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A Call to Action for Optimizing the Electronic Health Record in the Parenteral Nutrition Workflow

      Abstract

      Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.
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      References

        • Ayers P.
        • Guenter P.
        • Holcombe B.
        • Plogsted S.
        How to prescribe parenteral nutrition therapy.
        in: Ayers P. Guenter P. Holcombe B. Plogsted S. ASPEN Parenteral Nutrition Handbook. 2nd ed. American Society for Parenteral and Enteral Nutrition, Silver Spring, MD2014: 111-134
      1. National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP) from the Agency for Healthcare Research and Quality (AHRQ). http://hcupnet.ahrq.gov/. Accessed December 10, 2015.

      2. Institute for Safe Medication Practices. 2016-2017 Medication Safety Best Practices for Hospitals. http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf. Accessed January 23, 2017.

        • Worthington P.
        • Balint J.
        • Bechtold M.
        • et al.
        When is parenteral nutrition appropriate?.
        JPEN J Parenter Enteral Nutr. 2017; 41: 324-377
        • Boullata J.L.
        • Guenter P.
        • Mirtallo J.M.
        A parenteral nutrition use survey with gap analysis.
        JPEN J Parenter Enteral Nutr. 2013; 37: 212-222
        • Ayers P.
        • Adams S.
        • Boullata J.L.
        • et al.
        ASPEN parenteral nutrition safety consensus recommendations.
        JPEN J Parenter Enteral Nutr. 2014; 38: 296-333
        • Boullata J.I.
        • Gilbert K.
        • Sacks G.
        • et al.
        • American Society for Parenteral and Enteral Nutrition
        ASPEN clinical guidelines: Parenteral nutrition ordering, order review, compounding, labeling, and dispensing.
        JPEN J Parenter Enteral Nutr. 2014; 38: 334-377
        • Kochevar M.
        • Guenter P.
        • Holcombe B.
        ASPEN statement on parenteral nutrition standardization.
        JPEN J Parenter Enteral Nutr. 2007; 31: 441-448
        • Vanek V.W.
        • Ayers P.
        • Kraft M.
        • et al.
        Follow-up survey on functionality of nutrition documentation and ordering nutrition therapy in currently available electronic health record (EHR) systems.
        Nutr Clin Pract. 2016; 31: 401-415
        • Mirtallo J.
        • Canada T.
        • Johnson D.
        • et al.
        • ASPEN Board of Directors and Task Force for the Revision of Safe Practices for Parenteral Nutrition
        Safe practices for parenteral nutrition [published correction appears in JPEN J Parenter Enteral Nutr. 2006;30:177].
        JPEN J Parenter Enteral Nutr. 2004; 28: S39-S70
      3. Agency for Healthcare Research and Quality. Standardized ordering and administration of total parenteral nutrition reduces errors in children’s hospital. https://innovations.ahrq.gov/profiles/standardized-ordering-and-administration-total-parenteral-nutrition-reduces-errors. Accessed April 11, 2016.

        • Ayers P.
        • Guenter P.
        • Holcombe B.
        • Plogsted S.
        Review and verification of parenteral nutrition orders, preparing parenteral nutrition formulations, and labeling.
        in: Ayers P. Guenter P. Holcombe B. Plogsted S. ASPEN Parenteral Nutrition Handbook. 2nd ed. American Society for Parenteral and Enteral Nutrition, Silver Spring, MD2014: 135-163
        • Sacks G.S.
        Safety surrounding parenteral nutrition systems.
        JPEN J Parenter Enteral Nutr. 2012; 36: 20S-22S
        • Boullata J.I.
        Overview of the parenteral nutrition use process.
        JPEN J Parenter Enteral Nutr. 2012; 36: 10S-13S
        • Singer P.
        • Berger M.M.
        • Van den Berghe G.
        • et al.
        • ESPEN
        ESPEN guidelines on parenteral nutrition: Intensive care.
        Clin Nutr. 2009; 28: 387-400
        • Braga M.
        • Ljungqvist O.
        • Soeters P.
        • Fearon K.
        • Weimann A.
        • Bozzetti F.
        • ESPEN
        ESPEN guidelines on parenteral nutrition: Surgery.
        Clin Nutr. 2009; 28: 378-386
      4. Fat Emulsion: Drug Information. Lexicomp Online®. https://online.lexi.com. Accessed December 2015 through UpToDate.

