARE_SITE. That was the same two-layer hierarchy we have now for VISIT_OCCURRENCE and VISIT_DETAIL. We abandoned it, because there is no way this can be harmonized or standardized in any reasonable way. We got rid of ORGANIZATION, and left CARE_SITE, which is a physical place for any type of Visit to happen.

@Gowtham_Rao: Show them our proposed table.

[Gowtham_Rao]

Show them our proposed table

We (@Christian_Reich @Dymshyts @Dave_Kern @Gowtham_Rao) worked on cleaning up these concepts, and would like the communities input. See document. We propose to change the domain for the vocabulary 'Place of Service' (standard concept) to 'Visit', because we found that 'Place of Service' is an attribute of the Visit and not attribute of 'Care Site' as discussed here.

You hit the nail on the head @cukarthik ; the problem is that in most data sources, although it is called 'place of service' - it is not an attribute of the place, but it is an attribute of the service itself. In US health care, care-site is not a 'credentialing' information, but a 'claim'. e.g. place of service information comes in every claim on CMS 1500 form.

We then mapped (using concept_relationship and concept_ancestor table) the concepts in 'Place of Service' vocabulary belonging to the 'Visit' domain to other standard concept's in Visit domain.

[MPhilofsky]

What is the definition for "intensive care" visit?

Why is "Urgent Care" an Office Visit with the definition: "Office Visit = 'Patient goes to provider, but not inpatient, emergency room, ambulatory surgical center or other specialized units'?

Why is "Skilled Nursing Facility" labeled as "Inpatient" and not "Long Term Care"? Maybe I should ask the definition of Long Term Care instead?

[Gowtham_Rao]

definition for "intensive care" visit

These are services that are also called 'critical care', 'ICU' etc. Intensive care are for patients with severe and life-threatening illnesses and injuries, which require constant, close monitoring and support from specialist equipment and medications in order to ensure normal bodily functions (Ref)

Why is "Urgent Care" an Office Visit with the definition:

From patients point of view, the 'Urgent care' does not lead to overnight stay in the hospital. The experience is like going to a Doctor's office visit. (Ref) The main difference between traditional office visit and urgent care is a) no need for appointment, b) they will handle minor stuff like splinters, small wounds, acute infections, etc. that are not life-threatening emergencies.

Why is "Skilled Nursing Facility" labeled as "Inpatient"

In both Inpatient and Long Term Care, patient sleep in a healthcare facilities bed that is not 'home'. But the distinction between long-term vs short-term is not unambigious. How do we know that 'Skilled Nursing' was a long-term or short-term. When does a short-visit become long, 7 days, 30 days, 180 days, 365 days? Inpatient was thought to be the safest mapping.

[MPhilofsky]

The proposed vocabulary additions need clear definitions and conventions to be useful.

"Office Visit = 'Patient goes to provider, but not inpatient, emergency room, ambulatory surgical center or other specialized units'?

What's the definition for "other specialized units"? Office Visit needs to be distinguished from the Outpatient Visit. Why isn't Urgent Care an "other specialized unit"?

In both Inpatient and Long Term Care, patient sleep in a healthcare facilities bed that is not 'home'. But the distinction between long-term vs short-term is not unambigious.

I agree the distinction is ambiguous. We need better definitions. I mapped Skilled Nursing Facility to Long Term Care based on the term for Concept Name = "Long Term Care Visit". From Usagi:

Long Term Care Visit has a term name = Non-acute institutional stay. In my opinion, SNF, Rehab, LTC, etc. fall under the Non-acute institutional stay definition.

definition for "intensive care" visit

These are services that are also called 'critical care', 'ICU' etc. Intensive care are for patients with severe and life-threatening illnesses and injuries, which require constant, close monitoring and support from specialist equipment and medications in order to ensure normal bodily functions (Ref)

I still don't understand the definition for an "intensive care visit". I know the definition for the care site "intensive care". The link you provide gives the definition for an intensive care Care Site. It seems that care sites and visits are being combined.

[Gowtham_Rao]

Thanks! There is an opportunity to improve. In the US health Care claims system, HIPAA place of service is an attribute of the visit and not caresite. Why - because it is information that is provided at the claim level.

https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

Mapping that into higher order visits are done using omop generated vocabulary. That mapping was done by the OHDSI community in past one month and information was shared on this forum. Active roles were played by

We (@Christian_Reich @Dymshyts @Dave_Kern @Gowtham_Rao) worked on cleaning up these concepts, and would like the communities input. See document. We propose to change the domain for the vocabulary 'Place of Service' (standard concept) to 'Visit', because we found that 'Place of Service' is an attribute of the Visit and not attribute of 'Care Site' as discussed here

@jenniferduryea also helped

We can improve the omop generated vocabulary in a future release if the community agrees and thinks it's of value.

Plus - we don't have code level best practice instructions documented in omop vocabulary. E.g. each code does not have an instruction manual - a limitation

[Christian_Reich]

Are we rolling this out at the THEMIS meeting? Are we ready?

[Gowtham_Rao]

Are we ready?

Themis could tackle what omop generated vocabulary means what. E.g. what is intensive care.

However, external vocabulary adapted by OHDSI like place of service, type of bill may not need much discussion.

[Gowtham_Rao]

These are some OMOP generated concept_id's that are present in OMOP vocabulary. Do we know when was it introduced. It is incorrectly labelled as belonging to 'CMS place of service' vocabulary. CMS place of service vocabulary are here https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html . Should we assign a new vocabulary to these codes?