Partnership for a Healthier America eplans to Promote Healthy Weight Use Cases

Partnership for a Healthier America eplans to Promote Healthy Weight Use Cases Background: Childhood obesity is the most common chronic medical condition in children. Prevention and treatment of childhood obesity is based on promotion of healthy nutrition and physical activity behaviors and ongoing surveillance of weight status throughout childhood, particularly in primary care centers. The electronic health record (EHR) is widely recognized as a critical tool in this process. Purpose: The purpose of these use cases is to specify the essential information that must be captured and the key functions that must be performed by EHRs so that primary care teams and families can develop effective Healthy Weight Plans (HWPs) that help the child and family adopt behaviors oriented to achieving healthy weight,). HWPs should be tailored to children and families and be portable. Target Population: This document outlines specifications and use cases for Healthy Weight Planning using the EHR. The primary target population for these use cases is primary care providers that serve children across settings (schools, clinics, community health centers, private practices, etc.). Our focus is on primary care encounters, especially those for routine health care maintenance and weight management well-child visits for children of all ages and weights. Specifications for targeted treatment of overweight patients are not within the scope of this document, nor are the assessment and treatment of underweight patients. There are many ways that the elements of these use cases could be optimized for use in the EHR (e.g., alerts, highlighted values, pop-up reminders) but in most cases, this work does not provide that specificity within the use cases due to the considerable variation between products and workflows. Development Process: The recommendations in this document are based on best available evidence and were refined by a panel of national experts using expert consensus (see Appendix 1). Specifically we recruited recognized national experts in childhood obesity across a range of disciplines (pediatrics, family medicine, nutrition, nursing, behavior change, public health) and national organizations such as the American Academy of Pediatrics, American Academy of Family Physicians, National Association of Community Health Centers, and the American Academy of Nutrition and Dietetics. These experts independently ranked the importance of including specific elements that might be included in an EHRbased HWP. Areas of disagreement were discussed and experts then repeated their rankings independently. We selected those items on which greater than 75% of the experts agreed. Because there were a large number of targets selected for behavioral assessment and health messaging, we then compiled these responses and asked each expert to select his or her top five. High-level Use Case Summaries: Five essential processes for Healthy Weight Planning were identified by the Expert Panel. Descriptions of the five use cases developed for these processes are summarized below and specified in detail in the five use cases that follow. 1. Anthropometric Assessment and Weight Classification. In this process, the height, weight, and age of each patient is captured within the EHR and compared to the national reference values from the Center for Disease Control and Prevention s 2000 Growth Charts to define each child s weight status (underweight, healthy weight, overweight, obese). For children greater than or equal to two years old, the Body Mass Index (BMI) is used. For children less than two years old Weight-for-Length is used. For both measures, the corresponding percentile (% ile) for age and sex is used to classify weight status. Children greater or equal to the 95 th percentile are considered obese. Within the EHR, BMI and Weight-for-Length percentiles can be displayed as an exact number or plotted on standard growth charts. 2. Assessment of Weight-related Behaviors. A wide range of behaviors have been identified that effect childhood weight and obesity. The Expert Panel was asked to identify the most important modifiable behaviors. The categories that were identified included: 1) diet; 2) physical activity (and sedentary behaviors); 3) sleeping habits; and 4) readiness to change. Weight-related behaviors are assessed and documented within visit templates in the EHR and linked to goal setting (Use Case 3). HealthyWeightPlan_UseCases v2.5 Page 1

