1. S&I Framework Nutrition & Diet Elements October 12, 2011

2. Nutrition & Diet Elements Background of Nutrition Standards Use of Nutrition Data Elements Nutrition Terminology Submission to SNOMED-CT Additional Nutrition Standards Work Nutrition & Diet Data Elements In Detail A-B and C-D Data Elements & Nutrition Care

3. Background Nutrition professionals practicing in all areas of healthcare including in-patient acute care, long term care, and outpatient/ambulatory care use the Nutrition Care Process (NCP) Nutrition Care Process (NCP) for identifying, planning for, and meeting nutritional needs of patients/clients. The Nutrition Care Process includes four steps: Nutrition Assessment Diagnosis Intervention Monitoring & Evaluation Each step in the Nutrition Care Process has a set of standardized terms published by the Academy for Nutrition and Dietetics (AND) as the International Dietetics & Nutrition Terminology (IDNT)International Dietetics & Nutrition Terminology (IDNT). Work is currently underway to submit these terms to SNOMED-CT. The narrative summary and underlying IDNT codes would represent the nutrition and diet data that should be included in clinical summaries, nutrition consult request summaries, as well as discharge summary and instructions.

4. Elements of ADA Nutrition Care Process Standardize Language in Use Use of ADAs 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 Which elements of the ADAs Nutrition Care Process Standardized Language are you using at your primary worksite? (Only those who said yes to question 15). Not asked Nutrition Informatics Survey 2011 HIMSS Analytics

5. IDNT-to-SNOMED Project Summary Total: 646 terms, 146 headings (792 spreadsheet lines) 6% of terms already in SNOMED CT 49 % of terms ready for SNOMED CT submission 30% of headings ready for SNOMED CT submission 41% of terms and 61% of headings still need review

6. Additional Work HL7 Nutrition and Diet Orders Domain Analysis Model The first informative ballot of was balloted in September 2011. The second round of the ballot is scheduled for January or May 2012. HL7 Patient Care Allergy Project: HL7: EHR Functional Profile in Nutrition: The testing phase will last approximately 18 months, followed by changes to the profile as determined by test implementers, and balloting as a normative standard in January 2013. HL7Patient Care Pressure Ulcer Prevention Model: Inclusion of Nutrition Care in Prevention & Treatment S&I Nursing Codes Mapping Sub-Work Group: IDNT mapped to existing TOC-CIM categories Additional Model Federal Health Information Model Federal Health Information Model : model of healthcare data developed for federal agencies, the Veterans Administration; untested.

7. Diet CIM Object Summary CIM Object Name CIM Object DefinitionCDA ID ReferencesCIM Object Priority Diet The diet that has been ordered or recommended by the clinician. (Distinct from the diet that the patient reports they follow, e.g. a vegetarian diet). Diet appears in 2 places. The first is the diet that has been ordered or recommended by the clinician. The second is the diet that the patient is actually consuming. This second instance will be for patient self- monitoring. Clinical Example: Patient is advised to follow a low salt, low fat and reduced calorie diet. 1.3.6.1.4.1.19376.1.5.3.1.3.33 B Data Elements for PCP to Specialist with Consultation Request (including closed loop referral) B Data Elements from Hospital to PCP or other facility (e.g. long term care or sub- acute care) B Data Elements to Patient: Data Exchange to a PHR. Diet Narrative Current Text: Records a narrative description of the expectations for diet, including proposals, goals and order requests for monitoring, tracking, or improving the dietary control of the patient, used in a discharge from a facility such as an emergency department, hospital, or nursing home. Recommend as in Consolidated CDA Templates (US Realm) September 2011: This section records a narrative description of the expectations for diet and nutrition including nutrition prescription, proposals, goals, and order requests for monitoring, tracking, or improving the nutritional status of the patient, used in a discharge from a facility such as an emergency department, hospital, or nursing home. 1.3.6.1.4.1.19376.1.5.3.1.3.33 B Data Elements for PCP to Specialist with Consultation Request (including closed loop referral) B Data Elements from Hospital to PCP or other facility (e.g. long term care or sub- acute care) B Data Elements to Patient: Data Exchange to a PHR.

