How Electronic Health Records Can Help Prevent Suicides

Electronic health records (EHRs) facilitate immediate feedback to healthcare providers and offer ways to identify and track potentially suicidal patients. Using EHRs, with the involvement of primary care providers, in suicide assessment and prevention may significantly help identify suicidal patients who are not actively seeking mental health treatment and ultimately reduce overall suicide rates. Understanding the major effect that training and EHR decision support can have on suicidality, the Institute for Family Health, a not-for-profit community health center network located in New York, launched a two-prong approach striving for a zero suicide rate in the populations it serves.

Partnering with the Mental Health Association of Ulster County and Dr. Max Banilivy, the Institute set upon a mission to train its entire staff using the evidence-based models SAFETALK and ASIST. In 2008, the Institute implemented a policy mandating suicide prevention training for every employee. All staff, regardless of discipline or position, must participate in at least one of the trainings: behavioral health staff participate in the two-day ASIST training and all other staff attend the 3-hour SAFETALK training.

The Institute’s second initiative was implementation of the EHR system Epic (Epic Systems, Verona, Wisconsin) 10 years ago for the identification and assessment of patients at risk for suicide. While the Institute implemented Epic, it simultaneously launched a depression identification and treatment program, making it the first organization to build the PHQ9 depression screening tool into their EHR, scoring it as a lab value. When the PHQ-9 score is a 10 or above, it is added as an abnormal lab value in the EHR, which then alerts providers to the patient’s potential risk. Many organizations only flag scores over 10 as an alert; the Institute took it one step further, adding the additional indicator of using a decimal point score for how a patient answers on question 9 (Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself?), which better alerts staff to the patient’s thoughts of suicide. While electronic health technology and the use of the PHQ-9 has advanced since that time, the Institute maintains one of the country’s highest screening rates at almost 90%.

Now, the Institute requires that all patients who respond positively to the PHQ-9 suicide screening question have “suicide risk” put on their problem list, which means it is visible to all providers who see the patient regardless of discipline, and it is “blown in” to each provider’s note, automatically bringing immediate attention to the patient’s risk for suicide. Staff are required to ask the patient if they are at risk. Then, they must develop and review the safety plan and, if necessary, seek mental health support if they are not a mental health provider.

A safety plan has been built into the EHR that is designed to be completed concurrently with the patient and can be printed individually or as part of an after-visit summary for the patient. As part of a comprehensive suicide prevention program, the Institute developed policies that require direct care staff of any discipline to address suicidality during all interactions.

Population of focus: Adults in a community health center or hospital

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Organization: Institute for Family Health