3. Promotion of Healthy Weight Behavior through Setting Goals and Planning to Achieve Them. Prevention and treatment of obesity requires the adoption of healthy behaviors such as reducing intake of sugary beverages, increasing physical activity, and obtaining sufficient sleep. Best available evidence has shown that goal setting by children and parents in collaboration with a primary care team, when coupled with appropriate messaging and planning to achieve those goals, can lead to long-term behavior change and prevention and reduction of obesity. The EHR can support goal setting by enabling families and primary care teams to select one or more goals from a set of potential behaviors in need of change and then linking these goals with a tailored set of activities and resources. 4. Resource Identification. Developing plans to achieve goals requires identifying barriers to achieving the goals and strategies to overcome those barriers. One key strategy that the experts recommend is that primary care teams identify and link patients to resources in the community that can assist in improving diet (green grocery stores, farmers markets, nutrition counselors, etc.) and physical activity (YMCA, dance programs, parks and recreational areas, trainers/coaches, etc.). The EHR can capture and store a tailored set of resources within the clinical care system and the community where the patient resides. 5. Healthy Weight Plan Creation. This process includes the creation of a summary document using the EHR data gathered during the visit. The document, a Healthy Weight Plan, is created before the end of the visit, is designed to be used by patients and parents, and is portable (printed at visit or sent electronically). Included in the HWP are: 1) summary of current diet and physical activity behaviors (and sedentary behaviors); 2) presentation of goals selected during the visit; and 3) summary of resources identified to help support these goals. The EHR supports this process by compiling data captured during the visit, displaying the information in a readable format, and allowing each child and family to view and elect to share this information with, schools, other clinicians and caregivers involved in the care of the child, and community resources and supports to promote healthy choices across a child s life. The EHR also stores a copy of the document for future reference and to track progress to goals. HealthyWeightPlan_UseCases v2.5 Page 2

Use Case 1: Anthropometric Assessment and Weight Classification. In this process, the height, weight, and age of each patient is captured within the EHR and compared to the national reference values from the Center for Disease Control and Prevention s 2000 Growth Charts to define each child s weight status (underweight, healthy weight, overweight, obese). For children greater than or equal to 2 years old, the Body Mass Index (BMI) is used. For children less than 2 years old Weight-for-Length is used. For both measures, the corresponding percentile (% ile) for age and sex is used to classify weight status. Children greater or equal to the 95 th percentile are considered obese. Within the EHR, BMI and Weight-for-Length % iles can be displayed as an exact number or plotted on standard growth charts. Use Case Name: Anthropometric Assessment and Weight Classification Use Case ID#: 1 Actor(s): Primary care teams, Patients, Parents/Caregivers Summary: This use case focuses on anthropometric assessment and classification of weight status. Weight status (underweight, healthy weight, overweight, obese) is calculated using Weight-for-Length for children less than 2 years old and body mass index (BMI) for children older greater than or equal to 2 years old. Both measures are assigned a percentile using the measured value and the child s age and sex to find a corresponding percentile in reference tables published by the Centers for Disease Control and Prevention s 2000 Growth Charts (2 years old to less than 20 years old) or WHO (less than 2 years old). Percentiles can either be presented as exact numbers, or plotted graphically in relation to standard percentile lines (5 th, 10 th, 25 th, 50 th, 75 th, 90 th, and 95 th ) on a growth chart. For adults 20 years and older, the adult BMI formula applies. Measured values are stored electronically and measured on a regular basis to be able to follow trends in weight. Trigger: Whenever a user enters weight and recumbent length on the same date for a child from birth to less than 2 years old, or Whenever a user enters height and weight on the same date for a child aged 2 to 22 years Preconditions: The following data elements are captured and stored in the EHR: date of birth, sex, height, weight, recumbent length (birth to less than 2 years old). Units of measure for height, weight and recumbent length are captured and conversion algorithms between metric and US Standard units are embedded in the EHR. Basic Course of Events: At an office visit, the primary care team enters weight and height, or recumbent length, depending on the age of the child at the visit For children greater than or equal to 2 years old, BMI and BMI percentile for age and sex (hereafter known as BMI percentile ) are calculated in real time. The link to the formula for calculating BMI is http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/childrens_bmi_f ormula.html The links for calculating BMI percentiles are: http://www.cdc.gov/growthcharts/1977charts.htm http://www.cdc.gov/growthcharts/computer_programs.htm) For children less than 2 years old, Weight-for-Length and Weight-for-Length percentile for age are calculated in real time The links for calculating Weight-for-Length percentiles are: http://www.cdc.gov/growthcharts/1977charts.htm http://www.cdc.gov/growthcharts/computer_programs.htm) For adults 20 years old and older, BMI is calculated in real time; BMI percentiles are not calculated for this age group. The resulting age-appropriate BMI and associated BMI and Weight-for length HealthyWeightPlan_UseCases v2.5 Page 3