8. Name of Data Element Definition of Data ElementISO/HL7 Data typeExamples & Guidance Data Element Priority Nutrition Diagnosis Identification and labeling of a nutrition problem that a food and nutrition professional is responsible for treating independently. Typically includes three categories: 1.Intake (too much or too little of a food or nutrient compared to actual or estimated needs.) 2.Clinical (nutrition problems that relate to medical or physical conditions) 3.Behavioral-Environmental (knowledge, attitudes, beliefs, physical environment, access to food, or food safety) ED (Encapsulated Data) CE (Coded Element) (value set is all of the SNOMED- coded interventions in the IDNT list. Clinical Examples: Inadequate oral intake related to intolerance as evidenced by frequent nausea and vomiting prior to admission. Altered nutrition-related laboratory values related to diabetes mellitus as evidenced by diabetic ketoacidosis. Biting/Chewing (masticatory) difficulty (SNOMED CT CID 175130015 ) related to xerostomia as evidenced by Speech Language Pathologist evaluation. B PES Statement (Problem/Etiology Signs/Symptoms Problem or Nutrition Diagnosis Label (Describes alterations in the patients nutritional status) Etiology (Cause/Contributing factors linked to the nutrition diagnosis ) Signs/Symptoms (Data used to determine that the patient has the nutrition diagnosis specified, linked to etiology) ED (Encapsulated Data) CE (Coded Element) (value set is all of the SNOMED- coded interventions in the IDNT list. B Nutrition Diagnosis

9. Name of Data Element Definition of Data ElementISO/HL7 Data typeExamples & Guidance Data Element Priority Nutrition Prescription The patients individualized recommended dietary intake of energy and/or selected foods or nutrients based on current reference standards and dietary guidelines and the patients health condition and nutrition diagnosis. This includes the nutrition recommendation by the dietitian. CE (Coded Element) or CF (Coded Element with formatted values) or PQ (Physical Quantitiy) Clinical Examples: Recommend Isosource 1.5 tube feeding per small bowel feeding tube at 70 ml per hour to provide 2310 calories (27 Kcal/Kg), and 105 gm protein (1.2 gm/Kg) per day. Recommend patient consume 2000 calories, 80 grams protein per day for optimal wound healing. Typically includes a PES Statement: Problem/Etiology/ B Diet CIM Objects (In Detail)

10. Name of Data Element Definition of Data ElementISO/HL7 Data typeExamples & Guidance Data Element Priority Nutrition Intervention Purposefully planned actions intended to positively change a nutrition-related behavior, environmental condition, or aspect of health status for an individual (and his or her family or caregivers), target group, or the community at large. A food and nutrition professional works in conjunction with the patient/client(s) and other health care providers, programs, or agencies during the nutrition intervention phase. CE (Coded Element) (value set is all of the SNOMED-coded interventions in the IDNT list. Clinical Examples: Enteral nutrition solution: 1 Kcal/cc formula for 1600 Kcal/day Adaptive equipment for feeding assistance. Nutrition counseling based on motivational interviewing strategy. Includes SNOMED Codes (IDNT mapped to SNOMED) and/or LOINC B Nutrition Intervention

11. Name of Data Element Definition of Data Element ISO/HL7 Data type Examples & Guidance Data Element Priority Patient Instructions Directions to the patient which have been agreed upon between dietitian and patient and conform to diet order, goals and care plan. ED (Encapsulated Data) Clinical Example: Reduce intake of refined carbohydrates, reduce fat consumption & increase omega-3 fatty acid intake per written guidance. B Nutrition Intervention (Continued)

12. Nutrition/Diet Order (Detail) Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Diet Description Narrative description of the recommended diet or daily nutrient intake LIST (List Sequence) or ED (Encapsulated Data) Examples: General Healthful Diet; or 80 gm protein + Consistent Carbohydrate + 2g sodium + 2g potassium + 800-1000mg Phosphorus + 1500 mL Fluid Restricted B Diet Type Code Set of codes that controls the type of diet modification that a patient should receive or follow CE (Coded Element) Note: Local codes only at present Or Per IHE: LOINC 42344-2 Examples: DASH (Dietary Approaches to Stop Hypertension), Kosher, or Vegan B Texture Modification Required Indicator specifying whether the patient/client requires food texture modifications BL (Boolean) Patient safety issue. Yes - Patient has documented difficulty chewing/swallowing due to stroke. Failure to properly convey this information could lead to a choking hazard. B Texture Modifier Code Describes the consistency or how the food or type of food should be modified for consumption. CE (Coded Element) Pudding-thick, chopped or ground B Food Type Code Indicates what type of food, e.g., meats, or liquids, require a texture modification CE (Coded Element) Patient undergoing treatment and rehabilitation following a stroke may require honey-thickened liquids, ground meats and chopped vegetables. B

