Guest Blog by Sarah Rusnack, MS, RD, LD
As with all areas of medicine, nutrition practice relies on evidence generated from research studies. For the latest guidelines and research summaries, check out the recently renovated Evidence Analysis Library of the Academy of Nutrition and Dietetics. The EAL is driven by thorough review of published research studies, and many thanks to the reviewers who work to make this repository of information available and searchable!
If you'd like to participate earlier in the evidence generating process, check out the listing of clinical trials currently underway at ClinicalTrials.gov. Provided by the National Institutes of Health, this website allows the public to search for human participants' research studies that are recruiting, active, or complete. Use the search bar on the home page to search for trials relating to conditions or topics. For example, as of this writing there are 1,006 studies registered on ClinicalTrials.gov about vitamin E. As an example of informatics in action, if you search "vitamin E" on this site, it will automatically also search for synonyms and related terms, such as alpha-tocopherol.
Another way to participate in research is to create a profile with ResearchMatch.org. Whereas ClinicalTrials.gov lets you find research studies, ResearchMatch lets research studies find you. ResearchMatch was developed by Vanderbilt University with funding from the NIH, and allows users to create a free profile with as much (or as little) of their health information as they wish.
Once your profile is created, ResearchMatch will anonymously check your information against the inclusion and exclusion criteria for studies that are looking for participants. If you are a possible match for a study, you will receive an email with information about the study and how you may be able to participate. If you choose, you can then grant the study permission to contact you. If the study doesn't interest you, then the researchers will never know your name or your health information. You decide whether to share your information with a study.
There's a tremendous amount of informatics helping run both ClinicalTrials.gov and ResearchMatch.org, but volunteers are the most important piece of the puzzle. Check them both out today!
Posted by Lindsey Hoggle, MS, RDN, PMP
The spectrum of nutrition implementation in Electronic
Health Records (EHR) is both vast and highly inconsistent. A recent member wrote reporting that as a
private practice RDN, the physician’s office she worked for did not want her to
document in their record; they simply scanned her nutrition care note in and
uploaded it into the EHR. So what do you
say to that?
- Data that is scanned into an EHR is seldom
"re-usable" by the EHR because the data is not stored as structured (think
Excel spreadsheet, where you can identify data by columns and rows) nor does it
occur along side of existing and future data already in the EHR
(weights/heights in a scanned document will not show up on the graph of the
- If the provider is reporting via Electronic
Clinical Quality Measures (eCQM), additional documentation via mandated codes
may help provide better reporting data.
The Academy has been working for over 2 years to map and submit the
Nutrition Care Process Terminology –or MCPT (previously the IDNT) to now
mandated clinical terminologies in the United States –both SNOMED-CT
(Systematized Nomenclature of Medicine Clinical Terms) and LOINC (Logical Observation Identifiers Names and
Codes). These "mapping" spreadsheets
should be used by your EHR vendor to assure nutrition care lands on the same
Care Plan as other professionals in the EHR. The mapping spreadsheets are
available via the 2014 version of the eNCPT.
- Nutrition Data can now be included in
"transitions of care" documents between facilities – once the HL7 Draft Standard Consolidated Clinical
Document Architecture (C-CDA) Release 2 is put into operation. That means that their patient on a diet
modifications can have that data arrive at the hospital on their next
- Nutrition content in Health Care Information
Technology Standards of the future can include "Clinical Decision Support" – or
the ability to put nutrition care on the same option list of medications.
- Sharing patient data with the patient and across
all episodes of care is a requirement of both the Meaningful Use
Medicare/Medicaid EHR Financial Incentive program and will be an important part
of performance indicators on quality care.
I could go on with other points; the take-away
is that nutrition advocacy comes with the territory of practicing nutrition
care. We have made great progress but
the need for constant advocacy will continue.
Please share any stories you have!
Posted by Lindsey Hoggle, MS, RDN, PMP
For sure, the adoption of electronic health records (EHR) in the U.S. is proceeding at an unprecedented pace-primarily due to the HITECH Act. As I have mentioned previously, the Academy has participated in the activities driven by this law since it began in 2009. As a regular participant at in-person meetings (both the HIT Policy Committee and the HIT Standards Committee) in Washington, DC, I have had the wonderful privilege of meeting and asking the advice of national leaders in health care and health information technology. From my first public comments (in September 2009) asking for use of the Academy’s Nutrition Care Process (NCP) and the International Dietetics and Nutrition Terminology (now called the Nutrition Care Process Terminology or NCPT), the recurring theme was to ask for what I call the differentiating "brand" of nutrition care via the RDN—the NCP. As I asked one expert after another – "What do we (the Academy) need to do to make sure we are included as a part of the health care team as health care goes digital?" The answer has been the same—consistently—for the past five years:
- Nutrition care must be included in health IT standards -via Health Level Seven (HL7)
- Nutrition terminologies must be in those now mandated for use in Certified EHRs (Stage 2 mandates the use of (SNOMED-CT®) and (LOINC®) – Using the acronyms is easiest for now!
- Establish "Value Sets" of nutrition terms that EHR vendors can use
- Continue to “turn up the volume” on why nutrition care is critical to all aspects of health care
Following policy advice from Jeanne Blankenship (Vice President Policy Initiatives and Advocacy) for "constant, appropriate, appreciable pressure" – the Interoperability and Standards Committee and member volunteers have pushed forward for all of the above. As a result, there is now the NCP represented in the next release of a presently mandated HL7 standard (Release 1 of the standard must now be supported by all Certified EHRs). While the name may be intimidating – (HL7 Consolidated Clinical Document Architecture or C-CDA for short) - the message to RDNs and EHR vendors need not be:
- Use HL7 C-CDA Version 2 (pending publication of the standard any day now) to send electronic documents between facilities.