percentiles are stored as data elements in the EHR, or can be calculated on the fly and displayed on the same screen as height, weight and recumbent length data fields. Weight classification is determined based on BMI percentile using the following criteria: o Underweight: <5 th % o Healthy weight: > 5 th % and <85 th % o Overweight: 85 th % to <95 th % o Obese: >95 th % The primary care team can navigate to a longitudinal view of the child s growth chart Assumptions Required data elements are in the EHR Date of assessment is associated with each data element Activities occur within primary care setting HealthyWeightPlan_UseCases v2.5 Page 4

Use Case 2: Assessment of Weight-related Behaviors. A wide range of behaviors have been identified that affect childhood weight and obesity. The Expert Panel was asked to identify the most important modifiable behaviors. The categories that were identified included: 1) diet; 2) physical activity (and sedentary behaviors); 3) sleeping habits; and 4) readiness to change. Weight-related behaviors are assessed and documented within visit templates in the EHR and linked to goal setting (Use Case ID# 3). Use Case Name: Assessment of Weight-related Behaviors Use Case ID#: 2 Actor(s): Primary care teams, Patients, Parents/Caregivers Summary: This use case focuses on capturing the following information in the EHR and displayed in the HWP: 1. Assessment of current dietary behaviors 2. Assessment of current physical activity levels and activities 3. Assessment of sleeping habits 4. Assessment of readiness to change at least one weight-related behavior Trigger: During the assessment of weight-related behaviors. Preconditions: Basic Course of Events: The assessment of weight-related behaviors is applicable to all children who are not underweight at appropriate primary care encounters The primary care team assesses current behaviors and readiness to change by talking to the child, the parent or both. Weight-related behaviors to be assessed and documented in the EHR and associated references ages, goals and messages are listed in Appendix 2: Healthy Weight Plan Assessment Items and include the following categories: o Dietary Behaviors o Physical Activity and Sedentary Behaviors o Sleep-related Behaviors Readiness to Change: The primary care team assesses whether the family is ready to change at least one assessed behavior in a healthier direction (as defined in Appendix 2). Many Readiness to Change assessments are available. The assessment chosen must enable the child/family to rank their level of readiness from low (not ready to change at all) to high (very ready to change) and to assess trends in readiness over time. The EHR documents the level of readiness to change. The EHR stores the entered information as discrete data elements associated with the visit enabling the viewing of current behaviors identified at a given visit and the associated readiness to change ranking. In this way, the primary care team can focus on: 1) behaviors in need of change: and 2) whether the child/family is ready to make changes. Assumptions The EHR has the functionality to create and store a modifiable behavioral assessment integrated with the readiness to change assessment and goal setting by type of behavior Date of assessment is associated with each data element Activities occur within primary care setting HealthyWeightPlan_UseCases v2.5 Page 5

