School Nurse Role in Electronic School Health Records
It is the position of the National Association of School Nurses (NASN) that Electronic Health Records (EHRs) are essential for the registered professional school nurse (hereinafter referred to as school nurse) to provide efficient and effective care in the school and monitor the health of the entire student population. It is also the position of NASN that it is the school nurse's role to collaborate with school administrators to ensure that EHRs use meets the highest quality standards for the safety and protection of student, family and staff information. The meaningful use of EHRs in the school setting has the potential to maximize quality, decrease cost, and prevent errors, as well as promote the interoperability of school health records with providers in other care settings (Johnson & Bergren, 2011). Additionally, EHRs in the school setting provide a means of integrating health and educational data in a way that addresses the needs of children at risk for poor health or academic outcomes. EHRs also facilitate the sharing of data into a national database of student health data.
Documentation of health information is an expectation of professional school nursing practice according to the Scope and Standard of School Nursing Practice (American Nurses Association & National Association of School Nurses [ANA & NASN], 2011) and may be required by state health statutes. School nurses work with a variety of health information including immunization records, screening records, progress notes, physician orders, physical examination records, medication and treatment logs, reports of serious injury (Centers for Disease Control and Prevention [CDC],2013), individualized healthcare plans, emergency healthcare plans, third party medical records, consent forms, the management of students’ chronic health conditions (NASN, 2012), Medicaid, and other insurance billing forms, and flow charts. Health information in any form must be confidential, secure, accessible only by authorized staff, and protected from loss, alteration, or destruction. As an educational record, school health records must be transferrable to new school sites when a student progresses to other buildings within a district or moves outside of the district.
Society and the United States healthcare system is transitioning from paper to electronic technology. The Centers for Medicare and Medicaid Services (CMS) actively promotes EHRs with a goal of improving health care; school nurses share this same goal. EHRs improve the efficiency and the use of school health data such as absenteeism (CDC, 2013) to determine appropriate interventions (Johnson & Guthrie, 2012). EHRs support the ability to make the right information available to the right provider at the right time to benefit student care (Johnson & Guthrie, 2012). A central component of healthcare reform is the use of electronic health records with a focus on the “meaningful use” (MU) of the data in those records to achieve the triple aim – reduced cost, improved satisfaction and improved quality (Blumenthal, 2009; Policy Researchers and Implementers, n.d.).
In 2011, 74% of school nurses reported using EHRs (NASN, 2011). Therefore, it is important for school districts to have policies and procedures in place regarding the types, maintenance, protection, access, retention, destruction, and confidentiality of student health records. Information technology professionals with school districts may require expert assistance in addressing the requirements for health documentation standards; thus school nurses should participate in the selection of documentation systems as well as the development of appropriate policies and procedures.
School health records provide the mechanism for a school nurse to communicate information to students, families, the school multidisciplinary team, emergency personnel, other healthcare providers, and school nurse substitutes. Data from school health records can show evidence of student health problems that should be addressed. Data are also used for evaluation of school health programs, quality assurance, disease surveillance (Calman, Hauser, Lurio, Wu, & Pichardo, 2012) and evaluation of program outcomes.
The large caseloads and volumes of longitudinal student information collected by school nurses result in a quantity of data that is not readily managed by paper processes. Electronic documentation systems allow for efficient data management processes including the documentation, reporting, and analysis of student health data. Electronic data management systems also allow for the aggregation of data from multiple sources if the data elements are standardized across systems. The ability to build a database requires the EHRs to be able to speak the same language. Data in systems that use standardized languages and are interoperable across a variety of settings will allow the expansion of evidence to determine nursing interventions that support student academic success.
Using aggregate data from standardized school nurse documentation would support the development of a national school health database that could be used to describe the student healthcare needs, best outcome based interventions, and academic success (Johnson, Bergren, & Westbrook, 2012). The Office of the National Coordinator for Health Information Technology (ONC) predicted that the MU of EHRs will strengthen the communication of information, improve care coordination, and enhance the quality of care (Blumenthal, 2009). Aggregate data and EHRs also will assist school nurses to function within their broader role as public health nurses by providing the opportunity to improve links between other healthcare providers and public health departments (CDC, 2012).
