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Implementation of the Nutrition Care Process and International Dietetics and Nutrition Terminology in a Single-Center Hemodialysis Unit: Comparing Paper vs Electronic Records

Published:October 22, 2013DOI:https://doi.org/10.1016/j.jand.2013.07.033

      Abstract

      There is little doubt surrounding the benefits of the Nutrition Care Process and International Dietetics and Nutrition Terminology (IDNT) to dietetics practice; however, evidence to support the most efficient method of incorporating these into practice is lacking. The main objective of our study was to compare the efficiency and effectiveness of an electronic and a manual paper-based system for capturing the Nutrition Care Process and IDNT in a single in-center hemodialysis unit. A cohort of 56 adult patients receiving maintenance hemodialysis were followed for 12 months. During the first 6 months, patients received the usual standard care, with documentation via a manual paper-based system. During the following 6-month period (Months 7 to 12), nutrition care was documented by an electronic system. Workload efficiency, number of IDNT codes used related to nutrition-related diagnoses, interventions, monitoring and evaluation using IDNT, nutritional status using the scored Patient-Generated Subjective Global Assessment Tool of Quality of Life were the main outcome measures. Compared with paper-based documentation of nutrition care, our study demonstrated that an electronic system improved the efficiency of total time spent by the dietitian by 13 minutes per consultation. There were also a greater number of nutrition-related diagnoses resolved using the electronic system compared with the paper-based documentation (P<0.001). In conclusion, the implementation of an electronic system compared with a paper-based system in a population receiving hemodialysis resulted in significant improvements in the efficiency of nutrition care and effectiveness related to patient outcomes.

      Keywords

      Implementation of the Nutrition Care Process (NCP) and International Dietetics and Nutrition Terminology (IDNT) are two essential components to achieving consistent and comprehensive nutrition care and documentation. The need for standardization to accurately describe the broad spectrum of nutrition care and registered dietitians' unique body of knowledge is recognized as a priority for action by the Academy of Nutrition and Dietetics (Academy).
      • Hakel-Smith N.
      • Lewis N.M.
      A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes.
      The Academy adopted the NCP in 2003, four distinct yet inter-related steps seen as the roadmap to high-quality nutrition care.
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      The first IDNT document was published by the Academy 4 years later, capturing standardized language for each of the four components of the NCP: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.
      There have since been four editions of the IDNT reference manual, accommodating feedback from international adopters. Today the International Confederation of Dietetics Association

      International Confederation of Dietetic Associations. 2010. http://www.internationaldietetics.org/. Accessed April 10, 2012.

      and most dietetics bodies around the world have endorsed the use of the NCP and IDNT and promote it as a method to enhance not only communication within and between professions, but to enable practice-based research thereby providing the evidence base for dietetics practice.
      • Hakel-Smith N.
      • Lewis N.M.
      A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes.
      There is little doubt surrounding the benefits of the NCP and IDNT to dietetics practice; however, evidence to support the most efficient method of incorporation into practice is lacking.
      • Memmer D.
      Implementation and practical application of the nutrition care process in the dialysis unit.
      There have been few studies published that report the efficiency and effectiveness of implementing the NCP and IDNT using either a paper-based or electronic system, with no study to date directly comparing the two. A study looking at the benefits of implementing the NCP in paper-based nutrition care reported enhanced productivity and communication with other health professionals.
      • Corado L.
      • Pascual R.
      Successes in Implementing the Nutrition Care Process and Standardized Language In Clinical Practice.
      However, resources, including time, were identified as the key barrier by two other studies that looked at the implementation of a subset of IDNT (ie, nutrition diagnosis) using the paper-based method.
      • Memmer D.
      Implementation and practical application of the nutrition care process in the dialysis unit.
      • Van Heukelom H.
      • Fraser V.
      • Koh J.C.
      • et al.
      Implementing nutrition diagnosis at a multisite health care organization.
      Copes and Ramsay
      • Copes L.
      • Ramsay K.
      Using the standardized language for the Nutrition Care Process in the electronic health record to measure and report nutrition care outcomes.
      implemented IDNT in an electronic system and found that it provided a good indication of the effect of registered dietitians on patient care. Finally, implementation of the nutrition intervention and monitoring and evaluation steps of the NCP using IDNT in an electronic system highlighted an association between improved nutrition care and outcomes; however, the nutrition diagnosis was not reported.
      • Miller P.E.
      • Miller N.
      • Faith J.
      • et al.
      Implementation and evaluation of outcomes related to the Nutrition Care Process through the use of electronic health records.
      Outside of the dietetics literature it is well established that electronic systems providing decision support and patient tracking are far superior to paper-based systems. This was identified by a systematic review evaluating health electronic systems that indicated an improved quality of care with increased adherence to guidelines, documentation accuracy, and completeness.
      • Lau F.
      • Kuziemsky C.
      • Price M.
      • Gardner J.
      A review on systematic reviews of health information system studies.
      To date, the affect of the NCP and IDNT in electronic systems on clinical and economical end points has not been thoroughly investigated. The aim of our study was to compare an electronic system against a paper-based system for capturing the NCP with IDNT on efficiency and effectiveness of dietetics care in a hemodialysis setting.

