Please consider this completely revised solution in Googledoc (see at the end for URL and instructions). This is a significant surgery of how we would characterize the healthcare settings of the data. Please tell me what you think.
We have 3 types of tables: VISIT_OCCURRENCE and _DETAIL (both referred to as Visit from now on), CARE_SITE and PROVIDER. Visit refers to a structured process where the patient receives care, Care Site tells us the organization and Provider the flesh-and-blood healthcare provider. To describe these three we currently have a number of vocabularies and some self-cooked concepts:
- Place of Service
- UB04 Typ bill
- HES Specialty
It’s a mess. They are highly duplicative and all over the place. For example, the Medicare Specialty vocabulary contains concepts like “Skilled Nursing Facility” and “Radiation Therapy Center”. HES Specialty also has those types of facilities in there. NUCC, which contains the typical physician specialties, also features things like “Funeral Director”. In Medicare Specialty, we have non-medical entities like “Part B CAP Drug Vendor”. And so on.
- We need a comprehensive hierarchical system for this all. We can’t expect the ETLer to know what a “Doula” is, or if “Occupational Therapy” is some kind of a department or what kind of person is using an occupation as a therapy.
- One domain should describe the Provider, such that the provider_concept_id can define any such person. Providers can be of the medical (physicians and nurses) and non-medical kind (specialists, vendors).
- Another domain needs to characterize the way healthcare is organized. After long thinking and discussing with people, I believe this should describe the Visit, and not the Care Site.
- Care Sites need not have anything semantically characterizing them. They should be relegated to a mere physical or logical entity with a name attached.
This will be unfamiliar to some folks. In particular, I expect some flak over the following consequences:
- Care Sites can no longer have specialties. @mgkahn might have a fit over this. And I agree it is counter-intuitive at first glance, because there are these General Surgery Departments and Internal Medicine Wards all over the place. But all that Care Sites do is to enable visits to happen, and physicians with different specialties or non-medical providers delivering the care during those visits. And the visits could be of different kind for the same Care Site.
For example: My wife runs a Urogynecology outpating department in a hospital. Most of the physicians have that specialty (concept_id=45756773). But there are also ordinary gynecologists and an oncologist running around, plus a Nurse Practitioner. Now what? What specialty has the place?
Visits cannot have specialties, either. There is no such thing as a “Dermatology Office Visit”. What you can have is a Outpatient Office Visit with a Dermatologist doing something.
What used to be a specialty is really a descendant of the Provider concept “Physician”. There are also some specialized nurses, but not many.
Here is why you will like it:
You don’t have to stress anymore what exactly a Care Site is, and whether it is a physical or logical entity. In my wife’s example, the outpatient offices are located in an ugly 80ies brick building. But the surgeries are done in the OR of the main hospital 2 miles away. Unless that one is booked, then they can use an ambulatory surgery in the “old building”. Still following? It is impossible to model this stuff. But it doesn’t matter. The Care Site “Mount Auburn Urogynecology Associates” is registered with the insurance companies, and that’s all we need.
ETL will be very much simplified. Based on the coding system, it is very simple to create Visits. In the example of my wife’s department, all activities will result in Office, Clinic, Hospital Outpatient or Ambulatory Surgical Center Visits, no matter if claims or the EHR system was used to generate the records. And everything rolls up into “Outpatient Visit”.
We now have a hierarchy that allows stratifying things in a meaningful way. In Visit, we still have the existing top 5 Visits:
- Emergency Room and Inpatient Visit
- Inpatient Visit
- Outpatient Visit
- Emergency Room Visit
- Long Term Care Visit (renamed to “Non-hospital institutional visit”)
In addition, we also have 6 new ones:
- Laboratory Visit
- Telehealth Visit
- Pharmacy Visit
- Home Visit
- Transportation Visit
- Rehabilitation Visit
- Case Management Visit
In Providers everything rolls up into:
- Supplier/Commercial Service Provider
- Allied Health Professional
We can also address the problem of multiple provider specialties by picking the most granular common hierarchical concept. So, somebody who declares the specialties “Hepatology” and “Nephrology” gets “Internal Medicine”.
This is the full set in Google Doc.The Concepts are in green, the hierarchy in yellow, and the deduplications with one mapped to its equivalent in red. Synonyms are in brown.
Let me know.