Use Case 3: Promotion of Healthy Weight Behavior through Goal Setting. Prevention and treatment of obesity requires the adoption of healthy behaviors such as reducing intake of sugary beverages, increasing physical activity, and obtaining sufficient sleep. Best available evidence has shown that goal setting by children and parents in collaboration with a primary care team, when coupled with appropriate planning to achieve those goals, can lead to long-term behavior change and prevention and reduction of obesity. The EHR can support goal setting by enabling families and primary care teams to select one or more goals from a set of potential behaviors in need of change and then linking these goals with a tailored set of activities and resources. Use Case Name: Promotion of Healthy Weight Behavior through Goal Setting Use Case ID#: 3 Actor(s): Primary care teams, Patients, Parents/Caregivers Summary: This use case focuses on using the results of behavioral assessment and readiness to change assessment to develop one or more goals to pursue after the visit; this information is displayed in the HWP. Goal Setting includes: Identification of goals for behavior change (increasing healthy behaviors and/or decreasing unhealthy behaviors) that are appropriate for the patient based on discussion during the visit and patient-reported readiness to change. Messaging related to an ideal (targeted) level for the behavior as noted in Appendix 2: Healthy Weight Plan Assessment Items Goal selection (typically be an intermediary step between the current level and ideal level as noted in the Healthy Weight Plan Assessment Items table), may be selected from structured lists or selected in an open-ended manner Documentation of barriers and supports to attaining selected goals, may be selected from structured lists or selected in an open-ended manner Monitoring of progress against goals set during previous visits Trigger: During a primary care encounter when healthy behavior assessments are entered into the EHR Preconditions: Promotion of healthy weight behavior through goal setting is applicable to all children at any primary care encounter where an assessment of weight-related behaviors has been documented The primary care team will partner with the child and family to select goals that Basic Course of Events: are appropriate for the family context and the BMI classification of the child At a primary care encounter, the primary care team, based on the assessment of a patient s weight-related behaviors and associated readiness to change assessment, discusses with the family potential goals and approaches to moving reported behaviors in a healthier direction The primary care team uses structured templates to document agreed upon goals, and barriers and facilitators to achieving those goals as discrete data elements. Goals, barriers, and facilitators selected are linked to each behavior targeted for change within the EHR template; more than one goal can be associated with each behavior, and more than one barrier or support can be associated with each goal. When categorical lists are available, primary care teams can select goals, barriers, and supports from the lists. When not available, primary care teams may record goals, barriers, and supports in free-text The EHR stores the goals selected for each behavior assessed at the visit as discrete data elements and displays them on the HWP enabling the inclusion of goals set at the visit to be included in the HWP and to be monitored over time If the child and family are not ready to make any changes to an identified weight-related behavior based on the readiness to change assessment, then this information is documented in the EHR and goal-setting is not applicable. HealthyWeightPlan_UseCases v2.5 Page 6

Assumptions The EHR has the functionality to create and store by visit selected goals associated with each behavior targeted for change Date of assessment is associated with each data element Activities occur within primary care setting HealthyWeightPlan_UseCases v2.5 Page 7

Use Case 4: Resource Identification. After identifying goals, barriers, and supports, children and families must identify actionable strategies to achieve their goals. One key strategy that the experts recommend is that primary care teams identify and link patients to resources in the community that can assist in improving diet (green grocery stores, farmers markets, nutrition counselors, etc.) and physical activity (YMCA, dance programs, parks and recreational areas, trainers/coaches, etc.). The EHR can capture and store a tailored set of resources within the clinical care system and the community where the patient resides. Use Case Name: Resource Identification Use Case ID#: 4 Actor(s): Primary care teams, Patients, Parents/Caregivers Summary: This use case focuses on providing the following information on the Healthy Weight Plan: 1. Referral information to clinicians 1 2. Community resources to support diet and physical activity goals Trigger: Referral clinicians and community resources should be linked to the goals set for the patient at a given office visit. Currently, many primary care practices/clinics maintain a list of clinicians to whom they refer patients. Some integrate this information into their practice management system or EHR. Similarly, some maintain a list of community resources or have access to a care coordinator with such a list of resources. During a primary care encounter when at least one weight-related behavior assessment and goal is entered into the EHR (see Use Case ID# 2 and 3) at a visit, the primary care team clicks on the resource button. Preconditions: An assessment of a patient s weight-related behaviors and goals are identified during the encounter Basic Course of Events: At a primary care encounter, the primary care team, based on the assessment of a patient s weight-related behaviors and goals, identifies resources for the patient and his/her family Resources are documented in the EHR along with contact information including the name of the resource, phone number, website address and appointment information, if applicable. The primary care team records as much information as available for each resource associated with the selected weight-related behavior and associated goal(s). When categorical lists are available, primary care teams can select resources from the lists. When not available, primary care teams may record resources in free-text Resource information associated with each visit is stored in the EHR and can be edited, and viewed by the primary care team. Assumptions The EHR has the functionality to create and store a modifiable list of resource by visit Date of assessment is associated with each data element Activities occur within primary care setting 1 Clinicians include medical sub-specialists, dentists, pharmacists, nurses, psychologists or other behavioral change professionals and clinical nutritionists. HealthyWeightPlan_UseCases v2.5 Page 8