      Methods

      Patients

      A hemodialysis population was selected to undertake this study due to the relatively consistent patient group requiring long-term dietetics-related input; therefore, two different systems (electronic and paper-based) could be compared with fewer confounding factors. In addition, because this population has a high prevalence of nutrition-related problems, they are likely to benefit from a systematic approach to the identification and documentation of nutritional status using IDNT.
      • Locatelli F.
      • Fouque D.
      • Heimburger O.
      • et al.
      Nutritional status in dialysis patients: A European consensus.
      This was supported by a recent study reporting the practical application of the NCP in a hemodialysis population.
      • Memmer D.
      Implementation and practical application of the nutrition care process in the dialysis unit.
      Patients receiving maintenance hemodialysis from a tertiary hospital, with a dialysis vintage of >3 months, aged 18 years and older, and who provided consent were eligible for inclusion. Ninety-one patients met the inclusion criteria and were recruited between September and October 2010. Baseline data collected included cause of end stage renal disease (using Australia and New Zealand Dialysis and Transplant Registry categories), comorbidities, age, sex, dialysis vintage, and medications. The study was approved by the institution's Human Research Ethics Committee (HREC/10/QPAH/145).

      Study Design

      This was a 12-month longitudinal study. During Months 1 to 6, patients received usual standard of care with documentation of the NCP and IDNT via a manual paper-based system. Nutrition reviews by a qualified renal dietitian
      • Brommage D.
      • Karalis M.
      • Martin C.
      • et al.
      American Dietetic Association and the National Kidney Foundation Standards of Practice and Standards of Professional Performance for registered dietitians (generalist, specialty, and advanced) in nephrology care.
      were scheduled based on patients' needs after baseline assessment and on a referral basis from nursing and medical staff throughout Months 1 to 6. During Months 7 to 12 documentation of the NCP and IDNT was via an electronic system.
      An electronic system was developed to incorporate the following components: automated calculation and alerts for anthropometry and dietary data, download of monthly biochemistry data, IDNT checkboxes with prompts, and graphic tracking of patient data over time (see the Figure).
      FigureComparison of the Nutrition Care Process using a manual paper-based system and an electronic system in a 12-month longitudinal study in a chronic hemodialysis population. Use of International Dietetic and Nutrition Terminology (IDNT) for nutrition assessment was outside the scope of this study.
      Nutrition Care Process componentManual-paper based systemInnovative electronic system
      Nutrition assessment
      Anthropometry
      • Retrieved and transferred by hand
      • Manual calculation
      • Imported directly from institution's database
      • Automated calculations and alerts for increased risk (eg, weight reduction >2.5%)
      Medical history/medications, biochemistry, and clinical information
      • Retrieved and transferred by hand into medical record
      • Imported directly from the institution's database
      • Prepopulated options prompted (eg, common symptoms to check)
      Dietary intake data
      • Manual calculation and comparison of nutrition goals compared with actual intakes
      • Automated calculations using an electronic nutrition database (ie, energy, protein, and mineral counter)
      • Automated calculations of nutrition goals compared with actual intakes
      Nutrition diagnosis
      • Manual retrieval of IDNT codes from IDNT reference manual
      • Manual coding
      • Electronic coding with diagnosis prompts based on assessment
      Nutrition intervention
      • Manual retrieval of IDNT codes from IDNT reference manual
      • Manual coding
      • Electronic coding with intervention prompts based on diagnosis
      Nutrition monitoring and evaluation
      • Manual retrieval of IDNT codes from IDNT reference manual
      • Manual coding
      • Manual tracking
      • Prompts for scale-specific IDNT codes (eg, adherence [FH-5.1] [within the behavior class] with a scale of 1-10, where 1=not adherent and 10=completely adherent)
      • Automated monthly tracking with prompts (e-mail alerts) given to those at nutritional risk
