1. Nutrition & Diet Orders Oral Diets Qualitative (e.g. texture modifications or gluten- free) Quantitative (nutrient-level modifications, e.g. 2 gm sodium/day or 1.2 kg protein/kg body weight) Medical Nutritional Supplements Enteral/Tube Feedings Meal Service Requests/Messages Nutrition Consult Order Requests

2. Types of Diets Oral Diets Qualitative types General/Healthful Age-appropriate modifications, e.g., toddler Texture/Consistency Modified Allergy/Intolerance – to eliminate or limit foods with specific ingredients i.e. gluten-free Quantitative Nutrient-based Modifications Energy Modified Carbohydrate Modified Protein & Amino Acid Modified Fluid Modified (Restricting or limiting consumption of total fluids) Mineral Modified (sodium, potassium, phosphorus, etc.) Medical Nutritional Supplements Ordered by Generic Description of Product Formulation, e.g., High Protein/2.0 Kcal formula Ordered by Specific Product/Manufacturer ID Enteral Nutrition (for tube feedings) Other Nutrition Orders – Messages/Consults

3. Diet Taxonomy Examples Fat Modified Diet ( Nutrient = Total Fat) Definition: A diet of known fat composition consistent with the age and life stage of the patient/client Modifications: High fat diet (>100 grams of fat) grams oral Low fat diet (<30% of energy needs) oral Ketogenic Diet (Nutrient mix/ratio) Definition: A diet of known fat: protein plus carbohydrate ratio consistent with the age and life stage of the patient/client High fat to protein+carbohydrate ratio (4:1; 3:1) grams oral Total Cholesterol Definition: A diet of known cholesterol composition consistent with the age and life stage of the patient/client milligrams oral High (>250 mg) milligrams oral Low (<200 mg) milligrams oral

4. Nutrition Orders Storyboards New Diet Order for General/Healthful New Diet Order for multiple quantitative nutrients (Diabetic + Renal dialysis) New Diet Order for Texture Modifications Special Case (NPO) Pediatric (Infant formula) Enteral/Tube Feeding Special Meal/Tray Service Requests (Late Tray or Isolation/Disposables)

5. Diet Order Data Elements The order should contains the following basic information: Order ID (to identify this order & for subsequent updates e.g. Cancel ##) Patient name Patient identifier Patient location (unit – room – bed) Prescriber (who wrote the order) Date/Time of order (when the order was written/given) Start Date/Time – May need to be translated into meal periods (e.g. Now or Next Meal period which is Lunch) Stop Date/Time (Optional – not usual practice for most facilities) One or more diet codes (e.g. typically local codes) or One or more supplement/items (generic user-defined or specific ref codes) – item identifier/name, quantity, unit Text-notes (messages for meal service)

6. FNMS FOOD & NUTRITION MGT SYS CPOE or paper chart EMR Dietitian input Documentation of care plan, educ. And order labs, TPN and adjusts electrolytes Diet Clerk food preferences, allergies, intolerances; notifies diet consult, corrects diet order errors; inputs nourishment requests NURSING Order flavor of supplement, VO orders hold diet for test, allergies, late or early tray MD diet order, supplements, RD consult, VO orders, assigns magmt of TPN or TF others DIET ORDER SEQUENCE Limited access for VO or clinical privileges Limited access for info HL7 interface

7. Diet Supplement Flow Chart Electronic Health RecordFood and Nutrition Management System ORDER Supplement 1000 Calories per Day LIC PAT Role, Service location, Diet Code, Entity Order Received and Approved by Provider or Diet Clerk PROV Order fulfilled with available supplement that meets criteria Supplement Provided to Patient PAT Order Resulted

8. Order Processing Actions (Triggers/States) Activate Order (start date + time (meal)) Abort Order Suspend Order (clinicians have raised concerns - eliminate) Held (remove) Replace Order Revise Order (needs discussion)

9. Application Roles Order Manager - EHR/CPOE/HIS (sending app) Order Placer FNMS-Food/Nutrition System (receiving app) Fullfiller

10. Next Steps to DAM Need a Publishing Facilitator Additional Roles/Names of Participants to submit to publishing Identify from other DAM Information Model/Class Diagrams Conceptual State Machine Activity Diagrams (Interaction Diagrams) Functional Requirements Non-Functional Requirements Use-Case Bubble Diagrams

11. Rx/OO Update Orlando May 2011 Tuesday Q2 Presentation

12. Nutrition Order Categories Oral Diets Qualitative (e.g. texture modifications or gluten- free) Quantitative (nutrient-level modifications, e.g. 2 gm sodium/day or 1.2 g protein/kg body weight) Medical Nutritional Supplements Enteral/Tube Feedings Meal Service Requests/Messages Nutrition Consult Order Requests

13. Nutrition Taxonomy Examples Fat Modified ( Nutrient = Total Fat) Definition: A diet of known fat composition consistent with the age and life stage of the patient/client Modifications: High fat diet (>100 grams of fat) grams oral Low fat diet (<30% of energy needs) oral Ketogenic (Nutrient mix/ratio) Definition: A diet of known fat: protein plus carbohydrate ratio consistent with the age and life stage of the patient/client High fat to protein+carbohydrate ratio (4:1; 3:1) grams oral Total Cholesterol Definition: A diet of known cholesterol composition consistent with the age and life stage of the patient/client milligrams oral High (>250 mg) milligrams oral Low (<200 mg) milligrams oral

14. Nutrition Orders Storyboards Overlap w/ Rx Quantitative-type orders likely map to: Substance Administration Enteral/Tube Feeding Pediatric (Infant formulas: base + modifiers) Medical Oral Supplements Need for quantity & timing data types Concentration / Strength (Ratios) Feeding pump rates (e.g., 40 mL/hour x 24)

15. Enteral Storyboard Example Adam Everyman, a 55-year old male motor vehicle accident victim with multiple rib fractures, major lung contusions and haemothorax that has been drained is admitted to the Intensive Care Unit of Good Health Hospital from the Emergency Department for ventilator support. A nasogastric enteral access device has been placed and radiograph (X- ray) has confirmed proper placement. The patient has been assessed is now haemodynamically stable enough to begin enteral nutrition feedings while he awaits further surgery. After consultation with the nutrition support dietitian, a standard, polymeric enteral formula was selected from the hospitals established formulary and a total energy target of 20-25 kcal/kg body actual weight with 1.2 – 1.5 grams protein/kg ideal body weight has been set. Aaron Attending designates a diet order of Tube Feeding (w/ no other oral food intake) and the following enteral nutrition order using Good Health Hospitals EN order set protocol that directs advancement of the feedings from initiation to the target goal rate within the CPOE system.

16. TF Order Example & Data Elements Name: Thomas Trauma MRN: 00999 DOB: 1/9/1956 Room: ICU – 10Dosing Weight: 83.2 kg Order Start Date/Time: 20110109 @ 1400 Formula: Standard* * Could be generic description of types or product-specific e.g., BrandX Delivery Site: Route: GastricAccess: Nasogastric Method of Administration: Pump-assisted Concentration/Strength (Full Strength) 1.0 Rate:_20__Initial mL/hour Advance by: 10 mL/hour every _4_hour(s) to Goal of 70 mL/hour