1. Nutrition Informatics: Ten Top Things to Know in 2012-
Nutrition Informatics: Ten Top Things to Know in 2012
Marty Yadrick, MS, MBA, RD, FADA
NDEP Area 2-5
April 13, 2012

2. -
Objectives
Understand the impact that nutrition informatics has on the profession.
Apply the concepts of informatics to members’ areas of practice.
Identify how present regulations and nutrition related standards regarding health information technology are re-shaping the practice of nutrition.
Suggested Learning Codes: 1065 (Informatics), 1020, 1070

3. Nutrition Informatics
Streamlined definition:
“The intersection of
information, nutrition,
and technology.”
Nutrition Informatics Committee, 2010

4. When did it all begin? New or Old? First Publication:
But even before these landmark documents, our profession was already using nutrition informatics. We just had not called it that yet.
One of the first references to Nutrition Informatics can be found dating back to More recently, Hoggle points outs that nutrition experts have used computers and electronic media since their introduction 4 decades ago. So what I’m going to talk about is what many of us have been doing for years, we just need to make sure where we are
First Publication:
Thompson E, Tucker H. Computers in dietary studies.
J Am Diet Assoc Apr;40:

5. 10
Top Things to Know in 2012
Health care is “going digital” at a rapid pace.
HITECH has created a “Window of Opportunity.”
Digital NCP, IDNT, Structured Data & Standards are necessary .
Both disruption & innovation are part of evolving health care.
Informatics can improve all areas of practice.
The future is: “Data follows the patient.”
Share Data when TPO: Treatment, Payment, Operations are present.
mHealth is revolutionizing healthcare.
Stay current as new technologies evolve.
Many rich opportunities exist for dietetic professionals in HIT.

6. 1
Health care is “going digital” at a rapid pace.

7. Evolution of Technologies & Health IT
“Disruption
Age”
Information Age
“Attention Age”
1989
1993
1998
2004
2006
2009
2012
Internet
Search
Engines
Google
LinkedIn
Twitter
HITECH
Passed
ERH
Adoption
Phase
Social Media
~200+
EHRs
~1900+
EHRs

8. Technology - Goals Improve Reduce Standardize Accelerate Protect
With the help of technology we can:
Improve communication, outcomes, quality and return on investment
Reduce errors and duplication
Standardize nutrition care
Accelerate access to nutrition information
Protect patient’s privacy and ensure security
IOM To Error is Human

10. “Your hospital will be paperless the same day my bathroom is …”
Michael Shabot, MD
Memorial Hermann Healthcare System

11. 2 We are in midst of a Window of Opportunity
for Nutrition and Health IT

12. “HITECH Act”
Goal: Improving health and health care through the best possible applications of HIT.
To help accomplish this goal, the Act creates a system of incentives to encourage practices to implement EHRs and disincentives to penalize slow adoption.
“This initiative will be an important part of health reform as health professionals and health care institutions, both public and private, will be enabled to harness the full potential of digital technology to prevent and treat illnesses and to improve health.” ~David Blumenthal
Office of the National Coordinator of Health IT

13. Health Care Technology Adoption
President
Bush Issues
Executive Order
HITECH Act Passed
Stage I
MU Polices
Created
Stage 2
MU Begins
Stage 3
There are three Meaningful Use Stages. The first stage began in October 2010 for eligible hospitals and January 1, 2011 for eligible providers.
2004
2009
2010
2014
2016+
Electronic Health Record Adoption

14. Conceptual Approach to Meaningful Use
2-Apr-17
Conceptual Approach to Meaningful Use
Improved
outcomes
Advanced
clinical
processes
The levers for meaningful use are components of health care delivery which have the capability to improve health care. HITECH Programs, incentives and regulations focus on capturing health data for use and re-use, using the data to determine best clinical processes and overall--to improve health outcomes.
Data Capture
& Sharing
From: Dr. David Blumenthal “Medicare Medicaid EHR Incentives NPRM ”

15. EHR Adoption From 2004 Forward

16. Digital NCP, IDNT, Structured Data & Standards are necessary.3
Digital NCP, IDNT, Structured Data & Standards are necessary.

