Access to health care remains a challenge for many in our society, most particularly those who are the most vulnerable and those at the economic margins. The ability to shape functional, practical systems of care to meet the needs of our population continues to elude the best of health care planners. Children are one of the most vulnerable groups in our communities, particularly those in urban schools where there is a high proportion of economically disadvantaged families.
CareWeb (actually this particular CareWeb implementation) is a school-based health care program designed to provide an integrated, coordinated system of health care for children and their families using the combined resources of school nurses, nurse practitioners, and pediatricians supported by information technology. Developed first in a group of pilot schools in the Syracuse, New York school district the system can be expanded to include the entire school district and is equally applicable in other urban and rural settings.
CareWeb is a response to a school district in which 68% of the children, 24,000 children, are eligible for reduced price or free lunches which has a high correlation with Medicaid eligibility. These children are medically underserved through a combination of parental/family and community factors which interfere with their access to health care while increasing their risks and needs. Their attendance in school and performance are affected by interruptions in their health which often go untreated or left to expensive emergency room care.
As New York implements a system of managed care enrollment, these children are at risk for even poorer health care despite their Medicaid eligibility due to lack of transportation and parents' inability to take them for care and the lack of preparation on the part of many health care providers to meet the needs of high risk, medically underserved children who by definition will be costly to a managed care system.
CareWeb addresses these problems by becoming the primary provider of health care at the school site supported by powerful technology which allows school nurses, nurse practitioners and pediatricians to visualize the children, communicate in two way audio and video, and work from a single patient record across their geographically separated sites. This concept is based on a model of Distributed Medical Intelligence developed by David Warner M.D. (Warner, 1996). In this model (Figure 1), the child and the school nurse are located at the school, called the Care Portal. The nurse practitioners are in the school based clinics or the College of Nursing, labeled the Bridge site, and the pediatricians are in the Department of Pediatrics of the Health Science Center, or other managed-care providers labeled the Docking Station. All have access to the web -based expert information developed to support the provision of care and the child's health care record, taking advantage of both equipment and the web development expertise of computer scientists in the Northeast Parallel Architectures Center (NPAC) of Syracuse University.
The changing health care environment demands such new cost efficient approaches to health care and creates new incentives for keeping people well. In addition, many of our current health problems can be prevented only through promoting individual life styles which place the responsibility with the individual for self-care and self-management. Children must learn such capabilities from the beginning. The school, with its access to children and its health education resources, is one of the best places for such learning and care to occur.
This project forms a partnership of community and academic institutions to utilize the potential in the rapidly expanding field of information technology to develop a school-based program of health care for children in the Syracuse City Schools. In developing the technology to support this project we recognize that these same approaches could enjoy widespread application in the health care arena in both urban and rural areas and in a global context. We will keep such extensions in mind as we proceed. This approach will also provide national, even global visibility, so that we can become better poised to attract funding to expand these activities and broaden their impact. We recognize, too, the potential for commercial ventures in this arena.
The College of Nursing at Syracuse University holds the vision that nursing's contribution to the future of health care is that of empowering people for health, providing new models of demonstration projects and educating students who are prepared to participate in creating such a future for health care in our communities and in a global world. One of the vehicles for meeting these goals is the establishment of a Community Nursing Center.
The Community Nursing Center provides a vehicle for faculty to develop research and demonstration projects which model nursing approaches to health care and to study the clinical and cost outcomes of such endeavors. The Center also will provide college students with the opportunity to have clinical nursing experiences in an innovative and futuristic health care environment that exposes them to new models of health care as well as to the changing health care environment.
We start from the perspective that numerous research studies have documented that nurses in advanced practice (nurse practitioners, nurse midwives, and clinical specialists at the Master's level of education) can provide 80% of all primary health care. Particularly with groups who are educationally or economically disadvantaged, nurses may provide better health care than other traditional providers. In a global context, such nurses would be the highest level community health care providers, leading teams of community workers to access the disadvantaged and geographically remote sites. Such systems of care require medical back-up. Information technology linkages would open the doors to many new possible approaches to health care in a global context.
The second part of this partnership is the Northeast Parallel Architectures Center (NPAC) which is engaged in the development of Web -based communication systems.
Building on the considerable experience of NPAC scientists in developing and exploiting leading-edge Web technologies, we will apply these technologies in three principal areas: a) patient record databases, b) the Bridge element of Warner's Distributed Medical Intelligence (DMI) scheme with significant contributions also to the Care Portal and Docking Station sites and c) medical, nursing and health care education.
Following the remarkable business model of NetScape, Sun (Java) and other highly successful companies in the current Web revolution, we intend to make our prototypical information, programs, and strategies largely public, so that we can obtain rapid feedback and attract collaborators.
