Nutrition on FHIR®: Burning Calories & More for your EHR

March 3, 2016 Margaret K. Dittloff, MS RDN

Eric Haas, DVM

Conflict of Interest Margaret K. Dittloff, MS RDN Has no real or apparent conflicts of interest to report. Eric Haas, DVM MS Has no real or apparent conflicts of interest to report.

Learning Objectives • Discuss the model and principles for multi-disciplinary

team engagement in project identification, clinical scenarios, and collaboration necessary for inclusion in health IT standards community

• Summarize necessary efforts of clinicians, patients, and implementers/analysts when creating useful data exchange using FHIR® Nutrition Order Resource as a model

• Explain the use of FHIR technology/open API to support improved care coordination

Benefits Realized for Value of Health IT Value STEPS™ categories impacted are: Treatment/Clinical Electronic Secure Data Patient Engagement

http://www.himss.org/ValueSuite

* Pew Research Center, April 2015, “The Smartphone Difference”

Health IT Predications for 2016 http://www.healthcareitnews.com/blog/2016-predictions-health-it

“Apps will layer on top of transactional systems

empowered by FHIR . . . a better approach is crowdsourcing

among clinicians that will result in value-added apps that

connect to underlying EHRs via the protocols suggested in the

Argonaut Project (FHIR/OAuth/REST).” John Halamka MD

2016 Predictions for health IT January 04, 2016

Academy of Nutrition and Dietetics

Clinical-Acute/Inpatient

32%

Clinical-Ambulatory

18% Clinical-LTC

10%

Community 12%

Food Management 13%

Consultant/Business 8%

Education/Research 7%

AREAS OF PRACTICE

6

Largest Food & Nutrition Organization in the World - 73,000 Members

60% Clinical

“The intersection of information, nutrition,

and technology.”

(Academy of Nutrition and Dietetics – Nutrition Informatics Committee, 2010)

Nutrition Informatics

Health Care Implications of Chronic Diseases

Source: Centers for Disease Control and Prevention. National Center for Health Statistics. Health Data Interactive. www.cdc.gov/nchs/hdi.htm. [12/30/2015].

Nutrition is key to prevention and treatment of many chronic diseases including:

• Heart disease

• Cancer

• Stroke

• Diabetes

• Alzheimer’s disease

• Kidney disease

Health Risk Behaviors Contributing to Chronic Disease

Lack of Physical Activity or Exercise

Excess Alcohol Consumption

Poor Nutrition Smoking and Tobacco Use

Key Statistics

• Adults who consume fruit < 1 x day:

– 37.7% (2011) – 38.5% (2013)

• Adults who consume vegetables < 1 x day:

– 22.6% (2011) – 22.4% (2013)

of Americans eat too much sodium

Adult Obesity Has Doubled Since 1994

Source: Nutrition, Physical Activity and Obesity Data, Trends and Maps web site. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Chronic Disease Prevention and Health

Promotion, Division of Nutrition, Physical Activity and Obesity, Atlanta, GA, 2015. Available at http://www.cdc.gov/nccdphp/DNPAO/index.html.

Malnutrition in Hospitalized Patients

• 1 in 3 patients are malnourished upon admission

• ~20% decline in nutritional status or weight loss ≥5% during admission

• Prolongs LOS by 2 days Nutrition intervention has been shown to:

Shorten lengths-of-stay

Reduce readmissions with significant cost savings

Lessen complications (e.g., falls, pressure ulcers, surgical site infections)

SOURCES: Alliance for Patient Nutrition. http://malnutrition.com

A.S.P.E.N. Survey Average Ratings of Nutrition Content in EHRs by Discipline

Nutrition Documentation

Oral Diets

Oral Supplements

Tube Feedings

Parenteral Nutrition

Dietitians Fair Fair Fair Fair Fair Physicians Poor Fair Fair Fair Fair

Pharmacists Fair Fair Fair Fair Fair Nurse/NP Fair Good Good Fair Fair Other Fair Good Good Fair Good

Source: Vanek VW. Providing nutrition support in the Electronic Health Record Era: the good, the bad, and the ugly. Nutr Clin Pract. 2012;27:718-737.

A.S.P.E.N. Survey “Least Like” Nutrition Orders in the EHR

• Time-consuming and cumbersome to use (66)

• PN orders, compounding, and/or administration difficult and can result in errors (41)

• Limited or deficient in nutrition or nutrition support content (40)

• Oral diet orders incomplete and/or confusing (26) • Difficult for physicians and other staff to access and read

dietitian documentation and notes (22) • EN (tube feeding) orders incomplete and/or confusing (19) Source: Vanek VW. Providing nutrition support in the Electronic Health Record Era: the good, the bad, and the ugly. Nutr Clin Pract. 2012;27:718-737.

