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Food security screening: addressing EHR, coding challenges :

April 2, 2018

Over 20% of U.S. children live in a household without consistent access to food.

To promote food security among all children and families, the Academy supports screening families using the validated two-item Hunger Vital Sign (HVS) and including results in the electronic health record (EHR).

A positive screen requires a response of “often true” or “sometimes true” to either or both of the following statements:

  • “Within the past 12 months we worried whether our food would run out before we got money to buy more.”
  • “Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”

The Centers for Medicare & Medicaid Services Accountable Health Communities Screening Tool has incorporated the HVS, and individual institutions have brought the HVS into their EHRs in a variety of ways.

In October 2017, Boston Medical Center primary care clinics rolled out the THRIVE Screening & Referral Program, which includes the HVS. Patients complete a paper screener in the waiting room, and it is entered into the EHR. A medical assistant scores the screener and can enter orders like referrals to social work or therapeutic food pantries. The provider then can sign pending orders and add them to the problem list.

Hennepin County Medical Center in Minneapolis aims to have screeners standardized in all outpatient clinics by this spring. Clinic patients complete the screeners verbally. Patients with positive screens are offered a bag of groceries, a sheet of community resources and an EHR-based referral to Supplemental Nutrition Assistance Program outreach via a Feeding America Partner.

Providers who screen for social determinants of health are still learning the best ways to administer screeners and respond to positive screens. Some practitioners do not have the resources to support families, and many families already are connected to resources. In addition, there are concerns that asking these types of questions (particularly in front of a child) may be traumatic.

Providers also may have questions about how to document food insecurity screening in the EHR and code for screening. An Overview of Food Insecurity Coding in Health Care Settings: Existing and Emerging Opportunities from the Hunger Vital Sign National Community of Practice addresses coding concerns,

Clinicians can use International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code Z59.4 (lack of adequate food and safe drinking water) and the newly developed Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) code 733423003 (food insecurity) in the EMR/EHR for food insecurity diagnosis. The SNOMED food insecurity code is automatically mapped to ICD-10 code Z59.4.

With common language and appropriate coding, food security data can be shared across multiple platforms and with health departments and other community partners.

Logical Observation Identifiers Names and Codes (LOINC) offer practitioners an opportunity to code answers of the HVS in interoperable ways. The LOINC database creates a universal system of describing clinical variables like lab values, nursing diagnoses and patient care datasets. LOINC can encode valid instruments like the HVS to give each question a numeric code that can be shared across all EHRs just as lab values can be shared. As of December 2017, LOINC codes correlating with the HVS were approved and can be viewed at

Incorporating coding language to document food insecurity screening and interventions is a crucial part of providing individual patient care and transforming data into an interoperable language that can be shared. Pediatricians should communicate with their information technology departments to identify the best method to incorporate food insecurity screening as well as the appropriate coding systems. Such proactive approaches help provide a foundation to eliminate food insecurity in individual families and the community.

Katherine Joyce is a medical student and member of the AAP Council on Clinical Information Technology.

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