        • Vanek V.W.
        • Borum P.
        • Buchman A.
        • et al.
        • Novel Nutrient Task Force, Parenteral Multi-Vitamin and Multi-Trace Element Working Group; American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors
        ASPEN position paper: Recommendations for changes in commercially available parenteral multivitamin and multi-trace element products.
        Nutr Clin Pract. 2012; 27: 440-491
        • Vanek V.W.
        • Borum P.
        • Buchman A.
        • et al.
        • Novel Nutrient Task Force, Parenteral Vitamin and Trace Element Working Group and the American Society for Parenteral and Enteral Nutrition (ASPEN)
        A call to action to bring safer parenteral micronutrient products to the U.S. market.
        Nutr Clin Pract. 2015; 30: 559-569
        • Driscoll D.F.
        • Bhargava H.N.
        • Li L.
        • Zaim R.H.
        • Babayan V.K.
        • Bistrian B.R.
        Physicochemical stability of total nutrient admixtures.
        Am J Health Syst Pharm. 1995; 52: 623-634
        • Gervasio J.
        Total nutrient admixtures (3-in-1): Pros vs cons for adults.
        Nutr Clin Pract. 2015; 30: 331-335
        • Mirtallo J.M.
        • Dasta J.F.
        • Kleinschmidt K.C.
        • Varon J.
        State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications.
        Ann Pharmacother. 2010; 44: 688-700
        • Driscoll D.F.
        Lipid injectable emulsions: 2006.
        Nutr Clin Pract. 2006; 21: 381-386
      5. Trissel LA. Phosphates. Trissel’s™ 2 clinical pharmaceutics database. Cashiers, NC: TriPharma Communications. https://www.micromedexsolutions.com. Accessed January 2016.

        • Kraft M.D.
        • Btaiche I.F.
        • Sacks G.S.
        • Kudsk K.A.
        Treatment of electrolyte disorders in adult patients in the intensive care unit.
        Am J Health Syst Pharm. 2005; 62: 1663-1682
      6. Potassium chloride: Drug information. Lexicomp Online®. https://online.lexi.com. Accessed December 2015 through UpToDate.