Information Exchange EHRs PHRs

APIs & Apps

Building Nutrition Standards

Foundation Nutrition Care Process

Evidence-based Practice

Semantic/Content Vocabulary & Code Sets

(IDNT, SNOMED, LOINC)

Structure Information Models

Document Templates

HL7 Domain Analysis Model: Diet and Nutrition Orders

3 Types of Orders: • Oral Diets

• Oral Nutritional

Supplements

• Tube Feeding or (Infant) Formula Feedings

http://www.hl7.org/implement/standards/product_brief.cfm?product_id=289

Nutrition Standards – Our Secret Sauce

1. Organize your SMEs around real-world clinical scenarios.

2. Translate those into storyboards or use cases identifying both actors and data (PPT or Visio® will work)

3. Shake and bake. (AKA Harmonization and balloting) 4. Taste and sample. (Beta and Testing) 5. Adjust seasoning and repeat

starting at Step 3.

• 4-6 Subject Matter Experts (SME), more if needed

• 1 Information Modeler, preferably with HL7 experience

• 1 Clinical Terminologist Consultant (on retainer)

• 1-2 Implementers

• 1 Project Facilitator

Maturity Model Guiding Principle: Promote Innovation

Source: Interoperability Standards Task Force Recommendations, August 26, 2015. https://www.healthit.gov/FACAS/sites/faca/files/HITSC_ISATF_Recommendation_Slides_2015-08-26.pdf

To improve the interoperability of nutrition and diet order information across the continuum of care, it is critical that health

care providers and sending and receiving system vendors have a clear understanding of the components involved in ordering, preparing, and providing meal trays, formula feedings, and

nutritional supplements to patients and residents.

Let’s Take a Poll Q1: Are you familiar with FHIR?

1. Yes

2. No

FHIR® NutritionOrder Resource

Request for Oral Diets

Request for Oral Nutritional Supplements

Request for Tube Feedings

Why FHIR? – Fast (to design & to implement)

– Relative – no technology can make integration as fast as we’d like

– Healthcare – That’s why we’re here

– Interoperable – Ditto

– Resources – Building blocks – more on these to follow

• Focus on implementers • Target support for common scenarios • Leverage cross-industry web technologies • Support human readability as base level of interoperability • Make content freely available • Support multiple paradigms & architectures • Demonstrate best practice governance

FHIR Manifesto

NutritionOrder Resource • Resources are containers of information • References between Resource create a “web” of information

NutritionOrder

Allergy Intolerance

Patient Practitioner

Encounter

FHIR resource

“container” of information that represent something in the real world

Link between resources

Goal

CarePlan

Anatomy of a Resource

FHIR® NutritionOrder Resource

Request for Oral Diets

Request for Oral Nutritional Supplements

Request for Tube Feedings

FHIR® NutritionOrder Resource • Standard Terminology developed with DAM using SNOMED CT

http://hl7.org/fhir/DSTU2/index.html

NutritionOrder Resource: Example 1 Cardiac Diet: Storyboard: Dr. Adam Careful orders a low-sodium and fluid-restricted

diet for his patient Peter Chalmers. Starting on 2/10 breakfast, he orders a diet with a maximum 400 ml fluids and 2 grams sodium per day.

http://hl7.org/fhir/DSTU2/nutritionorder-example-cardiacdiet.html

NutritionOrder Resource: Example 2 Tube Feeding: Storyboard: Dr. Adam Careful orders diabetic specialty enteral

formula for his patient Peter Chalmers. Starting on 7/10 at 60ml/hr and gradually increasing to 100ml/hr over the next 6 hrs with a maximum delivery of 880 mls per day.

http://hl7.org/fhir/DSTU2/nutritionorder-example-enteralcontinuous.html

Let’s Take a Poll Q2: How will open API technology (FHIR) most benefit Health IT?

1. eHealth data exchange 2. Embedded apps in EHR 3. Mobile access for clinicians 4. Mobile apps for patients

Applications • Get Feedback

– Evaluation and Patient monitoring – FHIR Observation Resource

• Inpatient monitoring (e.g., feeding pump data) • Patient monitoring – mobile devices (Fitbit®, etc.)

• Use Feedback – Modification CarePlan or Goal Resources

• HIT Goals to improve care coordination and patient safety

Demonstration of Enteral Feeding NO and Observations

• Scenario: – Using the tube feeding example above – Create and store NutritionOrder Resources in “FHIR server” – Volume delivered to the Patient recorded and stored as

Observation Resources – Get Resources and Generate a quick graph of the actual

delivered volume/energy vs. what was ordered.

Demonstration of Enteral Feeding NO and Observations • Create and store NutritionOrder Resources in “FHIR server”

Demonstration of Enteral Feeding NO and Observations

• Get Resources and Generate a quick graph of the actual delivered volume/energy vs. what was ordered.

Feeding suspended to

transport patient for test procedure

A Summary of How Benefits Were Realized for the Value of Health IT - Treatment/Clinical Transitions of Care Care Coordination Malnutrition Monitoring - Electronic Secure Data Data exchange between Providers & Care Team Mobile access to data - Patient Engagement Mobile nutrition monitoring apps

http://www.himss.org/ValueSuite

Questions Thank You!

– Eric M Haas, DVM, MS Health eData Inc. ehaas@healthedatainc.com

– Margaret K. Dittloff, MS RDN mkd@cbord.com @mkdittloff