Use Case 5: Healthy Weight Plan Creation This process includes the creation of a summary document using the EHR data gathered during the visit. The document, a Healthy Weight Plan, is created before the end of the visit, is designed to be used by patients and families, and is portable (printed at visit or sent electronically). Included in the HWP are: 1) summary of current diet and physical activity behaviors (and sedentary behaviors); 2) presentation of goals selected during the visit, along with accompanying barriers and supports; and 3) summary of resources identified to help support these goals. The EHR supports this process by compiling data captured during the visit, displaying the information in a readable format, and allowing the sharing of the report with the child/family and other clinicians involved in the care of the child. The EHR also stores a copy of the document for future reference and to track progress to goals. Use Case Name: Healthy Weight Plan Creation Use Case ID#: 5 Actor(s): Primary care teams, Patients, Parents/Caregivers, Clinicians 2 Summary: Data captured during a visit are displayed in the HWP in a patient-friendly format and includes a way for the HWP to be signed by the primary care team and patient and his/her family. The HWP can be printed or electronically sent to the patient, family, and other clinicians in a HIPAA-compliant manner. The content of the HWP will change over time; each HWP for a patient is stored in the EHR for future reference. Trigger: The primary care team clicks the HWP button Preconditions: Healthy weight plans are created for patients who are participating in an appropriate primary care encounter and are not underweight. The following data elements are captured and stored in the EHR: 1. Patient s name 2. Provider s name who created the plan 3. Date of visit 4. Weight-related behaviors and associated readiness to change assessment 5. Goals for each weight-related behavior selected during the visit and activities to achieve those goals by an anticipated follow up date 6. Anticipated interval for follow-up or date for re-check or follow-up visit. 7. Identification of resources to support the goals Basic Course of At a primary care encounter, the primary care team clicks a HWP button to Events: create and display the HWP If any of the data elements (listed in Preconditions) needed to populate the HWP are not captured during a given office visit, then the system will indicate this and provide navigation to enter missing data or continue to the HWP. The HWP displays the following information: 1. Patient s name 2. Provider s name who created the plan 3. Date of visit 4. Height or recumbent length, weight (optional) 5. Weight-related behaviors and associated readiness to change assessment 6. Goals for each weight-related behavior selected as a target for change during the visit and activities to achieve those goals 7. If the child and family are not ready to make any changes to an identified weight-related behavior, then the weight related behavior will be 2 Clinicians include medical sub-specialists, dentists, pharmacists, nurses, psychologists or other behavioral change professionals and clinical nutritionists HealthyWeightPlan_UseCases v2.5 Page 9

documented on the HWP along with a message indicating that there has been agreement to discuss the topic again at the next visit. 8. Identification of resources to support each goal 9. Follow-up interval or next appointment date The HWP is endorsed by the primary care team, patient, and his/her family The primary care team and family agree on a method to deliver the report to the patient and his/her family and other clinicians Assumptions Data elements are in the EHR Date of assessment is associated with each healthy weight plan Activities occur within primary care setting The HWP is not intended to be the primary source of data in the EHR. However, if the HWP is designed as a clinical document to be exchanged as a Level 3 CDA, then the following data elements should be included on the HWP to facilitate the calculation of BMI from data in the CDA: date of birth, date of visit, sex, height (or recumbent length for a child from birth to 2 years old) and weight HealthyWeightPlan_UseCases v2.5 Page 10

