Improving Health Care in Schools: School Nurse Leader Gives District’s EHR System an A+

Photo of Marie DeSisto

Marie DeSisto

Marie DeSisto is an innovator when it comes to electronic health records (EHRs) and improving health care in schools. Thanks to her efforts, school nurses in Waltham, MA, are linked by an EHR system that helps them serve students in ways that go far beyond the basics. Just one example: EHR data on student obesity convinced budget-conscious administrators not to eliminate recess.

In honor of National Nurses Week and National School Nurse Day, ONC talked with Ms. DeSisto about Waltham’s EHRs—how the system was implemented, how it works, and how students and nurses benefit.

ONC:

First tell us a little about yourself and how you became interested in EHRs.

DeSisto:

I’m an RN with a master’s in nursing administration, and I’m also a nationally certified school nurse. I’m director of nurses for Waltham Public Schools. We have about 5,000 students, pre-K through grade 12, in 10 schools. We have a nurse in each school—three at the high school.

I’ve been at Waltham for 12 years, and before that I was a school nurse in another district. We had kind of a homegrown EHR program there, cobbled together by our IT people. I knew what a huge timesaver it could be, and there were all kinds of ways we could use data from a good system to improve health care in schools. So when I came to Waltham, I decided to look for a program that would really fill the bill. We’ve been using our EHR system for 11 years. Every nurse has a computer, and we’re all linked.

ONC:

Any challenges getting your system up and running?

DeSisto:

Cost is always an issue. But we were able to get a grant from the Massachusetts Department of Public Health, called an Essential School Health Service Grant. They didn’t tell us what software we had to get, just gave us some parameters. The system we chose, SNAP, is from a company called Professional Software for Nurses. The company’s trainer was a nurse herself, with experience in a school health room. It helped a lot that she spoke our language.

Another challenge was that some of the nurses were a little hesitant about converting to EHRs. But we had a couple of very enthusiastic early adopters, and they really helped get everybody on board. The whole process only took about two months. To motivate our nurses, we emphasized the timesaving aspect of the system. For example, our accident-reporting system had been burdensome—paper forms in triplicate. SNAP does it with the click of a button. That had a big wow factor, and the accident reports made a big impression on administration. It got us off to a good start.

ONC:

Tell us about how you use your EHR system—some examples of what it can do, or rather what you and your team can do with it.

DeSisto:

Vision screening comes to mind. We do the screenings and refer students for treatment or corrective lenses if they don’t pass. The big thing with our EHR system is that we can keep track of those referrals, and do follow-ups. Our completion rate for referrals jumped from 63 percent to 92 percent when we started using EHRs.

SNAP also helps us keep track of immunizations. Say there’s a concern about a potential problem in your school and the principal wants to know the status of immunizations. It can take hours and hours to check for immunization information on documents students have brought from the doctors, but you can pull it instantly from the EHRs.

We’ve also been using our system to track concussions. There’s so much interest now in sports-related injuries. Our trend data show an increase over the past four to five years. That may be because reporting is better, and people are just more aware. We’re helping parents, students, and primary care providers understand that concussions can have serious implications for learning ability.

The EHRs were very helpful when the H1N1 flu virus was going around. We could quickly track how many kids the nurses were dismissing from school, and the symptoms the nurses were seeing. We reported to the Massachusetts Department of Public Health every day, and they could see the patterns.

Another really useful thing—very practical—has been keeping track of injuries from falls. For example, we saw that a lot of first and second graders were getting hurt in falls during recess. So we worked with the principals to train recess monitors in safety. Our data also showed lots of slip-and-falls first thing in the morning, especially on rainy days. Most of that was staff, and it was taking up a great deal of nursing time. Just installing some carpet cut that down almost 100 percent.

ONC:

Can you give us some more examples of how the EHRs help the school nurses meet the students’ health needs or how EHRs can improve health care in schools?