Reports from EHR systems will allow school nurses to (Johnson & Guthrie, 2012, p. 28):
Documentation of the nursing interventions provided to students with chronic disease who need more complex care and management at schools is crucial for efficient disease management and collaboration with all of the student’s team members. The Robert Wood Johnson report (2010), Unlocking the Potential of School Nursing: Keeping Children Healthy, In School and Ready to Learn describes school nursing’s role as the “hidden system” of care. Management of chronic disease, costs and the impact on learning depend on school nurses who can expertly collaborate with the student’s family and medical home. EHRs are a crucial piece of communication and management of students with chronic disease.
School nurses can best advocate for quality EHRs by considering the following:
The five rights of electronic documentation systems include right data, right presentation, right decisions, right work processes, and right outcomes (Amatayakul, 2009).
Confidentiality assurance by following laws governing school health records include the Federal Family Education Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA) as well as individual state laws (United States Department of Health and Human Services & United States Department of Education [USDHH & USDE], 2008).
School nurses should address security by being involved on the school district technology team to provide input on the need for privacy and meet health documentation requirements. Special provisions must be established to protect EHRs and student privacy in the school district. The use of secure passwords, programs to thwart hackers, and screen savers -- as well as several areas of access for the student health data base and a policy of never leaving the computer unattended when student health data are accessible or viewable -- is necessary for security. Computer software should have over-write protection and an appropriate level of role-dependent secure access if multiple health office employees will be entering data.
Having a standardized electronic data system in the school setting is a reality for many schools in the U.S. In Delaware, all public school nurses use an EHR that is within the educational pupil accounting electronic records and uses standardized languages and coding of all health information and school nurse interventions (L. C. Wolfe, personal communication, September 2013). This facilitates a means for health data to be linked to student demographics and educational needs. Further, it provides an avenue for research into the relationships between school nursing activities and student outcomes.
EHRs are required for school nurses to use the aggregate data to build a standardized school health database that identifies student health trends, determines evidenced-based interventions, supports effective student healthcare models, and documents improved student academic success. Aggregated school health data allows for population-based disease surveillance (Baer, Rodriguez, &Duchin, 2011) and holds the potential for analysis by community and demographic groups, of the most effective strategies for school-based health promotion and illness prevention activities. In addressing EHR use, school nurses should, receive training on the use of the system, evaluate school district policies and procedures, initiate changes if indicated, and educate staff, students, and parents on the value of EHRs. Additionally, school nurses should be able to describe the security measures taken by the school district to protect student confidentiality. Without EHRs, the contributions of school nursing services to a child’s health and academic success cannot be fully examined or appreciated.
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Johnson, K. H., Bergren, M. D., & Westbrook, L. O. (2012). The promise of standardized data collection: School health variables identified by states. The Journal of School Nursing, 28(2), 95-107. doi: 10.1177/1059840511426434
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Robert Wood Johnson Foundation. (2010). Charting nursing’s future: Unlocking the potential of school nursing: Keeping children healthy, in school, and ready to learn. Retrieved from http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2010/rwjf64263
U.S. Department of Health and Human Services, & U.S. Department of Education. (2008). Joint guidance on the application of the family educational rights and privacy act (FERPA) and the health insurance portability and accountability act of 1996 (HIPAA) to student health records. Retrieved from http://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hipaa-guidance.pdf
Acknowledgment of Authors:
Cynthia Hiltz, MS, RN, LSN, NCSN
Katie Johnson, DNP, MN, RN-BC, NCSN
Julia Rae Lechtenberg, MSN, RN, NCSN
Erin Maughan, PhD, MS, RN, APHN-BC
Sharonlee Trefry, MSN, RN, NCSN
Adopted: January 2014
This document replaces the Issue Briefs School Health Records (July 2004) and Privacy Standards for Student Health Records (2004).
All position statements from the National Association of School Nurses will automatically expire five years after publication unless reaffirmed, revised, or retired at or before that time.