Who Cares For Your Sick Child In School?

Writ­ten by Dr. Page McNall

In our schools, more often than not, the nurse is not in the office. More than half of the nation’s schools have only a part-time nurse or no nurse at all. Mean­while, stu­dents, par­tic­u­larly Med­ic­aid and Children’s Health Insur­ance Pro­gram (CHIP) ben­e­fi­cia­ries, are suf­fer­ing from chronic con­di­tions at a rate nearly dou­ble 20 years ago. For Med­ic­aid and CHIP enrollees, the lack of atten­tion is reach­ing crit­i­cal lev­els. A 2011 GAOreport found Med­ic­aid and CHIP enrollees were falling far short of the 80% par­tic­i­pa­tion rate in Early Peri­odic Screen­ing Diag­no­sis and Treat­ment (EPSDT) pro­grams, while 63% need­ing care coor­di­na­tion didn’t receive it, and 40% of enrollees hadn’t had a well-child checkup in more than two years. The impact on the health care infra­struc­ture and expense to the Cen­ters for Med­ic­aid and Medicare Ser­vices (CMS), both through health care costs and poor data report­ing is profound.

Accord­ing to the National Asso­ci­a­tion of School Nurses (NASN), a quar­ter of the nation’s pub­lic schools is not served by a nurse at all. Another 30 per­cent are served by a “clus­ter nurse,” a sin­gle nurse who splits time between sev­eral schools. While Fed­eral guide­lines rec­om­mend one school nurse for every 750 stu­dents, only 17 states meet that require­ment. Many of the basic health needs of school-aged chil­dren, par­tic­u­larly Med­ic­aid and CHIP, are left untreated. Eli­gi­ble stu­dents with unmet med­ical needs place a greater bur­den upon local edu­ca­tion agen­cies (LEAs), which fre­quently have been unable to keep pace with the chang­ing land­scape of health care. While advances in health care infor­ma­tion tech­nol­ogy (IT) have moved doc­tors from pre­scrip­tion pads to iPads, and the range of med­ica­tions brought into schools has increased dra­mat­i­cally, many schools are still rely­ing on pencil-and-paper solu­tions that remain unchanged over decades. How­ever, schools also rep­re­sent an oppor­tu­nity. As CMSitself writes in guid­ance lit­er­a­ture, “School-based health ser­vices can rep­re­sent an effec­tive tool which can be used to bring more Medicaid-eligible chil­dren into pre­ven­tive and appro­pri­ate follow-up care.”

We have seen sev­eral school elec­tronic health records, how­ever they appear to fall short of meet­ing the goals and out­comes for which they are intended. How well do they help man­age cases? How well do they help coor­di­nate care between the school and the student’s physi­cian? Do they pro­vide insight to the stu­dents’ health? Does it inform the pub­lic of health risks using syn­dromic sur­veil­lance across the dis­trict? Does it feed to the CDC as an early warn­ing sys­tem of poten­tial epi­demics? The tech­nol­ogy exists and could be used to under­stand health threats to the pop­u­la­tion and indi­vid­ual in real time. Does your school sys­tem have this level of health insight?

Every year, I filled out paper­work on my child who attended the same school for 4 years and despite the infor­ma­tion pre­vi­ously given, I was asked for the same infor­ma­tion again and again. Anec­do­tally, I have seen this with many other par­ents in var­i­ous other school sys­tems. Is there an elec­tronic health record specif­i­cally for schools that serves as an inte­grated health care plat­form to improve health out­comes, reduce expenses through automa­tion and improved data integrity of stu­dent health infor­ma­tion, and cut the tan­gled knots of poor report­ing plagu­ing CMS?

Fur­ther com­pli­cat­ing mat­ters, accord­ing to a 2011 NASN mem­ber sur­vey, just 46 per­cent of school nurses are cur­rently using a fully elec­tronic stu­dent health record. Twenty-one per­cent of NASN mem­bers are still rely­ing on paper-and-pencil solu­tions only. Includ­ing schools with­out nurses, the num­bers dras­ti­cally increase, lead­ing to data errors, poorer health care and poorer health outcome.

Ide­ally, a school elec­tronic health record should pro­vide improved health care through bet­ter access to stu­dent health infor­ma­tion and mon­i­tor­ing. (For exam­ple, track­ing pre­scrip­tion med­ica­tions as they’re admin­is­tered, or record­ing basic triage and other health encoun­ters). Pro­vid­ing the link between schools and par­ents for edu­ca­tional infor­ma­tion that are mean­ing­ful to that par­ent and child, invite the oppor­tu­nity for bet­ter health and care coor­di­na­tion. Edu­ca­tional con­tent deliv­ers high value in the man­age­ment of chronic con­di­tions where both par­ents and the school nurse par­tic­i­pate in the child’s care. Lastly, it pro­vides a cost sav­ings through sev­eral sep­a­rate avenues, notably sav­ings in time and reduc­tion in errors as a result of intro­duc­ing an elec­tronic record, decreased costs related to fewer stu­dent absences through bet­ter pre­ven­ta­tive care, and stan­dard­ized data collection.

Many pub­lic schools suf­fer from dwin­dling bud­gets, which directly impacts the school health pro­gram. When cre­at­ing the bud­get, I doubt that the school dis­tricts under­stand the multi-faceted return on invest­ment that and elec­tronic stu­dent health record would reap for this gen­er­a­tion of chil­dren. After learn­ing about the school nurse dilemma, It only makes sense to give our school nurses the tools they need to take care of our children.