17. Integration of EHR at Healthcare Organizations
While the majority of respondents reported that they are using an EHR at their organization, only one-quarter reported that their EHR uses International Dietetics and Nutrition Terminology (IDNT) and/or Nutrition Care Process (NCP).
Using the definition above, please indicate the level of integration of your electronic health record at your organization (healthcare providers only)
N= 2,146

18. Elements of ADA Nutrition Care Process/ Standardized Language in Use
Use of ADA’s Nutrition Care Process Standardized Language has increased since this study was last conducted. At this time, approximately 61 percent of respondents reported that they use nutrition diagnostic terms.
Not asked
Not asked
Not asked
Which elements of ADA’s Nutrition Care Process Standardized Language are you using at your primary worksite? (Only those who said “yes” to question 15).

19. As HIT is adopted, formats & standards will
evolve as needed for exchange of information.
Human-Readable
Paper
Web browser
PDF
Machine-Readable
Formats which
a machine can interpret
An example is the barcode.
As health information technology is adopted and health care data exchanged, the “rules”, workflow and how data is represented will change. We move from paper (human readable) to computers (human and machine readable display) to interoperability (which requires data to be captured differently (such as the movement from quality measures to e-measures.)

20. Academy Work Related to Informatics
Nutrition Informatics
Committee
2010
2005
2006
2009
2003
Nutrition Care Process
Nutrition Informatics Work Group
EHR Toolkit
Stage 2
Comments Due
2007
2011
2012
2008
2002
2004
The timeline and speed for standards harmonization (and the entire HITECH Plan!) is very aggressive. Here are the key tasks ONC will be asking for collaboration on during just the next six months in regards to just the standards work. At the same time, there is a similar work plan for the policy determination which intersects and embraces the standards used in HITECH EHR adoption.
IDNT
Stage 1
Final Rule
HL7 Diet
Orders
EAL
HITECH
Dietetic Practice Based Network & Tool Kits

21. Both disruption & innovation are part of4
Both disruption & innovation are part of
evolving health care.

23. Used wisely, informatics can improve all areas5
Used wisely, informatics can improve all areas
of practice.

24. Applications/Technologies Used in Past 6 Months
Respondents were most likely to report that they used web tools for collaboration and communication to support daily activities. Three-quarters also reported using clinical nutrition management technologies in the past six months.
Please indicate which of the following technologies or computer applications you have used in the past six months to support your daily activities.
N= 3342

25. Comfort Level with Using Technology Patient Management
Approximately one-quarter of respondents indicated that they are expert users of patient management technologies or applications; another third characterized themselves as intermediate users. One-third indicated that this type of technology is not applicable for them.
N= 3342
Describe your comfort level with using technology or computer applications for each of the items below.

26. Comfort Level in Using Technology Top Ten “Expert” Areas
Respondents were most likely to identify themselves as expert users of word processing systems. In all categories, more respondents reported being expert users in 2011 than in 2008.
Areas of Expertise
Percent – 2008
Percent – 2011
Word processing
41.0%
45.8%
Web/Internet
33.4%
36.5%
Slide presentations
27.0%
34.0%
Nutrition assessment
23.7%
33.2%
Nutrition screening
22.4%
30.7%
Nutrition histories
20.7%
29.8%
Nutrient analysis
20.4%
25.9%
Webinars
8.9%
Patient management
17.5%
23.1%
Care plans
14.6%
21.5%
Describe your comfort level with using technology or computer applications for each of the items below.

27. Information - Intersects
When you take pieces of data/information and combine it with the various process we use such as the nutrition care process you will obtain knowledge that you can use to improve patient outcomes or improve care.
Standards, processes and technology required to turn data into knowledge.
E. Ayres 2008

28. Technology - Intersects
Humans plus technology can efficiently create knowledge
By using our common sense and nutrition background, we can include technology in our daily routines to produce knowledge and seek ways to improve patient care and reduce cost.
Friedman, CP J Am Med Inform Assoc Mar-Apr;16(2): Epub 2008 Dec 11

29. Technology/Computer Applications Most Likely To Be Accessed Electronically
Respondents were most likely to report that they access patient education materials and nutrient databases electronically. Nutrient database was most frequently selected previously.
Area
Percent – 2008
Percent – 2011
Patient education materials
72.1%
81.5%
Nutrient database
78.4%
81.1%
Evidence-based library
77.7%
Continuing professional education
66.8%
78.0%
Professional journals
67.3%
77.3%
Recipes/menus
75.3%
75.8%
Lay literature
66.4%
73.1%
Drug data/information from patients/clients NA
70.7%
Data information about patients
64.7%
Standards of practices
64.5%
We have listed a number of areas in which you may require data to support your daily work activities. Through which means have you accessed this data in the past six months.

