The Journal of School Nursing
2021, Vol. 37(1) 28-40
© The Author(s) 2020
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DOI: 10.1177/1059840520913323
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Christina Baker, MS, NCSN, RN-BC , and Bonnie Gance-Cleveland, PhD, RNC, PNP, FAAN
School-aged children spend around 1,080 hr at school each year and many of them have chronic diseases; therefore, it is imperative to include school nurses as part of the health care team. Care coordination between health care providers and school nurses is currently hindered by communication that relies on an inadequate system of fax, phone, and traditional mail. Using electronic health records (EHRs) to link school nurses and health care systems is usually limited in scope despite EHRs advancement in these health care systems. No literature is currently available showing the number of hospitals and health care systems that provide EHR access to school nurses. The purpose of this article was to present a literature review on EHR access for school nurses nationally. This review along with the legal and logistical considerations for this type of implementation will be discussed.
school nursing, electronic health records, care coordination, electronic medical records
The National Survey of Children’s Health (NSCH 2016–2017) estimated that over 22 million U.S. school-aged children are living with one or two or more health conditions, 11 million have special health care needs, and 7.5 million are not receiving needed care coordination (Child and Adolescent Health Measurement Initiative, 2016–2017). With schoolaged children spending an average of 180 days or 1,080 hr at school (Education Commission of the States, 2013), it is imperative to include the school nurse in care coordination of the children’s health care needs. The school nurse is the designated health professional in the educational setting to support the health and academic success of students with chronic health conditions by providing direct care, communication and collaborating with health care systems to facilitate the components of care coordination (Baker et al., 2017; National Association of School Nurses, 2018). To ensure individual academic success, these children and their families need support, care coordination, and communication between school nurses, the educational system, and health care providers. However, health policy researchers have found that communication and care coordination are lacking between schools and health care (Baker et al., 2017; Lucile Packard Foundation for Children’s Health, 2014).
Care coordination between health care providers and school nurses is currently hindered by communication that relies on an inadequate system of fax, phone, and traditional mail. In the hospital setting, 96% of U.S. nonfederal acute care hospitals possessed certified EHR technology (Henry et al., 2016), and yet this technology is not routinely being used to coordinate care with school nurses. A poll in a Webinar by the National Association of Chronic Disease Directors (NACDD, 2016) found only 6% of the 113 in the survey were implementing shared EHR use between health care systems and schools, and only 18% were exploring shared EHR use. Student’s health information may be protected under either the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Family Educational Rights and Privacy Act of 1974 (FERPA), or in certain circumstances both HIPAA and FERPA (U.S. Department of Health and Human Services & U.S. Department of Education, 2019). The interplay of these two federal guidelines can add an extra layer of confusion and may be a possible barrier to sharing of health information between school nurses and health care providers using an EHR.
There are various terms used to describe electronic information systems: electronic health record (EHR) and electronic medical record (EMR). In this literature review, some authors did use the term EMR to describe the electronic information system used to collaborate with the school nurses. However, according to the National Coordinator for Health Information Technology (ONC, 2011), the term EHR is more inclusive when talking about electronic systems that allow the sharing of information. According to ONC’s (2011) definitions, EMRs are considered a digital version of a paper chart in a clinician’s office but the information does not travel easily out of that practice EMR. An EHR goes beyond standard clinic data collection and can share information with other health care providers such as the EHRs in hospital systems.
The National Association of School Nurses (NASN) recognizes that EHRs in the school setting can serve to optimize care coordination through the capability to manage data and share it with members of the health care team outside of the school setting (NASN, 2019). In this position statement, NASN uses the term EHR to describe student EHRs. Typically, student health documentation using electronic methods may use a health module in a school-based student information system or use a commercial school nursing software and these student EHRs may be used to collect data for a variety of purposes (Johnson & Guthrie, 2012). NASN (2019) further states in their position statement that despite having health modules, the student EHRs
However, these student information systems are part of the educational system and are usually not connected with hospital-based EHRs. Currently, there is no known available process for integrating the functionality available in EHRs for school health documentation with EHRs used in the health care setting (Hinman & Davidson, 2009; Johnson & Guthrie, 2012). These gaps in knowledge led to the question: What is the national status of school nurses having access to an EHR to communicate with health care providers and obtain real-time, accurate information from EHRs? A literature review was conducted to address a lack of information about and the barriers that may hinder the use of hospitalbased EHRs for school health care coordination.
