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Ben Atkinson, MS RDN

April 17, 2018

Nutrition Informatics: Dietitians improving practice through technology

Speaker Disclosure

Receives travel reimbursement from theAND ISC.

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SpeakerBen Atkinson MS RD CD

Current ISC member, Vice-Chair (Chair ’18-’19)Works at Harborview Med Center in Seattle

Manages nutrition informatics program

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Learning Objectives• Describe Academy efforts to engage with IT

public sector and industry to include nutrition in initiatives

• Learn how RDNs & DTRs are currently working with informatics to improve their practice

• List 2 resources that nutrition professionals can use to gain knowledge of nutrition informatics

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Academy and InformaticsHouse Of Delegates (HOD) Spring 2016 Meeting

addressed: “Technological Innovations which Impact Food and Nutrition”

This presentation is part of the ISC’s response.

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We can all use informatics

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What it isNutrition Informatics is the intersection of

information, nutrition, and technology.

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InteroperabilityExchanging and interpreting shared data

8Image from www.peterkrantz.com

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Nutrition Informatics CommitteesWho at the Academy is working and

advocating for informatics?

What work has the Academy done in informatics?

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Informatics at the Academy

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A timeline of rapid growth

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1989Internet

1993Search engines

1998

2004 2006

2007

2003 Nutrition Care Process

2008 Nutrition Informatics Mega Issue

2010 Nutrition Informatics Committee

2011 ISC Subcommittee & CHI Workgroup

1979 Computers in Nutrition

1962 Computers in Dietary Studies - JADA

2007 Nutrition Informatics Workgroup

2014 Interoperability & Standards Committee

2004 Evidence Analysis Library

Nutrition Informatics Committee

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(established 2010)Committee Functions/Priorities1. Assist Academy members to adopt

informatics concepts to improve nutrition focused outcomes

2. Develop nutrition informatics based educational competencies and continuing education

3. Implement nutrition Informatics communication processes and publication documents

4. Collaborate both internally and externally to promote nutrition informatics

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Committee Functions/ Priorities

Goal 1: Participate in the international healthcare information technology (Health IT) community standards-setting organizations (ONC, HL7) to ensure the inclusion of nutrition and diet evidence-based practice, processes and terminology.Goal 2: Support the work of other Academy committees to ensure that best principles of data interoperability and Health IT standards drive all aspects of nutrition practice across all settings.Goal 3: Align projects with the Nutrition Informatics Committee and other DPGs with a vested interest in informatics

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NIC Interoperability and Standards Sub committee began in 2011

Interoperability & Standards Committee Established 2010

Results from Academy efforts delivered in 3 areas

Member Inquiry and Education Internal Collaborations External Collaborations

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Informatics at the Academy

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Nutrition Informatics Member Surveys ( 2008, 2011, 2014)Results published in Journal

Nutrition Informatics Community of Interest created in 2011free portal that any Academy member can joindiscussions on topics relating to Informatics Allows members to connect and share

Nutrition Informatics CompetenciesDelphi study identifies key informatics competencies across educational skill levels (2012)

Nutrition Information Blog -The Feed

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Member Inquiry and Education

FNCE Informatics TeamGenius Zone at FNCE (2013-present) showcases informatics across all areas of practice

Public Policy Workshop Hosted informational tables on Informatics

IMPACT* Act Task ForceRequires Health IT Transition of Care standard (Nutrition included in the standard)

Telehealth WorkgroupContributed informatics content to Telehealth Staff Work group

*Improving Medicare Post Acute Care Transformation Act 16

Internal Collaborations

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NCPROC (Nutrition Care Process Research Outcomes Committee)

• ISC collaboration to map eNCPT to mandated clinical terminologies

• Nutrition Care Manual – Diet order collaboration for general term submission into SNOMED-CT

Malnutrition eCQM –Participated in Malnutrition e-measure for creation of correlated Malnutrition value sets in Value Set Authority Center repository for U.S. eCQMs

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Internal Collaborations

External CollaborationsAMIA / Academy 10X10 Informatics Education program (2017

is 7th offering)Nutrition focused Informatics course129 Academy Graduates54.5 CPEU’s

Health Level Seven (HL7)Academy level participation since 2010Subject matter experts at HL7 Working Groups Meetings up to 3X yearCreation of Nutrition Health IT Standards Comment on Health IT standard ballots

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National Health IT Week is a Partner-driven awareness week focusing on the value of healthcare IT. This weeklong celebration brings together healthcare providers, non-profit organizations, corporations and many others working together to transform health. NPPs have the opportunity to be an official NHIT Week Partner, as well as participate in events and activities across the nation.

