Stream: implementers
Topic: Specifying non-medication substance administration
Floyd Eisenberg (Apr 09 2019 at 19:05):
An existing electronic clinical quality measure (eCQM) named "Exclusive Breast Milk Feeding" is looking for determining administration of Breast Milk, infant formula and TPN. The measure developer wants to know how FHIR represents those products in resources. The current FHIR resources allow NutritionOrder to specify an order for a diet (e.g., that is for exclusive breast milk feeding), but there is no clear way to indicate administration of breast milk, of infant formula or of TPN - only to specify the diet. There is a parallel requirement addressed for Medications using MedicationAdministration, or potentially, MedicationStatement to indicate what has been given.
Here is the only information we found in confluence. site http://confluence.hl7.org:8090/display/OO/Workspace+for+HCD+Use+Cases
Please advise how others are handling this issue using FHIR, or what FHIR resources exist or are in development.
Floyd Eisenberg (Apr 09 2019 at 19:06):
An existing electronic clinical quality measure (eCQM) named "Exclusive Breast Milk Feeding" is looking for determining administration of Breast Milk, infant formula and TPN. The measure developer wants to know how FHIR represents those products in resources. The current FHIR resources allow NutritionOrder to specify an order for a diet (e.g., that is for exclusive breast milk feeding), but there is no clear way to indicate administration of breast milk, of infant formula or of TPN - only to specify the diet. There is a parallel requirement addressed for Medications using MedicationAdministration, or potentially, MedicationStatement to indicate what has been given.
Here is the only information we found in confluence. site http://confluence.hl7.org:8090/display/OO/Workspace+for+HCD+Use+Cases
Please advise how others are handling this issue using FHIR, or what FHIR resources exist or are in development.
Jose Costa Teixeira (Apr 09 2019 at 19:43):
There is an ongoing discussion on Healthcare product which IIRC did take breast milk as one example of what should be covered.
Jose Costa Teixeira (Apr 09 2019 at 19:46):
My preference is to have a consistent way to register the usge/consumption of products - think "xxxAdministration" where xxx can be medication, device, or a BiologicallyDerivedProduct, or generally a "Product" if we ever went for a generic resource.
Jose Costa Teixeira (Apr 09 2019 at 19:47):
anyway, this is being discussed.
Jose Costa Teixeira (Apr 09 2019 at 19:47):
pinging @Hans Buitendijk @Eric Haas @Ioana Singureanu @Lorraine Constable (please ping others)
John Silva (Apr 09 2019 at 19:48):
@Floyd Eisenberg -- Interesting question. In the V2 world there were separate Diet messages (for Diet/nutritional orders [OMD^O03], on the administration side the Pharmacy/Treatment Administration message (RAS) would be used. The RAS seems to be closely related to the FHIR MedAdmin resource; the experts here can better explain how to map each of the TPN components into it it that's the appropriate place.
Jean Duteau (Apr 09 2019 at 20:01):
An existing electronic clinical quality measure (eCQM) named "Exclusive Breast Milk Feeding" is looking for determining administration of Breast Milk, infant formula and TPN. The measure developer wants to know how FHIR represents those products in resources. The current FHIR resources allow NutritionOrder to specify an order for a diet (e.g., that is for exclusive breast milk feeding), but there is no clear way to indicate administration of breast milk, of infant formula or of TPN - only to specify the diet. There is a parallel requirement addressed for Medications using MedicationAdministration, or potentially, MedicationStatement to indicate what has been given.
I think that you could use the NutritionOrder for this. Infant Formula is covered in the enteralFormula section. Breast Milk would be an Oral Diet with the type set to 'breast milk' - although I think that a ticket could be raised to change type to a choice of a code or a set of NutritionProducts. TPN is explicitly out-of-scope of the NutritionOrder, so that would be something else.
Eric Haas (Apr 09 2019 at 20:02):
@Floyd Eisenberg NutritionOrder states in its boundaries: "The NutritionOrder resource is used for requesting oral diets, oral nutrition supplements and enteral feedings in an in-patient setting. The MedicationRequest resource should be used for requesting parenteral (IV) nutrition and prescribing dietary supplements such as vitamin or mineral supplements."
