Nutrition Informatics: Dietitians improving practice through technology Ben Atkinson, MS RDN April 17, 2018 4/4/2018 Speaker Disclosure Receives travel reimbursement from the AND ISC. 2 1
Speaker Ben Atkinson MS RD CD Current ISC member, Vice-Chair (Chair 18-19) Works at Harborview Med Center in Seattle Manages nutrition informatics program 3 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 4 2
Academy and Informatics House Of Delegates (HOD) Spring 2016 Meeting addressed: Technological Innovations which Impact Food and Nutrition This presentation is part of the ISC s response. 5 We can all use informatics 6 3
What it is Nutrition Informatics is the intersection of information, nutrition, and technology. 7 Interoperability Exchanging and interpreting shared data Image from www.peterkrantz.com 8 4
Nutrition Informatics Committees Who at the Academy is working and advocating for informatics? What work has the Academy done in informatics? 9 Informatics at the Academy 10 5
A timeline of rapid growth 1962 Computers in Dietary Studies -JADA 1993 Search engines 2003 Nutrition Care Process 2004 2006 2008 Nutrition Informatics Mega Issue 2010 Nutrition Informatics Committee 2011 ISC Subcommittee & CHI Workgroup 1989 Internet 1979 Computers in Nutrition 1998 2004 Evidence Analysis Library 2007 2007 Nutrition Informatics Workgroup 2014 Interoperability & Standards Committee 11 Nutrition Informatics Committee (established 2010) Committee Functions/Priorities 1. 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 12 6
Interoperability & Standards Committee Established 2010 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 NIC Interoperability and Standards Sub committee began in 2011 13 Informatics at the Academy Results from Academy efforts delivered in 3 areas Member Inquiry and Education Internal Collaborations External Collaborations 14 7
Member Inquiry and Education Nutrition Informatics Member Surveys ( 2008, 2011, 2014) Results published in Journal Nutrition Informatics Community of Interest created in 2011 free portal that any Academy member can join discussions on topics relating to Informatics Allows members to connect and share Nutrition Informatics Competencies Delphi study identifies key informatics competencies across educational skill levels (2012) Nutrition Information Blog -The Feed 15 Internal Collaborations FNCE Informatics Team Genius Zone at FNCE (2013-present) showcases informatics across all areas of practice Public Policy Workshop Hosted informational tables on Informatics IMPACT* Act Task Force Requires Health IT Transition of Care standard (Nutrition included in the standard) Telehealth Workgroup Contributed informatics content to Telehealth Staff Work group *Improving Medicare Post Acute Care Transformation Act 16 8
Internal Collaborations 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 17 External Collaborations AMIA / Academy 10X10 Informatics Education program (2017 is 7 th offering) Nutrition focused Informatics course 129 Academy Graduates 54.5 CPEU s Health Level Seven (HL7) Academy level participation since 2010 Subject matter experts at HL7 Working Groups Meetings up to 3X year Creation of Nutrition Health IT Standards Comment on Health IT standard ballots 18 9
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. External Collaborations Healthcare Information and Management Systems Society (HIMSS) Non-profit partnership since 2011 Endorser since 2014 Multiple education events and joint presentations to annual Health IT conference Joint FNCE/ HIMMS sessions Long Term Post- Acute Care (LTPAC) Environmental Scan Participation in LTPAC Summit LTPAC and Nutrition Environmental Scan (in process) 20 10
Nutrition Informatics: The Framework for Practice in the Digital World External Collaborations American 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 21 Health IT Infrastructure in U.S. 22 11
Connecting the Healthcare IT Infrastructure to Nutrition Practice in the USA 23 Informatics Work at the Academy Nutrition Inclusion in Health IT Regulations, Standards and Policy U.S. Extension of SNOMED-CT 12
Current & Emerging IT Standards https://www.healthit.gov/sites/default/files/2017_isa_reference_edition-final.pdf Organization of Data Discharge Summary 13
Clinical Nutrition Electronic Health Records Personal Health Records Patient Portals Mobile monitoring Health Information Exchange Patient Generated Data 27 A real life use case Provider wants to provide adequate insulin to a diabetic patient in a hospital. How many carbs did the patient consume at lunch? 28 14
Use case (continued) Food & Nutrition System What kind of standard data does it contain? EHR What kind of standard data does it contain? Can they share this data? 29 Use case (continued) FHIR: Fast Healthcare Interoperability Resource Several US and international groups wanting to perform this. Currently there is no standardized way. 30 15