Healthcare Information and Management Systems Society (HIMSS)Non-profit partnership since 2011 Endorser since 2014Multiple education events and joint presentations to annual Health IT conference Joint FNCE/ HIMMS sessions

Long Term Post- Acute Care (LTPAC) Environmental ScanParticipation in LTPAC SummitLTPAC and Nutrition Environmental Scan (in process)

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External Collaborations

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Nutrition Informatics: The Framework for Practice in the Digital World

External CollaborationsAmerican Society for Health-Systems Pharmacists (ASHP) and American

Society of Parenteral and Enteral Nutrition (A.S.P.E.N.)White paper on Safe Ordering of Parental Nutrition in Electronic Health Record Systems (release in 2017)

U.S. Regulations on Health IT –Certified Health IT Nutrition Care Plan is included in 7 of 11 documented templates of now mandated Transition of Care health IT standard

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Health IT Infrastructure in U.S.

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Connecting the Healthcare IT Infrastructure to Nutrition Practice in the USA

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Informatics Work at the Academy

Nutrition Inclusion in Health IT Regulations, Standards and Policy

U.S. Extension of SNOMED-CT

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Current & Emerging IT Standards

https://www.healthit.gov/sites/default/files/2017_isa_reference_edition-final.pdf

Organization of Data

Discharge Summary

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Clinical Nutrition

• Electronic Health Records • Personal Health Records• Patient Portals• Mobile monitoring• Health Information Exchange • Patient Generated Data

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A real life use caseProvider wants to provide adequate insulin to a

diabetic patient in a hospital.

How many carbs did the patient consume at lunch?

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Use case (continued)Food & Nutrition System

What kind of standard data does it contain?

EHRWhat kind of standard data does it contain?

Can they share this data?

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Use case (continued)FHIR: Fast Healthcare Interoperability

Resource

Several US and international groups wanting to perform this.

Currently there is no standardized way.

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Use Case (continued)HL7

Utilizes workgroups

Orders & Observations, Patient Care WG’sFacilitate communication to Academy ISC

Started bi-weekly working sessions to create this messaging system: ‘Nutrition Intake’ based on FHIR Resources

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Use Case (continued)Next steps:

Build Nutrition Intake ‘Profile’ based on Medication Observation Resource

Aim for completion in Summer 2018

Could allow for:Nutr intake data to be sent from personal device to EHR

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Clinical Terminologies

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UNII – Unique Ingredient Identifier

SNOMED‐CTICD‐10LOINC

eNCPT

NCP

RDN

Hospital$$$

Reimbursement &Health costs reduction

Design Path of NCP in EHRs

Nursing Home

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Research/Quality Management

Registries

Data repositories

Data Outcomes from EHRs

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Quality Monitoring

Feeding suspended to transport 

patient for test procedure

Tube Feeding Infusion – In “Real Time”

From March 3, 2016 HIMSS presentation, “Nutrition on FHIR®: Burning Calories & More for your EHR” Margaret K. Dittloff, MS RDN & Eric Haas, DVM

Community Nutrition

http://www.washingtonpost.com/local/capital-area-food-bank-gaps-in-service/2015/06/16/7a09e604-147d-11e5-89f3-61410da94eb1_graphic.html

Public Health BMI MonitoringElectronic Benefits CardsSchool Food Nutrition

SystemsLong Term Support

Services

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Vision for Long-Term Support ServicesUpdates and displays eLTSS Plan; stores/transmits data

Updates and displays eLTSS Plan; stores/submits data

Updates and displays eLTSS Plan; stores/transmits data

Extract, Transform,& Load eLTSS Plan 

Data

Move from Patient‐Centered to Person‐Centered Planning and Information Exchangehttps://www.healthit.gov/FACAS/.../HITSC_eLTSS_Intro_for_2014-11-18_v2_0.ppt

Consultation and Private Practice

• Nutrition “Apps”

• Sensors, games, medical Peripherals

• Patient Generated Data

• Nutrition Care Software

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The Challenges for Nutrition

• Academy members must proactively request that nutrition content be included in their EHR

products. NCP is not automatically included.

• Academy members should engage with health IT liaisons to inform them of what nutrition is in

health IT standards, and why nutrition data should be included.

• Work is in progress to provide industry guidance regarding how to implement nutrition related

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Standards Templates

Clinical Terminologies

“Pillars” Support Interoperability

Data

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Clinical Document Architecture

How many people in clinical care have created or edited their own chart note?

This is where we want to move:Paper > EHR > EHR sharing > EHR to ANDHII etc

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IG Project Expectations

1Creation of a HL7 C-CDA R2.1 Implementation Guide for EHR Vendors guide correct NCP design.

