1. HL7 Version 3 Domain Analysis Model: Nutrition R1 Sponsored by: Academy of Nutrition and Dietetics (formerly American Dietetic Association) Project Update – Jan 2012 WGM

2. Project Status Informative Ballot R1 – Sept 2011 Reconciliation completed Sept WGM 2011 Reconciliation edits to storyboards 75% completed (J. Snyder/M. Dittloff) To Do: Reconciliation updates to model & diagrams Primarily to revise/merge Pediatric => Enteral Informative Ballot R2 – May 2012 Adding New Storyboards to provide more complete picture of nutrition content In progress – working with SME committee

3. New Nutrition Storyboards Acute / LTC Food Allergy Acute / LTC Food Intolerance Food Preference Revise Request Dietitian Consultation New Sub-Flow: Nutrition Care Process Nutrition Assessment Nutrition Diagnosis (Problem) Nutrition Interventions Nutrition Monitoring & Evaluation

4. Acute / LTC Food Allergy Adam Everyman is admitted to Green Acres Retirement Home after being discharged from Good Health Hospital. While reviewing Adams medical records transferred from Good Health Hospital and taking an updated patient history, Aaron Attending confirms that Adam Everyman has an allergy to eggs that initially manifests as hives quickly followed by anaphylactic shock. Aaron Attending adds the food allergy to the allergy list area of the patient record of the EHR system and documents it as severe (critical) noting the associated adverse reactions of hives followed by anaphylaxis. The food allergy is now readily visible to anyone who reviews the chart, including the nurse staff, pharmacists, and ancillary departments.

5. Acute / LTC Food Allergy – cont. The EHR system sends an electronic message via the interface to the FNMS notifying Food and Nutrition Services of Adam Everyman's food allergy to eggs along with the clinicians assessment of the severity/criticality and a summary of the reported adverse reaction symptoms. The FNMS acknowledges receipt of the new allergy order and updates Adams record in the FNMS. The FNMS is able to identify food products with eggs and remove them from Adam Everymans menu. Eggs are now prevented from being served to Adam Everyman, minimizing the risk of Adam Everyman experiencing hives or anaphylactic shock due to egg exposure during this stay at Green Acres Retirement Home.

6. Acute / LTC - Food Intolerance Adam Everyman is discharged from Good Health Hospital and admitted to Green Acres Retirement Home. While reviewing medical records transferred from Good Health Hospital and taking an updated patient history Aaron Attending identifies that Adam Everyman has food intolerance to lactose. When questioned about this, Adam Everyone states that he avoids milk and dairy due to GI cramping and diarrhea. Aaron Attending updates the appropriate section of the EHR and documents the lactose intolerance along with the adverse reactions reported by the patient. He also enters a lactose-free nutrition order.

7. Acute / LTC Food Intolerance – Cont. The EHR system sends an electronic message via the interface to the FNMS notifying Food and Nutrition Services of Adam Everyman's lactose intolerance and the lactose-free nutrition order. The FNMS acknowledges receipt of the new food intolerance order and updates Adams record in the FNMS. Using the intolerance code for lactose-free, the FNMS is able to prevent serving standard milk/dairy products and instead acceptable lactose-free substitutes are offered and/or served to Adam. Adam Everyman receives all his meals with acceptable lactose-free food substitutes increasing his satisfaction while minimizing the risk that he will have an adverse reaction from lactose ingestion.

8. Acute / LTC Food Preferences (ethnic, cultural, religious) Eve Everywoman has been transferred to the post- partum care unit of Good Health Hospital following birth of her child. Eve is hungry and her doctor has ordered a general/healthy diet so she can begin receiving meal trays. However, Eve tells her nurse, Nancy Nightingale, that she does not eat any beef or pork, but will eat other meat products including fish, seafood, poultry and eggs. Nancy updates Eves nutrition record in the EHR to notify the Food & Nutrition Services Department that Eve has special food preferences and selects (No Pork and No Beef) from a list of pre-defined food preference options.

9. Acute / Long-term Care Food Dislikes and Preferences The EHR system sends an electronic message via the interface to the FNMS notifying Food and Nutrition Services of Eves food preferences. The FNMS automatically acknowledges receipt of the list of food preferences and updates Eves nutrition record. A meal tray is prepared for Eve such that items containing beef or pork are substituted with other available meat/protein options for tonights dinner. Eve receives her dinner tray featuring a poultry entrée that satisfies her food preferences.

