Appendix C: International Standards and Resources

International Standards and Resources

• International Patient Summary (IPS)

  • Essential medical information for unplanned, cross border medical care. Allergies and intolerances, medications, medical devices (feeding pumps, central lines). To be implemented in 2025. Refugees with food insecurity or malnutrition(undernutrition).

• European Patient Summary

  • Essential medical information for unplanned medical care within the EU. Internally displaced persons with food insecurity or malnutrition (undernutrition).

• pan-Canadian Patient Summary Specification (PS-CA)

  • Essential medical information for unplanned medical care within Canada.

• Korean CDA Implementation Guide (K-CDA IG)

  • Adapted HL7 CDA standards to meet needs of the local healthcare system.

  • Jung S, Bae S, Seong D, Yi B. Standard Document Development for Health Information Exchange in Korea. Appl Clin Info 13:3, 592-601, 2022.

• HL7

  • FHIR, relationship described in Section 5

  • HL7 Domain Analysis Model for Nutrition Care Release 3, Universal Realm

  • HL7 EHR-System Electronic Nutrition Care Process Record System (ENCPRS) Functional Profile Release 2, Universal Realm

  • HL7 Version 3 Care Provision - Nutrition and Drug Preferences, Universal Realm

US Standards and Resources

• Consolidated Clinical Documentation Architecture (C-CDA)

  • HL7 CDA® R2 Implementation Guide: C-CDA R2.1 Supplemental Templates for Nutrition, US Realm

• Value Set Authority Center (VSAC), National Institutes of Health, National Library of Medicine

  • Approximately 34 sets of SNOMED CT terms that support documentation of a nutrition professional's encounter using NCP. Also supports FHIR Resources

• Assistant Secretary for Technology Policy/Office of National Coordinator for Health Information Technology (ASTP/ONC), Department of Health and Human Services

  • United States Core Data for Interoperability (USCDI)

  • Allergies and intolerances, Height and Weight with BMI, problem list, progress notes, medications, discharge summary. Additional nutrition content (enteral nutrition, MNT) has been proposed.

• Centers for Medicare and Medicaid (CMS)

• Electronic Quality Measures (eCQM)

  • Global Malnutrition Composite Score

    • Screening for malnutrition completed, assessment by dietitian completed in a timely manner, provider diagnosis based on dietitian's and their examination, care plan

    • Supported by a number of VSAC value sets