30. 6
The future is: “Data follows the patient.”

31. INTEROPERABILITY

32. Technology/Computer Applications Most Likely To Be Accessed Electronically
Respondents were most likely to report that they access patient education materials and nutrient databases electronically. Nutrient database was most frequently selected previously.
Area
Percent – 2008
Percent – 2011
Patient education materials
72.1%
81.5%
Nutrient database
78.4%
81.1%
Evidence-based library
77.7%
Continuing professional education
66.8%
78.0%
Professional journals
67.3%
77.3%
Recipes/menus
75.3%
75.8%
Lay literature
66.4%
73.1%
Drug data/information from patients/clients NA
70.7%
Data information about patients
64.7%
Standards of practices
64.5%
We have listed a number of areas in which you may require data to support your daily work activities. Through which means have you accessed this data in the past six months.

33. EHR Interoperability HL7 HL7 Nutrition Information System
ADT Interface
Diet Order Interface
HIE
EHRs
HL7
EHR Functional Profile
Diet Order Taxonomy
Continuity of Care Document (CCD)
PHR
Registries
Interoperability

34. 7
Share Data when TPO are present:
Treatment, Payment, Operations.

35. Healthcare Privacy and Security – How does it apply to Dietitians?
Care settings
Hospitals
Wellness Programs with Health Plans
Long-term care
Public Health
Consultants
Other (schools, prisons, etc.)
Hospitals/Long-term care and other provider institutions– dietitians working in the in-patient setting focus on proper food and nutrition in order to promote good health, often addressing dietary modification to address medical issues. The entity itself is a HIPAA Covered Entity. In this setting, the dietitian would have access to a patients medical record and would themselves be considered a covered entity as a medical practitioner.
Public Health organizations and Health Plans are also covered and those that work for them are covered as well.
Consultant dietitians can contract independently to provide nutrition services and educational programs to individuals and health care facilities as well as sports teams, fitness clubs, supermarkets, and other health and nutrition-related businesses. If they collect information on the patient in electronic form, they should follow HIPAA rules as well.
If take information in electronic form it is covered under HIPAA

36. Healthcare Privacy and Security – Legislation and Regulation
HIPAA Regulations – applies to “covered entities”
Health plans, health care clearinghouses, and health care providers that engage in electronic transactions for which HIPAA standards have been adopted
Applies to “Business Associates” - those that perform work for or on behalf of Covered Entities
Other regulations - Federal Privacy Act, Federal Trade Commission Act, Gramm Leach Bliley, Sarbanes Oxley, 42CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records Rule, Other Laws (e.g., CLIA, FERPA, ERISA)
Most of you have heard of “HIPAA.” HIPAA is a LAW that required congress to write two related regulations – the HIPAA Privacy Rule and the HIPAA Security Rule.
HIPAA applies to organizations and their employees. Also, individual providers (not affiliated with an organization) are also covered.
The major categories of organizations that are covered includes: health care providers, health plans, health care clearinghouses (organizations that are involved in payment processing). These are called “Covered Entities.”
Individual providers (not affiliated with an organization) also can be covered.
And as of February 2009, with the enactment of the “stimulus bill” (ARRA) - HITECH (next slide), so called “Business Associates” are also covered.
Business Associates are organizations that perform work for or on behalf of a Covered Entity. So, whenever a Covered Entity shares electronic patient information with an external organization for the purpose of doing work for them, that organization becomes a Business Associate and is then covered by HIPAA.
It is also important for organizations to know what other privacy regulations might apply to them based on the work they do – and I provide a short list of examples on this slide.
Now, let’s talk about ARRA/HITECH ….
Used with Permission: Willa Fields, DNSc, RN, FHIMSS &
Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS, FAAN