10. Dietitian Consultation Flow * Update/revise to link dietitian consultation back to enter new or modify nutrition orders

11. Revised - Dietitian Consultation Request Adam Everyman, a cancer patient who has experienced significant weight loss since beginning chemotherapy, is admitted to the Oncology Unit at Good Health Hospital. He is on currently on a General oral diet. Rachel Resident writes an order for a Dietitian consultation in electronic medical record (EHR) which includes her electronic signature and a date/time stamp. The Dietitian consultation order request auto-populates on the dietitian task list within the EHR and/or it may be communicated through the EHR to Food & Nutrition Services via an electronic interface to the FNMS.

12. Dietitian Consultation Request Food & Nutrition Services contacts Connie Chow, the Dietitian responsible for the oncology unit, and communicates the details of the dietitian consultation order. Connie completes the requested service by conducting a nutrition assessment and then documents Adams nutrition diagnoses/problems along with recommended nutrition interventions in the nutrition care plan area within the EHR which includes her electronic signature, date and time stamp. Rachel Resident reviews the nutrition recommendations and concurs, so she modifies Adams current nutrition orders.*

13. Nutrition Care Process Model

14. Conduct Nutrition Assessment Food & Nutrition Services contacts Connie Chow, the dietitian responsible for the oncology unit, and communicates the request for a dietitian consultation order for newly admitted cancer patient, Adam Everyman, who has experienced significant weight loss since beginning chemotherapy. She collects important and relevant assessment data including current diet order, weight history and recent energy intake from the EHR and FNMS along with information from Adam and his family about his current and usual eating pattern and recent changes in appetite. Connie notes that Adam reports that he has a poor appetite and has lost 5 pounds in the past week. Adam also complains of mouth pain. Connie observes that Adam has several mouth sores. She further documents that both at home and since being admitted to Good Health Hospital, Adam is consuming less than his current energy needs. Connie calculates Adams estimated calorie and protein needs based on his medical condition.

15. Document Nutrition Diagnoses/Problems Connie documents Adams assessment data which justifies the following nutrition diagnoses (nutrition problems): Inadequate energy intake related to decreased appetite as evidenced by energy consumption less than assessed needs and unintended weight loss of 5 pounds in one week. Chewing difficulty related to mouth pain from oral sores as evidenced by oral side effects of chemotherapy

16. Document Nutrition Interventions & Recommendations Connie recommends a nutrition intervention of a commercial beverage medical food supplement between meals (three times per day) for nutrition supplementation and a Mechanical Soft diet to address chewing difficulty. She enters the recommendations for a commercial beverage medical food supplement item available per the hospitals formulary standards and for the diet change into the EHR and flags it for Rachel Resident to review, approve and countersign as per the hospitals protocol.

17. Document Nutrition Care Plan – Monitoring & Evaluation Criteria These recommended diet prescription, nutrition interventions and nutrition care plan goals are documented along with monitoring and evaluation goals for the patient of: 1)Consume > 75% assessed energy needs in 3 days, and 2)Will not lose additional weight in the next two weeks.

19. Next Steps to May 2012 Ballot Notification of Intent to Ballot: Feb 26 Editor Question: Should this be R2, or R1 – Iteration 2? Initial Content Deadline: March 4 V3 Preview Content: March 11 Content Deadline: March 18

20. WGM Update - May 2011 Background slides from prior presentations leading up to R1 DAM ballot in Sept 2011

21. Diet Types - Oral Qualitative types General / Healthful Age-appropriate modifications (e.g., toddler, elderly) Texture / Consistency Modified Allergy/Intolerance: limit or eliminate specific foods / ingredients (e.g. gluten-free) Preferences: observe patients personal/religious food choices to increase compliance Quantitative Types - 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.)

22. Diet Types – Cont Oral Medical Nutritional Supplements Ordered by Specific Product/Manufacturer ID Ordered by Generic Description of Product Formulation High Protein/2.0 Kcal formula Non-Oral Enteral Nutrition (for tube feedings) Other Nutrition Orders – Messages/Consults

23. 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

24. 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)

25. 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

26. 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

27. 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)

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

29. 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)

30. 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