Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care Cassandra E

FROM THE ACADEMY

Consensus Recommendations for Optimizing Electronic Health Records for Nutrition Care Cassandra E. Kight, PhD, RDN, CNSC; Jean M. Bouche, RD, CD, CNSC; Angie Curry, RN, CCDS; David Frankenﬁeld, MS, RD; Katy Good, RN, CCDS, CCS; Peggi Guenter, PhD, RN, FAAN, FASPEN; Brian Murphy; Constantina Papoutsakis, PhD, RD; Emily Brown Richards, RD, CND, CNSC; Vincent W. Vanek, MD, FACS, FASPEN; Deanne Wilk, RN, CCDS, CCS; Amy Wootton, RDN; Academy of Nutrition and Dietetics; American Society for Parenteral and Enteral Nutrition; Association of Clinical Documentation Improvement Specialists

ABSTRACT Provision of nutrition care is vital to the health and well-being of any patient who enters the health care system, whether in the ambulatory, inpatient, or long-term care setting. Interdisciplinary professionals—nurses, physicians, advanced practice providers, pharmacists, and dietitians—identify and treat nutrition problems or clinical conditions in each of these health care settings. The documentation of nutrition care in a structured format from screening and assessment to discharge allows communication of the nutrition treatment plans. The goal of this document is to provide recommendations to clinicians for working with an organization’s Information Systems department to create tools for documentation of nutrition care in the electronic health record. These recommendations can also serve as guidance for health care organizations choosing and implementing health care software. J Acad Nutr Diet. 2019;-(-):---.

LECTRONIC HEALTH RECORDS tions (now referred to as The Joint malnutrition, and food insecurity; and (EHRs) offer access to patient Commission) for patient care with education and counseling for nutrition information locally, regionally, paper-based workflows.1 More and health issues. Health care costs in and nationally, and facilitate recently, the Academy of Nutrition the United States in 2017 were $3.5 E 5 coordination of care across health care and Dietetics (the Academy) published trillion. Diagnoses with nutrition settings. Health care clinicians who the Nutrition Care Process,2,3 which is therapy as an important component frequently provide direct patient care a systematic framework and language include obesity, with health care costs that influences nutrition care—nurses; to guide nutrition and dietetics practi- of $147 billion to $210 billion per year6; pharmacists; medical providers, tioners in documenting delivery of diabetes, with annual costs of $327 including physicians and advanced nutrition care. The American Society billion7; and gastrointestinal, liver, and practice providers; and dietitians—will for Parenteral and Enteral Nutrition pancreatic diseases, with an estimated be referred to here as nutrition clini- (ASPEN) developed Nutrition Care annual cost of $135.9 billion.8 The cians. Nutrition care of the patient in Pathways4 to provide the interprofes- direct medical costs for disease- the inpatient, ambulatory, or long-term sional nutrition clinician a framework associated malnutrition based on the health care setting commences with to guide nutrition care for pediatric National Health and Nutrition Exami- screening and assessment. Known or (Figure 1) and adult patients nation Survey, excluding institutional- suspected nutrition deficiencies or (Figure 2). The pathways illustrate rec- ized participants, were estimated to be problems are addressed with informa- ommended steps from screening $15.5 billion annually.9 The estimated tion from nutrition screening and through discharge from a health care costs of inpatient stays related to assessment. The first Nutrition Care setting with a focus on malnutrition. malnutrition accounted for nearly $49 Process flowchart was published in However, the provision of nutrition billion, or 12.6% of aggregate hospital 1994 to propose nutrition care indica- care for any nutrition condition in any costs, compared to $389.1 billion for all tors to the Joint Commission on health care setting follows the pathway non-maternal and non-neonatal Accreditation of Healthcare Organiza- steps: identification, assessment, intervention, monitoring, and discharge This article is being copublished by the planning. Academy of Nutrition and Dietetics, ª 2212-2672/Copyright 2019 the Academy Nutrition clinicians address inade- American Society for Parenteral and of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition, and quate or excessive food intake; nutrient Enteral Nutrition, and Association of Association of Clinical Documentation deficiencies or nutrient excesses Clinical Documentation Improvement Improvement Specialists. Published by related to fluid, vitamins and/or min- Specialists. Minor differences in style may appear in each publication, but the article Elsevier Inc. All rights reserved. erals, alterations in gastrointestinal https://doi.org/10.1016/j.jand.2019.07.018 is substantially the same in each journal. function from the mouth to the colon,

ª 2019 the Academy of Nutrition and Dietetics, American Society for Parenteral and Enteral Nutrition, and Association of Clinical Documentation Improvement Specialists. Published by Elsevier Inc. All rights reserved. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1 FROM THE ACADEMY

A.S.P.E.N. PEDIATRIC NUTRITION CARE PATHWAY (Age 1 month – 18 years)

AT RISK FOR MALNUTRITION/ MALNUTRITION PRESENT?

ADMISSION YES NO Anthropometrics Obtained [MA, RN]

Weight, Height/Length, Head Circumference and Mid-Upper NUTRITION CONSULT RESCREEN IN 4 DAYS Arm Circumference GENERATED [RD, RN] RD Notiﬁed (via EMR, automatic RISK FACTORS TO MONITOR trigger, documented in MR) WHILE HOSPITALIZED: NUTRITION SCREEN NPO/CLD >3 days [RN] Intake <50% for >3 days Admission screen completed within 24 Weight loss NUTRITION ASSESSMENT hours using validated tool Intubation [RD, NST] High risk disease or medical Results documented in Complete within one day of condition medical record. receiving consult

Food and Nutrition History Anthropometrics Biochemical Data/Medical Tests & Procedures Nutrition Focused Physical Exam NO (NFPE) Client/Medical History MALNUTRITION PRESENT?

