S&I Framework
Nutrition & Diet Elements
October 12, 2011
Nutrition & Diet Elements
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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
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)
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).
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.
Nutrition Informatics Survey 2011 HIMSS Analytics
Elements of ADA Nutrition Care Process
Standardize Language in Use
Use of ADA’s 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
Not asked
Not asked
Which elements of the ADA’s Nutrition Care Process Standardized Language are you using at your primary worksite? (Only those who said
“yes” to question 15).
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
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 : model of healthcare data developed for
federal agencies, the Veterans Administration; untested.
Diet CIM Object Summary
CIM Object
Name
Diet
Diet
Narrative
CIM Object Definition
CDA ID References
The diet that has been ordered or
recommended by the clinician. (Distinct from
1.3.6.1.4.1.19376.1.5.3.1.3.33
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 selfmonitoring.
Clinical Example: Patient is advised to follow a
low salt, low fat and reduced calorie diet.
Current Text: Records a narrative description of the
expectations for diet, including proposals, goals and 1.3.6.1.4.1.19376.1.5.3.1.3.33
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.
CIM Object Priority
“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 subacute care)
“B” Data Elements to Patient:
Data Exchange to a PHR.
“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 subacute care)
“B” Data Elements to Patient:
Data Exchange to a PHR.
Nutrition Diagnosis
Name of Data
Element
Definition of Data Element
ISO/HL7 Data type
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)
PES Statement
Problem or Nutrition Diagnosis Label
(Problem/Etiology
(Describes alterations in the
Signs/Symptoms
patient’s 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)
Nutrition
Diagnosis
CE (Coded Element) (value
set is all of the SNOMEDcoded interventions in the
IDNT list.
Examples & Guidance
Clinical Examples:
Data Element
Priority
B
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.
CE (Coded Element) (value
set is all of the SNOMEDcoded interventions in the
IDNT list.
B
Diet CIM Objects (In Detail)
Name of Data
Element
Definition of Data Element
ISO/HL7 Data type
Nutrition
Prescription
The patient’s individualized
recommended dietary intake of
energy and/or selected foods or
nutrients based on current
reference standards and dietary
guidelines and the patient’s 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)
Examples & Guidance
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/
Data Element
Priority
B
Nutrition Intervention
Name of Data
Element
Nutrition
Intervention
Definition of Data Element
ISO/HL7 Data type Examples & Guidance Data Element
Priority
Purposefully planned actions intended to positively
CE (Coded Element) Clinical Examples:
B
change a nutrition-related behavior, environmental
(value set is all of
Enteral nutrition
condition, or aspect of health status for an individual
the SNOMED-coded solution: 1 Kcal/cc
(and his or her family or caregivers), target group, or the interventions in the formula for 1600
community at large. A food and nutrition professional
IDNT list.
Kcal/day
works in conjunction with the patient/client(s) and other
health care providers, programs, or agencies during the
Adaptive equipment
nutrition intervention phase.
for feeding assistance.
Nutrition counseling
based on motivational
interviewing strategy.
Includes SNOMED
Codes (IDNT mapped
to SNOMED) and/or
LOINC
Nutrition Intervention (Continued)
Name of Data
Element
Patient
Instructions
Definition of Data Element
ISO/HL7 Data
type
Directions to the patient which have been agreed upon ED
between dietitian and patient and conform to diet order, (Encapsulated
goals and care plan.
Data)
Examples & Guidance
Clinical Example:
Reduce intake of refined
carbohydrates, reduce fat
consumption & increase
omega-3 fatty acid intake
per written guidance.
Data Element
Priority
B
Nutrition/Diet Order (Detail)
Name of Data Element
Diet Description
Diet Type Code
Definition of Data Element
ISO/HL7 Datatype
Narrative description of the
LIST (List Sequence) or ED
recommended diet or daily
(Encapsulated Data)
nutrient intake
Set of codes that controls
the type of diet
modification that a patient
should receive or follow
Examples and
Guidance
Data
Element
Priority
Examples:
General Healthful Diet;
or
“80 gm protein + Consistent Carbohydrate
+ 2g sodium + 2g potassium + 800-1000mg
Phosphorus + 1500 mL Fluid Restricted “
B
CE (Coded Element)
Examples:
Note: Local codes only at
DASH (Dietary Approaches to Stop
present
Hypertension), Kosher, or Vegan
Or Per IHE: LOINC 42344-2
Texture Modification
Required
Indicator specifying
whether the patient/client
requires food texture
modifications
BL (Boolean)
Texture Modifier Code
Describes the consistency
or how the food or type of
food should be modified
for consumption.