      All data collection throughout the 12 months was undertaken by a single renal dietitian. The data collection used to evaluate the NCP was undertaken at baseline (Month 1), after implementation and use of a paper-based IDNT coding processes (Month 6), and then after implementation and use of an electronic record, which incorporated automated nutrition assessment and IDNT (Month 12). These data collection included each step in the NCP: nutrition assessment (ie, nutritional status, anthropometry, biochemistry, dietary intake, quality of life as measured by the EQ-5D utility index [EuroQol Group]), nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (ie, IDNT coding). The cost-efficiency variables included productivity (assessed using a validated workload mapping tool
      • Simmons N.C.
      • Kuys S.S.
      Trial of an allied health workload allocation model.
      ) and occasions of service (ie, number of patient consultations). Cost-efficiency was measured during a 6-week period at the end of each intervention; that is, at the end of Month 6 (paper-based) and Month 12 (electronic system), and occasions of service were recorded throughout the full 12-months.
      Nutritional status was measured using the scored patient-generated subjective global assessment tool (PG-SGA).
      • Ottery F.D.
      Patient-generated subjective global assessment.
      PG-SGA is validated for use with patients receiving hemodialysis
      • Desbrow B.
      • Bauer J.
      • Blum C.
      • et al.
      Assessment of nutritional status in hemodialysis patients using patient-generated subjective global assessment.
      and provides a global rating of A (well nourished), B (mild to moderately malnourished), or C (severely malnourished).
      • Ottery F.D.
      Patient-generated subjective global assessment.
      This rating is based upon weight change, dietary intake, gastrointestinal symptoms, a physical examination, and the patient's functional capacity. A PG-SGA score was also calculated, with a higher score reflecting a higher risk of malnutrition and an increased need for nutrition intervention and symptom management.
      Body weight was measured using SK-VET calibrated electronic scales (Wedderburn) correct to 0.1 kg. Patients were measured without shoes, before and after dialysis. This was part of standard clinical care and was recorded in the patients' dialysis prescription charts. Body weight was used as an indicator of both fluid (interdialytic weight gain; that is, predialysis weight minus postdialysis weight averaged using the last 6 measurements [in kilograms]) and nutritional status (changes in postdialysis weight [in kilograms]). Height was measured at baseline using a wall-mounted stadiometer. Body mass index was calculated as weight (in kilograms)/height (in meters)2.
      Dietary intake was assessed using a 24-hour food recall according to the US Department of Agriculture multiple pass method, which accounted for both dialysis and nondialysis days.
      • Conway J.M.
      • Ingwersen L.A.
      • Moshfegh A.J.
      Accuracy of dietary recall using the USDA five-step multiple-pass method in men: An observational validation study.
      Energy, protein, potassium, phosphate, and sodium intakes were evaluated and compared with each patient's nutrition goals expressed as a percentage. Nutrition goals were determined using the Evidence-Based Practice Guidelines for Nutritional Management of Chronic Kidney Disease.
      • Ash S.
      • Campbell K.
      • MacLaughlin H.
      • et al.
      Evidence based practice guidelines for the nutritional management of chronic kidney disease.
      Biochemical parameters were assessed monthly as part of the dialysis unit's standard protocol, including albumin, C-reactive protein (as a marker of inflammation), urea, potassium, and phosphate status. However, only the biochemical parameters from Month 6 and Month 12 were used for the outcome analysis.
      IDNT was used for the diagnosis, intervention, and monitoring and evaluation steps of the NCP from the American Dietetic Association (ADA) International Dietetics and Nutrition Terminology (IDNT) Reference Manual, 3rd edition.
      During the first 6 months, the coding of IDNT was performed manually and recorded. During the following 6 months, the intervention period, IDNT was coded using the electronic system. Nutrition assessment was undertaken at each consultation but not reported using IDNT coding system for the purpose of this article.
      Diagnostic codes were assigned based on the nutrition and biochemical targets described in the Evidence-Based Practice Guidelines for Nutritional Management of Chronic Kidney Disease
      • Ash S.
      • Campbell K.
      • MacLaughlin H.
      • et al.
      Evidence based practice guidelines for the nutritional management of chronic kidney disease.
      and Caring for Australasians with Renal Impairment chronic kidney disease guidelines.

