As a Joint Commission-accredited facility, Coffeyville Regional Medical Center in Coffeyville, Kansas, recognizes the importance of assessing and identifying patients at risk for suicide.

THE PROBLEM

While working to create documentation on the matter, staff learned about their electronic health record vendor Meditech's impending Depression Screening and Suicide Prevention Toolkit. In addition to satisfying the Joint Commission's requirements, staff learned this toolkit would help its clinicians make informed decisions about suicidal patients.

"We were concerned with how to perform additional screenings for depression and suicide risk on every patient," said Amber K. Beaumont, RN, clinical analyst at Coffeyville Regional Medical Center. "Patient and clinician time is very precious, and adding two multi-question screening tools seemed like a daunting task. That is why we were so excited to hear that Meditech was working on a tool kit that would address depression and suicide risk screening."

PROPOSAL

Meditech proposed to have their toolkit development team work with their in-house physicians and nurses to develop a workflow that would allow for the streamlining of screening patients in the emergency department and ambulatory settings. Included in these workflows would be embedded clinical decision support.

"The proposed solution would start with screening all patients with the PHQ-2 depression screening, as well as the ninth question from the PHQ-9, which addresses suicidal ideation," Beaumont explained. "If the patient indicates that they're suicidal, the system would automatically trigger a follow-up assessment, the C-SSRS."

"The workflows introduced with this tool kit include conditionally requiring questions, which allows the nurses to ask only the questions that are indicated by the patient's answers."

Amber K. Beaumont, RN, Coffeyville Regional Medical Center

Throughout both screenings, clinical decision support would drive the user to answer only the questions indicated. The results of the PHQ and C-SSRS screenings would then be broadcast throughout the chart so that other clinicians can act accordingly.

"In the background, for office patients, CPT code 96127 will automatically be sent to billing for review if the full PHQ-9 is done and/or the C-SSRS is completed," said Al Monteiro, IT consultant at Coffeyville Regional Medical Center.

"Additionally, in the office setting, workflows will be designed to prevent double documentation for the CMS 2 MIPS measure. It was clear from the start that Meditech's tool kit development team had done excellent research and were very prepared with the workflow designs that they were proposing."

MARKETPLACE

There are many vendors with electronic health records systems on the health IT market, including Allscripts, athenahealth, Cerner, DrChrono, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.

MEETING THE CHALLENGE

The most significant and successful aspect of the Depression Screening and Suicide Prevention Toolkit is the clinical decision support, Beaumont reported.

"The workflows introduced with this tool kit include conditionally requiring questions, which allows the nurses to ask only the questions that are indicated by the patient's answers," she said. "If the patient is not depressed or suicidal there are far fewer questions that need to be asked. View-only explanations of those questions, so the nurses know how to better ask the questions, also are provided."

The scores and risk levels then are broadcast through the chart so that during physician review, they not only have the results of the screening, but also interpretations of those screenings, she added.

"In the emergency department and inpatient settings, nurses are screening the patients," she noted. "The results then are being broadcasted to the physician screens so they have all the relevant information in real time. This has allowed us to make sure that patients who have come into the facility with unrelated complaints are still treated for depression and suicidal ideation."

Throughout the implementation of the new workflows, staff relied on the expertise and guidance of the Meditech tool kit development team. The team provided leadership, project planning and technical support throughout the project.

"By using required questions for our depression screening in the clinics, we ensured that our clinicians would not be able to bypass this screening without providing a valid reason," Monteiro explained. "We also made it mandatory to document follow-up, while helping with clinical decision-making as well as ensuring we are providing optimal patient care.

"The clinical decision support that Meditech's tool kit built into the system allowed for the screening process to be automated," he continued. "The nurses are taken from question to question, skipping those that they do not need to ask, if they are not indicated based on previous responses. Their responses then flow over to the physician, who can expand on them."

The population health tool in use, Meditech's Patient Registries, has also helped Coffeyville Regional with follow-up care and patient management after screening is done, and between patient visits. The tool helps staff track which patients are diagnosed with depression and what is being done as part of their care.

"This technology was able to be embedded directly into the existing workflows, so it did not add any extra burden in terms of jumping to other screens, or using tools they were unfamiliar with."

Al Monteiro, Coffeyville Regional Medical Center

"Thanks to our success with the depression registry, we have actually been inspired to start using additional Meditech patient registries, such as chronic care management, as we have seen what these tools can do to help us better manage these patient populations," Monteiro said.

The tool kit development team was instrumental in ensuring staff was comfortable with the new patient registry technology, as well as ensuring that CPT codes and MIPS nomenclature were mapped properly, he added.

RESULTS

"First and foremost, within the first month of implementation, Coffeyville caught five patients at risk for suicide who may have not been detected otherwise," Monteiro reported. "We were then able to get them the help they needed. This helped drive buy-in throughout the organization.

"In addition to adding the screening tools, the workflows are synced up with the MIPS CMS 2 measure for office patients," he continued. "Prior to implementing the toolkit, Coffeyville was not attesting for this measure, but within a month we had reached an attestation rate of around 20%. After about 10 months, the attestation rate increased to 67%."

Coffeyville Regional also was able to embed CPT code 96127 within the ambulatory workflow. This has resulted in approximately $800 per month in additional revenue prior to the pandemic that may not have been billed for in the past.

ADVICE FOR OTHERS

"I highly recommend organizations use such clinical decision support tools, because it makes the nurses' workflow more efficient," Monteiro advised. "It assisted us in refining how questions were being asked, prevented unnecessary questions from being asked, and [achieved] results immediately. This technology was able to be embedded directly into the existing workflows, so it did not add any extra burden in terms of jumping to other screens, or using tools they were unfamiliar with."

Patients who never would have brought up questions about their mental health were prompted to have the conversation with their healthcare providers and received the care that they needed because of this technology, he added.

"Having clinically validated and proven tools such as the PHQ-9 and C-SSRS, which previously were done on paper, embedded directly in the software is extremely valuable," he said.

Beaumont said she encourages all organizations to take part in implementing a screening tool that does not just include suicide, but also addresses depression.

"Many patients at suicidal risk are overlooked when depression is not evaluated," she concluded. "The importance of this screening is life-worthy. It doesn't make sense why a couple of questions can't be introduced to the patient encounter that could have such a dramatic impact on their future mental health. This is an area of patient safety that is often overlooked and was so easy to address using this technology."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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