We’ve had a couple of posts recently (well 3) talking about how we can use FHIR resources to represent some common clinical scenarios as a prelude to the clinical connectathon in September. Each of the scenarios exercised a different part of FHIR (and had a slightly different clinical focus):
- The Chronic Care Scenario has a heavy emphasis on the Care Plan
- The Acute Care scenario provoked a discussion on how we should be using the Encounter resource – and further highlighted a need to refer form an Observation to an Encounter
- And finally the scenario dealing with Allergies led us to think about my favourite resource – the List.
(Here’s a bit more detail…)
There’s been a bit of discussion in the HL7 lists recently about the concept of a Clinical Assessment – and how best to represent it in FHIR. As it turns out, one of the scenarios put forward by Patient Care that we won’t be exercising (yet) is the process around making a Nutrition Assessment, and Elaine (one of the Patient Care co-chairs) has asked if I could do a post on this scenario to help stimulate discussion – so here it is.
Nutrition Assessment Use Case
The purpose of this use case is to describe the process of completing a nutrition assessment and documenting a nutrition diagnosis/problem. (Excerpt from HL7 V3 Diet Order DAM)
Use Case Sequence of Steps
- Dietitian receives the Dietitian Consultation order.
- Dietitian collects assessment data to include the following:
- Anthropometric data are collected from the EHR system and include, but are not limited to, the patient’s height, weight (current, usual and history of weight change), weight change while in hospital (loss or gain), and body mass index (BMI). (Observation)
- Biochemical data are collected from the EHR system. (Observation)
- Client history is collected from the EHR system to include, but not be limited to, medical diagnoses and medications. (Condition, Medication*
- Food history is gathered by direct interviews with patient, family, and staff as well as data within the EHR system and Food and Nutrition Management System (FNMS). These data include, but are not limited to, the diet order, usual eating pattern and food related behaviors, changes in appetite, amounts of food/fluids typically consumed, and amounts of foods/fluids consumed since being admitted. (Observation and/or Questionnaire)
- Nutrition-focused physical findings (observations) are collected from patient observation, staff interviews, and/or the EHR system. This includes physical signs such as the presence of mouth sores and muscle wasting, significant weight loss over a specific period of time. (Observation)
- Comparative standards such as energy and protein calculations to determine nutritional needs may be calculated by the dietitian. (Observation)
- A nutrition diagnosis/problem may be identified by the dietitian and documented in the EHR system based on the assessment data collected. The nutrition diagnosis/problem statement includes three components: the (nutrition) problem, the etiology of the problem, and the signs and symptoms of the problem utilizing standard terminology. (Observations)
This process would be followed by recommendations/interventions (working on this, may be part of Care Plan), a care plan(CarePlan), other procedures(procedure orders are TBD), and/or a referral (Referral).
The outcome of this clinical synthesis leads to the following type of statement:
- Inadequate energy intake related to decreased appetite as evidenced by energy consumption less than assessed needs and weight loss of 5 pounds in one week.
- Chewing difficulty related to mouth pain from oral sores as evidenced by oral side effects of chemotherapy.
- Starvation-related malnutrition related to suboptimal protein and energy intake as evidenced by decreased muscle mass and diminished hand-grip strength.
These diagnostic statements (such as Starvation-related Malnutrition) are used to:
- Populate the problem list
- Lead to a codeable concept that is used for billing (In progress)
So lets start by going through the scenario and highlight the resources we might use.
- The “Dietician Consultation order” sounds like a Referral (being developed by Patient Care) with the workflow being mediated through an Order.
- The dietician collects some historical data from the EHR – likely in the form of Observations. There’s no indication of how which observations are selected – this could just be ‘ah hoc’ viewing of records, or could be a more structured process such as the auto-populating of a Questionnaire – perhaps using a FHIR Query and/or the new ObservationDefinition resource to define the concepts (This is being proposed for the next DSTU – note that the purpose of this resource is the definition of these items – not their actual representation)
- Then there are a number of data items being collected by direct interviews. We’d probably store the actual data collected as Observations – potentially linked to one or more Encounters – but we could also use a questionnaire to guide the data capture.
- There’s mention of calculations that potentially lead to further observations – “energy and protein calculations to determine nutritional need”. I don’t think there’s currently a way of representing these calculations in FHIR, though some of the work being done for Clinical Quality might be applicable.
- Then there’s a number diagnosis/problems identified by the dietitian – these would be Conditions. There’s mention of aetiology and symptoms/signs (Condition.evidence) and also Condition.notes for plain text. And Condition.asserter would show that the dietitian made the diagnosis. These would be saved as Condition resources, but could also be references from the List resource representing the Problem List.
- Following the assessment there are “recommendations/interventions, a care plan, other procedures, and/or a referral”. It’s likely that CarePlan, Procedure and Referral resources would be useful here. I think there’s also a Recommendation resource being planned (but I don’t see it in the Resource Proposal page so can’t be sure, but sounds like a good idea).
Some specific questions were asked. There are some comments below – but there’s likely to be a fair amount of debate about the best answers!
Is a diagnosis a type of observation as per the current FHIR observation resource?
Probably the Condition is the better option.
When FHIR points to a CodeableConcept for billing what is used?
Well, there’s a Coverage resource proposed, and that talks about a possible Invoice resource, so it would contain the required coding to represent the service delivered. Likely the Financial Management committee will take ownership of this…
How does the concept of defining a diagnosis relate to the proposed Prognosis assessment (a type of assessment).
That’s a good question. The proposed Prognosis resource talks about “Prognosis describes the expected outcome for a particular subject based on an analysis of present condition and surrounding factors”. There’s a draft of the resource here (re-named as RiskAssessment) – it is an early draft though… So the “present Condition” (and, I suspect the other concept of “Concern”) would come into play here.
How do these FHIR resources relate to the OpenEHR archetypes of:
openEHR-EHR-EVALUATION.problem_diagnosis.v1
openEHR-EHR-COMPOSITION.problem_list.v1
Well, there’s a pilot project underway with openEHR looking at allergy models, so it is to be hoped that – if successful – it could be extended to other clinical models.
Will a profile work for clinical assessments or is a unique resource required to define the diagnostic element in FHIR?
Not sure what is meant by “diagnostic element” in this question. Assuming that it refers to the Assessment, then there is the draft RiskAssessment resource described above.
Is a profile pointing to questionnaire, observations and condition complete?
Again, not quite sure what ‘complete’ means in this context. If it means ‘sufficient to meet the requirements of the Use Case’, then I guess it will depend on the complexity of the use case. However, as that is one of the purposes of a Profile then it would certainly be a goal.
So there you go. Feel free to comment – either as comments to this post or directly to the Patient Care or FHIR list.