DeSisto:

We have quite a few students with chronic conditions, like asthma or diabetes. We can do an individual health care plan for these students, with everything on medications, nursing interventions. We can track blood pressure and blood sugar readings, make graphs that show changes, and print those out for parents to take to the doctor. The system also helps us with medications. It tracks how many doses we’ve administered, so we know if the student is forgetting to come in for meds. That’s so important. And we can see when we need to ask the parent for more pills.

The system also gives us nursing assessment templates. Say a student comes in for a headache, the nurse can click on the headache template and it prompts questions such as “Did you have a head injury?”

ONC:

Any other examples of how you’ve been able to use EHR data?

DeSisto:

We have always measured student height and weight, but our EHRs let us put that information to use. Our data showed that 40 percent of students in our district are either overweight or obese. The data documented this problem, and that convinced the superintendent to reinstate health education programs and not to cut recess. I really think if all schools in the country used EHRs, we wouldn’t have a child obesity problem. We could have seen it coming and taken action.

ONC:

What’s on your “wish list” for EHRs?

DeSisto:

We aren’t yet linked with other school districts, and we aren’t linked directly with providers. That would be great. I’d also like to see standardization across the country. For example, we have about 190 students with EpiPens for life-threatening allergies. We send data on EpiPen administrations to the Massachusetts Department of Public Health. Massachusetts is the only state that does that. If everyone did it, think what we could learn by comparing states and regions, and how that would affect health care in schools.

ONC:

Any advice for other school districts that are thinking about implementing EHRs?

DeSisto:

Take plenty of time to check available systems carefully. Make sure that the one you choose links to your district’s administrative software—what they use for attendance and demographics. It should be a one-way link, though; you don’t want any outside access to your students’ EHRs.

Make sure the system is visually easy to use and that it’s intuitive to the way nurses think. It also needs to be flexible, so the nurses can make it work for them. For example, you should be able to log more than one student at a time.

You also have to be very careful about privacy and security. The system has to be password protected, and you should be able to track who is making changes. I can hit a button and see right away who entered a particular statement or number.

ONC:

Any final thoughts?

DeSisto:

I am the Massachusetts director for the National Association of School Nurses (NASN).  NASN is a strong advocate for EHR adoption in school systems and believes it can help improve health care in schools. School nurses work hard to keep students safe, healthy, and ready to learn. A good EHR system supports this work in so many ways. It’s worth every penny.

For More Information

We Want to Hear From You

What did you think of the blog post? How do you feel about EHRs being implementing in school districts to help improve health care in schools? Let us know your thoughts by commenting below.

11 Comments

  1. This is an interesting area because it would be easy to argue that many healthcare issues such as obesity and asthma can be traced back to childhood and it is therefore important to start tracking and treating early. We have wondered why free and open source software EHRs could not be used for this purpose with some minor customization. Most school nurse EHR systems are quite expensive and as a result many counties use a paper based system.

    Here are some of the perceived advantages of a low cost/free EHR for school nurses: 1. A web-based EHR could create a separate practice for each school with data aggregating to a central site. 2. A variety of reports could be generated near real time 3. Growth charts and immunizations are already part of the software. 4. Customizable templates would make student visits fast. 5. Roles and privileges can determine access 6. Most EHRs have a system clock/audit trail. 7. Auto-faxes would send save time by referring automatically generated SOAP-type notes to specialists 8. Parents could use the PHR function so they have access to meds, growth charts, immunizations. etc.

    We attempted to investigate the use of a free web based EHR (certified for meaningful use) in the Florida School System but were surprised by the unanswered phone calls and emails to the State Educational Office. This seems like an area rich for research and innovation……Bob Hoyt MD

    • Linda Crawford says:

      What an awesome idea Robert! I have never heard of free web based EHR. I have been seeking EHR for both school office and school based health centers for years and cost is always the problem. I am now also trying to find a method for the homeless population to track their medical information – immunizations, medications, etc and this sounds like just the thing. Wish there was more information out there!