YES

DETERMINE MALNUTRITION SEVERITY [RD, NST]

KEY DETERMINE CHRONICITY [RD] MA Medical Assistant Action Steps Acute <3 months Documentation Steps OT Occupational Therapist Chronic ≥3 months Communication Steps PT Physical Therapist RN Registered Nurse SLP Speech-Language Pathologist RD Registered Dietitian DETERMINE ETIOLOGY NPO/ CLD Nothing by NST Nutrition Support mouth/Clear Liquid Diet [RD, MD/NP/PA, RN, SW] Team EMR/MR Electronic MD Medical Doctor Medical Record or Medical • Medical Evaluation Record NP Nurse Practitioner Non-Illness Related (Social, Environmental, Behavioral) HC Head circumference PA Physician Assistant • Social (Evaluate Resources, Support, Stressors, R/O Neglect) PharmD Pharmacist MUAC Mid-upper arm circumference SW Social Worker WIC Women, Infants, and Children MORE ON NEXT PAGE Figure 1. American Society for Parenteral and Enteral Nutrition pediatric nutrition care pathway. (Reprinted with permission from ASPEN Copyright 2015.)

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DOCUMENT MALNUTRITION CODE MALNUTRITION [RD, MD/NP/PA] Notify coder RD to document malnutrition severity, chronicity and supporting evidence Appropriate pediatric codes MD to document severity of malnutrition in progress note and add diagnosis to hospital problem list

INTERVENTION MONITOR, EVALUATE & ATTEND MEDICAL ROUNDS [RD, RN, MD/NP/PA, SW, PharmD, PT, OT, SLP] [RD, RN, MD/NP/PA, SW, PharmD, PT, OT, SLP]

Oral Nutrition and/or Vitamin/Mineral Supplements Daily Weights (<12 months old) or Daily to 2x/week Weights Medically & Developmentally Appropriate Diet (>12 months old) Nutrition Support (Enteral, Parenteral) Weekly Height/Length, HC (<2 years old), MUAC Education (Malnutrition, Increasing calories/protein) Biochemical Data/Medical Tests & Procedures Intake/Output Constipation, Diarrhea, Feeding problems, Infection, Gastrointestinal Tolerance Spasticity, Muscle weakness) Access Devices (feeding tubes, central venous access)

Nutrition Focused Physical Exam (NFPE)

NUTRITION REASSESSMENT [RD, NST] RE-EVALUATE CARE PLAN [MD/NP/PA, RD, RN, SW, PharmD, PT, OT, SLP] NUTRITION STATUS IMPROVING? Rule out Medical/Social Causes NO Feeding Evaluation Optimize Nutrition Intervention YES

CONTINUE CURRENT PLAN/MONITOR [RD, RN, MD, NP/PA, SW, PharmD, PT, OT, SLP]

YES Action Steps MA Medical Assistant Documentation Steps OT Occupational Therapist PT Physical Therapist DISCHARGE PLAN Communication Steps RN Registered Nurse SLP Speech-Language [MD, RD, RN, PharmD, SW] Pathologist RD Registered Dietitian Nutrition Education NPO/ CLD Nothing by NST Nutrition Support mouth/Clear Liquid Diet Order Home Enteral or Parenteral Nutrition Supplies Team EMR/MR Electronic Order Oral Nutritional Supplements (Prescription, WIC form) MD Medical Doctor Medical Record or Medical Identify Medical Team for Home Management NP Nurse Practitioner Record Schedule Follow Up Appointment with Medical Team PA Physician Assistant HC Head circumference Place Home Care Orders (Home Weights, Nurse Visits) PharmD Pharmacist MUAC Mid-upper arm Obtain and Document Discharge Weight, Length, HC, MUAC circumference SW Social Worker Communicate Discharge Anthropometrics and Nutrition Care WIC Women, Infants, Plan with Managing Home Medical Team and Children

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A.S.P.E.N. ADULT NUTRITION CARE PATHWAY (Age 18+ years)

SUSPECTED MALNUTRITION?

YES NO

ADMISSION GENERATE FOLLOW UP/RESCREEN NUTRITION CONSULT [RD, NST, DT, OR DESIGNEE] Obtain actual, measured height/weight and BMI and Via EMR, automatic trigger or Every 3-7 days to prevent document on admission documented in MR hospital-acquired malnutrition Validated screening tool completed Based on length of stay • Screen completed in 24 hours Upon transition of care • Results documented in EMR Physician consult on admission NUTRITION ASSESSMENT [RD, NST]

Completed within 24 hours of consult Food and Nutrition History Anthropometrics NO Biochemical data/Medical Tests & Procedures MALNUTRITION Nutrition Focused Physical IDENTIFIED? Exam (NFPE) Clinical and Medical History AND/A.S.P.E.N. malnutrition characteristics

YES

Action Steps CM Case Manager RD documents malnutrition risk status Documentation Steps OT Occupational Therapist RD documents supporting evidence of malnutrition severity Communication Steps PT Physical Therapist MD documents malnutrition and severity RN Registered Nurse AND Academy of Nutrition and Dietetics in progress note and adds to problem list RD Registered Dietitian A.S.P.E.N. American DT Diet Technician Society for Parenteral and NFPE Nutrition Focused Enteral Nutrition Physical Exam PN Parenteral Nutrition CODE MALNUTRITION NST Nutrition Support EN Enteral Nutrition DIAGNOSIS Team NPO/CLD Nothing by Coder notiﬁed of diagnosis MD Medical Doctor Mouth/Clear Liquid Diet Adult Malnutrition Codes NP Nurse Practitioner EMR/MR Electronic PA Physician Assistant Medical Record or Medical Record PharmD Pharmacist BMI Body Mass Index MORE ON NEXT PAGE Figure 2. American Society for Parenteral and Enteral Nutrition adult nutrition care pathway. (Reprinted with permission from ASPEN Copyright 2015.)