The primary author conducted this literature review by using the preferred reporting items for systematic reviews and metaanalysis (PRISMA) guidelines (Moher et al., 2009). The search included these databases: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), OVID Medline, and EMBASE. Search terms were electronic health records (EHR), electronic medical records, school health nursing, school nurse, school nursing, andhospital information systems. Search methods were confirmed in consultation with a university-based librarian. English articles published from January 1, 2009, to October 18, 2019, were included. International articles were excluded because of unique HIPAA and FERPA issues in the U.S. Articles reporting on school-based EHRs and immunization information systems (IIS) were excluded because the focus was on the use of EHRs that contain full medical record information access (e.g. not just immunization) and communication with health care providers and systems.
The final search identified 64 potential articles with 22 duplicates. Forty-two abstracts were screened for inclusion and exclusion criteria. Another 34 articles were excluded after abstract screening: articles about student’s electronic school records without links to providers or health systems, school-based health center EHRs, or school data collection and record keeping (n = 17); IISs (n = 4); non school nurse–based electronic documentation and nursing data sets (n = 5) and lay publications unable to access (n = 8). A total of eight articles met inclusion/exclusion criteria and were included in this review. Three sources of gray literature not found in the literature and education search were a study by Shattuck and Saperstein (2016) that was not published but shared with the author by Margo Lalich, former School Health Services Director, Multnomah Education Service District; a Webinar (NACDD, 2016) that included three panelists (Adelson, Lalich, and Kane); and an issue brief from National Association of Chronic Disease Directors (Martinez, 2016). A total of 11 records and reports were used for the review. Table 1 is a review of locations, type of access, and the references from the literature used in the article.
TheliteraturereviewresultsarepresentedinaPRISMA flowchart in Figure 1. Also, Table 2 highlights the final articles in this review. An analysis of the information in these articles about the types of access to EHRs helps to paint the picture of the progress, successes, benefits, barriers, and various limitations in giving school nurses access to hospital-based EHRs and secure portals for the sharing of medical information with health care providers.
The articles related to school nurse access to a hospitalbased EHR reported various access types—view-only access (Farmer, 2015; Guilday, 2014; Martinez, 2016; Portera, 2014; Radis et al., 2016) versus view-only (no documentation) with bidirectional communication through the EHR (Adelson and Lalich in NACDD, 2016; Reeves et al., 2016).
Hospital-Based EHR: View-Only Access
The literature revealed three health systems providing school nurses view-only access to the EHR. One of the first hospital systems to allow view-only EHR access to school nurses was a collaboration, Student Health Collaborative (SHC), between Nemours Health Care System, the Delaware School Nurses Association, and the Delaware Department of Education with a pilot program in 2012 (Guilday, 2014). For the 2013–2014 school year, 240 Delaware school nurses had signed a user agreement to get access to NemoursLink (based on EpicCare Link, which is licensed from Epic Systems Corporation) their view-only portal of their EHR (Portera, 2014). After the first full year of implementation, surveys of the school nurses pre- and postaccess found a statistically significant difference in time accessing information and reported an increase in the feeling that they were part of the health care team (Guilday, 2014). From parents’ surveys, they also found that linking the school nurses to the EHR helped parents to understand that the school nurse’s office is a logical extension of their child’s primary-care provider and view school nurses as part of their child’s health care team (Portera, 2014). School nurses from the Nemours Delaware program expressed ways to strengthen the SHC in the future: allowing two-way communication so clinicians can see the school medical record, allowing documentation by school nurses, messaging clinicians, and the ability to upload school medical data like blood sugar values (Farmer, 2015). Kane (2016) reported some preliminary nonpublished data from the EMR evaluation. This evaluation focused on asthma-related emergency department (ED) visits 1 year prior to and 1 year after enrollment of student in the SHC. They found a decrease in ED visits: In 2012/2013, they reported 79 asthma-related visits for 34 students versus 38 visits for 24 patients. The following year they found similar decreases: 38 visits for 11 patients versus 29 visits for 20 patients. The Nemours SHC has been a foundational program that many other authors reference and have collaborated with for guidance.
Radis et al. (2016) reported on their program in New Haven, CT, where the public health department supplies nurses for the schools. They worked on negotiating access to the Yale New Haven Hospitals (YNHH) EHR along with the Connecticut Childhood Immunization Registry (CIRTS) and an electronic lead surveillance program called MAVEN (Consilience Software Inc.). The authors were able to obtain view-only access to CIRTS and MAVEN, but they were not able to gain access to the hospital-based EHR for all the school nurses. The plan was to start with EHR access for the health department central staff and eventually give access to the school nurses, the literature search found no other updated information. This program did not provide any data on the evaluation of the impact of EHR access for school nurses.
