Nutrition & Diet Orders Oral Diets Qualitative (e.g. texture modifications or gluten-free) Quantitative (nutrient-level modifications, e.g. 2 gm sodium/day or 1.2 kg protein/kg body weight) Medical Nutritional Supplements Enteral/Tube Feedings Meal Service Requests/Messages Nutrition Consult Order Requests

Types of Diets Oral Diets Medical Nutritional Supplements Qualitative types General/Healthful Age-appropriate modifications, e.g., toddler Texture/Consistency Modified Allergy/Intolerance – to eliminate or limit foods with specific ingredients i.e. gluten-free Quantitative Nutrient-based Modifications Energy Modified Carbohydrate Modified Protein & Amino Acid Modified Fluid Modified (Restricting or limiting consumption of total fluids) Mineral Modified (sodium, potassium, phosphorus, etc.) Medical Nutritional Supplements Ordered by Generic Description of Product Formulation, e.g., High Protein/2.0 Kcal formula Ordered by Specific Product/Manufacturer ID Enteral Nutrition (for tube feedings) Other Nutrition Orders – Messages/Consults

Diet Taxonomy Examples Fat Modified Diet (Nutrient = Total Fat) Definition: A diet of known fat composition consistent with the age and life stage of the patient/client Modifications: High fat diet (>100 grams of fat) grams oral       Low fat diet (<30% of energy needs)   oral   Ketogenic Diet (Nutrient mix/ratio) Definition: A diet of known fat: protein plus carbohydrate ratio consistent with the age and life stage of the patient/client High fat to protein+carbohydrate ratio (4:1; 3:1) grams oral   Total Cholesterol Definition: A diet of known cholesterol composition consistent with the age and life stage of the patient/client   milligrams oral       High (>250 mg) milligrams oral       Low (<200 mg) milligrams oral

Nutrition Orders Storyboards New Diet Order for General/Healthful New Diet Order for multiple quantitative nutrients (Diabetic + Renal dialysis) New Diet Order for Texture Modifications Special Case (NPO) Pediatric (Infant formula) Enteral/Tube Feeding Special Meal/Tray Service Requests (Late Tray or Isolation/Disposables) Left out on purpose – Out of Scope --Advance Diet as Tolerated

Diet Order Data Elements The order should contains the following basic information:   Order ID (to identify this order & for subsequent updates e.g. Cancel ##) Patient name Patient identifier Patient location (unit – room – bed) Prescriber (who wrote the order) Date/Time of order (when the order was written/given) Start Date/Time – May need to be translated into meal periods (e.g. Now or Next Meal period which is Lunch) Stop Date/Time (Optional – not usual practice for most facilities)  One or more diet codes (e.g. typically local codes) or One or more supplement/items (generic user-defined or specific ref codes) – item identifier/name, quantity, unit Text-notes (messages for meal service) Family members and guests Who is allowed to fill out the patient’s menu Test Messages – Buckets to define these (so we don’t lose interoperable) e.g. name-value pair

FOOD & NUTRITION MGT SYS DIET ORDER SEQUENCE MD diet order, supplements, RD consult, VO orders, assigns magmt of TPN or TF others CPOE or paper chart EMR NURSING Order flavor of supplement, VO orders hold diet for test, allergies, late or early tray HL7 interface Dietitian input Documentation of care plan, educ. And order labs, TPN and adjusts electrolytes Diet Clerk food preferences, allergies, intolerances; notifies diet consult, corrects diet order errors; inputs nourishment requests Conventional Not as much patient contact, less time to identify problems. EMR = Order Manager (EHR, CPOE . . . ) Limited access for VO or clinical privileges Limited access for info FNMS FOOD & NUTRITION MGT SYS

Diet Supplement Flow Chart Electronic Health Record Food and Nutrition Management System ORDER Supplement 1000 Calories per Day LIC Order Received and Approved by Provider or Diet Clerk PAT Role, Service location, Diet Code, Entity PROV Order fulfilled with available supplement that meets criteria Order Resulted Supplement Provided to Patient PAT

Order Processing Actions (Triggers/States) Activate Order (start date + time (meal)) Abort Order Suspend Order (clinicians have raised concerns) Held (remove) Replace Order Revise Order (needs discussion) Grey out and remove states not desired (e.g. no Suspend) New = unverified order Cancelled (unverified orders) Nullifed – entered in error (wrong patient) States are Null to Active Completed – not expected

Application Roles Order Manager - EHR/CPOE/HIS (sending app) Order Placer FNMS-Food/Nutrition System (receiving app) Fullfiller

Next Steps to DAM Need a Publishing Facilitator Additional Roles/Names of Participants Identify from other DAM Information Model/Class Diagrams Conceptual State Machine Activity Diagrams (Interaction Diagrams) Functional Requirements Non-Functional Requirements Use-Case Bubble Diagrams For new roles (Diet Clerk) – send Patrick an email to forward to publishing to get them added