How Can I Best Facilitate the Transition of Health Office Staff from ...

abstractHow Can I Best Facilitate the Transition of Health Office Stafffrom Using Written Student Health Records (SHRs)to Electronic Health Records (EHRs) in MMSD?Jane ImholteHuegel Elementary and Memorial High SchoolsMMSD Classroom Action Research vol. 2010 School Nurses Promoting Wellness in Students and StaffMy research question and study focuses on the transition process of MMSD Health Services stafffrom written student health records to electronic health records using Infinite Campus Health.Data include information from pilot study of nurses and nurses’ assistants using the HealthModule this school year, and a survey of Health Services staff’s needs regarding electronicrecords and training. Appendices include pilot group feedback form, Health Services IC HealthSurvey, and a glossary of terms.Data Collection Methods: EVALUATION/FEEDBACK, FOCUS GROUP, LITERATUREREVIEW, SURVEYStudy Descriptors: COLLABORATION/TEAMING, HEALTH, TECHNOLOGY,TRANSITIONC.A.R. Group Facilitators: Sara Parrell & Sally Zirbel-Donisch

HOW CAN I BEST FACILITATE THE TRANSITION OF HEALTH OFFICE STAFFFROM USING WRITTEN STUDENT HEALTH RECORDS (SHRs)TO ELECTRONIC HEALTH RECORDS (EHRs) IN MMSDBackgroundJane ImholteHuegel Elementary and Memorial High SchoolI have been a school nurse in Madison for twenty years completing my first ClassroomAction Research in 2008 on elementary students needing to sleep during the school day. I haveworked primarily in the elementary and early childhood setting as a school nurse until four yearsago when the opportunity presented for me to practice at the high school level. I have had theopportunity to work at West High School and currently at Memorial High School. Since so muchof my previous school nurse practice has been with younger children, I felt the need to look moreintensively at my high school practice.So, to try to increase my knowledge and improve my practice with high school students Iam again doing Classroom Action Research (CAR). At both of the high schools, I have had thegood fortune to work in collaboration with two other school nurses. I value this collaboration asmy previous school nurse practice has been an isolated role being the “only school nurse” in theschool. It is truly wonderful to work together as a team.Developing a QuestionThere are many questions and topic areas to explore and learn more about for me at thehigh school level. My nurse colleague and I decided to work together on CAR with the hope thatwe could learn together and be able to make a difference for our students. We identified severalcommon problems as high school nurses. Initially, we questioned high school students’perceptions of health, wellness and prevention because we see so many students seeking healthcare on a “need to” basis by going to the Emergency Room, and many students don’t have aprimary care provider/clinic. Further, when we arrange for students to go for physicals, withtransportation arranged outside of school hours, they frequently do not keep these appointments.We wondered what we could do to motivate high school students to seek primary, preventativehealth care.

However, after my colleague met with a student regarding a negative pregnancy test, wehad questions regarding our role with students on this issue. The student was disappointed shewasn’t pregnant because she had relationship problems with her mother and she thought a baby“would love her unconditionally”. In addition, the student shared that she has friends with babieswho say “it is easy.” We both were surprised by this interaction and it caused more discussion,reading, and thinking on our part and we considered a question: how can I as a school nurse helpadolescents with low self – esteem from participating in high risk behaviors? In our practice atMemorial, we observed that more African-American adolescent females were getting pregnantand keeping their babies. We wondered about their process for considering options, and believedthey were limiting their expectations. In some cases, it appeared as if becoming a mother wasvalued higher than completing their high school education. Or perhaps they thought they coulddo both. Our question evolved, again: how can we increase our understanding of the factorsinfluencing African-American adolescent females regarding sexual activity and pregnancy? Tobegin, we decided to interview three to four high school aged African- American students who arecurrently pregnant and/or are parenting and attending high school. However, I became concernedabout talking to adolescents about sensitive subject areas (sexual activity, contraception andpregnancy, to name a few) without parent permission, and needed to explore the consent issuefurther.Onward, right? Wrong! A change in direction occurred when my colleague decided towithdraw from CAR. Flexibility is the name of the game for school nurses, and I elected tochoose a topic more related to a different part of my role. Two years ago my assignment changedto include working as one of two nurse team-leaders charged with implementing Infinite CampusHealth (our MMSD information software system) and the change over to electronic health records(EHRs) in MMSD Health Services.Some assumptions I have regarding using EHRs are that health care providers (HCPs)would increase their efficiency and, therefore, increase time spent providing care and improvinghealth care quality. I have always taken pride in my nursing practice as being a very thoroughpractitioner which includes completing careful documentation of the care I provide. This beingsaid, I feel school nurses have to duplicate and over document in our district which takes us awayfrom caring for students. We document in the Omega system. We chart medications on the