HL7 holds the (free) access via a license to the IG.

This prevents any changes to the IG that “break” the ability to design NCP in EHRs.

2Academy Member Took Kit (by staff) will provide clinical-technicalguidance to nutrition and dietetics professional as they design NCP in their EHR system.

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Repercussions of No Implementation Guide

No consistent EHR design for building the Nutrition Care Process for RDNs in any setting

Limited use of eCQMs and ANDHII (as there is no systematic process to move the data out of the EHR)

Limited inclusion in the IMPACT Act Long term Post-Acute Transitions of Care as there is no structure

Feedback from EHR Implementers is that the NCP breaks down/gets lost upon discharge planning. This TOC will provide a venue to make sure nutrition interventions are properly communicated to patient and subsequent care providers.

Transitions of Care Implementation Guide

Guides EHR Vendors to create the Nutrition Care Process in a way that supports nutrition data being: • Shared across care settings for improved quality of care (IMPACT Act)• Pulled into electronic Clinical Quality Measures (MQii)• Populated into Outcomes Reports• Populated into ANDHII• Coded for RDN financial return on the investment (Future MACRA/MIPS)

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Dietetics Education

Teaching Informatics

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Current Model2017 Standards:Currently, no specific informatics standards for any

level of dietetics educationHowever, informatics can be infused in most every

standardTeaching “digital natives”

how to use technologysystematically and purposefully in theirfuture careers as a clinician, researcher ormanager.

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Examples of Informatics:

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KRDN 3.1: Use the Nutrition Care Process to make decisions, identify nutrition-related problems and determine and evaluate nutrition interventions.

Use of the EAL, Nutrition Care Manual, ANDHII, and development of educational programs for nutrition-related problems

KRDN 4.3: Describe the regulation system related to billing and coding, what services are reimbursable by third party payers, and how reimbursement may be obtained.

Education on Health IT standards, terminologies, and the work of the Academy to include nutrition as part of standards.

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Changes to Dietetics RegistrationCommission on Dietetic Registration (CDR)

In 2024, in order to be eligible for the RD exam, the registrant will need to have completed a dietetic internship or coordinated program and have a Master’s degree in any field.

ACENDCurrently working on the Future Education Model which will include Master’s prepared entry level RDNStandards will also change the Associate’s and Bachelor’s requirements/credentials.

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Future Education Model:Informatics competencies were added at the

Bachelor’s and Master’s levels:http://www.eatrightpro.org/resources/acend/accreditation-standards-fees-

and-policies/future-education-model

Bachelor’s Performance Indicators:1.13.1 Applies technology in the decision making process1.13.2 Describes factors to consider when accessing and evaluating nutritional health information online1.13.3 Identifies trends in nutritional health care and food systems1.13.4 Uses electronic databases to obtain information1.13.5 Proficiently uses technology to enhance practice and client/patient care

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Future Education Model cont.Master’s Performance Indicators:

1.13.1 Analyzes data derived from electronic media to make best decisions related to nutrition and diet1.13.2 Evaluates accuracy and reliability when accessing and evaluating nutrition information online1.13.3 Designs and/or operates nutrition informatics systems in practice1.13.4 Uses electronic databases to obtain information and evaluate credible sources in decision making1.13.5 Proficiently uses technology to enhance practice and client/patient care

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Continuing Education Opportunities:Technology Informatics Guiding Education Reform (T.I.G.E.R.)

TIGER advances the integration of health informatics by: tiger@himss.org

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Available Resources:Nutrition Informatics Community of Interest, open to all

Academy members: https://adanic.webauthor.com

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Nutrition Informatics ContentFood and Nutrition Magazine:

The Feed blog: www.foodandnutrition.org/Blog/The-FeedApp reviews: www.foodandnutrition.org/Nutrition-Apps/Social media guides: www.foodandnutrition.org/Social-Pro/

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HIMSS Collaborative

http://www.himss.org/nutrition-informatics-town-hall-series

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Nutrition Informatics Certificate

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SummaryInformatics work at the Academy has driven

nutrition content in health IT standards now required in the U.S.

Expectations are that “data follows the patient” in U.S. healthcare.

Informatics skills and knowledge are necessary in all areas of practice.

Informatics educational opportunities are available for members.

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Informatics Resources (hyperlinked)

AMIA Academy Informatics Education CourseAcademy Informatics Community of Interest“The Feed” Nutrition Informatics BlogInformatics Competencies National Delphi Study HIMSS Webinar: Roar with TIGER and Informatics

CompetenciesMalnutrition electronic Clinical Quality MeasuresNational Health IT WeekHIMSS17 Malnutrition Blog

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