(C-CDA R2 is a document template standard that identifies what data must be sent to and from facilities.)
- Use coded data contained in the C-CDA for documenting nutrition care via the NCP.
While NCPT may be used on the "user interface" – it MUST be "mapped" to SNOMED-CT and LOINC on the "back end".This is a critical point to assure we can document and measure care provided by RDNs from this point forward.
- The second release has nutrition in 7 different template types (as compared to "discharge diet" being only one field in one template type in Release 1):
- Progress Note
- Transfer Summary
- Discharge Summary
- Referral Note
- Continuity of Care Record (CCD)
- Care Plan
- Consult Note
While having to advocate for nutrition care seems illogical to RDNs, it comes with the territory. We need to continue to impress that nutrition care be part of the treatment plan. For an example of why we need to use the HL7 health IT standards which contain nutrition, read a recent HIMSS post. And remember—Constant appropriate appreciable pressure. It does work!
Posted by: Lindsey B Hoggle, MS, RDN, PMP
Questions about "HIPAA", health care privacy and security always require considerable time to answer. As the United States adopts and uses electronic health records and other sources of health information technology, multiple parameters should be used to evaluate risk. While data breeches involving credit cards allow for an easier recovery—such as credit monitoring and issuance of a new credit card, health data breeches are complicated. If private, very personal data that could be used to discriminate against individuals is erroneously accessed or shared—it cannot be "called back", "replaced" or "corrected". As privacy and security standards and policies are tightened, there is a great "one stop shop" for privacy and security of health data using EHRs. Members should also check their local, state level laws on health data policies as these pre-empt any national requirements. For more information, go to: Health Information Privacy, Security, and Your EHR.
Posted by Lindsey B Hoggle, MS, RDN, PMP
This past May 7, the fifth Academy 10x10 Education Course in Informatics launched! Twenty students are enrolled in the only nutrition focused 10x10 program. Here are some interesting statistics about this program:
- Ninety (90) students have passed the course in the first four years.
- Students from over 32 states have participated (including Alaska and Hawaii) plus Canada, Puerto Rico and Germany!
- Several of the positions held by students include: clinical, food service management, community, systems analysts and developers of health care software.
- Each student authors a short project (either one they have or intend to implement or a conceptual one).
- All students may receive graduate credit if they complete the Oregon Health and Sciences exam for this course (which includes a nominal fee).
- The Foundation of the Academy of Nutrition and Dietetics has awarded over $40,000 in educational grants to students taking the 10x10!
Not ready for the 10x10 but want to investigate how nutrition informatics covers all areas of practice for nutrition?
Preview the HIMSS Town Hall Series for a snapshot of nutrition informatics: Nutrition Informatics 101, Nutrition Informatics Delphi Study, and Meaningful Use in Action-Exploring the Possibility of Nutrition Informatics.
Look for an upcoming Certificate in Nutrition Informatics and be sure to join the 1,136 members on the Nutrition Informatics Community of Interest by logging in with your Academy User ID and password.
And lastly, Congratulations to Marty Yadrick, MBI, MS, MBA, RDN, FADA, Past-President of the Academy for completing his Masters of Biomedical Informatics after taking the 10x10 and now serving as an instructor for the AMIA/Academy 10x10!!
The FIFTH offering
of the popular biomedical informatics program -
Academy/AMIA 10x10 Education Program begins on May 7, 2014! This year, the Academy of Nutrition and Dietetics
Foundation continues to offer grants to Academy members. Read first
the details about the Academy's offering of the Program and if interested in
applying for a Foundation Grant, please complete the 2014
Application for Foundation Grants for the Academy/AMIA 10x10 by April 18,
Submitted by John W. Snyder, DTR, RD
While working to implement the Health Level 7 (HL7) Role Code
terminology set used to define the relationship to patient for family medical
history, a question came up regarding how to map the end-user “pick-list”
selections to HL7 terms. The vendor had not provided a full copy of the
terminology set based on terms contained in OID 2.16.840.1.113883.5.111 and
asked the following question:
What is the
difference between “Son/Daughter” and “Natural Son/Daughter”?
The HL7 Role Code terminology set works as follows:
Child (Level 1)
– Son (Level 2)
oNatural Son (Level 3)
oAdopted Son (Level 3)
oFoster Son (Level 3)
oStep Son (level 3)
– Daughter (Level 2)
oNatural Daughter (Level 3)
oAdopted Daughter (Level 3)
oFoster Daughter (Level 3)
oStep Daughter (Level 3)
In an ideal world, all electronic health record systems (EHR-S)
would provide users every possible selection, and users would select the
correct value. The reality is that providing users with 80+ different types of
relationships to select from when entering family history information is
perhaps not realistic, and the Centers for Medicare & Medicaid Services has
not mandated a level of specificity that all EHR-S must achieve for certification.
This means we must map data selected by an end-user to a value in a terminology
In the above example, mapping a
generic to a more specific (eg, Son/Daughter→Natural Son/Daughter) is not
considered a good practice, because it creates invalid data. In this particular
case, mapping Son/Daughter to Natural Son/Daughter has only about a 25% chance
of accuracy. Mapping from the more specific to a generic (eg, Natural Son/Daughter→Son/Daughter)
is an acceptable practice, because downstream it does not invalidate data even
though it removes specificity.
The goal of gathering this information is
to populate Summary of Care/Continuity of Care documents for interoperability,
provide meaningful use data to the government via the Quality Reporting
Document Architecture standard, research, and likely some other uses I have not
thought to include. In all of these uses, it is necessary to consider sacrificing
data specificity as an industry best practice in order to maintain data