medication log. We also chart medication that we are giving in the cumulative medication log inthe SHR. Then, we also chart updates on student health conditions and some health office visitsin the SHR. As school budgets become tighter, allocations for school nurses and nurse’sassistants will most likely also be reduced; we are challenged to be as efficient as possible andstill provide the best quality care that we can. It is my assumption that that EHRs may decreasethe “paperwork” part of our jobs and allow more time to give more care to students. Finally, I amconcerned that transitioning school health office staff to the use of EHRs will be difficult withresistance to changing from written to electronic record-keeping. My research question became:How can I best facilitate the transition of health office staff from using written studenthealth records (SHRs) to electronic health records (EHRs) in MMSD? (See Glossary orTerms for definitions of all technical terms.)Literature ReviewIn the state of Wisconsin, there are several types of student records. It is important tounderstand the different types of student records as they each have different confidentiality,sharing and retention rules. Pupil physical health records means “ those pupil records thatinclude basic health information about a pupil, including the pupil’s immunization records, anemergency medical card, a log of first aid and medicine administered to the pupil, an athleticpermit card, a record concerning the pupil’s ability to participate in an education program, anylead screening records required under statue no. 254.162, the results of any routine screeningtest, such as for hearing, vision or scoliosis, and any follow up to such test, and any other basichealth information, as determined by the state superintendent.” (Wisconsin State Legislature)The student health record (SHR) is a “patient health care record (PHR) “ any pupil record thatrelates to a pupil’s physical health (excluding HIV testing records) and that is not a pupilphysical health record shall be treated as a patient health care record under statute nos. 146.81to 146.84” . (Wisconsin State Legislature)According to Schwab and Pholman (2004), school nurses have questions regarding theownership and storage location of student health records (SHRs). The school nurse functions as ahealth care professional and a student support person in schools. The school nurse isknowledgeable about what information from the student’s health record can and cannot be shared

with school staff which is most often based on school district policies and procedures andindividual state laws and confidentiality statutes.The first national survey on RN use of EHRs was completed by DesRoches et al, (2008)looking at the relationship of registered nurses’ (RNs) use of EHR, beliefs about the quality ofcare and if use of EHRs is associated with less time spent doing paperwork and more timeproviding direct care to patients. The findings of this study were that the routine use of minimallyfunctional EMRs by RNs in inpatient and ambulatory settings varied and that less than 1 in 5 RNswork currently in settings that endorsed minimally functional EHRs. There were generalconcerns that using EHRs would increase time spent completing documentation. However, thestudy revealed that RNs do not spend more time completing patient documentation when usingEHRs.A study by O. G. Otieno et al. (2007) noted that even though EHRs are being used inmany healthcare settings, and that their effective and efficient data processing benefits healthcareproviders, little evaluation has been completed by their users. The aim of this study was todevelop a survey instrument to measure nurses’ EHR use, quality and satisfaction. The researchoutcomes include a proposed, generalized, standardized instrument to measure EHR use, qualityand user satisfaction.The use of EHRs was examined in a recent study by P. Carayon et al. (2009) about howEHRs can be used to improve clinician performance and produce positive individual andorganizational outcomes. This study described a case study of the implementation of a EHRssystem in a small family practice clinic. The data showed increased computer entry by physiciansbut few changes in their work practices. However, there were major changes in the work of otherclinic and office staff.Gathering DataMMSD explored several student information software systems to purchase for district useincluding Infinite Campus. Others that were considered and rejected include; Century StarStudent, eSis, paC Skyward, Power School and Zangle C Innovation. Health ServicesCoordinator, Freddi Adelson, was involved in the student information software review processalong with a committee of other MMSD administrators and staff members.