Special needs nurses (SNNs) who work for Multnomah Education Service District’s School Health Services gained access in 2014 to the Oregon Health Sciences University (OHSU) EHR (Epic Systems Corporation; Shattuck & Saperstein, 2016). These SNNs provided case management services for 162 medically complex students; consultation services for the other school nurses; and were the liaison between the parent, school community, and medical providers (Lalich, 2016). This access included the ability to email physicians associated with OHSU. They do not mention communication included other interdisciplinary care team members such as nurse practitioners or social workers, for example. In the Shattuck and Saperstein (2016) report, they describe the physicians as “medical providers who were involved with the care of the specific students selected for the nurse’s survey” (p. 4), the majority were primary-care physicians. In the report, they evaluated survey data from four SNNs, 32 medical providers, and 29 parents of children in the SNNs caseload. SNNs surveys included students in which they had EHR access and those students who did not have access to their EHR.
The report questions
In summary, they found that access to EHRs allowed the nurses to quickly access the student’s medical record to find out the results of office visits, check medications, and communicate with providers. In some instances, they found orders in the EHR for care during school hours that had never been communicated to the school. SNN’s expressed a significant reduction in the time and effort needed to coordinate care when they had access to the OHSU EHRs as compared to the effort required for students where they did not have access. Interestingly, the parents felt that they understood their child’s medical needs and could communicate with the SNNs in contrast to the SNNs providing many examples where families provided only partial information about diagnosis or treatment. Health care providers identified the same benefits of care, better communication, and access to updated information. However, the providers did also have some reservations—mainly on privacy and security issues with EHR access. Half of the providers in the study did not even know that the SNNs had access to the EHR. This report suggests that, in general, provider education about nursing practice in the schools and the importance of school nurses need to have a complete understanding of a child’s medical status, and prescribed treatments may help other health systems grant school nurses access to EHRs.
The Wisconsin Department of Public Instruction and Children’s Hospital of Wisconsin began a program in 2015 to give access to the hospital-based EHR for school nurses in one district (Adelson, 2016). They focused on using an asthma action plan (AAP) for bidirectional communication through secure email messaging in the EHR. There is no more information found in the literature search on the progress of this program.
A program in North Carolina (Reeves et al., 2016) connected school-based care teams and primary-care providers via electronic communication through the hospital-based EMR for pediatric asthma patients. They use the term EMR to describe what is similar to an EHR. The school nurses were employed by the health department which gave them access to the Cerner (Kansas City, MO) EHR in a view-only capacity. In the program, they were able to demonstrate the feasibility of electronic communication between the school nurses and primary-care providers through the use of the hospital-based EMR email messaging system. They also analyzed EMR data from the students with asthma in the study, which showed a significant decrease (from 60% to 21%) in hospital admissions for the students whose school nurse communicated through the EMR with the primarycare provider. However, the program did not achieve widespread adoption of messaging beyond use for this asthma population.
Secure portals and EHRs can be used to allow electronic documentation and communication between school nurses and health care providers (Dean et al., 2014; Hanson et al., 2013). In Missouri, they looked at using an EHR explicitly purchased for capturing health screening data in the schools that were shared with the student’s health care providers through the EHR’s secure fax functionality (Dean et al., 2014). Staff documented screening results and health information provided by the child’s parent or legal guardian in this secure, internet-accessible EHR. School nurses or unlicensed assistive personnel (UAPs) also documented post-6-month referral follow-up data. Dean et al. (2014) reported the transition to the use of the EHR and real-time charting of the screening data increased the accuracy of and the access to the data and increased health-related referrals to the health care provider. One goal of using this EHR was to establish a child-centered longitudinal EHR, but it was not integrated with a hospital-based or clinic based EHR. The communication through the EHR between the school and primarycare provider was accomplished through the EHR’s secure faxing functionality. The authors do state their hopes that eventually linking the Healthe Kids EHR with both the students’ health record and their primary health care provider record would be a way to improve the coordination and the quality of care, which can lead to decreased health care expenditures for unnecessary exacerbations or preventable conditions (Johnson & Bergren, 2011).
