Submitted by CamilleBonta on
Explicit Enumeration of Parenteral Nutrition Orders
The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the Council of Pediatric Nutrition Professionals (CPNP) strongly support the inclusion of nutrition orders as a required data class in USCDI v7, and we specifically urge ONC to explicitly enumerate parenteral nutrition (PN) orders within this scope.
NASPGHAN represents more than 3,000 pediatric subspecialist physicians caring for infants, children, and adolescents with gastrointestinal, hepatic, and pancreatic disorders—conditions in which nutrition assessment is fundamental to diagnosis, disease management, and therapeutic decision-making. CPNP represents roughly 350 pediatric nutrition professionals who perform and document nutrition assessments across inpatient, outpatient, and home-care settings.
Nutrition orders—including oral, enteral, and parenteral therapies—are therapeutic interventions that carry significant safety implications. Interoperability failures related to nutrition orders remain a well-documented source of patient harm, particularly during transitions of care.
Clinical and Safety Rationale
Nutrition is a foundational component of both pediatric and adult care, yet nutrition data remain standardized and fragmented across current electronic health record (EHR) systems. In a national survey of pediatric clinicians (1), only 54% reported having a standardized workflow for documenting food allergies and intolerances, and clinicians consistently reported difficulty locating nutrition-related information across disparate sections of the EHR. Notably, 73% reported awareness of nutrition-related safety events at their institutions, including adverse reactions linked to incomplete or inaccessible documentation of diet orders, allergies, or nutrition plans. A commonly cited contributing factor was lack of interoperability of nutrition orders and diet information across care transitions, resulting in lost, outdated, or conflicting information as patients move between inpatient, outpatient, emergency, procedural, and home care settings.
These documentation and interoperability failures are associated with measurable patient harm at the population level. Analysis of the FDA’s Center for Food Safety and Applied Nutrition Adverse Event Reporting System (CAERS) (2) demonstrates a 15.5-fold increase in serious food- and diet-related adverse events among children since 2004, including hospitalizations and deaths. These trends represent both a public health warning signal and a systems-level failure in health information infrastructure. They underscore the need for structured, interoperable nutrition documentation within EHRs to support prevention, early recognition, and effective response to nutrition-related adverse events.
Across care settings, nutrition orders are inconsistently structured, variably documented, and poorly interoperable among inpatient, outpatient, pharmacy, durable medical equipment, and home infusion systems. This fragmentation directly contributes to:
- Loss of, or conflict between, nutrition orders (including PN, oral diets, human milk, enteral nutrition, and therapeutic diets)
- Inconsistent and incomplete documentation of food allergens and intolerances
- Omissions, duplications, and administration errors
PN, in particular, represents a high-risk, medication-like therapy used in medically complex infants, children, and adults. PN ordering requires complex calculations, individualized formulations, and close coordination among prescribers, pharmacists, and nursing staff. Multiple professional societies have highlighted that existing EHR systems do not adequately support PN workflows, significantly increasing the risk of prescribing, compounding, and administration errors. Despite well-documented safety risks, PN orders are frequently excluded from standardized interoperability frameworks, limiting continuity of care and undermining safety checks during transitions.
Similarly, the increasing diversity and complexity of commercial and specialty formulas used to manage nutrition conditions heightens the risk of nutrition-related adverse events. Current EHR systems often lack the ability to accurately and consistently capture formula product names, compositions, and administration details. Patient and caregivers are frequently unable to reliably communicate this information across settings due to product complexity. The absence of standardized nutrition data elements and interoperability perpetuates gaps in safety (leading to increased visits/hospitalizations, delay in recovery and/or adverse health events), particularly as patients move between clinical environments and across the lifespan.
Importance of Explicit Inclusion of PN Orders
PN should be treated with the same rigor as other high-risk medication orders within USCDI. Failure to explicitly include PN within the nutrition order scope risks continued under-implementation by vendors and inconsistent adoption across health systems.
Explicit enumeration of PN orders in USCDI v7 would:
- Align national interoperability standards with established patient-safety evidence
- Improve bidirectional communication between ordering, pharmacy, and administration systems
- Reduce preventable adverse events in vulnerable populations
- Reflect real-world clinical workflows and regulatory expectations
Explicit Regulatory Requests for ONC (USCDI v7)
We respectfully request that ONC:
- Include all nutrition orders as a required USCDI v7 data class
- Explicitly enumerate PN orders, including:
Total PN
Partial PN
Lipid emulsions
PN additives
- Require structured, interoperable representation of nutrition order elements, including:
Name (including therapeutic diet, formula, additives in human milk, parenteral components)
Route of administration (oral, enteral, parenteral)
Composition and dosing
Frequency and duration
Linked allergens and intolerances
- Ensure bidirectional interoperability across:
Provider and dietitian order entry
Pharmacy verification and compounding systems
Bedside and home administration systems
USCDI v7 Alignment Map
| USCDI Priority Area | Nutrition Use Case | Safety Impact |
| Orders & Interventions | Oral, enteral, and parenteral nutrition orders | Prevents omission, duplication, and prescribing errors |
| Assessments | Nutrition status and allergy/intolerance data | Reduces adverse reactions |
| Care Transitions | Inpatient ↔ outpatient ↔ home infusion | Preserves nutrition plans across settings |
| Patient Safety | Medication-like therapies (PN) | Aligns with known safety risks |
Conclusion
Nutrition orders—particularly PN—are clinical therapies with well-documented safety vulnerabilities when electronic workflows are fragmented. Inclusion of interoperable nutrition orders and explicit enumeration of PN in USCDI v7 are essential to protecting patients, supporting clinical teams, and advancing national interoperability goals.
NASPGHAN and CPNP strongly urge ONC to adopt these recommendations in the final USCDI v7 standard.
Respectfully submitted,
NASPGHAN and CPNP
REFERENCES
1. Young JA, Feuling MB, Huang JS. Toward a single source of truth: the case for centralized nutrition documentation in electronic medical records. JPGN Rep. 2026;7:159-166. doi:10.1002/jpr3.70111
2. Huang JS, Young J, Garcia MA. Rising Food and Diet Adverse Events in United States Children: A Call for Better Food Labeling and Nutrition Documentation. J Pediatr. 2026;288:114821. doi:10.1016/j.jpeds.2025.114821
Submitted by rdillaire on
CMS-CCSQ Applauds this data element’s inclusion in USCDIv7
CMS CCSQ supports the inclusion of Nutrition Order in USCDI v7.