Eric Haas (Apr 09 2019 at 20:03):
it has the element
"administration 0..* BackboneElement Formula feeding instruction as structured data"
So it does describe how to tube feed an infant. For TPN use med admin. I am confused why there is confusion or don't understand the use case
Eric Haas (Apr 09 2019 at 20:04):
And @Jean Duteau just beat me to the punch
Floyd Eisenberg (Apr 09 2019 at 20:06):
NutritionOrder does work for diet, it is specific administration or defining what the infant ate (i.e., is the nutrition order fulfilled or is something else given. That is the use case. I can let the measure developer speak to the issue as well. They should be signing on.
Jose Costa Teixeira (Apr 09 2019 at 20:51):
NutritionOrder does not cover the actual administration. Only intended administration
Jose Costa Teixeira (Apr 09 2019 at 20:54):
so my understanding is that the question makes sense indeed, and we are looking at how to record administration of products (beyond medication which is relatively clear for implementers). But we are not there yet.
Floyd Eisenberg (Apr 09 2019 at 20:56):
thank you Jose - that is the issue. My understanding is that there might be two ways for data entry of administration - (1) in the Neonatal ICU (NICU), the breast milk might be bar coded and administration occurs using the medication administration app, or (2) intake is recorded on the intake and output record, but not necessarily in structured format. So there may be a feasibility issue in determining exactly what was included in the infant's intake (e.g., sterile water, breast milk, formula, etc.). But there is currently no clear way to identify such intake with FHIR resources unless someone can help to direct us.
John Silva (Apr 09 2019 at 21:33):
@Floyd Eisenberg - do you also need to differentiate mother's milk from donor's milk? If so, not sure how that would be represented in the MedAdmin. (and yes, there also needs to be the totaling of all these fluids/nutritions to keep track of the baby's net fluid balance, besides the nutritional aspects of what they consume. There may also be additional nutrients added as well.)
Jose Costa Teixeira (Apr 09 2019 at 21:35):
But there is currently no clear way to identify such intake with FHIR resources unless someone can help to direct us.
You are correct. There is currently no clear way IMO.
Jose Costa Teixeira (Apr 09 2019 at 21:36):
Floyd Eisenberg do you also need to differentiate mother's milk from donor's milk? If so, not sure how that would be represented in the MedAdmin.
It shouldn't be represented in MedAdmin or MedStatement. We need a resource for that.
John Silva (Apr 09 2019 at 21:42):
@Jose Costa Teixeira -- and where would the nutritional values be recorded, also in the MedStatement (on the ingredients)? I believe this is especially important in determining caloric intake in neonates (and all as well but critically important in babies)
Floyd Eisenberg (Apr 09 2019 at 21:51):
Thanks for the question. From the perspective of this particular measure, the intent is to know that breast milk only was administered in lieu of all other intake (including sterile water, formula, etc.). I’m not sure if donor milk is allowable and will check with the measure developer. For a more generic sense, yes, all intake and totaling of all fluids/nutrients would be needed as well as fluid output (generally measured in we diapers though).
Eric Haas (Apr 09 2019 at 22:39):
so there is active discussion by the nutrition folks a nutrition statement or observation profiling what was consumed. @Margaret Dittloff can you chime in here?
Margaret Dittloff (Apr 10 2019 at 02:01):
Nutrition SMEs concur that there is currently not an ideal way to record food or formula administration/intake using existing FHIR resources. Enteral
(tube feeding volume) administration has same issue. Both are most typically recorded in nursing I/Os flowsheets. When last we brought forth some similar use cases, folks pointed us toward using Observation (and working to develop a profile) as @Eric Haas suggests.
@Antonio De Nigro perhaps you could comment on the challenges you had using this in your recent nutrition food record work? We have an interested group starting calls to work on these gaps. Nutrition FHIR call is planned for Fridays at 2 PM ET starting April 12th.See the OO nutrition listserv group or main OO listserv for call details.
Jose Costa Teixeira (Apr 10 2019 at 04:05):
I think we need a resource for capturing "what was administered": Volume, kind of product, etc, not an observation profile.
Other things may be an observation, but an administration of a product should not be an observation.
Jose Costa Teixeira (Apr 10 2019 at 04:07):
if we have a dedicated resource for medication administration, we should have one for other administrations, not an observation.
As a developer, if I am giving a product to a paitent, it may be hard enough to decide between MedAdministration and (a hypothetical) NutritionAdministration just because they may be classified differently in my hospital. I would not want to decide between an observation and an administration.
Jose Costa Teixeira (Apr 10 2019 at 04:09):
I think that would mess up any downstream data analysis unnecessarily.