My IC Health journey began in fall 2008 along with another school nurse, Colleen Duffie.We are allocated one half day each week to work on IC Health with the goal being to see if ICHealth could be used in MMSD Health Services. This doesn’t sound like such a big deal initiallybut it is much more complicated then it would seem. First of all, we are nurses and not computerexperts or programmers. However, we have experience and knowledge about school nursing andworking in school health offices with students, parents and staff. We initially weren’t even ableto find the Health module in the IC Sandbox. Slowly, with the help and patience of the MMSDIC computer technician, we were able to develop and pilot the screening tab and hearing andvision follow up tab to complete a pilot in several schools by the end of the first year we workedon IC Health. Then, we went district wide in fall of 2009, asking all Health Office staff to recordthe results of hearing and vision screening in IC Health.In December 2009, health office staff was asked for feedback on the use of IC Health (seeAppendix I). This survey included questions about using IC for vision and hearing screening, theuse of Health Conditions tab, the Health Alerts program, Contact Log and current IC Healthdirections. Eight responses were received. Some health office staff used IC for entering Hearingand Vision screening results and some had used the screening follow up tab. Most didn’t knowwhere to find the chart of Vision Follow up Codes and the LEA Vision Screening ConversionChart. Most respondents used the Contact Log every time they speak with a parent and find ittime saving because of not having to document in two places (Contact Log and SHRs). They didhave some problems using IC for creating and formatting class lists.Next, health office staffs from five MMSD schools were trained to pilot IC Health OfficeVisits, Health Office Calendar, Medications and Treatments to begin on the first day of the 2009-10 school year, replacing the Omega system. The following problem areas were identified fromthis pilot group during the 2009-10 school year:• Missing data issues• Making changes to text in IC: Inability to track who makes changes or when changes are made.• Where to input free text and notes?

Health Office Visits comment box or Complaint box Contact Log Conditions updates Need a place to be able to put “non-visit” information for that would typically gointo the SHR.• Medications/Treatments History of previous medications/treatments ordered or given Unable to submit additional medication supply without entering entire medicationas if new order Dose submitted issues Medication amount shows a negative number under “remaining doses” When medication is “below threshold” student no longer will show up onHealth Office Daily Calendar unless re-entered as a new medication “As needed” medications don’t show up as a choice under “add med dose”if there are 0 doses remaining, will have to re-enter as if a new medication• Overall slowness of the system especially for students with daily scheduled healthvisits was a concern especially when several students present at the same time andneed to be given care.The last data collected was The Infinite Campus Health Services Survey (see Appendix II)completed by school nurses and nurse’s assistants to seek information regarding their current ICHealth comfort level. This survey also asked what aspects of the current Omega System HO stafffind most useful to determine if similar functionality will be needed in IC Health. Finally, thissurvey sought input from health office staff about their training needs in the transition fromwritten SHRs to EHRs. There were a total of 61 surveys completed; 29 by school nurses and 32by nurse’s assistants. The data collected from these surveys are included in the following charts:

Nurses and nurse’s assistants are very comfortable using student information, the contactlog and completing Hearing and Vision screening in IC Health. Nurses are verycomfortable using Health Alerts and Health Conditions in IC Health. Both are generallynot comfortable creating and using Ad Hoc Queries and Excel.

The parts of the current Omega System that Nurses and Nurse’s Assistants find mosthelpful are the daily log with scheduled medications and procedures, current school yearstudent HO visit history and to a lesser degree, student HO visit history transferring to new

school when students transfer to different MMSD schools. The capability to printmedication and procedure lists was not found to be helpful because these lists change sofrequently so staff use the HO computerized log and also refer to the written logs completedby school nurses that are kept in the medication binder in the HO.

Question #3 responses show generally that nurses and nurse’s assistants feel that havingmore menu choices, more service provision choices, the ability to add text during a visitelectronically, charting at the time care is provided to students in the HO and being able toview student HO visit history as very important or important. Nurses’ rate being able todocument non-visit health information as very important in contrast to nurse’s assistantsseeing this to be less important.

The results of question #4 surprised me by the high numbers of nurses and nurse’sassistants preferring to have IC Health training in small groups in a computer lab and bywritten information. Nurses also strongly favor having instructions on My MMSD. Lastly,both nurses and nurse’s assistants are somewhat interested in having some virtual trainingoptions.Summary of Findings, Recommendations and ReflectionsThe data collected from the health office staff IC Health pilot groups and from the InfiniteCampus Health Services surveys reflects, to my surprise, a general willingness to transition fromwritten SHRs to EHRs. The data received from the two pilot groups are small, yet, identify keyproblems and system areas that need more development in IC Health to be able to be usedeffectively by MMSD health office staff in their daily work with students. I value the feedbackfrom the pilot groups because they are actually using the program and are committed to learning anew system to document school health care. This is not an easy undertaking given the variabilityand intensity of student needs that present in school health offices daily. As a result of the pilotwork, the IC Nurse Team along with MMSD computer technical staff and IC Support have beenable to identify specific health items that will need to be in place so that we will be able to godistrict-wide with IC Health in fall 2010.This means that school health offices will no longer be using the Omega system to logstudents into the computer in school health offices and instead will be using IC Health module.Health office staff will log students’ daily health office visits for illness, injury, medicationadministration and treatments. The Health Office Visit tab will be used for nonscheduled studenthealth office visits due to illnesses and injuries that will have drop down menus to choosecomplaints, observations, interventions and discharges instead of using codes in Omega. Therewill also be the ability to add free text for additional information regarding health office visits;that has not been a choice in the Omega system.