      Caring For Australasians with Renal Impairment (CARI). Chronic kidney disease guidelines. 2006. http://www.kdigo.org/guidelinescompare/cari.html. Accessed April 10, 2012.

      Diagnostic code Excessive fluid intake (ie, NI-3.2) was assigned based on expert opinion classified as interdialytic weight gains ≥3% body weight. Diagnostic codes for underweight (ie, NC-3.1) and obesity (ie, NC-3.3) were assigned based on body mass index <20 and ≥30, respectively.
      • Eveleth P.B.
      Physical status: The use and interpretation of anthropometry. Report of a WHO Expert Committee.
      The number of times a specific nutrition diagnosis was used and resolved was reported in addition to the total number of diagnostic codes used and resolved per patient during Months 1 to 6 (paper-based system) and Months 7 to 12 (electronic system).
      Productivity was assessed using a validated workload mapping tool that captured each task undertaken daily.
      • Simmons N.C.
      • Kuys S.S.
      Trial of an allied health workload allocation model.
      The aim of this tool is to identify work patterns where clinical time is spent relating to patient care, meetings, and other activities of a clinician. The tasks were divided into defined classification from National Allied Health Casemix Committee Healthy Activity Classification,

      National Allied Health Casemix Committee. Health activity hierarchy version 1.1: An Australian standard describing the range of activities provided by health professionals. 2001. http://www.nahcc.org.au/pdfs/hah.pdf. Accessed April 10, 2012.

      which incorporates time spent face-to-face in patient consultations, defined as direct patient time (DPT) and time spent on meetings, professional development, teaching, and training, defined as non-direct patient time (NDPT). The renal dietitian reported time spent directly with patients (DPT) and other activities (NDPT) during a 6-week period coinciding with data collection at the end of each of the study periods (Months 6 and 12). Occasions of service (ie, number of patient consultations) were recorded for the full 12 months from clinical statistics.
      Quality of life was measured using the EQ-5D questionnaire. Three components of the EQ-5D were reported: EQ-5D descriptive system (five questions), EQ visual analogue scale of overall health state, and EQ-5D index descriptive system.
      The EQ-5D descriptive system consisted of five questions in five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has three levels: no problems (score=1), some problems (score=2), and severe problems (score=3), which formed the descriptive system. The visual analogue component involved patients' self-assessment of their overall health state on a 20-cm visual scale, where 100 was “best imaginable” and zero was “worst imaginable” health state. The EQ-5D index descriptive system was used to create a weighted summary index incorporating five dimensions of functioning and well-being using the reference data from the United Kingdom to determine the weighted index.

      Statistical Analysis

      All data were assessed for normality and the summary statistics were expressed as mean±standard deviation for normally distributed measures, median and minimum-maximum for the one non-normally distributed measure (PG-SGA score), and frequency and percent for categorical data. Only the nutrition-related diagnoses with a point prevalence of ≥5% were reported. Comparisons of mean values at Months 6 and 12 (independent samples) for the whole population were made using t test for normally distributed data, Mann-Whitney U test for non-normally distributed data, and χ2 test for categorical data. Comparisons of means in the cohort of participants who remained under this service for the full 12 months (dependent samples) were made using paired t test for normally distributed data, Wilcoxon signed-ranked test for non-normally distributed data, and McNemar test for categorical data. The null hypothesis was rejected at the 0.05 level. All of the statistical analyses were performed using Stata (version 11.1, 2010, Statacorp).

      Results

      Study Population

      Ninety-two patients were invited into the study at baseline and only one patient declined consent. There was a 62% (n=56) completion rate at Month 12, with reasons for discharge from the study including dialysis relocation (n=15), mortality (n=10), acutely unwell requiring hospitalization (n=5), transplantation (n=4), and refusal (n=1).
      The cohort (N=91) was 55% men with a mean age of 58±15 years. The main cause of end stage renal failure was diabetic nephropathy (32%), followed by glomerulonephritics (20%) and the median dialysis vintage was 46.5 months (minimum 3 months and maximum 236 months). There were no significant differences in patient demographics or baseline prevalence of nutrition diagnoses between patients who completed the full 12 months (included in analysis) (n=56) and those who discontinued the study before 12 months (not included in the analysis) (n=35).