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NUTRITION CARE PLAN AND INTERVENTION MONITORING & EVALUATION [RD, NST, RN, MD/PA/NP, PharmD] [RD, NST, RN, MD/PA/NP, PharmD, PT, OT]

Nutrition care plan created & documented; Follow-up within 3 days Monitoring parameters Initiate order/identify type of nutrition • Tolerance of nutrient intake support required • Oral intake including supplements, • Provide least restrictive, medically appropriate diet vitamins, minerals • Determine need for nutritional supplementation • Enteral/Parenteral intake • Treatment of medical issues impacting • Anthropometric data (weight trends) nutrition intake and utilization • Biochemical data Determine access needs for specialized nutrition • Functional status support to maximize nutritional intake (Enteral feeding tubes, IV access for PN) • Review medications regarding impact on nutritional intake Communicate nutrition care plan with team members on multidisciplinary patient care rounds Educate patient/caregiver regarding plan of care.

REVISE NUTRITION DOCUMENT PARAMETERS THAT CARE PLAN NO INDICATE IMPROVEMENT IN NUTRITION STATUS [RD, NST, PT, OT]

Adequate nutrient intake Stable or increased weight YES Stability of biochemical data Improved strength and function

CONTINUE CURRENT NUTRITION CARE PLAN

Reassess every 3-5 days Begin discharge planning

Action Steps CM Case Manager Documentation Steps OT Occupational Therapist DISCHARGE PLAN Communication Steps PT Physical Therapist [RD, RN, MD/PA/NP, PharmD, CM] RN Registered Nurse AND Academy of Nutrition and Dietetics Education / Counseling with patient and caregivers RD Registered Dietitian Communication of PN, EN or Oral Nutrition Supplement prescription A.S.P.E.N. American DT Diet Technician Society for Parenteral and Case management for continuity of care NFPE Nutrition Focused Enteral Nutrition Outpatient follow-up as appropriate Physical Exam PN Parenteral Nutrition NST Nutrition Support EN Enteral Nutrition Team NPO/CLD Nothing by MD Medical Doctor Mouth/Clear Liquid Diet NP Nurse Practitioner EMR/MR Electronic PA Physician Assistant Medical Record or Medical Record PharmD Pharmacist BMI Body Mass Index

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inpatient stays.10 It is imperative that of having structured data for nutrition and, in those cases, the judgment of nutrition clinicians document the care is to visually depict a patient’s the treating professional should identification of nutrition conditions nutrition history within one view, such prevail. with associated interventions to allow as a flowsheet report or graph. Struc- communication of the treatment plan tured data also enable increased se- to all clinicians in any health care mantic interoperability between EHR NUTRITION SCREENING setting. Nutrition diagnoses left unrec- systems.11 Unstructured data include Nutrition screening is the first step in ognized by lack of identification or text in clinical notes or comment boxes the ASPEN Nutrition Care Pathways treatment and follow-up care or scanned documents. Both data to identify individuals at risk for contribute to the high costs of medical forms reflect the patient’s nutrition malnutrition.4 The Joint Commission care. history for communication to other promotes the use of standards of care The following consensus recommen- providers and to the patient. There are for hospitals to provide safe and high- dations from a workgroup of ASPEN, small variations in the structured quality patient care. Its standards per- the Academy, and the Association of vs unstructured forms contained taining to nutrition screening and Clinical Documentation Improvement within different EHR platforms; how- assessment are located in the section Specialists outline opportunities for ever, this permits the end user to “Provision of Care, Treatment, and EHR optimization for various interpro- integrate both types of data into one Services (PC.01.02.01)”12: fessional activities presented within report while developing the patient The goal of assessment is to deter- the framework of the ASPEN Nutrition care plan. mine the care, treatment, and ser- Care Pathways. While the steps are The vendor and institution EHR vices that will meet the patient’s identical for both pediatric and adult implementation analysts are familiar initial and continuing needs. Patient patients, the separate pathways vary in with typical provider and care team needs must be reassessed throughout timeline and tools for each population workflows and understand the docu- the course of care, treatment, and during hospitalization. Therefore, the mentation requirements for providing services. Identifying and delivering consensus recommendations apply to patient care and appropriate billing. the right care, treatment, and services both pediatrics and adults, but differ- Build, implementation, and optimiza- depends on the following three ences between the patient populations tion of an EHR system should be a processes: will be identified, where appropriate. clinical project and not just an Infor- 1. Collecting information about The consensus recommendations are mation Systems project. Nutrition cli- the patient’s health history as appropriate for the patient at any entry nicians are the experts for content and well as physical, functional, and point into the health care system. The workflows and should be part of the psychosocial status. task force, using this pathway, has EHR implementation and ongoing 2. Analyzing the information in provided recommendations for 1) maintenance teams. ASPEN, the Acad- order to understand the pa- nutrition screening and assessment; 2) emy, and the Association of Clinical tient’s needs for care, treat- nutrition diagnosis; 3) nutrition care Documentation Improvement Special- ment, and services. plan and interventions; 4) monitoring, ists have developed these consensus 3. Making care, treatment, and reassessment, and nutrition goals; and recommendations to guide EHR and services decisions based on 5) discharge plan. related developers and implementa- the analysis of information Each health care discipline docu- tion teams on the optimal build for collected. ments information in the EHR in both documentation and treatment in- structured and unstructured data for- terventions involved in patient nutri- The depth and frequency of assess- mats. Structured data are data that tion care to maximize the quality of ment depends on a number of factors, reside in a fixed field, are stored in a patient care and health care team including the patient’s needs, program database, and can be easily retrieved effectiveness and efficiency. goals, and the care, treatment, and for reports, flowsheets, or graphs. The recommendations found in the services provided. Assessment activ- Structured data are unambiguous; document do not constitute medical ities may vary between settings, as specific; and defined, usually within or other professional advice and defined by the hospital’s leaders. In- allowed parameters ranging from should not be taken as such. To the formation gathered at the patient’s first anthropometric data to specific paren- extent that the information published contact might indicate the need for teral nutrition (PN) components. The herein may be used to assist in the more data or a more intensive assess- nutrition clinician enters structured care of patients, this is the result of ment. At a minimum, the need for data directly into the EHR with infor- thesoleprofessionaljudgmentofthe further assessment is determined by mation such as vital signs, nutrition attending health care professional the care, treatment, and services assessment findings, orders, medica- whosejudgmentistheprimary sought; the patient’s presenting con- tions, procedures, and diagnoses; and component of quality medical care. dition(s); and whether the patient views structured data in many forms, The information presented here is not agrees to the recommended care, such as the above, and problem lists, a substitute for the exercise of such treatment, and services. allergies, and laboratory findings. judgment by the health care profes- The Elements of Performance state: Structured data options for entering sional. Circumstances in clinical set- information in the EHR can include tings and patient indications may The hospital defines, in writing, the checkboxes, dropdown lists, and radio require actions different from those scope and content of screening, buttons. The advantage to the end user recommended in this document assessment, and reassessment.