37. Breaches: By Device Type
Number of Incidents
% of Total Incidents
Number of Patients
% of Patients
Portable Devices 43
15%
1,353,260
13%
Laptop 72
26%
1,630,236
16%
Hard Drives 3 1%
1,207,654
11%
Desktop Computer 54
19%
883,622 9%
Network Servers 34
12%
1,440,954
14%
Paper Records 50
18%
241,256 2%
Other 16 6%
2,630,970
25% * 9 3%
9,347
<0.1%
Source: Data was obtained on June 6, 2011 through the Department of Health and Human Services’ website for organizations reporting breaches which affected more than 500 individuals.
Used with Permission: Willa Fields, DNSc, RN, FHIMSS &
Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS, FAAN

38. Use strong passwords and change them often
Office of the National Coordinator for Health IT (ONC) 10 Best Security Practices
Use strong passwords and change them often
Install and maintain anti-virus software
Use a firewall
Control access to PHI
Control physical access
Limit network access
Plan for the unexpected
Maintain good computer habits
PROTECT MOBILE DEVICES
Establish a security culture

39. Healthcare Privacy and Security – Legislation and Regulation
ARRA/HITECH
Applied HIPAA to Business Associates - Privacy & Sec Rule
Created New/Updated Privacy Statutes – Privacy Rule
Breach Notification
Accounting of Disclosures
Business Associates ►
Modified Enforcement/Penalties - required update to Enforcement Rule
HHS must do Rulemaking and Promulgate Guidance
Marketing/Sale of PHI
Patient Access/Disclosure Restrictions
Limited Data Set/Minimum Necessary
On February 17, 2009, President Obama signed into law the American Recovery and Reinvestment Act of 2009, H.R. 1. The legislation aims to stimulate the economy through investments in infrastructure, unemployment benefits, transportation, education, and healthcare, providing nearly $20 billion to aid in the development of a robust IT infrastructure for healthcare and to assist providers and other entities in adopting and using health IT.
The Health Information Technology for Economic and Clinical Health (HITECH) Act of ARRA contains a section with requirements for HHS to write some new privacy regulations.
Here is a brief overview of the statutory requirement listed on this slide in case you get questions:
Breach Notification – This provision establishes a federal security breach notification requirement for breaches of health information. It requires that an individual be notified if there is an unauthorized access, disclosure or use of their health information. It also requires that large breaches (those affecting 500 or more individuals) be reported to HHS.
Accounting of Disclosures – This provision gives patients the right to request an accounting of disclosures of their health information made through an electronic health record.
New HIPAA Business Associates - This provision ensures that new entities that were not contemplated when HIPAA was written (such as PHR vendors, RHIOs, HIEs, etc.) are subject to the same privacy and security rules as providers and health insurers, by requiring Business Associate contracts and treating these entities as Business Associates under HIPAA.
Sale/Marketing of Protected Health Information (PHI) – These provisions require new restrictions on marketing using PHI and on the circumstances under which an entity can receive remuneration (money) for PHI.
Access – provides an individual the right to have access to certain information about them in electronic format
Limited Data Set/Minimum Necessary – This provision requires CEs to limit the use and disclosure of PHI to a limited data set, or, if needed, to the “Minimum Necessary” to accomplish the purpose of the use or disclosure.
And finally,
Enforcement/Penalties – This section of the bill contains several provisions that are aimed at increasing civil and criminal consequences for violating HIPAA as well as providing for increased enforcement activities by HHS.
It is important to understand that each of these statutory requirements requires the relevant Government agency (in this case, HHS) to conduct “rulemaking” or provide guidance that provides the specific implementation requirements for those covered by the laws. The rulemaking process for the statutory provisions listed on this slide is underway and is on multiple, parallel tracks or timelines. As well, some compliance deadlines are upon us.
Some in place (e.g. Breach notification, others underway and some with draft language) just comment period finished Accounting of Disclosures in early August
I would also like to add that the Act’s language is complex, and new rules are issued often, and as such, HIMSS’ staff and volunteer members will continue to review it and update our educational materials and guidance on this topic. None of the information provided in today’s webinar should be construed as legal advice. For additional clarification, I strongly encourage folks to read the legislative text and/or consult with legal counsel. HIMSS maintains a web page containing guidance and educational materials that provide basic information and tools for understanding and meeting these new laws and associated regulations.

