Data Element
Enteral Nutrition Volume
Description

The volume of formula to provide at each feeding. This data element must be provided in conjunction with the Enteral Nutrition Type and other Enteral Nutrition data elements.
Submitted By: Becky Gradl / Academy of Nutrition and Dietetics
Data Element Information
Use Case Description(s)
Use Case Description Per 42 C.F.R. 482.28 (https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.28) for hospitals and 42 C.F.R. 483.60 (https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483#483.60) for long-term care facilities, facilities must ensure patients’ or residents’ nutritional needs are met through therapeutic diets that meet any nutritional and special dietary needs. The data elements described in this submission for a new Nutrition and Diet class represent the minimum data elements that should be interoperable to support these regulations.

In the long-term care setting, therapeutic diets are defined (in Interpretive Guidelines for as "a diet ordered by a physician or other delegated provider that is part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet (e.g., sodium or potassium), or to provide mechanically altered food when indicated." In the hospital setting, CMS stated (https://www.federalregister.gov/d/2014-10687/p-172) that they "consider all patient diets to be therapeutic in nature, regardless of the modality used to support the nutritional needs of the patient” given they are part of the totality of treatment. The data elements included are those necessary to define the care delivered and facilitate transitions.

Currently, most EHR systems are collecting the data elements described in this submission for a new Nutrition and Diet class and transmitting them to a food management system so that patients or residents may be provided with appropriate meals. Either a dietitian or a physician will enter the data elements in the EHR to create the diet order that is then sent to the food management system so the food and nutrition services can provide appropriate meals. Similarly, any changes to a patient or resident’s diet order is typically made in the EHR and transmitted again to the food management system; typically, only one diet order is active at a given time.
Estimate the breadth of applicability of the use case(s) for this data element All patients and residents are impacted by this new Nutrition and Diet class. This would also impact all healthcare facilities who provide meals to patients and residents, including, but not limited to hospitals, long term care, rehabilitation facilities, and home health. Practitioners such as physicians, nurses, and dietitians would capture, access, use and exchange this data and people who work to prepare and serve meals, including food service companies such as Sysco, Aramark, and Compass Group would also use the data elements.
Link to use case project page http://www.hl7.org/implement/standards/product_brief.cfm?product_id=289
Use Case Description Diet orders are also critical during transitions of care, smoothing the transition process and reinforcing discharge planning to help prevent hospital readmissions and improve quality of life across the continuum of care.

When there is a transition of care, nutrition and diet data elements are sometimes included, however should always be included to prevent any patient safety issues or unnecessary tests and costs associated with the need to reevaluate a patient for an appropriate therapeutic diet to meet their nutritional or special dietary needs. These proposed requirements to enhance communication between providers should reduce risks of complications and adverse events for patients and residents, for many of whom nutrition is a particularly essential part of the plan of care.
Estimate the breadth of applicability of the use case(s) for this data element Any patients who require a transition of care are impacted by this new Nutrition and Diet class. This would also impact those healthcare facilities who provide meals to patients and residents, including, but not limited to hospitals, long term care, rehabilitation facilities, and home health that the patient is transferred from and to. Practitioners such as physicians, nurses, and dietitians would also use this data related to the transition of care.
Link to use case project page http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) HL7 Version 2 – ODS – Dietary orders, supplements, and preferences (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185)
HL7 Version 3 Standard: Orders; Diet and Nutrition, Release 1 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=317)
HL7 FHIR NutritionOrder (https://www.hl7.org/fhir/nutritionorder.html)

In addition, many there are many nutrition-related terms in SNOMED CT. Many of these terms have been put in value sets in VSAC or through HL7 terminology. Here are some examples:
Diet Type (OID 2.16.840.1.113883.4.642.3.385) – HL7 terminology
Nutrient Modifier (OID 2.16.840.1.113883.4.642.3.386) – HL7 terminology
Nutrition Supplement (OID 2.16.840.1.113883.4.642.3.390) – HL7 terminology
Enteral Nutrition Type (OID 2.16.840.1.113883.4.642.3.391) – HL7 terminology
Enteral Nutrition Additive (OID 2.16.840.1.113883.4.642.3.392) – HL7 terminology
Food Allergies and Intolerance (OID 2.16.840.1.113762.1.4.1186.3) - VSAC
Feeding Device Grouping (OID 2.16.840.1.113762.1.4.1095.87) - VSAC

http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185
Additional Specifications Nutrition data is included in nine of the thirteen "transitions of care" documents between facilities in the HL7 Consolidated Clinical Document Architecture (C-CDA) Release 2. This should ensure (if implemented) that patients on a modified diet will have that data arrive at the hospital or other connected facility upon transition and admission. See section 2.40 in HL7 CDA® R2 Implementation Guide: Consolidated CDA Templates for Clinical Notes - US Realm is a Nutrition Section, including value sets, for Nutrition and Diet data elements. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492

There is also additional nutrition templates in HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, Release 1 - US Realm. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=478
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts Per HL7, 95% of healthcare organizations in the US are using some form of the V2 standards. As examples of EHRs using the ODS for exchange of Nutrition and Diet data elements are EPIC, Cerner, and MatrixCare, while CBORD, Delegate, Computrition, and MealTracker are examples of food management systems.
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts Per HL7, 95% of healthcare organizations in the US are using some form of the V2 standards. As examples of EHRs using the ODS for exchange of Nutrition and Diet data elements are EPIC, Cerner, and MatrixCare, while CBORD, Delegate, Computrition, and MealTracker are examples of food management systems.

While most organizations are using the ODS in HL7 V2 standards to exchange Nutrition and Diet data elements, the use of FHIR and the NutritionOrder resource (https://www.hl7.org/fhir/nutritionorder.html) should be encouraged as it better supports interoperability and a more complex structure for the exchange of the data. The NutritionOrder resource has a maturity of FMM3.

http://www.hl7.org/implement/standards/product_brief.cfm?product_id=185
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) There are limited to no restrictions on the standardization of the data elements in the Nutrition and Diet class. The majority of data elements already have potential value sets through VSAC (with SNOMED CT), through HL7 terminology, or other open source terminologies.
Restrictions on Use (e.g. licensing, user fees) There are limited to no restrictions on the use of the data elements in the Nutrition and Diet class. The majority of data elements already have potential value sets through VSAC (with SNOMED CT), through HL7 terminology, or other open source terminologies.
Privacy and Security Concerns Since the data elements proposed in the new Nutrition and Diet class are currently being exchanged, they should continue to follow any existing privacy and security requirements, if any.
Estimate of Overall Burden Since the data elements in the proposed Nutrition and Diet class are currently being captured and exchanged through HL7 V2 standards in many systems, there should be limited to no burden to implement. This also applies to those systems using the C-CDA standards as well. If FHIR is not currently being utilized and is required as the standard to exchange the Nutrition and Diet class data elements, this may pose additional burden to implement.
Other Implementation Challenges There are no other known challenges to implement.
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
Criterion #1
Maturity - Current Standards		 Level 2 - Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
Criterion #2
Maturity - Current Use 		Level 2 - Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
Criterion #3
Maturity - Current Exchange		 Level 2 - Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
Criterion #4
Use Case(s) - Breadth of Applicability		 Level 2 - Use cases apply to most care settings or specialties.

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