      Nutrition-Related Diagnosis

      There was no significant difference in the number of times a specific diagnosis was used between the paper-based system (Months 1 to 6) and the electronic system (Months 7 to 12) (Table 1).
      Table 1Comparison of the number of times a specific nutrition-related diagnostic code was used and resolved using a paper-based vs an electronic system, in 56 patients undergoing chronic hemodialysis treatment in a single Australian center
      Outcome parameterPaper-Based Standard Care (Months 1-6) (n=56)Electronic System (Months 7-12) (n=56)
      Diagnosis MadeResolution AchievedDiagnosis MadeResolution Achieved
      P<0.05 compared with mean number of nutrition diagnoses resolved during paper-based standard care.
      n%n%n%n%
      Nutrition diagnostic codes
      Intake domain
      NI-3.2: Excessive fluid intake213821029521221
      NI-5.1: Increased nutrient needs (energy/protein)4712547125
      NI-5.2: Malnutrition61123347125
      NI-5.3: Inadequate protein-energy1527853916667
      NI-5.7.1: Inadequate protein14253211629531
      NI-5.10.2.5: Excessive potassium intake132343118321056
      NI-5.10.2.6: Excessive phosphate intake1018220916667
      NI-5.10.2.7: Excessive sodium intake25453122952621
      Clinical domain
      NC-2.2: Altered nutrition-related laboratory value (phosphate)407192341732049
      NC-3.1: Underweight7130061100
      NC- 3.3: Overweight/obesity132300132300
      Behavioral- environmental domain
      NB-1.1: Food-and nutrition-related knowledge deficit35133611467
      P<0.05 compared with mean number of nutrition diagnoses resolved during paper-based standard care.

      Nutrition Interventions and Monitoring and Evaluation

      The most common nutrition intervention codes, defined as those that were applied in >50% of the occasions of service, included specific foods/beverages or groups (ie, ND-1.3), medications (phosphate binders) (ie, ND-6.1), priority modification (ie, E-1.2), transtheoretical model/stages of change (ie, C-1.4), and motivational interviewing (ie, C-2.1). There was no significant difference in the nutrition interventions delivered in the study between the paper-based and electronic system. However, the number of times a specific monitoring and evaluation code was used highlighted a significant difference between the use of three codes within the knowledge/beliefs/attitudes (ie, FH-4) and behaviors (ie, FH-5) class; specifically, area and level of knowledge (ie, FH-4.1.1), readiness to change nutrition-related behaviors (ie, FH-4.2.7), and self-reported adherence score (ie, FH-5.1.1). These three codes showed a statistically significant increase in use during the electronic system intervention (Months 7 to 12) (P<0.001).