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Patient information is collected an organization to report their inpatient rehabilitation facilities, long- according to these requirements. screening compliance during The Joint term acute care hospitals, skilled In defining the scope and content of Commission’s regularly scheduled au- nursing facilities, and community- the information it collects, the dits and advises clinical nutrition based clinics or non-profits, such as organization may want to managers and clinic managers whether those for diabetes prevention and consider information that it can there is adequate staffing to provide treatment. obtain, with the patient’s consent, nutrition services. The Joint Commis- from the patient’s family and the sion has no requirements regarding a patient’s other care providers, as timeframe for rescreening hospitalized NUTRITION DIAGNOSIS well as information conveyed on patients for nutrition risk if the initial The nutrition screening and assess- any medical jewelry. screen was normal. However, ASPEN ment steps of the Nutrition Care Assessment and reassessment infor- recommends a repeat nutrition screen Pathway result in identification of mation includes the patient’s every 3 to 7 days for adults and every 4 nutrition problems that require treat- perception of the effectiveness of, days for pediatric patients if the hos- ment by nutrition clinicians. The Aca- and any side effects related to, his pital admission nutrition screen de- demy’s Nutrition Care Process utilizes or her medication(s). termines the patient is not at risk for nutrition diagnosis to standardize The hospital defines, in writing, malnutrition.14,20 A longer period nutrition diagnostic terminology.2 A criteria that identify when addi- before rescreening may be appropriate nutrition diagnosis as defined by the tional, specialized, or more infor patients in other care settings. Academy describes a specific nutrition depth assessments are per- problem that can be improved or formed. Note: Examples of resolved through nutrition in- criteria could include those that NUTRITION ASSESSMENT terventions. The domains of nutrition identify when a nutritional, The next step in the Nutrition Care diagnosis include “intake,” which is functional, or pain assessment Pathway is nutrition assessment.4 A defined as too much or too little of a should be performed for patients positive nutrition screen result should food or nutrient compared to actual or who are at risk. trigger an automatic notification to the estimated needs; “clinical” is defined as The hospital has defined criteria that dietitian for a nutrition assessment to nutrition problems that relate to med- identify when nutritional plans be completed within the timeframe ical or physical conditions; and are developed.12 specified at each institution, as “behavioral-environmental” is defined described here. Nutrition assessment as knowledge, attitude, beliefs, physical The nutrition screening tool in all data include food or nutrition-related environment, access to food, or food health care settings should be easy and history, biochemical data, medical safety.23 A medical diagnosis, on the quick to score, as well as standardized tests, procedures, anthropometric other hand, is used by health care and validated. There are several stan- measurements, client history, and providers and coders as described in dardized and validated nutrition nutrition-focused physical examination the International Statistical Classifica- screening tools available for adults,13-16 findings. Nutrition Care Pathway steps tion of Diseases and Related Health but the availability of these tools is should be incorporated into the EHR Problems, 10th Revision (ICD-10)24 more limited for pediatric patients.17,18 build and workflow following the codes. Documentation of the nutrition The nutrition screen is typically per- guidelines set forth by Health Level 7 diagnosis used by dietitians and ICD-10 formed by a nurse or dietitian and is (HL7) and the newly revised standards codes used by providers both describe incorporated into the required office of the Electronic Nutrition Care Process problems that require nutrition inter- visit or hospital admission documen- Record System guidelines. HL7 Inter- vention and treatment to resolve to tation for the patients that require national has undertaken a project in improve patient health and well-being. nutrition screening. The generation of conjunction with the Academy to Malnutrition is one nutrition (clinical scores from screening tools in the EHR create an Electronic Nutrition Care domain) and medical diagnosis (ICD-10 enables triggering of further workflow Process Record System.21 The goal is to code) that affects patient care as well steps in the pathway through reports develop a standard list of functions and as appropriate coding, billing, and and alerts. Clinical Decision Support is criteria for integration of the Aca- reimbursement.25 Patients can be a process that provides guidance to demy’s Nutrition Care Process to align diagnosed with malnutrition in any clinicians during patient care with with the HL7 International EHR System health care setting. Organizations configuration by the Information Sys- Functional Model that provides a should adopt explicit malnutrition tems staff of alerts to release at standard description and common un- criteria that all health care pro- appropriate times in the workflow to derstanding of functions for health care fessionals can apply consistently. improve efficiency and outcomes and settings. The Academy has also devel- Developing malnutrition criteria that avoid errors.19 Clinical Decision Sup- oped the Consolidated Clinical Docu- include representatives from nutrition port interventions associated with ment Architecture R2.1 Nutrition and medicine with clinical documen- nutrition screening include creation of Transitions of Care Implementation tation integrity and coding de- a nutrition consult order when the Guide, an HL7 standard that identifies partments improves malnutrition screen value indicates risk or display of what nutrition data should be included documentation required for billing. The screen scores on the dietitian’s daily in an EHR in any transitions of care Academy and ASPEN published rec- patient unit reports. A structured data setting.22 Transitions of care settings ommended criteria for the identifica- element for nutrition screening allows include home health agencies, tion of adult26 and pediatric27

