Project Update – Jan 2012 WGM
HL7 Version 3 Domain
Analysis Model: Nutrition R1
Sponsored by:
Academy of Nutrition and Dietetics
(formerly American Dietetic Association)
Project Status
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Informative Ballot R1 – Sept 2011
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Reconciliation completed Sept WGM 2011
Reconciliation edits to storyboards 75% completed
(J. Snyder/M. Dittloff)
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To Do: Reconciliation updates to model & diagrams
 Primarily to revise/merge Pediatric => Enteral
Informative Ballot R2 – May 2012
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Adding New Storyboards to provide more complete
picture of nutrition content
In progress – working with SME committee
New Nutrition Storyboards
Acute / LTC Food Allergy
 Acute / LTC Food Intolerance
 Food Preference
 Revise Request Dietitian Consultation
 New Sub-Flow: Nutrition Care Process
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Nutrition Assessment
Nutrition Diagnosis (Problem)
Nutrition Interventions
Nutrition Monitoring & Evaluation
Acute / LTC Food Allergy
Adam Everyman is admitted to Green Acres Retirement
Home after being discharged from Good Health Hospital.
While reviewing Adam’s 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.
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
clinician’s 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 Adam’s record in the FNMS. The FNMS is able
to identify food products with eggs and remove them from
Adam Everyman’s 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.
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.
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 Adam’s 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.
Acute / LTC Food Preferences
(ethnic, cultural, religious)
Eve Everywoman has been transferred to the postpartum 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 Eve’s 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.
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 Eve’s food preferences. The FNMS
automatically acknowledges receipt of the list of food
preferences and updates Eve’s 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 tonight’s dinner. Eve receives her dinner tray
featuring a poultry entrée that satisfies her food
preferences.
Dietitian Consultation Flow
* Update/revise to link dietitian consultation back to
enter new or modify nutrition orders
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.
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 Adam’s 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 Adam’s
current nutrition orders.*
Nutrition Care Process Model
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 Adam’s
estimated calorie and protein needs based on his medical condition.
Document Nutrition Diagnoses/Problems
Connie documents Adam’s 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
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 hospital’s formulary
standards and for the diet change into the EHR and flags it for
Rachel Resident to review, approve and countersign as per the
hospital’s protocol.
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.
Next Steps to May 2012 Ballot
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Notification of Intent to Ballot: Feb 26
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Editor Question: Should this be R2, or R1 – Iteration 2?
Initial Content Deadline: March 4
 V3 Preview Content: March 11
 Content Deadline: March 18
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WGM Update - May 2011
Background slides from prior
presentations leading up to R1
DAM ballot in Sept 2011
Diet Types - Oral
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Qualitative types
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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 patient’s personal/religious food choices to increase
compliance
Quantitative Types - Nutrient-based Modifications
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Energy Modified
Carbohydrate Modified
Protein & Amino Acid Modified
Fluid Modified (Restricting or limiting consumption of total fluids)
Mineral Modified (sodium, potassium, phosphorus, etc.)
Diet Types – Con’t
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Oral
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Medical Nutritional Supplements
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Ordered by Specific Product/Manufacturer ID
Ordered by Generic Description of Product Formulation
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Non-Oral
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High Protein/2.0 Kcal formula
Enteral Nutrition (for tube feedings)
Other Nutrition Orders – Messages/Consults
Diet Taxonomy Examples
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Fat Modified Diet (Nutrient = Total Fat)
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Definition: A diet of known fat composition consistent with the age
and life stage of the patient/client
Modifications:
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Ketogenic Diet (Nutrient mix/ratio)
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High fat diet (>100 grams of fat) grams oral
Low fat diet (<30% of energy needs) oral
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
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Definition: A diet of known cholesterol composition consistent with
the age and life stage of the patient/client milligrams oral
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High (>250 mg) milligrams oral
Low (<200 mg) milligrams oral
Diet Order Data Elements
The order should contains the following basic information:
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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)
DIET ORDER SEQUENCE
MD diet order,
supplements, RD
consult, VO orders,
assigns magmt of
TPN or TF others
CPOE or paper
chart
EMR
NURSING Order flavor of
supplement, VO orders hold
diet for test, allergies, late or
early tray
Dietitian input
Limited access for
VO or clinical
privileges
Limited access for
info
HL7 interface
Documentation of
care plan, educ. And
order labs, TPN and
adjusts electrolytes
FNMS
FOOD & NUTRITION
MGT SYS
Diet Clerk food
preferences,
allergies,
intolerances;
notifies diet
consult, corrects
diet order errors;
inputs nourishment
requests
Diet Supplement Flow Chart
Electronic Health Record
ORDER
Supplement 1000
Calories per Day
PAT Role, Service
location, Diet Code,
Entity
Food and Nutrition Management System
LIC
Order Received and
Approved by Provider or Diet
Clerk
PROV
Order
Resulted
PAT
Order fulfilled with
available supplement that
meets criteria
Supplement Provided to
Patient
Order Processing Actions
(Triggers/States)
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Activate Order
(start date + time
(meal))
Abort Order
Suspend Order
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(clinicians
have raised
concerns eliminate)
Held (remove)
Replace Order
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Revise Order
(needs
discussion)
Application Roles
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Order Manager - EHR/CPOE/HIS
(sending app)
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Order Placer
FNMS-Food/Nutrition System (receiving
app)
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Fullfiller
Nutrition Orders Storyboards
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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
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Special Meal/Tray Service Requests
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(Late Tray or Isolation/Disposables)
Next Steps to DAM
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Need a Publishing Facilitator
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Additional Roles/Names of Participants to submit to
publishing
Identify from other DAM
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Information Model/Class Diagrams
Conceptual State Machine
Activity Diagrams (Interaction Diagrams)
Functional Requirements
Non-Functional Requirements
Use-Case Bubble Diagrams