Use Case (continued) HL7 Utilizes workgroups Orders & Observations, Patient Care WG s Facilitate communication to Academy ISC Started bi-weekly working sessions to create this messaging system: Nutrition Intake based on FHIR Resources 31 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 32 16
Clinical Terminologies UNII Unique Ingredient Identifier 33 Design Path of NCP in EHRs SNOMED CT ICD 10 LOINC encpt Nursing Home NCP RDN Hospital $$$ Reimbursement & Health costs reduction 17
Research/Quality Management Registries Data repositories Data Outcomes from EHRs 35 18
Quality Monitoring Tube Feeding Infusion In Real Time Feeding suspended to transport patient for test procedure From March 3, 2016 HIMSS presentation, Nutrition on FHIR : Burning Calories & More for your EHR Margaret K. Dittloff, MS RDN & Eric Haas, DVM 37 Community Nutrition Public Health BMI Monitoring Electronic Benefits Cards School Food Nutrition Systems Long Term Support Services http://www.washingtonpost.com/local/capital-area-food-bank-gaps-in-service/2015/06/16/7a09e604-147d-11e5-89f3-61410da94eb1_graphic.html 19
Vision for Long-Term Support Services Updates and displays eltss Plan; stores/transmits data Updates and displays eltss Plan; stores/transmits data Updates and displays eltss Plan; stores/submits data Move from Patient Centered to Person Centered Planning and Information Exchange https://www.healthit.gov/facas/.../hitsc_eltss_intro_for_2014-11-18_v2_0.ppt Extract, Transform, & Load eltss Plan Data Consultation and Private Practice Nutrition Apps Sensors, games, medical Peripherals Patient Generated Data Nutrition Care Software 40 20
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 health IT standards. 41 Pillars Support Interoperability Data Standards Templates Clinical Terminologies 21
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 43 IG Project Expectations 1 Creation 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. 2 Academy Member Took Kit (by staff) will provide clinicaltechnical guidance to nutrition and dietetics professional as they design NCP in their EHR system. 22
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) 23
47 Dietetics Education Teaching Informatics 48 24
Current Model 2017 Standards: Currently, no specific informatics standards for any level of dietetics education However, informatics can be infused in most every standard Teaching digital natives how to use technology systematically and purposefully in their future careers as a clinician, researcher or manager. 49 Examples of Informatics: 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 nutritionrelated 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. 50 25
Changes to Dietetics Registration Commission 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. ACEND Currently working on the Future Education Model which will include Master s prepared entry level RDN Standards will also change the Associate s and Bachelor s requirements/credentials. 51 Future Education Model: Informatics competencies were added at the Bachelor s and Master s levels: http://www.eatrightpro.org/resources/acend/accreditation-standards-feesand-policies/future-education-model Bachelor s Performance Indicators: 1.13.1 Applies technology in the decision making process 1.13.2 Describes factors to consider when accessing and evaluating nutritional health information online 1.13.3 Identifies trends in nutritional health care and food systems 1.13.4 Uses electronic databases to obtain information 1.13.5 Proficiently uses technology to enhance practice and client/patient care 52 26
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 diet 1.13.2 Evaluates accuracy and reliability when accessing and evaluating nutrition information online 1.13.3 Designs and/or operates nutrition informatics systems in practice 1.13.4 Uses electronic databases to obtain information and evaluate credible sources in decision making 1.13.5 Proficiently uses technology to enhance practice and client/patient care 53 Continuing Education Opportunities: Technology Informatics Guiding Education Reform (T.I.G.E.R.) TIGER advances the integration of health informatics by: tiger@himss.org 54 27
55 Available Resources: Nutrition Informatics Community of Interest, open to all Academy members: https://adanic.webauthor.com 56 28
Nutrition Informatics Content Food and Nutrition Magazine: The Feed blog: www.foodandnutrition.org/blog/the-feed App reviews: www.foodandnutrition.org/nutrition-apps/ Social media guides: www.foodandnutrition.org/social-pro/ 57 HIMSS Collaborative http://www.himss.org/nutrition-informatics-town-hall-series 58 29
Nutrition Informatics Certificate 59 Summary Informatics 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. 60 30
Informatics Resources (hyperlinked) AMIA Academy Informatics Education Course Academy Informatics Community of Interest The Feed Nutrition Informatics Blog Informatics Competencies National Delphi Study HIMSS Webinar: Roar with TIGER and Informatics Competencies Malnutrition electronic Clinical Quality Measures National Health IT Week HIMSS17 Malnutrition Blog 61 31