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malnutrition. The malnutrition di- reimbursement, benchmarking, and alterations. The Academy’s Nutrition agnoses have been mapped to ICD-10 high-quality patient care.29 Care Manuals include appropriate diets codes: mild protein-calorie malnutri- for many nutrition care settings.30,31 tion is E44.1, moderate protein-calorie The diet orders in the Nutrition Care malnutrition is E44.0, and (unspeci- NUTRITION CARE PLAN AND Manuals provide guidance for the fied) severe protein-calorie malnutri- INTERVENTION naming convention and types of diets tion is E43. Many hospitals have A nutrition care plan based on data to configure in the diet order module. adopted the Academy and ASPEN gathered in the nutrition assessment Some diet orders require a single se- consensus criteria for malnutrition as will address identified nutrition di- lection, while others require multiple written, or developed their own clinical agnoses. The care plan defines specific select options. The health care organi- indicators by addition or removal of nutrition interventions to alter or zation determines standard definitions criteria. Comprehensive documenta- eliminate the etiologies of nutrition for nutrient levels, such as potassium, tion by the nutrition care clinician and problems. It also includes goals to protein, and fiber, which should be the medical providers to support describe the anticipated response to clear to the clinicians ordering and compliant coding and capture of the these interventions. Interventions are a implementing these orders. When the nutrition diagnosis includes: 1) the planned set of specific behaviors or diet order changes due to short-term diagnosis and its severity, for example, actions performed, which are dele- nil per os status or addition of a new severe protein-calorie malnutrition, gated, coordinated, or recommended modification, the EHR should carry the documented by a provider (physician, by a nutrition clinician that facilitates parameters over from the previous diet advanced practitioner provider); 2) the achievement of the desired goals, such to the new diet order with the ability of clinical indicators to support the diag- as improved intake with nutrition the clinician to modify these parame- nosis, for example, weight loss of 10% support, weight stabilization, or ters as needed. For example, if a patient in a 3-month time frame; 3) develop- improved wound healing. Nutrition is on a consistent carbohydrate diet ment of a treatment plan to address the care plans are documented by all and the cardiology consultant subse- diagnosis of malnutrition, for example, nutrition clinicians, though they are quently changes the diet to heart- initiation of enteral nutrition (EN); 4) typically discipline-specific and not healthy, the consistent carbohydrate progress and/or changes in patient’s integrated. Appropriate documentation restriction should remain by default. status in reassessment notes, for and ordering in the EHR will help ONS orders should be configured to example, patient tolerating goal EN and improve the likelihood that patients allow flexibility on the type of supple- weight loss stopped. Malnutrition is a receive the indicated nutrition inter- ment and timing of administration of secondary diagnosis that can affect the vention and treatment. Documentation the supplement to meet the patient’s Medicare Severity-Diagnosis Related of the treatment care plan helps ensure needs. H7 diet order standards are Group Complications or Comorbidities that all members of the health care available to assist in the build and and Major Complications or Comor- team know the interventions needed to implementation of electronic trans- bidities.28 While nutrition clinicians address a patient’s nutrition diagnoses. mission of nutrition orders.32 Foodser- usually diagnose malnutrition, it is Nutrition interventions include oral vice computer systems are often imperative that this diagnosis is docu- diets, oral nutrition supplements integrated with the EHR and employ mented in structured data format for (ONS), EN, and PN. Nutrition in- electronic transmission of nutrition automatic inclusion in the attending terventions also include nutrition- orders using HL7 standards. physician/team documentation tem- related medications or supplements, The use of standardized electronic plates to document how the diagnosis such as vitamin or mineral prepara- EN orders improves patient safety by impacted treatment, nursing care, and tions, as well as assessing for and reducing the opportunities for incom- length of stay.29 Addition of the making changes in nutrition therapies plete, ambiguous, or incorrect EN or- malnutrition diagnosis to the problem to prevent or treat drugenutrient in- ders.33 Critical components of the EN list by the physician, or nutrition teractions. Nutrition education and order include the EN formula name, clinician if allowed by organizational nutrition counseling for the patient the delivery site (ie, route), the policies, facilitates transfer of the and family, as well as coordination of administration method (eg, contin- diagnosis across and between health nutrition care, are other types of uous, cyclic, or bolus), the rate of infu- care systems. nutrition interventions that can be vital sion with goal rate or volume, and The nutrition diagnosis section of the to improving or maintaining nutrition water flush instructions. The use of EHR incorporates information from status.23 The EHR system should required fields within the EN order for nutrition screening and assessment to accommodate and be configured these critical components will prevent generate the plan of care to treat within an organization to allow the order submission until the order is nutrition problems that will be appropriate ordering and documenta- complete. A free text comment box in described in the nutrition in- tion of these interventions. the EN order allows for entry of order terventions. Documenting a nutrition Diet orders can be simple or com- instructions to clarify administration diagnosis has the potential to direct plex, with multiple modifications. The instructions. An EN order set that in- nutrition interventions and the re- order functionality in the EHR should cludes these details for the diet order sources required to care for the patient. promote easy and clear application of and orders for laboratory monitoring, Accurate documentation by physicians necessary diet restrictions, including assessment of tolerance, and consults and advanced practice providers must dysphagia modifications and assistance could be developed by organizations.33 be present to support coding, with feeding or environmental Implementation of scanning software