Appendix 1: Expert Panel Members Name Organization 3 William Adams, MD Shikha Anand, MD Elaine Ayres, MS, RD Sarah Barlow, MD Brook Belay, MD Leslie Caroli William Dietz, MD, PhD Christina Economos, PhD Jennifer Foltz, MD Kevin Gilbert, PhD Sandra Hassink, MD Trina Histon, PhD Lindsay Hoggle, MS Charles Homer, MD Noelle Kleszynski, MPH Jason Mitchell, MD Wilson Pace, MD, FAAFP Marypat Hughes, MS, RD, CD/N Stephen Pont, MD Boston Medical Center National Initiative for Children s Healthcare Quality National Institutes of Health Texas Children s Hospital Center for Disease Control and Prevention Family Voices Former Centers for Disease Control and Prevention official Tufts University School of Nutrition Science and Policy and the School of Medicine Center for Disease Control and Prevention Information Resources, Inc. Nemours Pediatrics Kaiser Permanente Academy of Nutrition and Dietetics National Initiative for Children s Healthcare Quality Association of American Indian Physicians American Academy of Family Physicians University of Colorado Hospital, Williams Family Medicine Center Columbia University Program at Lawrence Hospital Dell Children s Medical Center of Central Texas M. Elena V. Rios, MD, MSPH National Hispanic Medical Association Shirley Schantz, RN Robert Schwartz, MD National Association of School Nurses Wake Forest Baptist Medical Center Carolyn Silzle, MS, MBA, RD, LD Children's Healthcare of Atlanta Elise Tavares, MD, MPH Reginald Washington, MD Donald Weaver, MD Shale Wong, MD Boston Children s Hospital Rocky Mountain Hospital for Children Detroit Medical Center University of Colorado School of Medicine 3 Organizational affiliation is provided for identification purposes only and does not imply endorsement of the work of the expert panel. HealthyWeightPlan_UseCases v2.5 Page 11

Appendix 2: Healthy Weight Assessment Items Category Description Reference Age(s) Diet Currently Birth to less Breastfeeding breastfeeding? than 12 (BF) months Diet Sugar Sweetened Beverages (SSB) Diet 100% Juice Diet Formula If yes, is all milk breast milk? Number of 6 oz servings per day Number of 6 oz servings per day Addition of cereal to bottle Birth to less than 12 months Birth through 21 Birth to less than 12 months Birth to less than 12 months Diet Formula Ounces per day Birth to less than 12 months Diet Milk Diet Vegetables Diet Healthy Snacks Diet Family Meals 8 Ounce portions per day Portions per day % of snacks that are healthy Number of meals that are prepared at home and eaten as a family 1 through 21 6 mo through 21 1 through 21 1 through 21 Measure Goal Message Unit(s) Yes/No Yes Encourage BF Yes/No Yes Encourage breast milk instead of formula Portions per day Portions per day 0 Encourage 0 servings per day 0 Encourage 0 servings per day Yes/No No Discourage parents from adding cereal to bottle Ounces per day Portions per day Age/size appropriate Discourage overfeeding <= 3 Encourage 3 or less portions per day 5 Encourage 5 portions per day Portions per day Percent 100% Encourage healthy snacks Meals per 90% Encourage regular week family meals Sleep - Schedules Sleep - Nightime Consistent bedtime and routine Hours of sleep each night? Hours of sleep each night? Hours of sleep each night? Hours of sleep each night? 6 months to 21 years 1 through 2 3 through 5 6 through 10 11 through 21 Yes/No Yes Encourage regular predictable sleep schedule night night night night 12-14 Encourage sufficient nightly sleep 11-13 Encourage sufficient nightly sleep 10-11 Encourage sufficient nightly sleep 8.5-9.5 Encourage sufficient nightly sleep Moderate or vigorous exercise Average minutes per episode 1 through 21 Minutes per episode 60 Encourage 1 hour of activity per day Average number of 1 through 21 Episodes 7 Encourage activity HealthyWeightPlan_UseCases v2.5 Page 12

Category Description Reference Measure Goal Message Age(s) Unit(s) episodes per week per week every day Screen Time Total (TV, video, computing) day of recreational screen time school day of recreational screen time 0 through 1 2 through 21 day day 0 Encourage no screen time at all <= 2 Encourage total screen time of less than 2 hours Screen Time - TV school day of recreational TV time 2 through 21 day Less than 2 hours total screen time Encourage total screen time of less than 2 hours HealthyWeightPlan_UseCases v2.5 Page 13