        • Pittiruti M.
        • Hamilton H.
        • Biffi R.
        • MacFie J.
        • Pertkiewicz M.
        • ESPEN
        ESPEN guidelines on parenteral nutrition: Central venous catheters (access, care, diagnosis and therapy of complications).
        Clin Nutr. 2009; 28: 365-377
        • ASPEN Board of Directors and the Clinical Guidelines Task Force
        Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients.
        JPEN J Parenter Enteral Nutr. 2002; 26: 1SA-138SA
        • Sathe M.N.
        • Patel A.S.
        Update in pediatrics: Focus on fat-soluble vitamins.
        Nutr Clin Pract. 2010; 25: 340-346
        • Koletzko B.
        • Goulet O.
        • Hunt J.
        • et al.
        Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society of Clinical Nutrition and Metabolism (EPSEN), supported by the European Society of Paediatric Research (ESPR).
        J Pediatr Gastroenterol Nutr. 2005; 41: S19-S27
        • Koo W.
        • Christie J.
        • Saba M.
        • Lulic-Botica M.
        • Warren L.
        Water-soluble essential micronutrients.
        in: Corkins M.R. ASPEN Pediatric Nutrition Support Core Curriculum. 2nd ed. ASPEN, Silver Spring, MD2015: 69-90
        • Holliday M.A.
        • Segar W.E.
        The maintenance need for water in parenteral fluid therapy.
        Pediatrics. 1957; 19: 823-832
        • Greene H.L.
        • Hambidge K.M.
        • Schanler R.
        • Tsang R.C.
        Guidelines for the use of vitamins, trace elements, calcium, magnesium, and phosphorus in infants and children receiving total parenteral nutrition: Report of the Subcommittee on Pediatric Parenteral Nutrient Requirements from the Committee on Clinical Practice Issues of the American Society for Clinical Nutrition.
        Am J Clin Nutr. 1988; 48: 1324-1342
        • Dudrick S.J.
        Rhoads lecture: A 45-year obsession and passionate pursuit of optimal nutrition support: Puppies, pediatrics, surgery, geriatrics, home TPN, ASPEN, et cetera.
        JPEN J Parenter Enteral Nutr. 2005; 29: 272-287
        • Wilmore D.W.
        • Dudrick S.J.
        Growth and development of an infant receiving all nutrients exclusively by vein.
        JAMA. 1968; 203: 860-864
        • Dudrick S.J.
        • Wilmore D.W.
        • Vars H.M.
        • Rhoads J.E.
        Long-term total parenteral nutrition with growth, development, and positive nitrogen balance.
        Surgery. 1968; 64: 134-142
        • Driscoll D.F.
        Pharmaceutical and clinical aspects of lipid injectable emulsions.
        JPEN J Parenter Enteral Nutr. 2017; 41: 125-134
        • Allwood M.C.
        • Kearney M.C.
        Compatibility and stability of additives in parenteral nutrition admixtures.
        Nutrition. 1998; 14: 697-706
        • Sacks G.S.
        • Rough S.
        • Kudsk K.A.
        Frequency and severity of harm of medication errors related to the parenteral nutrition process in a large university teaching hospital.
        Pharmacotherapy. 2009; 29: 966-974
        • Bonnabry P.
        • Cingria L.
        • Sadeghipour F.
        • Ing H.
        • Fonzo-Christe C.
        • Pfister R.E.
        Use of a systematic risk analysis method to improve safety in the production of paediatric parenteral nutrition solutions.
        Qual Saf Health Care. 2005; 14: 93-98
        • Brown C.L.
        • Garrison N.A.
        • Hutchinson A.A.
        Error reduction when prescribing neonatal parenteral nutrition.
        Am J Perinatol. 2007; 24: 417-427
        • American Society of Health-System Pharmacists
        ASHP guidelines on the safe use of automated compounding devices for the preparation of parenteral nutrition admixtures.
        Am J Health-Syst Pharm. 2000; 57: 1343-1348
        • MacKay M.
        • Anderson C.
        • Boehme S.
        • Cash J.
        • Zobell J.
        Frequency and severity of parenteral nutrition errors at a large children’s hospital after implementation of electronic ordering and compounding.
        Nutr Clin Pract. 2016; 31: 195-206
        • Hilmas E.
        • Peoples J.D.
        Parenteral nutrition prescribing processes using computerized prescriber order entry: Opportunities to improve safety.
        JPEN J Parenter Enteral Nutr. 2012; 36: 32S-35S
      7. Institute for Safe Medication Practices. Another tragic parenteral nutrition compounding error. ISMP Medication Safety Alert! April 21, 2011. https://www.ismp.org/newsletters/acutecare/articles/20110421.asp. Accessed May 12, 2016.

      8. Institute for Safe Medication Practices. Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors. ISMP Medication Safety Alert! June 28, 2012. https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=25. Accessed April 11, 2016.

      9. US Food and Drug Administration. First Annual Report on Drug Shortages for Calendar Year 2013. http://www.fda.gov/downloads/drugs/drugsafety/drugshortages/ucm384892.pdf. Accessed May 12, 2016.

      10. US Food and Drug Administration. Drug Shortages Infographic. https://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm441579.htm. Updated December 15, 2016. Accessed March 27, 2018.

        • Staes C.
        • Jacobs J.
        • Mayer J.
        • et al.
        Description of outbreaks of health-care-associated infections related to compounding pharmacies, 2000-12.
        Am J Health-Syst Pharm. 2013; 70: 1301-1312
        • Davis C.
        • Javid P.J.
        • Horslen S.
        Selenium deficiency in pediatric patients with intestinal failure as a consequence of drug shortage.
        JPEN J Parenter Enteral Nutr. 2014; 38: 115-118
        • Pramyothin P.
        • Kim D.W.
        • Young L.S.
        • et al.
        Anemia and leukopenia in a long-term parenteral nutrition patient during a shortage of parenteral trace element products in the United States.
        JPEN J Parenter Enteral Nutr. 2013; 37: 425-429
      11. Robbins R. Children are dying. The Washingtonian, May 22, 2013. www.washingtonian.com/articles/people/children-are-dying/index.php. Accessed January 1, 2016.