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with the EHR would increase the ac- conditions were extended to long-term improves efficiency of the clinician’s curacy of delivering the right product care settings.39 These privileges may daily tasks with integration of intake to the right patient at the right time, as require a nutrition clinician consult data with anthropometrics and has been demonstrated in the neonatal from the provider requesting that they biochemical data to revise nutrition intensive care unit34 and children’s order these therapies. If the nutrition orders, such as for EN or PN. Structured hospitals.35 clinician is unable to place the nutri- data at the facility level are key to data- PN is a high-alert medication that is tion support order per their health care driven quality improvement initiatives best ordered using a computerized privileges, options include pending or to meet organizational mission, goals, provider order entry system.36 The PN holding the order for prescribing and strategic plans. Consistency be- order components should be available providers to review and sign. Other tween health care facilities is key to in the computerized provider order considerations would be to implement conducting large-scale nutrition out- entry system with all PN ingredients in electronic notifications to review, comes research, such as the Malnutri- full generic name with specific advance, or change an order based tion Quality Improvement Initiative, ordering amounts per day for adult on laboratory values, intake and which includes recommendations for patients and per kilogram per day for output, medications, and physical electronic clinical quality measures for neonatal and pediatric patients. Clin- assessment findings. Electronic order all steps of the Nutrition Care ical Decision Support can alert those sets may enhance the order process, Pathway.41 The clinical quality mea- prescribing PN when order compo- as well as provide consistent sures developed include those for nents exceed recommended or safe treatment plans among providers and nutrition screening, assessment, diag- clinical limits or exceed limits of organizations.33,36 nosis, and interventions. compatibility. Other important order In monitoring nutrition and evalua- requirements of the computerized tion, the use of a template format, such provider order entry include patient NUTRITION MONITORING AND as the Consolidated Clinical Document dosing weight, indications for PN, route EVALUATION Architecture, will not only create a of administration (central vein or pe- The monitoring and evaluation (reas- standardized approach to nutrition ripheral vein), method of administra- sessment) step of the Nutrition Care documentation, but will also promote tion (continuous vs cyclic), PN Pathway is vital to resolution of the nutrition interoperability across the administration date and time, and PN nutrition diagnoses. It is the step in care spectrum.22 The template will instructions for total volume and infu- which a nutrition clinician determines improve transition of nutrition care sion rate. The EHR should be able to whether the Nutrition Care Plan is upon discharge from the hospital to the transmit these orders via direct inter- helping to resolve nutrition problems next care setting. face to an automated compounding or if it needs revision. ASPEN recom- device to avoid manual transcription of mends follow-up within 3 days for the electronic PN orders into the auto- hospitalized patients diagnosed with DISCHARGE PLAN mated compounding device, which in- malnutrition.40 During initial hospital Discharge planning is an interdisci- creases the chances of a transcription assessment, the nutrition clinician plinary approach to provide continuity error. ASPEN, the Academy, and the should designate a time for reassess- of care. It is a process that begins at American Society of Health-System ment(s) in accordance with hospital admission when the provider de- Pharmacists have published joint policies. If the patient is seen in an termines anticipated post-hospital consensus recommendations that ambulatory setting, follow-up ap- services and planning that includes address, in more detail, the PN func- pointments are typically scheduled the patient and family,42 development tionality needed in an EHR.37 when the initial reason for visit cannot of a structured discharge plan tailored Historically, providers, that is, prac- be resolved in one visit. Data in the to meet the individual’s needs,43 and titioners with independent prescriptive nutrition reassessment include infor- discharge coordination rounds with authority, including physicians, mation that has accrued since the interdisciplinary participants to ensure advanced practice nurses, and physi- initial assessment, including oral diet, completion of discharge teaching.44,45 cian assistants, ordered the nutrition ONS, EN, PN, and other nutrient intake; Inclusion of resolved and unresolved therapies for hospitalized patients, new or changed biochemical results; nutrition diagnoses, especially malnu- including oral diets, ONS, EN, and/or medical tests and procedures; serial trition, in the hospital discharge sum- PN, per Centers for Medicare & anthropometric measurements; and mary provides valuable information to Medicaid Service regulations. However, nutrition-focused physical findings. the primary care, referring, or next- in 2014, the Centers for Medicare & When the nutrition clinician docu- setting physician for ongoing treat- Medicaid Service Conditions of Partici- ments the reassessment findings, the ment. Electronic discharge orders and pation were revised to allow dietitians previously established nutrition di- instructions should include ongoing and other qualified nutrition clinicians agnoses and goals should auto- nutrition support as appropriate, fre- to independently order therapeutic di- populate, ensuring consistency in quency of follow-up evaluation by the ets, ONS, EN, PN, and nutrition-related care. Language to describe the status of health care team for laboratory studies, laboratory and imaging tests, if within the nutrition goals may include nutrition reassessment, and physical the clinician’s scope of practice per the resolved, unresolved, improvement examination. state laws and regulations, and the shown, or no longer appropriate. Patients should receive after-hospital hospital’s medical staff rules, regula- The use of structured data to capture or clinic visit summaries, which are tions, and bylaws.38 In 2016, these nutrition reassessment parameters generated from structured data and

