Nutrition is integral to optimal health and the practice of nutrition care is woven throughout the systems that treat and facilitate health care. Effective systems for acute care and primary care integrate nutrition therapy into the patient’s care and therefore, it is essential to include nutrition care processes in care team communications and documentation to promote the right care at the right time for optimized health outcomes. To that end, incorporating validated and standardized nutrition concepts in the electronic health record (EHR) is crucial to developing a robust, comprehensive care plan.
The Academy of Nutrition and Dietetics started a conversation in 2007 about the need for informatics initiatives that support all areas of nutrition practice. Early nutrition terminology work began with the development of the International Dietetics and Nutrition Terminology (IDNT) which evolved into the electronic Nutrition Care Process Terminology (eNCPT) Reference Manual in 2014. As part of this proactive effort, the Academy initiated work with the Health Level Seven (HL7) EHR working group to create an Electronic Nutrition Care Process Record System (ENCPRS) Functional Profile that identifies the essential capabilities of performance for dietetics and nutrition practice that should be used in an EHR.
I recently had the pleasure of talking with Ben Atkinson, MS, RDN, CD, Manager of Informatics and Wellness at Harborview Medical Center, and the Vice-Chair of the Academy’s Interoperability and Standards Committee, and would like to share our conversation as well as my insights on their progress.
Q: As an introduction, can you tell us about your role on the committee?
A: “My role as Vice-Chair, or second in command, is one of ten appointed positions made up of nutrition professionals. The focus of the work is on standards development; for example, a current workgroup project is defining ‘nutrition intake.’
I have been doing informatics work since 2002, when I started a job at the University of Washington Medical Center. My job was to take a newly implemented food and nutrition information system and run with it. I ended up creating electronic interfaces for admission, discharge and transfer (ADT), and diet orders. These allowed me to streamline nursing unit pantry inventory and stocking, and implement online purchasing from food service vendors. I was 22 years old, with a smattering of food service experience and basic familiarity with technology. My first month on the job I created the Thanksgiving patient menu in the computer system, and the menus all printed out with tuna sandwiches and fried chicken as the entrée. I spent the entire Wednesday before the holiday collecting all 400 patient menus that had been passed out, correcting the errors, passing them back out, and collecting them again!
Currently, I work at Harborview Medical Center in Seattle, WA. It is part of the University of Washington, and is the only Level One Trauma Center in the 5-state northwest region. I manage the food and nutrition information system, and work with our multiple EHRs (we have three different ones!) for clinical integration. Lately, I have been attempting to add information about food insecurity to our Epic outpatient health record, with the goal of having that information documented for all our clinicians to see and use.”
Q: Since the development of the Nutrition Terminology Reference Manual, what have been the challenges?
A: “Implementing the standardized nutrition terminology from the reference manual so that clinicians and nutrition professionals could use it adequately was a huge initial hurdle. I was in graduate school at the time and my graduating class at the University of Washington was the first class to be taught it. My class ended up teaching many of the preceptors how to use it.
Currently, while there are standardized terms for the Nutrition Care Process, inserting them into EHRs has been challenging. Since nutrition care is not mandated to be included into EHR development, individual clinical sites and users must determine how to handle clinical nutrition themselves. The Interoperability Standards Committee (ISC) and other members are currently working to develop an implementation guide to provide technical guidance on how to incorporate nutrition-related clinical information into the HL7 Consolidated Clinical Document Architecture (CCDA), a health IT standard required for EHR certification in the U.S.”
Q: What are the current needs for nutrition in informatics and what is the progress?
A: “One of the current needs in health informatics is for information about food intake to be shared between systems. Whether it is between your personal health record (Fitbit or app on your mobile device) and your healthcare provider, or between nursing staff on an acute care unit and the nutrition department, there is no standardized way to share this information.
The ISC, HL7, and several vendors are working towards creating a standardized method for transmitting this information. The work is similar to the way medication orders are communicated, though the complexity of custom recipes and served versus eaten meals in the inpatient setting add to the challenge. The work is being created within the HL7 Fast Healthcare Interoperability Resource (FHIR) framework, which is much more user friendly to vendor developers.”
Q: How will including standardized nutrition terms add to the direction that value based payment and accountable care organizations are headed?
A: “Advocacy work at the Academy is intended to include nutrition in health IT standards and regulations. Standardized nutrition terms from the eNCPT allow for consistent definitions across care settings. The eNCPT also mapped these terms to mandated clinical terminologies (e.g. SNOMED and LOINC). From the perspective of EHR analysts and nutrition clinicians, implementing and maintaining food and nutrition systems and nutrition modules in EHRs will be much more streamlined if nutrition care is consistent. Data will be retrievable for large-scale reporting for internal quality management and improvement. Communication between organizations will also improve because nutrition-related data would be understood by both sending and receiving organizations, less faxed clinical notes!”
Takeaway 1 – The Academy has made great progress on developing nutrition standards and pursuing strong collaboration in the informatics community.
Takeaway 2 – Nutrition care process terminology domains in the eNCPT (Nutrition Assessment, Nutrition Diagnosis, Nutrition Intervention, and Monitoring and Evaluation) should be consistently included in the EHR to promote best practices.
Takeaway 3 – Nutrition documentation in the EHR supports quality care and has the potential for future inclusion in regulatory reporting programs such as CMS’s Quality Payment Program. Some measures that might benefit from nutrition standards are:
- Documentation of Current Medications in the Medical Record – eMeasure ID: CMS68v6 (nutritional supplements and herbals)
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents – eMeasure ID: CMS155v5
Mary Zeigle, is a clinical analyst with the Clinical Terminology group at 3M Health Information Systems.
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