We have begun to accumulate information from various sources on the Web and are continuing to search for additional sites and items in this rapidly expanding information universe. Our plan is to organize such collections of Web sites and listings of other information sources on a continual basis. This information will be accessible by search engines and directory index structures (by analogy, for example, with Yahoo). We will also take advantage of new features of Web browsers such as multiple interacting frames and Java applets, as well as Web Tools developed at NPAC by Research Professor Wojtek Furmanski. This information will thus serve as a "collaboratory space" not only for those working on the project in Syracuse but also for those we will attract to the project from elsewhere.
Using the approach just described, we will customize a Web server providing the essential health care information resources needed by school nurses (at Care Portals in the schools) and by nurse practitioners (at the Bridge site). These will include a) hypertext, indexed and searchable information of a general textbook nature, including multimedia aspects such as images and video clips and b) a patient record database for the student population. This database will include medical histories for the general population of students in the school, as well as detailed case histories and emergency information for "inclusion program" students with severe chronic medical conditions who have now been mainstreamed into the public school setting.
To enhance the resources described above, we will develop special tools including the "Neat Thing" (Warner et al) hardware/software interface to enhance the capabilities and lives of severely disabled students. This will be based on the successful Intervention Informatics developments by Warner and coworkers but now extended to the Web environment. We will also interface medical instruments, notably those manufactured by Welch Allyn, to computers and Web server that will enhance the ability of school nurses to recognize problems presented by student patients, and also to convey the images and the analysis thereof to the Bridge (nurse practitioner) and, as needed, to the Docking Station (SUNY HSC pediatricians).
Using Web technologies, which are rapidly evolving, we will develop a global network based on the Warner DMI model, as mentioned above. The network will be highly dynamic and extensible and will be manipulated and reconfigured continually with the aid of WebFlow visual authoring tools currently under development at NPAC.
Utilizing the health care expertise of nurse and physician faculty we will design care protocols which will be undergirded by expert knowledge bases. These will form the basis of the collaborative practice between the nurse practitioners and pediatricians.
Both the clients and school nurses will be the focus of educational efforts developed from the medical information acquisition and compilation designs. Consumer health education will be provided to children and families as appropriate to the problems which bring them for care. In lay language, but based on expert knowledge bases, consumer health education literature will be generated for common general situations and for individual specific situations.
Modules will also be developed from the expert information bases to educate the school nurses about the areas relevant to the clinical situation. Eventually these will be packaged in such a way as to be available for academic credit as well as continuing education.
II.Increase the case managing capabilities of school nurses and school nurse practitioners by providing technological links to informational and diagnostic programs available on the Web.
A. School health practitioners would have health care information retrieval capabilities from the Web.
B. Databases would be established for three major categories of health care needs in the school population.
1. Primary health care for the school-age child and young adult.
2. Primary health care for students with chronic health care needs.
3. Primary health care for students with severe handicapping conditions.
III.Establish the use of health care "data probes" allowing school nurse practitioners and physicians to formulate immediate diagnoses for the most common health care problems of children.
IV.Increase the availability and accessibility of school nurse and school nurse practitioner education programs.
A. Develop education programs that will enable school nurses and nurse practitioners to respond to their changing role as the primary health care provider of school-aged children.
B. Create educational opportunities within the College of Nursing, resulting in certificate and degree programs for school health nurses and school practitioners.
V.Increase the capability of School Health Practitioners to identify and store data and monitor health care information including electronic patient charting.
A. Establish linkages between schools and university data based research.
B. Establish outcome -based school health protocols which would maximize educational opportunities for all school-age children.
VI. Evaluate the impact of care provided by the linked system in terms of both clinical and cost parameters.
VII. Integrate the primary care of school children with systems of managed care.
VIII. Address issues of health care policy and financing as these effect the provision of comprehensive health care for children in schools.
IX. Educate beginning and advances practice nurses in futuristic and technologically supported systems of care.
I. Provide primary health care services managed by nurses and nurse practitioners with appropriate primary care medical back-up and support by subspecialty services for children with complex chronic illnesses.
II. Empower children to learn self-care, to develop a knowledge base for understanding their own health and to become responsible for their own health.
III. Provide health care at the school site where children are, expanded to include their family's needs and to gain the maximum involvement and support of their families.
IV. Integrate maximum utilization of existing resources, i.e. school nurses as care managers and first level providers and health education resources brought to bear on the problems of children's health.
V. Educate existing and new health professionals in creative, innovative approaches to health care.
VI. Integrate the maximum use of cost-effective technology to support the system of care and the measurement of cost and clinical outcomes and impact.
VII. Create ways to link effective health care for underserved children with emerging systems of managed care.
VIII. Link health care to available social services which address issues of the home environment and other factors influencing children's health.
We expect to present the project in May conferences as a demonstration.
We seek funding to develop the first three pilot schools as an
operating system to begin in September, 1996 and to expand the
system as funding is available.
Updated Version
4/2/96