The Southeast Minnesota Beacon Project used the idea that the AAP for schools was an essential tool for care coordination (Hanson et al., 2013). They developed and implemented a secure portal designed for the electronic exchange of the AAP between providers and schools. There is no description of the secure portal or the process involved for including the school nurse except that it was set up to allow for automatic transfer of the AAP to the school following signed parental permission. They trained over 50 school nurses to use the AAP portal, but there is no data representing how many used the portal. They did conduct a portal survey (see all results in Table 2). Of the 12 school nurses who completed the survey, 92% reported increased efficiency regarding the tracking of the AAP-related paperwork for school office use. The authors stated that the “electronically shared AAP improves the current AAP and asthma-related care model by expanding health information exchange to offer a seamless exchange of patient information between the school and the primary-care provider in relation to the asthmatic child” (p. 916). They concluded that electronic sharing of the AAP has the potential to increase efficiency and enhance effective communication among health care providers, families, and schools.
There are multiple barriers and requirements for success in planning and executing school nurse access to EHRs and electronic communication with health care systems and health care providers. Examples such as getting parent consent and gaining their trust, investment of time and technology, having strong change agents and champions, and understanding the interplay between HIPAA and FERPA can contribute to a program success.
HIPAA and FERPA. Sharing of protected health information to school nurses through an EHR or secure electronic portal is guided by HIPAA and FERPA. A guide titled Data Privacy in School Nursing: Navigating the Complex Landscape of Data Privacy Laws (Part II) by Lowery (2019) explains the intricacies of HIPAA and FERPA. The primary federal law that governs confidentiality and information sharing by schools is the FERPA, while the main federal law that controls data privacy and sharing by health care professionals is HIPAA. The most salient point to remember about the interplay of HIPAA and FERPA in the school setting is that health care providers may share health information with a school nurse under HIPAA for “treatment purposes” without parent authorization. So, a health care provider may discuss a student’s treatment information with the student’s school nurse, and the school nurse may contact the physician to clarify the physician’s recommendations. However, once the school nurse enters that information into the student’s school record, then FERPA applies. This creates barriers for the exchange of health-related information from school nurses to health care systems because FERPA requires previous parental consent (Hinman & Davidson, 2009). Because HIPAA and FERPA guidelines must be followed, having a mutually trusted, secure, and compatible system of communication across these two types of organizations will take time and possibly involve a revision of existing federal regulations pertaining to electronic transfer of protected educational and health information (Reeves et al., 2016).
All the articles required a consent from the parent for school nurse access. Reeves et al. cited a duplicative consent process related to HIPAA and FERPA regulations. Getting parental consent was a barrier for school nurse access, and they found that parents did not always trust the school nurse having access to their child’s medical records. Shattuck and Saperstein (2016) report one provider commented “Families are very hesitant to share info directly with school, especially if related to mental health and social services” (p. 16). However, Hanson et al. (2013) had found that initial concerns that parents would not consent were unfounded, and parental participation increased over the 5 years of the study.
Cost and technology. Information about the costs, resources, and technology involved with giving school nurses access to the EHRs, and secure portals was limited. Hanson et al. (2016) said their program in Minnesota needed to modify software to accurately capture relevant data, ensure secure storage of collected data, and obtain laptops. Still, they had no costs related to the EHR since Cerner Corporation donated the software, laptop devices, and the hosting services. The program in Wisconsin was based on a grant awarded from the U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology (Adelson, 2016). Radis et al. (2016) stated that the initial access for the school nurses in the Connecticut program did not fully realize because the only option for this service involved costly annual fees from the YNHH-based EHR. Once the hospital system had a use case with an outside agency to provides case management, this established the precedent for other community health agencies such as the health department school nurses to opt in with the read-only access. Kane (2016) mentioned that utilizing systems already in place, like NemoursLink readonly access EHR, may help with decreasing costs. Understanding what this EHR access may cost the hospital system or school system would be valuable information for others interested in creating a program of access to EHRs for school nurses.
Need for change agents and champions. Many of the authors emphasized the need for champions and emphasized for school nurses to gain access to student health databases, such as an EHR, policy change is needed. For policy change related to sharing of health information to occur, there is the need for change agents as well as champions to guide the efforts on sharing of health information and the role of school nurses (Adelson, 2016; Kane, 2016; Radis et al., 2016; Reeves et al., 2016; Shattuck & Saperstein, 2016). Policy changes may be needed in the health care and educational realms for realizing more robust sharing of health information. Also, education for providers as well as parents is needed to understand the importance of the school nurse having access to timely, accurate medical information.
