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Nutrition Informatics Blog



Meaningful Use Ripple IV: Diet Orders & Free Text

It sounds like such a simple concept: the physician picks up the chart, writes the diet order and it is transmitted via a multitude of ways to the Food Service Department.  With Electronic Health Records, this process takes on a host of very different considerations.  Many times, Diet Orders are included in an “Order Set” (such as a “Cardiac Rehab” set which is “known” to be a “Low Fat, 4 gram Sodium Diet”), a protocol (defined by the research design underway) or as part of Computerized Physician/Provider Order Entry (CPOE)—where a provider enters all of the orders appropriate for the patient. 

Many RDs who help create these orders (as part of the EHR Implementation Team) are challenged with the best way to name them.  Work is underway now at ADA to create the appropriate design for naming and using diet orders.  Why do we need this?  Several reasons—for outcomes reporting, for consistency in order delivering and tray delivery, for best practices, communication (physicians wants one diet, but inadvertently orders another) and more. 

You may ask—why not just have a “free text” field where providers can enter anything they want?! One of the concepts of HITECH Meaningful Use and Standards Rules are to “Discourage Free Text.”  If you have ever seen the results of what can happen with free text—this makes sense.  For example—if a provider is ordering 1500 KCAL 2 GM Sodium, everyone seems to have his or her own style—

  • 1500 Kcal 2 Gram Sodium
  • 1500 calorie 2 Gm Sodium
  • 1500 KCAL 2000 mg NA
  • 1500 kilocalorie 2 G NA
  • 1500 Kcal 2000 mg Sodium
  • 1500 Kc 2 g sodum (misspelled)


….I think you get my point.  A software program (or computer) does not know these all mean the same, so a list such as this appears as a conglomeration of a list of different orders.  On the other hand, if a provider has a list to choose from and “select” via a radio button or a drop-down menu, all of the above orders would appear the same.  Such the reason for ONC/CMS discouraging free text or “text box”  except where indicated.

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Comments (13):
10/10/2010 7:42:24 PM by Ivonne Cueva_1

To help our clinicians find the right diet order, we added a synonym to each primary diet name. This synonym starts with "Diet". Then the clinician can type in the search term "Diet" and at a glance (as long as there are fewer than 100) see all the diets we have at St. Jude Children's Research Hospital in Memphis- Cathy Welsh

10/12/2010 1:04:10 PM by Ivonne Cueva_1

Hi Cathy, Yes--it does help things sort by creating a naming convention within your order set! Thanks for sharing. This is one of those unique concepts of working with database design that makes so much sense. Let us know more tips, as it helps! Lindsey

11/1/2010 3:56:04 PM by Ivonne Cueva_1

There's a very well-known caveat in clinical system design and implementation; if you don't involve the end user, you are going to fail. I keep hearing about the RD's need to have diet orders. Yet the folks we have to listen to are the ones who do the ordering! I study user interface interactions. I recall one RD who was very proud of her new, improved method to order diets using her new, improved clinical system. Well, it took 10 steps to order a special diet. I asked her what her providers thought about that. Guess what? They weren't happy. It's not enough to call for structured data entry. Until RDs fully understand database design and build, the importance of the user interaction with the system, and finally, yes, the need for structured data input, we won't have folks using whatever diet order we decide to name it! In a well-designed and built system, there are ways to use local synonyms to map to the diet order terminology we want. In fact, most of the terms we need to use are already there. We only need to find them, make sure we've defined them, and then train RDs to support system builds to use them!

11/7/2010 11:40:52 AM by Ivonne Cueva_1

Pam, You bring up several great points: 1. User Centered Design has evolved as a critical condition of creating systems which work effectively and the user actually wants to use. 2. Work Processes: the multi-click process of ordering a special diet has been created in so many different instances in EHRs. We are fotunate health professionals are willing to share the successes and tribulations--so we all may learn. 3. ADA has and continues to work on member communication on such issues, and has put significant resources towards assuring nutrition terminology and processes are a natural component of EHRs. Thanks for sharing!