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embedded clinical documentation, studies. The technology of EHRs is ever- 6. The healthcare costs of obesity. The such as care instructions. Components changing, where now clinicians can State of Obesity website. https://www. stateofobesity.org/healthcare-costs-obesity/. of the nutrition plan include the intake patient photos and store to their Accessed May 3, 2019. terventions recommended by the medical record to document muscle 7. The cost of diabetes. American Diabetes nutrition clinician, along with recom- and fat depletion or vitamin and min- Association website. http://www. mendations for follow-up care. If eral deficiencies using their personal diabetes.org/advocacy/news-events/cost- nutrition education was an interven- phone, for example. EHRs offer the of-diabetes.html. Accessed May 3, 2019. tion to address a nutrition diagnosis, nutrition clinician the ability to track 8. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, the EHR should provide a link to the important steps in the provision of and pancreatic diseases in the United educational material for future refer- nutrition care that follow the ASPEN States: Update 2018. Gastroenterology. ence. When patients need EN or PN, Nutrition Care Pathways—nutrition 2019;156(1):254-272 e211. the EHR should generate a form with screening and assessment, documen- 9. Goates S, Du K, Braunschweig CA, the patient’s prescription or order for tation of the nutrition diagnosis, the Arensberg MB. Economic burden of disease-associated malnutrition at the the home infusion company or durable nutrition care plan and associated in- state level. PLoS One. 2016;11(9): medical equipment agency. The home terventions, reassessment of data to e0161833. nutrition support company will need determine whether nutrition goals are 10. Barrett MLBM, Owens PL. Non-maternal the same information discussed here improving the nutrition diagnosis, and and non-neonatal inpatient stays in the United States involving malnutrition, 2016. under nutrition interventions for EN the nutrition discharge plan for US Agency for Healthcare Research and and PN, such as product, formulation, ongoing treatment of unresolved Quality. https://www.hcup-us.ahrq.gov/ and rate and time of administration, nutrition problems. The EHR can pro- reports/HCUPMalnutritionHospReport_083 018.pdf. Published August 30, 2018. and the name of the physician who will vide tools for the nutrition clinician to Accessed March 7, 2019. provide post-discharge care. Vitamins document nutrition data in structured 11. Interoperability and health information and minerals and other medications and unstructured data that communi- exchange. HIMSS website. https://www. appropriate to the Nutrition Care Plan cate the patient’s nutrition history himss.org/library/interoperability-health- prescribed through the medication from one clinician to the next. The information-exchange. Accessed May 3, 2019. administration module will be trans- nutrition leaders in an organization 12. The Joint Commission E-Dition. https://e- mitted electronically to the patient’s should ensure their technologically dition.jcrinc.com. Accessed January 7, pharmacy or next facility. savvy clinicians advocate for the needs 2019. The Joint Commission has standards of their colleagues with the Informa- 13. Anthony PS. Nutrition screening tools for that address transitions of care and has tion System teams who are responsible hospitalized patients. Nutr Clin Pract. 2008;23(4):373-382. an initiative underway to offer various for the build and maintenance of the 14. Mueller C, Compher C, Ellen DM; Amer- interventions and resources to improve system for their department. The ican Society for Parenteral and Enteral these transitions of care. The Joint appointed technologically savvy clini- Nutrition (A.S.P.E.N) Board of Directors. Commission requires that the active cians should also participate in ongoing A.S.P.E.N. clinical guidelines: Nutrition issues, diagnosis, medications, required improvement and maintenance to screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr. services, warning signs of worsening meet the ever-changing best practices 2011;35(1):16-24. conditions, and whom to contact 24 of nutrition care. 15. Correia MITD. Nutrition screening hours per day, 7 days per week in case vs nutrition assessment: What’s the dif- of an emergency be provided to the ference? Nutr Clin Pract. 2018;33(1): References 62-72. patient and/or caregivers in an alter- 1. Kushner RF, Ayello EA, Beyer PL, et al. 16. Academy of Nutrition and Dietetics, Evi- nate care setting on hospital National Coordinating Committee for dence Analysis Library. Nutrition 46 discharge. When being discharged to Nutrition Standards clinical indicators of screening in adults, 2016-2018. https:// nutrition care. J Am Diet Assoc. www.andeal.org/topic.cfm?menu¼5382. an alternative care setting, many hos- 1994;94(10):1168-1177. pitals send a Continuity of Care form March 5, 2019. 2. Swan WI, Vivanti A, Hakel-Smith NA, et al. along with the patient that documents 17. White M, Lawson K, Ramsey R, et al. Nutrition Care Process and Model update: Simple nutrition screening tool for pedi- these items and other pertinent infor- Toward realizing people-centered care atric inpatients. JPEN J Parenter Enteral mation. The Continuity of Care form and outcomes management. J Acad Nutr Nutr. 2016;40(3):392-398. Diet. 2017;117(12):2003-2014. should be integrated into the EHR, such 18. Academy of Nutrition and Dietetics, Evi- 3. Swan WI, Pertel DG, Hotson B, et al. that it is easy to find and review. Paper dence Analysis Library. Nutrition Nutrition Care Process (NCP) update part screening pediatrics. https://www.andeal. Continuity of Care forms may get lost 2: Developing and using the NCP termi- org/topic.cfm?menu¼5767. Accessed fi or delayed in getting scanned into the nology to demonstrate ef cacy of nutri- March 5, 2019. fi tion care and related outcomes. J Acad EHR and, once scanned, may be dif - Nutr Diet. 2019;119(5):840-855. 19. What is Clinical Decision Support (CDS)? cult to find for review. HealthIT.gov website. https://www. 4. Adult and pediatric nutrition care path- healthit.gov/topic/safety/clinical-decision- ways. ASPEN website. http://www. support. Accessed June 4, 2019. nutritioncare.org/guidelines_and_clinical_ CONCLUSIONS resources/Malnutrition_Solution_Center/. 20. Ukleja A, Gilbert K, Mogensen KM, et al. Accessed March 3, 2019. Standards for nutrition support: Adult An EHR presents patient data in digital hospitalized patients. Nutr Clin Pract. 5. National health expenditure data. Centers 2018;33(6):906-920. format to be used for the provision of for Medicare & Medicaid Services website. medical care, shared across health care https://www.cms.gov/research-statistics- 21. Project Summary for Electronic Nutrition data-and-systems/statistics-trends- Care Process Record System (ENCPRS) settings within and between organiza- fi ’ and-reports/nationalhealthexpenddata/ Functional Pro le. HL7 International website. tions, for the patient s personal health nationalhealthaccountshistorical.html. http://www.hl7.org/special/committees/ record, and for population health Accessed May 3, 2019. projman/searchableprojectindex.cfm?