13. Nutrition/Diet Order (Detail – Continued) Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Nutrient Modification Required Indicator specifying whether the patient/client requires a therapeutic or modified diet to eliminate, decrease, or increase certain substances in the diet (e.g., sodium, potassium) BL (Boolean) Modify distribution, type, or amount of food and nutrients (IDNT: ND-1.2) Example: Diabetic patient requires controlled intake of carbohydrates. Renal dialysis patient requires 1.2 grams protein/kg body weight, < 2 grams sodium/day, and 800-1000 mg Phosphorus/day B Nutrient Type Code Code which identifies the nutrient which is to be modified CE (Coded Element) E.g., Sodium or ProteinB Quantity/Quantity Modifier Indicates how much of the nutrient is being ordered. May need to be expressed as a range, thus a modifier e.g, or PQ (Physical Quanitity)/ Ratio B

14. Nutritional Supplement – (In Progress) Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Product Name/Description LIST (List Sequence) Patient is not meeting nutrient intake requirements and requires additional calories and protein. RD recommends a high protein liquid nutritional supplement 3 times a day between meals. B Product ID CE (Coded Element)B QuantityPQ (Physical Quantity) Frequency IVL (Interval) B

15. Enteral Nutrition – (In Progress) Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Rate or Frequency Time frame over which a product is administered PQ IVL_TS Rate or Frequency of the feeding: Continuous tube feeding via pump, 65 mL per hour Or 720 mL bolus feedings, 3 x per day B Concentration/Strength Dilution or lack of dilution of the product prior to administration. Full Strength Half Strength B Energy Density Amount of calories (energy) provided per volume Infant formulas are mixed to a specified caloric density, e.g., 24 kcal/flluid oz, or 27 kcal/fluid oz B Product Name/Description B Product ID B Administration Method A code that details how the food is to be administered, e.g., Pump- assisted. B Delivery Site A code that identifies where the tube should deliver food to, eg. gastric. B Instructions Narrative instructions pertaining to care and maintenance of the feeding tube. Example: Flush tube with __mL water every 3 hours. B

16. Nutrition Care Provider Name of Data ElementDefinition of Data ElementISO/HL7 Datatype Examples and Guidance Data Element Priority Assigned Entity Nutrition professional (RD) responsible for completing the request nutrition consult and developing the nutrition prescription, and nutrition plan of care EN (Entity Name) Palmetto Hospital Janice Jones B Clinician Contact information Address, phone and email information for the RD provider AD (Address) TN (Telephone Number) 1410 Main Street Columbia, South Carolina 22001 803-777-7777 B Healthcare Provider Identifier National Uniform Claim Committee Health Care Provider Taxonomy CE (Coded Element)B Effective Time Date and time of the nutrition assessment, consult or when the nutrition prescription was completed IVL-TS (Interval- Timestamp) B

17. Name of Data Element Definition of Data ElementISO/HL7 Data typeExamples & Guidance Data Element Priority Monitoring & Evaluation Utilization of consistent data longitudinally for the purpose of evaluation and outcomes. Includes both patient evaluation of goals, re-assessment of existing parameters and evaluation of new data. CE (Coded Element) (value set is all of the SNOMED-coded interventions in the IDNT list. ED (Encapsulated Data) Clinical Examples: Patient has reduced sodium and cholesterol consumption and reduced BMI from 30 to 27. Outcomes over past 9 months reflect a reduction in BP and LDL. B Nutrition Monitoring & Evaluation

18. Nutrition Data Elements & CIM A-B Active Medication List (including vitamin/mineral, herbal supplements) Active Problem List Intolerances including Allergies (Food) Goals (Nutrition Related) Patient Instructions (Food Modification/Enteral/Parenteral) Social History (Alcohol) Vital Signs (Ht/Wt/BMI with Date Stamp)

19. Nutrition Data Elements & CIM C-D Anticipatory Guidance Goals Health Maintenance Patient Self-Management Physical Activity (? Possibility of B) Social Determinants of Health Instrumental Activities of Daily Living Activities of Daily Living