One problem identified in the pilot schools is that health office visits do not transfer withstudents from one school to another school. As a result, a Health Office Visit Report, which is acopy of all health office visits, will transfer with students. Finally, a non-visit tab will be availableto document information regarding a student that is not from a health office visit that would beusually kept in yellow SHRs…this would replace hand-written charting. There is still a great dealof work to be done in order to implement changes for the 2010-2011 school year, but we havemade huge progress and have the support of most school nurses, nurse’s assistants, the HealthCoordinator and our Chief Information Officer.This brings me back to my question: How can I best facilitate the transition of healthoffice staff from written student health records (SHRs) to electronic health records (EHRs)?The Infinite Campus Health services Survey (Appendix II) completed by 29 school nurses and 32nurse’s assistants provides information on staff needs regarding the move to EHRs and trainingpreferences. The survey data reveals several parallels between school nurses and nurse’sassistants’ responses including drop down menu choices, choice of more than one service andhaving a text box available for additional information during a health office visit. A part of theEHR that differed for school nurses and nurse’s assistants is being able to document non-visitinformation. This may be due to school nurse’s documenting this type of information more oftenthan nurse’s assistants in daily practice and in the difference in job roles and responsibilities.Overall, comments from school nurses and nurse’s assistants were positive to “go electronic” inorder to save time and avoid duplication of charting. Several comments indicate that staff preferworking with one system instead of having to go back and forth between IC and Omega andespecially liked using the Contact Log.According the Infinite Campus Health Services Survey data, the training most staffpreferred was to have written directions in a step-by-step format, small group instruction in acomputer lab and instructions on MyMMSD. In addition, the IC Health program areas that moststaff identified as needing more instruction and training is creating and using Ad Hoc Queries andusing Excel. Secondarily, Hearing and Vision Screening and Follow Up were also identified asareas that staff were not as comfortable using and needing more training. The plan is to scheduleIC Health training during the week before the start of school in August 2010 for all health officestaff. I plan to work on IC Health and the training program over the summer to include some

“web-type” training, small group computer training and written IC Health materials. I’mconsidering creating a DVD to demonstrate the different parts of IC Health to health office staffso they could see it work!Finally, I think it is worth noting that change is difficult for some and that there willalways be some resistance to moving to new ways of doing things. As one staff noted in theirsurvey, “we need to realize there is a learning curve to which you have to make a commitment,and it takes time and effort if you want to learn some of these things.” I am hoping as we moveforward in this journey from written to electronic that health office, staff will continue to be openand continue to work collaboratively with me to make the transition.

ReferencesCarayon, Pascale, Smith, Paul, Hundt, Ann Schoofs, Kuruchittham, Vipat and Li, Qian.Implementation of an Electronic Health Records System in a Small Clinic: theViewpoint of Clinic Staff. Behavior & Information Technology, 2009, 28(1), 5-20.DesRoches, Catherine, Donelan, Karen, Buerhaus, Peter, Potter, Valerie, and Zhonghe, LI.Registered Nurses’ Use of Electronic Health Records: Findings From a NationalSurvey. The Medscape Journal of Medicine, 2008, 10(7), 1-12.Otieno, Ochieng George, Toyama, Hinako, Asonuma, Motohiro, Kanai-Pak, Masako, andNaitoh, Keiko. Nurses’ Views on the Use, Quality and User Satifaction withElectronic Medical Records: Questionnaire Development, Journal of AvdvancedNursing, (2007), 20(2), 209-219.Schwab, Nadine C. & Pohlman, Katherine J., Records - The Achilles’ Heel of School Nursing:Answers to Bothersome Questions, The Journal of School Nursing, (2004), 20(4), 236-241.Wisconsin State Legislature, Legislative Reference Bureau, Statute Numbers 253.162,(Screening Requirements), 146.81 (Health Care Records, Definitions) to 145.84(Violoations related to Patient Health Care Records), (2007-08 Statutes updatedthrough 2009 Wisconsin Act 189 and March 31, 2010).