Jose Costa Teixeira (Apr 10 2019 at 04:10):
Same applies for administration statement - whatever we do, it should be somehow consistent between drugs and other products (what is the difference anyway?)
Jose Costa Teixeira (Apr 10 2019 at 04:12):
my take is that we do need a resource to capture xxxAdministration, and xxxStatement, but the boundaries between those should be very clear (Pharmacy paved the way, and their boundaries are quite good IMO - not perfect yet, but "implementable" good)
John Silva (Apr 10 2019 at 09:50):
Just looked at the V2 Chapter 4 -- it describes how to handle Order/Dispense/Give/Administer not only pharmacy products but TPN (and other nutritional IVs), vaccines, and blood products. So, to Jose's point, there may need to be some common pattern in FHIR to do something similar, i.e. handling of all kinds of ordered/dispensed/administered 'things' (V2 calls them 'treatments' since even things like PT, OT and such can be ordered and administered.)
Lisa Anderson (Apr 10 2019 at 13:48):
@Floyd Eisenberg Thanks, Floyd, that is the issue with NutritionOrder. For the quality measure, we want to know exactly what the patient received, not just what was ordered.
Lisa Anderson (Apr 10 2019 at 13:51):
Thanks for the question. From the perspective of this particular measure, the intent is to know that breast milk only was administered in lieu of all other intake (including sterile water, formula, etc.). I’m not sure if donor milk is allowable and will check with the measure developer. For a more generic sense, yes, all intake and totaling of all fluids/nutrients would be needed as well as fluid output (generally measured in we diapers though).
@Floyd Eisenberg and @Jose Costa Teixeira From the perspective of the quality measure, it does not matter if the breast milk is from the mother or donor.
Margaret Dittloff (Apr 10 2019 at 14:52):
my take is that we do need a resource to capture xxxAdministration, and xxxStatement, but the boundaries between those should be very clear (Pharmacy paved the way, and their boundaries are quite good IMO - not perfect yet, but "implementable" good)
@Jose Costa Teixeira I agree. Apps trying to compute total intake for fluids or nutrients (e.g. Calorie Count, etc) will benefit from a dedicated resource. The OO Nutrition group can bring forward a new resource proposal for NutritionStatement and Nutrition(Product)Administration starting from what works well with these in Medication resources.
John Silva (Apr 10 2019 at 15:27):
@Margaret Dittloff - Sounds good. It also sounds like there is a common pattern that maybe fits with the order workflow pattern that encompasses not only the order but the 'downstream states' of the actions/events and results of the order. (I guess this is already in the Workflow pattern though there isn't a 'Nutrition Admin' or a 'Vaccine Admin' or a 'Blood Product Admin' if these specializations are needed?)
Jose Costa Teixeira (Apr 10 2019 at 22:09):
Both this possible pattern, and the need for new resources is what the OO group is discussing in the Health Product calls. @Hans Buitendijk is conducting the works
Sebastiaan Raap (May 03 2019 at 12:32):
Jose Costa Teixeira I agree. Apps trying to compute total intake for fluids or nutrients (e.g. Calorie Count, etc) will benefit from a dedicated resource. The OO Nutrition group can bring forward a new resource proposal for NutritionStatement and Nutrition(Product)Administration starting from what works well with these in Medication resources.
@Margaret Dittloff Any news on this subject? We're currently trying to find resources which could represent the feeding pattern of an infant. IMO resources like NutritionStatement and Nutrition(Product)Administration would help us. please see https://zibs.nl/wiki/FeedingPatternInfant-v1.0(2017EN)
Sebastiaan Raap (May 03 2019 at 12:50):
@Hans Buitendijk ping
Margaret Dittloff (May 07 2019 at 20:24):
@Sebastiaan Raap Yes, the nutrition sub-group for OO is working to bring forward a new resource proposal for NutritionIntake (exact naming TBD). This group is meeting weekly on Fridays 2 PM ET, except not during WGM. We are gathering use cases for patient reported food/meal intake, clinician reported (like a 24-hour recall or food freq. assessment by the dietitian) as well as administration of formula (which includes infant/pediatric formula or breastmilk fed orally or via tube) and adult enteral (tube feed), We will definitely review your use cases and add pointers to your examples. @Becky Gradl who is leading this project can chime in with more details .
Sebastiaan Raap (May 08 2019 at 11:22):
Thank you Margeret, is there a wiki where I can monitor the progress?
Last updated: Apr 12 2022 at 19:14 UTC