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action¼edit&ProjectNumber¼706. Accessed 29. Phillips W, Browning M. A clinician’s 05/12/2014-10687/medicare-and-medicaid- March 5, 2019. guide to defining, identifying and doc- programs-regulatory-provisions-to-promote- umenting malnutrition in hospitalized program-efficiency-transparency-and. 22. Project Summary for HL7 CDA R2 Imple- patients. Pract Gastroenterol. 2017;41(11): Accessed March 5, 2019. menation Guide: C-CDA R2.1 Supple- 19-33. mental Templates for Nutrition, Release 1 39. Centers for Medicare & Medicaid Services. (US Realm). HL7 International website. 30. Academy of Nutrition and Dietetics. Medicare and Medicaid programs; reform http://www.hl7.org/special/Committees/ Nutrition Care Manual. https://www. of requirements for long-term care projman/searchableProjectIndex.cfm? nutritioncaremanual.org/. Accessed January facilities. https://www.federalregister. action¼edit&ProjectNumber¼1371. 7, 2019. gov/documents/2016/10/04/2016-23503/ Accessed March 5, 2019. 31. 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AUTHOR INFORMATION C. E. Kight is a clinical nutrition specialist, UW HealtheUniversity of Wisconsin Hospitals and Clinics, Madison. J. M. Bouche is a nutrition support dietitian, Option Care, Wauwatosa, WI. A. Curry is a senior consultant and client services manager, Healthcare Division, Nuance Communications, Burlington, MA. D. Frankenfield is a manager and nutrition support dietitian and D. Wilk is a manager, clinical documentation improvement, Penn State Health, Hershey, PA. K. Good is a manager, education services, Enjoin, Collierville, TN. P. Guenter is senior director of clinical practice, quality, and advocacy, American Society for Parenteral and Enteral Nutrition, Silver Spring, MD. B. Murphy is director, Association of Clinical Docu- mentation Improvement Specialists, Middleton, MA. C. Papoutsakis is senior director, Data Science Center, Academy of Nutrition and Dietetics, Chicago, IL. E. Brown Richards is a clinical dietitian, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY. V. W. Vanek is regional medical informatics officer, Mercy Health Youngstown Region, Youngstown, OH. A. Wootton is director of nutrition management, MatrixCare, Bloomington, MN. STATEMENT OF POTENTIAL CONFLICT OF INTEREST A. Curry has employee stock options in Nuance Communications. C. Papoutsakis is an employee of the Academy of Nutrition and Dietetics, which has a financial interest in the Nutrition Care Process Terminology (NCPT) described here. A. Wootton is an employee of MatrixCare. No potential conflict of interest was reported by the remaining authors. FUNDING/SUPPORT No funding support was received for this article.

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