    • Kathleen Johnson says:

      I agree and would like to see interoperability of school health data with clinic data. Parental permission at the point of care could be electronically transmitted allowing electronic medication/treatment orders to be communicated directly into the student’s school health record. Daily treatment and response data collected at school could be transmitted to the clinic record.
      The possibilities for care coordination for children with chronic heatlh conditions are very exciting particularly in the context of Accountable Care Organizations and the development of personal health data systems. There is potential to develop evidence for effective student focused health promotion interventions.
      NASN is supporting a project to describe the current state of school health documentation systems to identify what systems are currently in use in schools.

      Katie Johnson

      *Johnson, K. H., & Bergren, M. D. (2011). Meaningful use of school health data. The Journal of School Nursing, 27 102-110. doi:10.1177/1059840510391095
      *Johnson, K. H., & Guthrie, S. (2012). Harnessing the power of student health data: Selecting, using, and implementing electronic school health documentation systems. NASN School Nurse, 27(1), 27-33.
      *Johnson, K. H., Bergren, M. D., & Westbrook, L. O. (2012). The promise of standardized data collection: School health variables identified by states. Journal of School Nursing, 28(2), 95-107.

  2. Farrant Sakaguchi says:

    I am a family physician and am doing a fellowship in Medical Informatics. In terms of a free web-based EHR there are at least a couple. They are free because they are supported by ads. The one I use in my clinic is called PracticeFusion. The ads do not bother me. It is NOT the most efficient or the most connected. However, it is free and easy to use. They have pretty good customer support, help forums, and training. (If you let them know that I referred you I might even get some bonus or reward.) Another one that I started to look into is called Mitochon systems. I do not know much of anything about this other system.

    Despite trying to offer a solution worth consideration with these two examples of free, web-based EHR’s, one should be careful about how to proceed. The success of the story was based on a quick system that was designed with the current workflow in mind, and it provided an easy way to report on absences, injuries, etc – basically it help manage data well. These pre-built platforms are NOT built around your workflow – though there are many success stories. Additionally, the data-management capability is currently quite limited in PracticeFusion.

    If you have any questions about my own experiences and opinions, please feel free to google me. I practice out of Sandy, UT and am doing my fellowship at the University of Utah.

  3. James says:

    The thing that worries me the most in school healthcare is definitely the diet of the students. I think the recent London photo-blog expose’s this well with the low amount of nutrition and vegetables students are getting. We should up to natural foods instead of processed frozen foods in the cafeterias and that should help students become healthier in general and possibly even helping the students lose 10 pounds.

  4. Jane Morai says:

    Marie has done a great job of implementing electronic health records. It’s something I wish was available when I was growing up. My health records were mostly on paper and much of my medical history was either lost of damaged making it harder for doctors and health care physicians to understand my condition as I got older and needed medical attention. Having records in digital formats helps prevent lost information and makes it easier for those in the medical industry to collaborate and help their patients achieve optimal health and in the case of schools it appears to have had a good effect on education decision makers about the importance of healthy cafeteria food and regular exercise, including play time during recess.

  5. Nurse says:

    Student obesity is an agenda as well. Cost might be an issue for these sort of campaigns to get the students to eat healthy and for the school cafeterias or canteens to distribute more organic and healthy food. But again the parents could contribute some or donate to school funds or implement an organic farms which include some hydroponic systems. This will also encourage the students to learn about hydroponics and learn how to grow their own organic food and be healthy actively participating in such programs. This is beneficial in both physically where student get their hand dirty building the farms and mentally by learning how to eat healthy and knowing what you eat.

  6. Vignesh says:

    Good Article! This is a very great idea. If obesity can be controlled and checked at school level, probability of people becoming obese in later years reduces due to much more knowledge about the subject.

Leave a ReplyComment Policy


*