      Clinical Outcomes

      The mean number of nutrition diagnoses resolved during the electronic system period (Months 7 to 12) was significantly greater compared with the paper-based system (Months 1 to 6) (1.5±1.0 vs 0.7±0.8 resolutions/patient; P<0.05). There were no other significant differences in clinical outcomes at Months 6 and 12 (see Table 2). However, there was a trend for an improvement in the number of patients meeting the serum phosphate recommendations following the 6-month electronic system intervention. The number of patients meeting the phosphate guideline increased from 25% to 39% following implementation of the electronic system; however, this did not reach statistical significance (P=0.074).
      Table 2Results of a 12-month comparison between a paper-based and an electronic system on clinical outcomes in 56 patients undergoing chronic hemodialysis in a single Australian center
      Outcome parameterBaselinePaper-based (Months 1-6)Electronic (Months 7-12)P value
      P Values reflect the comparison between prevalence of clinical outcomes at Months 6 and 12 using paired t test for normally distributed data, Wilcoxon signed-rank test for non-normally distributed data, and McNemar test for categorical data.
      No. of diagnoses resolved, mean±standard deviation0.7±0.81.5±1.0<0.001
      Nutritional status
      Subjective global assessment B (mild to moderate)/C (severe), % (n)9 (5)8.5 (3)6.0 (3)1.00
      Patient-generated subjective global assessment score, median (range)1 (0-13)1 (0-14)1 (0-9)0.094
      Anthropometry
      Body mass index, mean±standard deviation26.0±5.225.7±5.225.8±5.20.695
      6-mo dry weight change (kg), mean %±standard deviation−1.0±3.60.6±3.80.280
      Interdialytic weight gain (kg), mean±standard deviation2.7±1.32.6±1.12.9±1.00.972
      Biochemistry
      Phosphate (mmol/L
      To convert mmol/L phosphate to mg/dL, multiply mmol/L by 3.09. to convert mg/dL phosphate to mmol/L, multiply mg/dL by 0.323. Phosphate of 1.6 mmol/L=4.94 mg/dL.
      ), mean±standard deviation
      1.8±0.51.8±0.51.8±0.60.513
      Phosphate ≤1.6 mmol/L
      To convert mmol/L phosphate to mg/dL, multiply mmol/L by 3.09. to convert mg/dL phosphate to mmol/L, multiply mg/dL by 0.323. Phosphate of 1.6 mmol/L=4.94 mg/dL.
      , % (n)
      36 (20)25 (14)39 (22)0.074
      Potassium (mmol/L), mean±standard deviation4.7±0.74.7±0.75.0±0.70.999
      Potassium ≤5.5 mmol/L, % (n)86 (48)79 (44)72 (46)0.875
      Dietary intake, mean±standard deviation
      Energy intake, kj/kg body weight109±25113±35115±280.827
      Protein intake, g/kg body weight1.1±0.431.2±0.41.2±0.30.693
      Quality of life
      Indicated some degree of limitation (score 2 or 3).
      Mobility, % (n)30 (17)30 (17)36 (20)0.508
      Self-care, % (n)13 (7)13 (7)13 (7)1.00
      Usual activity, % (n)39 (22)39 (22)34 (19)0.581
      Pain/discomfort, % (n)50 (28)50 (28)38 (21)0.039
      Anxiety/depression, % (n)16 (9)14 (8)18 (13)0.180
      Visual analogue scale score, mean±standard deviation68±2272±2173±190.900
      EuroQol EQ-5D index score, mean±standard deviation0.75±0.300.74±0.320.77±0.290.433
      a P Values reflect the comparison between prevalence of clinical outcomes at Months 6 and 12 using paired t test for normally distributed data, Wilcoxon signed-rank test for non-normally distributed data, and McNemar test for categorical data.
      b To convert mmol/L phosphate to mg/dL, multiply mmol/L by 3.09. to convert mg/dL phosphate to mmol/L, multiply mg/dL by 0.323. Phosphate of 1.6 mmol/L=4.94 mg/dL.
      c Indicated some degree of limitation (score 2 or 3).
      There was some improvement in the reported quality of life of the patients (pain and discomfort; P=0.039), although there was no significant difference in visual analogue scale or EQ-5D index between the paper-based and electronic system (Table 2).

      Cost Outcomes

      The productivity of dietetics-related care using the electronic system was significantly enhanced. Total time spent by the renal dietitian undertaking a full nutrition assessment with the patient was less using the electronic system compared with the paper-based system (57 minutes/patient vs 70 minutes/patient; P<0.001). This time saving came from both DPT (7 minutes less [reduced 14%]; P<0.001) and NDPT (6 minutes less [reduced 29%]; P<0.001). There was no difference in the occasions of service between the two systems (2.3 service occasions per patient).

      Discussion

      Compared with the paper-based system, the electronic documentation resulted in enhanced productivity without compromising patient outcomes. The benefits of standardizing the framework and documentation of nutrition care through implementation of the NCP and IDNT is well recognized
      • Lacey K.
      • Pritchett E.
      Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management.
      ; however, the method of implementation—paper-based or electronic system—has not been evaluated in detail before this study. Our study found that the implementation of an electronic system in a population receiving hemodialysis was most beneficial for the implementation of IDNT compared with a paper-based system.
      The cost of dietetics-related care in terms of labor time using the electronic system was significantly decreased (Months 7 to 12) compared with paper-based (Months 1 to 6) with no detrimental effect on patients' quality of life or nutrition-related clinical outcomes. During the routine nutrition assessments total patient time was decreased on average by 13 minutes per patient using the electronic system. If this is applied to a typical renal dietitian's workload in the United States—managing routine monthly assessments on 100 to 150 maintenance patients—this would equate to an annual saving of 260 to 390 hours or $6,500 to $10,000 (based on an hourly rate of $25/h).

      DietitianPay.com. Renal dietitian salary information. 2012. http://dietitianpay.com/1/1/salary/Renal-Dietitian-Salary. Accessed August 3, 2012.