CE (Coded Element)
Food Type Code
Indicates what type of
food, e.g., meats, or liquids,
require a texture
CE (Coded Element)
modification
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.
Pudding-thick , chopped or ground
Patient undergoing treatment and
rehabilitation following a stroke may
require honey-thickened liquids, ground
meats and chopped vegetables.
B
B
B
B
Nutrition/Diet Order (Detail – Continued)
Name of Data Element
Nutrient Modification
Required
Definition of Data Element
ISO/HL7 Datatype
Indicator specifying whether the
patient/client requires a
therapeutic or modified diet
to eliminate, decrease, or
increase certain substances in
BL (Boolean)
the diet (e.g., sodium,
potassium)
Nutrient Type Code
Code which identifies the
nutrient which is to be modified
Quantity/Quantity
Modifier
Indicates how much of the
nutrient is being
PQ (Physical Quanitity)/
ordered.
Ratio
May need to be expressed as a
range, thus a modifier e.g, <, > or
CE (Coded Element)
Examples and
Guidance
Data
Element
Priority
Modify distribution, type, or amount of
food and nutrients (IDNT: ND-1.2)
Example: Diabetic patient requires
controlled intake of carbohydrates.
B
Renal dialysis patient requires 1.2 grams
protein/kg body weight, < 2 grams
sodium/day, and 800-1000 mg
Phosphorus/day
E.g., Sodium or Protein
B
B
Nutritional Supplement – (In Progress)
Name of Data Element
Product Name/Description
Product ID
Quantity
Frequency
Definition of Data Element
ISO/HL7 Datatype
LIST (List Sequence)
CE (Coded Element)
Examples and
Guidance
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.
Data Element
Priority
B
B
PQ (Physical Quantity)
IVL (Interval)
B
Enteral Nutrition – (In Progress)
Name of Data Element
Rate or
Frequency
Concentration/Strength
Energy Density
Definition of Data Element
Time frame over which a
product is administered
Dilution or lack of dilution
of the product prior to
administration.
Amount of calories
(energy) provided per
volume
Examples and
Guidance
Data
Element
Priority
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
Full Strength
Half Strength
B
Infant formulas are mixed to a specified
caloric density, e.g., 24 kcal/flluid oz, or
27 kcal/fluid oz
B
ISO/HL7 Datatype
PQ
IVL_TS
Product Name/Description
Product ID
Administration Method
Delivery Site
Instructions
B
B
A code that details how the
food is to be
administered, e.g., Pumpassisted.
A code that identifies
where the tube should
deliver food to, eg. gastric.
Narrative instructions
pertaining to care and
maintenance of the
feeding tube.
B
B
Example:
Flush tube with __mL water every 3
hours.
B
Nutrition Care Provider
Name of Data Element
Assigned Entity
Clinician Contact
information
Healthcare Provider
Identifier
Effective Time
Definition of Data Element
ISO/HL7 Datatype
Nutrition professional (RD)
responsible for completing
the request nutrition
EN (Entity Name)
consult and developing
the nutrition prescription,
and nutrition plan of care
Address, phone and email
information for the RD
AD (Address)
TN (Telephone Number)
provider
National Uniform Claim
Committee Health Care
Provider Taxonomy
Date and time of the
nutrition assessment,
consult or when the
nutrition prescription was
completed
Examples and
Guidance
Data
Element
Priority
Palmetto Hospital
Janice Jones
B
1410 Main Street
Columbia, South Carolina 22001
803-777-7777
B
CE (Coded Element)
B
IVL-TS (IntervalTimestamp)
B
Nutrition Monitoring & Evaluation
Name of Data
Element
Monitoring &
Evaluation
Definition of Data Element
ISO/HL7 Data type
Examples & Guidance
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.
Clinical Examples:
ED (Encapsulated
Data)
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 .
Data Element
Priority
B
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)
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