The articles in the literature review present various avenues for using hospital-based EHRs/EMRs and secure portals for sharing student’s medical information between school nurses and health care providers. In general, the articles reported more efficiency in accessing medical information, increased accuracy of the health information, better communication and care coordination between school nurses and health care providers, and the school nurses increased involvement as part of the health care team. With more research looking at positive effects such as decreased costs related to decreased hospital admissions (Reeves et al., 2016), the case for costs involved in this EHR access may be justified. School nurses need to be at the forefront of presenting to health care systems their value in care coordination. Barriers for school nurses and health care systems to overcome involve getting hospital and school system approval for access and obtaining consent for sharing of information, skills needed for using the technology, costs involved, education on HIPAA and FERPA guidelines, issues with technology connectivity, and reservations about school nurse access from health care providers and parents.
This literature review highlights the lack of research studies and published information about school nurse access to hospital-based EHRs. Only one published primary study looked at patient outcomes (Reeves et al., 2016), and the results were based on a small sample size of 30 students with asthma. Kane (2016) in the NACDD (2016) Webinar and Guilday (2014) presented data collected on the school nurse EHR access with Nemours Delaware but the actual research study was not published. This author then was not able to analyze the Nemours research study. What Kane (2016) did present on patient outcomes focused on students with asthma. Three of the five programs with bidirectional communication focused solely on students with asthma, using the AAP as the mode of communication in the EHR or portal (Adelson, 2016; Hanson et al., 2013; Reeves et al., 2016). Further research is needed about the effects of EHR access for school nurses in relationship to other chronic diseases seen in schools, like diabetes, severe allergies, and seizures, and students requiring medical complex care at school. The school nurse surveys from Shattuck and Saperstein (2016) were based on only four SNNs for about 39 medically complex students with a limited focus.
Therewasalackofinformationaboutthecosts,and that could be a limiting factor for hospitals and educational systems. The programs in this literature review either did not address the costs or reported that grant funding (Adelson, 2016; Hanson et al., 2013) or donations from companies (Dean et al, 2014) helped to fund the hardware, software, and other resources needed to provide the EHR access to the school nurses. Further studies are needed to look at, for example, what is the price of sharing the EHR in terms of hardware, human resources for program management, marketing, deliverables, and technology support and training?
Stakeholders and experts in educational, administrative, clinical, legal, privacy, security, and information technology arenas need to be engaged to develop programs for school nurse access to EHRs. School nurses and other health care providers must understand both HIPAA and FERPA laws to facilitate communication and the sharing of health information (Lowrey, 2019). Further research to explore the cost of giving school nurses access as well as the positive health outcomes for students and reductions in expenses related to ED and hospital admissions may provide the evidence for building programs that include school nurse access to EHRs.
A misunderstanding by health care providers, educational staff, and parents can hinder giving school nurses access to necessary medical information. As EHRs continue to develop and expand as an essential part of health care, they have the potential to allow interprofessional health care team members and patients to appropriately access and securely share vital medical information electronically, possibly improving the speed, quality, safety, and cost of patient care (Reeves et al., 2016). Including the school nurse as a member of the interprofessional health care team and sharing vital medical information with them are crucial components of care coordination for better outcomes for students so that they have optimal health and are readytolearnatschool.
The authors thank Christine Perreault, manager, School Health; J. D. Rigdon, clinical applications services, Children’s Hospital Colorado; and John Jones, associate professor, University of Colorado, Anschutz Medical Campus.
Christina Baker contributed to conception, design, acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Bonnie Gance-Cleveland contributed to acquisition, analysis, and interpretation; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Christina Baker, MS, NCSN, RN-BC https://orcid.org/0000-0002-6391-0314
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Christina Baker, MS, NCSN, RN-BC, has been a school nurse at Children’s Hospital Colorado since 2014 and a Pediatric Nurse Research Fellow since 2017. She has her master’s in nursing informatics and is a PhD student at the College of Nursing, University of Colorado, Anschutz Medical Campus.
Bonnie Gance-Cleveland, PhD, RNC, PNP, FAAN, is the Loretta Ford Professor. She earned her bachelor’s degree in nursing, her master’s degree in nursing, and her PhD from the University of Colorado. Her practice and research focus are on decreasing health disparities in vulnerable populations by (a) advancing science for culturally sensitive care; (b) collaborating with professional organizations to develop evidence-based, culturally sensitive practice guidelines; and (c) use of technology to promote evidence-based practice (EBP).
1 Children’s Hospital Colorado, Aurora, CO, USA
2 College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
Corresponding Author:Christina Baker, MS, NCSN, RN-BC, Children’s Hospital Colorado, 13123 East 16th Avenue, B215, Aurora, CO 80045, USA.Email: christina.baker@childrenscolorado.org