Glossary of Terms: Imholte, 2010Contact Log – Tab in Infinite Campus Health for health office staff to document contacts made onbehalf of students. This tab provides record of who made the contact, type ofcontact and to whom the contact was made.EHRs – Electronic Health RecordsHCP – Health Care ProviderHealth Alerts Program – Program in Infinite Campus Health used by school nurses for studentswith emergency health conditionsHealth Conditions Tab – Tab in Infinite Campus Health used by school nurses for student healthconditionsHO – Health OfficeHealth Office Calendar – Daily schedule of Health Office visits used in Infinite Campus HealthIC – Infinite CampusIC Health Office Visit Tab – The tab in Infinite Campus Health where individual student healthoffice visits are completedIC Sandbox – A non-live version of Infinite Campus to use for practicing how to use InfiniteCampusLEA Vision Screening Conversion Chart - Type of vision screening chart used for screeningyoung childrenOmega System – Older computer software used in MMSD health offices for logging studenthealth office visitsSHRs – Confidential Student Health Records health office staff use to record written informationon student’s health in their schools.Vision Follow Up Codes – Codes used by school nurses when completing vision follow uprepresenting various vision conditions. These codes are used in Health Servicesdata collection.

Appendix I: Imholte, 2010Feedback on use of IC for health servicesUsing IC for Vision and Hearing data:Did you enter using the grade list or do individual searches by student name?Were you able to refer to the chart of Vision Follow-Up codes?Were you able to refer to the LEA conversion chart?Were you able to easily use the Vision/Hearing follow-up tab?Other comments about vision/hearing entries:Comments about the Health Conditions tab:Comments about using the Health Alerts tab :Do you refer to the IC manual for Health Services January 2008?Do you need other directions for using IC? If so, what specific directions do you in need?

APPENDIX II: Imholte, 2010As you know, MMSD Health Services has been using and piloting some parts of Electronic Health Recordsin Infinite Campus. I am currently doing Classroom Action Research on the use of electronic recordkeeping in school health records. I WOULD APPRECIATE YOUR COOPERATION IN COMPLETINGTHIS SURVEY BY THE END OF TODAY’S INSERVICE, THANK YOU!!! Jane Imholte SCHOOL NURSE CLASSROOM ACTION RESEARCH:INFINITE CAMPUS HEALTH SERVICES SURVEYSchool Nurse___________________Nurse’s Assistant___________________School Setting(s): ____ Elem ____ Middle ____ High School ____Middle/HS ____AlternativeNumber of years in MMSD: ____ 1-2 ____3-5 ____5-10 ____10-20 ____ More than 20Do you have any prior experience using Electronic Health Records? ___Yes ___ No.If you answered Yes, provide brief explanation about your experience along with any advantagesand disadvantages in this space:Please check one box for each question:How comfortable are you using the followingparts of Infinite Campus?VeryComfortableComfortableUsing Student Information: Searching forStudent Name/Number, Address, Family/Emergency Contacts, Telephone NumbersEnrollmentScheduleHearing and Vision ScreeningHearing and Vision Follow UpContact LogHealth Alerts (Nurses Only)Health Conditions (Nurses Only)Creating/Using Ad Hoc QueriesUsing and Formatting ExcelPlease check one box for each question:What components of the current Omega system do yousee as most helpful in your HO work?VeryHelpfulHelpfulDaily Log with Scheduled Medications/ProceduresAbility to Print Medication/Procedure ListsAbility to Review Individual Student HO Visit historywithin current school yearStudent HO visits information transfers to new schoolwhen students transfer during the current school yearNotComfortableNot HelpfulOVER →

Please check one box for each question:How helpful would the following electronic recordchanges be in your daily HO work?VeryImportantImportantDrop Down Menu Choices instead of using OmegaCodesAbility to choose more services provide than one ascurrently being done in Omega. (i.e. St comes to theHO with a sore throat. In Omega, we would put onechoice, HC-Health Care vs. the ability to add moreinterventions; such as HC-Health Care, RX-PRN MedUnder Protocol). This would then replace having tochart in the Yellow SHR.Able to type brief additional info in a text box re: HOVisit if needed. Also, replacing yellow SHR charting.Able to chart at time when care is given to reduceerrors and follow HO Guidelines for Management ofIllnesses and Injuries in the School SettingAbility to Review Previous HO Visit History.Ability to record Non-Visit information often kept inYellow SHRsPlease check all that would apply.What training would be most helpful for you to use Electronic Health Records?Written Instructions/ManualLarge Group Instruction at Computer LabSmall Group Instruction Computer LabVirtual Computer TrainingInstructions on My MMSDYour Ideas/Suggestions:NotImportantAny other concerns, suggestions or thoughts?