        • Institute for Safe Medication Practices
        Drug shortages: National survey reveals high level of frustration, low level of safety.
        ISMP Medication Safety Alert. 2010; 15 (Sept 23)
        • Institute for Safe Medication Practices
        Survey links PN component shortages to adverse outcomes.
        ISMP Medication Safety Alert. 2014; 19 (Feb 13)
        • Wright L.
        • Grisso A.G.
        • Feldott C.C.
        • et al.
        Using computerized prescriber order entry to implement actions of the pharmacy and therapeutics committee.
        Hosp Pharm. 2007; 42: 763-766
        • Hassig T.B.
        • McKinzie T.B.
        • Fortier C.R.
        • et al.
        Clinical management strategies and implications for parenteral nutrition shortages in adult patients.
        Pharmacotherapy. 2014; 34: 72-84
      12. Health Level Seven International. HL7 Messaging Standard Version 2.8.2. http://www.hl7.org/implement/standards/product_brief.cfm?product_id=403. Accessed April 25, 2017.

        • Chaffee B.W.
        • Bonasso J.
        Strategies for pharmacy integration and pharmacy information system interfaces, part 2: Scope of work and technical aspects of interfaces.
        Am J Health-Syst Pharm. 2004; 61: 506-514
      13. Health Level Seven (HL7) Pharmacy Working Group. Attach 7.06 PN in EHRs Pharmacy WG Meeting. http://www.hl7.org/Special/committees/medication/minutes.cfm. Published January 11, 2016. Accessed March 27, 2018.

        • Jones S.S.
        • Rudin R.S.
        • Perry T.
        • Shekelle P.G.
        Health information technology: An updated systematic review with a focus on meaningful use.
        Ann Intern Med. 2014; 160: 48-64
        • Van der Sijs H.
        • Aarts J.
        • Vulto A.
        • Berg M.
        Overriding of prescribing alerts in computerized physician order entry.
        J Am Med Inform Assoc. 2006; 13: 138-147
        • Stout S.M.
        • Cober M.P.
        Metabolic effects of cyclic parenteral nutrition infusion in adults and children.
        Nutr Clin Pract. 2010; 25: 277-281
        • Krzywda E.A.
        • Andris D.A.
        • Whipple J.K.
        • et al.
        Glucose response to abrupt initiation and discontinuation of total parenteral nutrition.
        JPEN J Parenter Enteral Nutr. 1993; 17: 64-67
        • Suryadevara S.
        • Celestin J.
        • DeChicco R.
        • et al.
        Type and prevalence of adverse events during the parenteral nutrition cycling process in patients being prepared for discharge.
        Nutr Clin Pract. 2012; 27: 268-273
        • Eisenberg P.G.
        • Gianino S.
        • Clutter W.E.
        • Fleshman J.W.
        Abrupt discontinuation of cycled parenteral nutrition is safe.
        Dis Colon Rectum. 1995; 38: 933-939
        • Wagman L.D.
        • Newsome H.H.
        • Miller K.B.
        • Thomas R.B.
        • Weir G.C.
        The effect of acute discontinuation of total parenteral nutrition.
        Ann Surg. 1986; 204: 524-529
        • Nirula R.
        • Yamada K.
        • Waxman K.
        The effect of abrupt cessation of total parenteral nutrition on serum glucose: A randomized trial.
        Am Surg. 2000; 66: 866-869
        • Werlin S.L.
        • Wyatt D.
        • Camitta B.
        Effect of abrupt discontinuation of high glucose infusion rates during parenteral nutrition.
        J Pediatr. 1994; 124: 441-444
        • Bendorf K.
        • Friesen C.A.
        • Roberts C.C.
        Glucose response to discontinuation of parenteral nutrition in patients less than 3 years of age.
        JPEN J Parenter Enteral Nutr. 1996; 20: 120-122
        • Ireton-Jones C.
        • DeLegge M.
        Home parenteral nutrition registry: A five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support.
        Nutrition. 2005; 21: 156-160
        • Howard L.
        Home parenteral nutrition: Survival, cost, and quality of life.
        Gastroenterology. 2006; 130: S52-S59
      14. Office of the National Coordinator of Health IT Website: A shared nationwide interoperability roadmap. https://www.healthit.gov/policy-researchers-implementers/interoperability. Accessed November 21, 2016.