12/3/2010 8:29:08 PM by Ivonne Cueva_1

Diet orders present one of the most signifcant challanges to the electronic health record. If you think about it, the possibilities for a diet order are a VERY large number if not nearly infinite. Calories, macronurients, micronutrients, bioactive compounds, life cycle stages, allergies/intolerances, research efforts and so forth can all be considered. Then work through nutrition support, infant formulas... . We simplify the possibilites by referencing RDIs, FDA guidelines, indentifying diet order patterns unique to the care setting. Some opt to manage nutrition support as medication rather than "food." Then there has to be agreement on terms as Pam suggests. There is also the issue of tacking instructions and directives on to the diet order(may eat when awake and alert). I think this is one of the most complex CPOE issues and is rarely given careful consideration(workflow and use case analyses)durng EHR development and implementation. It is likely that diet orders and the electronic health record will need to become very different and communicate very differently from diet orders and the paper record.

12/21/2010 5:24:22 PM by Lindsey Hoggle

Bill, You description is wonderfully worded--a great summary of perhaps one of the challenges we now face. No one facility or provider do things the same way, so having one standard approach is difficult. I am glad we are having this discussion, as I think the better we can describe the components of a diet order, the better it helps the providers and patients involved. We will always have a category which holds the outliers (which may be an infinite list, as you suggest!) Thank you for your input and please stay involved in the discussion! Happy Holidays...

1/14/2011 6:48:56 AM by Ivonne Cueva_1

When one looks at the many past references and discussions naming diets, there has been a progression (albeit very slow) towards improved naming conventions for diets, especially as described in institutional operations. In my opinion, dietitians have an obligation to always work towards the safest and clearest language so all the 'users' (from food service staff to professionals)can safely and consistently provide the safest care along with the food quality. With all the layers and layers of information systems in heath care in our futures, standardizing the language of diet names within an organization, region and preferably nationally and even internationally will bring much strength to patient care. For one thing, teaching food service staff, chefs, etc; Is there not an ADA project addressing this topic? Terese Scollard MBA. RD. LD

1/17/2011 12:10:12 PM by Annalynn Skipper PhD, RD, FADA

Yes Therese, a project designed to provide dietitians, electronic health record vendors and other users with a diet order taxonomy is being conducted by the Nutrition Care Process Standardized Language Committee. We've solicited input from various ADA groups, vendors, and other professions. We are in the process of gathering international feedback as well. Regards, Annalynn Skipper PhD, RD, FADA

6/24/2011 3:52:04 PM by Ivonne Cueva_1

I know there have been discussions (but I cannot find them) regarding CPOE, diet orders and physicians wanting to order "advance diet as tolerated". What has worked for other facilities to replace this phrase with more specific diet ordering practice by the physician. Our physicians are beginning CPOE build and the general admission order sets. We have Cerner, so any comments/suggestions would be appreciated. I do need to provide our CPOE group a response as soon as possible. Thanks, Marcie Barnes, RD,LD,CNSC

6/25/2011 12:26:36 PM by Ivonne Cueva_1

Marcie, We will be in touch off-line, but also will be having some ADA resources very soon which allow for rich collaboration and discussion. You are asking a questions which surfaces even more recently of late. I can comment in terms of HITECH regulations and the Order Sets will include Clinical Decision Support which the clinician making the order must act upon. This will likely complicate the process of "Advance as tolerated." I hope others will comment on this and provide their experiences. Thanks for your comments. Lindsey

6/28/2011 3:03:48 AM by Ivonne Cueva_1

Advancing diets has become a very interesting experiment in the flexibility of clinical information systems. There are a number of ways that these orders can be accommodated but the RD needs to know the ramifications of each option. In a paper environment, what used to happen was that the responsible provider would write "Advance Diet as Tolerated", which in most cases would mean that the end diet was a regular diet unless otherwise specified. Upon receipt of the order, the nurse would assess patient readiness for changes in diet composition and consistency and (depending on the organization) either recommend to the provider or order the new diet. All was done within policy and procedure. We are now in an environment where regulatory agencies frown on use of the Diet as Tolerated (DAT) or Advance Diet as Tolerated (ADAT) order as being too ambiguous and potentially deleterious. However, providers must have a way to convey the need to slowly introduce foods/textures depending on patient tolerance and condition. Many systems will allow the use of ADAT orders within an order set where each step is specified along with criteria that define readiness for advancement. In other systems, the beginning and end diet are specified in CPOE with the intermediate steps done within nursing communication or nursing orders. Both work; although I tell clients to be wary when using nursing communication or nursing orders, as these tend to not be included in the data exchanged when the patient is discharged. The issue becomes even more complex when thinking about how to design a system that ensures orders are correctly entered. There's a trend among folks who don't fully understand what the busy healthcare provider's day is like to insist on "hard stops", meaning that if the information isn't entered exactly the way the system wants, the provider is stopped from proceeding further. As you can imagine, everyone wants a hard stop for their silo. However, these should be used as little as possible, as hard stops accomplish two things: providers create workarounds that might or might not be effective from the system standpoint and providers rebel leading to the potential for implementation failure! I'm generally not in favor of changing the name of a diet simply because CPOE is on the way. You want to disrupt provider workflow as little as possible. Knowing that the term ADAT should go away, if you go that route, be sure to involve providers who will be responsible for patient care in any workflow decisions. They've got to be part of this so that the final order is easy to enter, easily understood, and ensures the patient gets what is best suited to their current condition. And obviously, we need to make sure that we capture the RD's role in the workflow!