40. Healthcare Privacy and Security – Patient Privacy Concerns
Types of information collected
How the information is handled internally
Whether and how information is disclosed to external parties
Children’s privacy
Security policies and procedures: physical and transmission
Data mining/analysis policies
AARP, “Personal Health Records: An Overview of What is Available to the Public”
Here is a list of patient concerns about privacy (from an AARP survey). We won’t go over each of these in-depth, but it is important to note that patients (even in AARP’s demographic) are very sophisticated in their knowledge about electronic data and their related concerns. Each of our organizations and each practitioner should understand that this example list comprehensively covers these concerns.
Used with Permission: Willa Fields, DNSc, RN, FHIMSS &
Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS, FAAN

41. Breaches Breaches will happen!
Users abusing their privileges (snooping, fraud, medical or financial ID theft)
Loss/Theft of Mobile/Portable Devices and/or Media
Business Associates – breaches of data they hold
Research
Test environment
Copiers
What is a breach and what kind of things are happening? Most prevalent is internal – authorized user.
Research – mis-use info
Test environment – IT implementations – not using live patient data.
Copy machines have hard drivers – making a copy places it on the hard drive and now it is an electronic format.
Probably know only about ½ of the breaches that are occurring.
Breaches will happen!

43. 8
mhealth is revolutionizing healthcare.

44. “mHealth” or “eHealth”?
“e-patients” “e-health” 2007 Health 2.0
Use of a specific set of Web tools (blogs, Podcasts, tagging, search, wikis, etc) by actors in health care including doctors, patients, and scientists, ….in order to personalize health care, collaborate, and promote health education
Note: Used by both Patients and providers.
E-Patients represent a new breed of
Informed health consumers, using the
Internet to gather information about a
medical condition or particular interest to
them.
Health Project Partners, LLC

45. Gadget Ownership

46. Advantages Mobile Technologies
To Simplify Workflow
Record Keeping & Analysis
Increasing Productivity & Customer Satisfaction
Supporting Chronically Ill at Home
Collecting & Using Community & Clinical Health Data in Under-Resourced & Geographically Remote Areas
Real-time monitoring of Patient Vital Signs
Direct Provision of Care (Telemedicine)

47. mHealth Applications Monitor heart rate Measure blood glucose
Maintain medication compliance
Text alerts and reminders
Conduct eVisits
Access EHRs
View telediagnostics
View PACS images
Communication
Access to resources
Point of care documentation
Disease management
Education
Administrative
Financial
Ambulance/EMS
Public health
Pharma/clinical trials

48. Barriers Protection of Protected Health Information
Different platforms: iPhone, Droid, Motorola, etc.
Learning Curve
“Filter Fatigue”
Regulation (FDA Guidance on “Mobile Medical Apps”)
“Culture of Safety” Focus
Political Climate (IOM vs FDA Stance on 510(K) Clearance
IOM recommends “robust post-marketing surveillance” as well as rebuilding the 510 (k) Clearance from the ground up. This program allows FDA Clearance on devices based upon “similarity” to previous inventions, and does not require clinical trials.
Health Project Partners, LLC

49. Transporting data with mobile devices is inherently risky
Transporting data with mobile devices is inherently risky. There must be an overriding justification for this practice that rises above mere convenience.
Used with Permission: Willa Fields, DNSc, RN, FHIMSS &
Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS, FAAN

50. Considerations for app design
Health literacy – 20% of Americans read at a 5th or 6th grade level
Readability tests
Use more graphics and audio
Cultural appropriateness
Patients with Disabilities (screen reader, captions)

51. Stay current as new technologies are9
Stay current as new technologies are
used in health care

52. iTunes Apps

53. How you communicate will change

54. Many rich opportunities exist for dietetic10
Many rich opportunities exist for dietetic
professionals in HIT.

55. The Door is wide open….. Come be a NIRD!
So the door is wide open, come on in and see how informatics will change the future of our profession. We want you to be a Nutrition Informatics RD

56. Competencies - Delphi Study Completed and will be published in the Journal
Students
Entry Level
Practitioners
Specialists
Experts
Informaticists

57. Visit www.AMIA.org/education/10x10-courses
AMIA/Academy 10X10
Introductory course in Biomedical Informatics
w/Emphasis on Nutrition
April 25 – Sept 26, 2012 (on-line)
In person session Oct 6 at FNCE
Tuition: $2195
54.5 CEU’s !!!
Option for 3.0 graduate credits from OHSU
Visit
Get new dates

58. GET INVOLVED!