      The implementation of IDNT into clinical practice was enhanced by the electronic checkbox and nutrition diagnosis features of the electronic system. The enhanced efficiency of IDNT coding using the electronic system, compared with paper-based, was reflected in the decreased NDPT; that is, documentation time during the intervention period (Months 7 to12). This suggests that an electronic system may better facilitate the uptake of IDNT among registered dietitians who are current non-IDNT users and reported time as a barrier to its implementation.
      • Vivanti A.
      • Ferguson M.
      • Porter J.
      • O'Sullivan T.
      Staff knowledge, confidence and perceptions prior to implementation of the Nutrition Care Process (NCP) and International Dietetics and Nutrition Terminology (IDNT).
      The other key benefit of the electronic system with respect to the implementation of IDNT was the enhanced support to apply the complete list of IDNT codes to the NCP. The use of the electronic system fostered the routine use of monitoring and evaluation indicators that had predefined scales. This was evidenced by the significant increase in the use of three indicators within the knowledge/beliefs/attitudes (ie, FH-4) and behaviors (ie, FH-5) monitoring and evaluation classes, which required further specification/scaling; for example, in area and level of knowledge (ie, FH-4.1.1): classified as inadequate, basic, moderate, and comprehensive. Application of systematic indicators such as these enhance the measurable nature of dietetics practice, linking nutrition care to patient outcomes.
      A greater number of nutrition-related diagnoses were resolved using the electronic system compared with Months 1 to 6 using the paper-based system. This suggests there may be an improvement in the delivery of nutrition care using an electronic system. A likely explanation for this increased resolution of nutrition diagnoses was the tracking system built into the electronic system facilitating proactive care and more accurate triaging of dietetics practitioner time to patient need.
      The principal limitation of our study was that it was pilot in nature and therefore had a lack of randomization and control group; however, given the issues of being a single site, randomizing and conducting separate models of care within the same facility was not considered feasible.
      This research is fundamental to guiding the dietetics profession through the implementation phase of the NCP and IDNT into daily practice. Whether this benefit will be translated into enhanced uptake of the NCP and IDNT by registered dietitians remains to be investigated. There have been limited studies reporting benefits using either electronic systems—such as electronic medical records
      • Copes L.
      • Ramsay K.
      Using the standardized language for the Nutrition Care Process in the electronic health record to measure and report nutrition care outcomes.
      • Miller P.E.
      • Miller N.
      • Faith J.
      • et al.
      Implementation and evaluation of outcomes related to the Nutrition Care Process through the use of electronic health records.
      —or paper-based
      • Corado L.
      • Pascual R.
      Successes in Implementing the Nutrition Care Process and Standardized Language In Clinical Practice.
      • Van Heukelom H.
      • Fraser V.
      • Koh J.C.
      • et al.
      Implementing nutrition diagnosis at a multisite health care organization.
      methods to implement NCP and or IDNT. The few studies that have evaluated IDNT implementation in EMR identified both potential benefits and limitations of current systems, including the opportunity to evaluate the effectiveness of interventions on nutrition care outcomes
      • Miller P.E.
      • Miller N.
      • Faith J.
      • et al.
      Implementation and evaluation of outcomes related to the Nutrition Care Process through the use of electronic health records.
      and functionality restrictions within the system,
      • Copes L.
      • Ramsay K.
      Using the standardized language for the Nutrition Care Process in the electronic health record to measure and report nutrition care outcomes.
      respectively. Our study has drawn on these recommendations and extended beyond to ensure more efficient software and early planning preimplementation occurred. This study's holistic approach to IDNT implementation, although as intended by the Academy, is novel in that it has not been previously reported.

      Conclusions

      The implementation of an electronic vs paper-based system resulted in improvements in patient outcomes and significant improvements in the efficiency of implementing the NCP and IDNT. This has substantial potential for cost savings and improving patient outcomes. This study supports the implementation of an electronic system to maximize the efficiency and effectiveness of dietetics care.

      References

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      Biography

      K. L. Campbell is an advanced accredited practising dietitian and a senior research fellow, Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia, and a lecturer, School of Medicine, The University of Queensland, Brisbane, Australia.
      M. Rossi is an accredited practising dietitian and a clinical dietitian, Department of Nutrition and Dietetics, Princess Alexandra Hospital Brisbane, Queensland, Australia, and a doctoral degree student, School of Medicine, The University of Queensland, Brisbane, Australia.
      M. Ferguson is a registered and an advanced accredited practicing dietitian and director, Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia, and senior lecturer, School of Human Movement Studies, The University of Queensland, Brisbane, Queensland, Australia.