6/30/2011 11:56:13 AM by Ivonne Cueva_1

Great discussion on this issue. My thoughts are: 1. ADA has many individuals and groups working on how to standardize diet orders so that they are understood by all. Due to the many different situations under which a diet order exists, it is difficult to harmonize all the needs into one diet order term. 2. The future of health care via health information technology is one of “interoperability”: data needs to follow the patient and be used downstream in ways which benefit the patient and possibly that of research. 3. “Diet as Tolerated” is ambiguous! The comment that its meaning and use is dependent upon the facility it originates at is true. And yes, we do want to have a usable diet order when the patient moves to the next “Transition of Care”. 4. I agree that we don’t want workarounds. That’s why conversations like this are critical—so ADA can consider the many complexities as standards and vocabularies are used. Even that will still produce, in any situation—outliers—those situations where no “one size fits all.” 5. I consider Regulatory Agencies to be a necessary evil (with all respect!). Without a set of agreed to guidelines, we will never see the data follow the patient. We have to work with regulatory agencies (and ADA is deep in discussions) to help them understand we, as dietitians want what is best for the patient—and have practices, standards and vocabularies which need to be integrated into their rules. 6. Much of the harmonization of standards, regulations and discussions are going on right now—which makes implementation in actual settings a bear, as the final suggestions have not yet surfaced. In closing, the next 12-24 months are a very critical time for “all-hands-on-deck” for advocacy around issues such as this. ADA is working non-stop from the regulation advocacy standpoint; dietitians must advocate on EHR Committees within their own facility to assure that dietitians work flow is captured and that the best patient care is realized, given the information we have at the moment. Thanks for this rich discussion and I hope we continue it.

7/2/2011 11:45:08 AM by Ivonne Cueva_1

It is one of my goals this year to standardize diet orders. I hate to say it but it is going to take a "culture change" wave to make this happen. Starting of in our new diet office electronic system, I built 7 master menu types, from there we have many "restrictions". In hopes to start standardization, I used a format to create diet orders and currently am the only one with rights to do so in the system (I guess that is one way to begin standardization) However, I started off with ohhh about 1500 diet order combinations (keep in mind a different one for each fluid restriction on top of the diet order) needless to say, we are closer to 2500 after 6 month's post go live. My own clinical staff, the medical staff and nursing can not seem to "get over" the actual diet order the way it was written and diet order specified on the ticket. Even though the 4gm,Low Cholesteral diet is the exact same diet as Heart Healthy, there is this need to have 4gm,Low chol show up on ticket, so I built both. I keep thinking, we have got to develop a policy that states that a particular diet order/menu meets will be provided for a various list of diet order combinations. Wouldn't that help with this standardization? Also, in my opinion and from two very difficult experiences, I name all my Consistencies First. For instance, PUR,HH, this would be Pureed diet, HH. If it is a fluid, that is first NEC, Mech soft. This helps focus on the consistency (safety first) and diet next. Consistency problems can lead to death much easier/faster than a problem with the wrong type of food on a tray (with the exception of allergies) I am talking more on the lines of diabetic, heart healthy, low fiber ect..... All recipes on the meal ticket show PUREE peaches, NEC coffee, or GRD hamburger, ext... So the tray line sees the capital letters and does not miss something like a Peaches, pureed. It has helped out greatly. Thank you

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