      15. Office of the National Coordinator of Health IT Website: ONC Health IT Certification Program. https://www.healthit.gov/policy-researchers-implementers/about-onc-health-it-certification-program. Accessed November 21, 2016.

      16. Centers for Medicare and Medicaid Services. IMPACT Act of 2014 Data Standardization & Cross Setting Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-MeasuresMeasures.html. Updated September 14, 2016. Accessed March 27, 2018.

      17. Office of the National Coordinator of Health IT Website: 2015 Edition Health IT Standards Criteria. https://www.healthit.gov/policy-researchers-implementers/2015-edition-final-rule. Accessed November 21, 2016.

      18. Office of the National Coordinator of Health IT Website: 2017 Interoperability Standards Advisory. https://www.healthit.gov/isa/. Accessed April 25, 2017.

      Biography

      V. W. Vanek is chair of the clinical nutrition committee, regional medical informatics officer, and associate director of surgical education, St Elizabeth Youngstown Hospital, Youngstown, OH, and a member of the American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.

      Biography

      P. Ayers is chief of clinical pharmacy services, Mississippi Baptist Medical Center, Jackson; a clinical associate professor, University of Mississippi, Oxford; and a member of the American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, and the American Society of Health-System Pharmacists, Bethesda, MD.

      Biography

      M. Kraft is a clinical professor, College of Pharmacy, University of Michigan, Ann Arbor; and a member of the American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.

      Biography

      J. M. Bouche is a registered dietitian, Option Care Home Infusion, Wauwatosa, WI; and a member of the American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, and the Academy of Nutrition and Dietetics, Chicago, IL.

      Biography

      V. T. Do is an informatics pharmacist, Oregon Health & Science University, Portland; and a member of the American Society of Health-System Pharmacists, Bethesda, MD.

      Biography

      C. W. Durham is a clinical pharmacist, Sentra Healthcare, Virginia Beach, VA; and a member of the American Society of Health-System Pharmacists, Bethesda, MD.

      Biography

      P. Guenter is the senior director of clinical practice, quality, and advocacy, and a member of the American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.

      Biography

      L. Hoggle was director of nutrition informatics for the Academy of Nutrition and Dietetics, Chicago, IL, at the time this article was written and is a member of the Academy.

      Biography

      S. Kent is a clinical systems analyst, Cleveland Clinic, Cleveland, OH; and a member of the Academy of Nutrition and Dietetics, Chicago, IL.

      Biography

      E. T. Lin is a medication management informaticist, Mayo Clinic, Rochester, MN; and a member of the American Society of Health-System Pharmacists, Bethesda, MD.

      Biography

      L. S. Molinar is a nutrition informaticist, Salem Health, Salem, OR; and a member of the Academy of Nutrition and Dietetics, Chicago, IL.

      Biography

      S. W. Plogsted is a clinical pharmacist, Nationwide Children’s Hospital, Columbus, OH; and a member of the American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.

      Biography

      J. M. Poehls is a clinical associate professor, University of Wisconsin Hospitals and Clinics, Madison; and a member of the American Society of Health-System Pharmacists, Bethesda, MD.

      Biography

      P. Turner is an associate professor, University of Oklahoma Health Sciences Center, Oklahoma City; and a member of the Academy of Nutrition and Dietetics, Chicago, IL.

      Biography

      C. Van Way III is a professor of surgery, University of Missouri, Kansas City; and a member of the American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.