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Featured topic and speakers
What is an extreme risk order? How many states have ERPO laws? What are the criteria for an ERPO? Do ERPO laws work?
AMA Chief Experience Officer Todd Unger is joined by two guests from Johns Hopkins University. Spencer Cantrell, JD, is an assistant scientist of health policy and management at the Johns Hopkins Center for Gun Violence Solutions. She is also the co-lead of the National ERPO Resource Center. Katherine Hoops, MD, MPH, is an associate professor of pediatric critical care medicine. She also represents critical care medicine on the AMA Firearm Injury Prevention Task Force.
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Speakers
- Spencer Cantrell, JD, assistant scientist of health policy and management, Johns Hopkins Center for Gun Violence Solutions; co-lead, National ERPO Resource Center
- Katherine Hoops, MD, MPH, associate professor of pediatric critical care medicine, Johns Hopkins University
Transcript
Dr. Hoops: There isn't a clinician I know that wouldn't invest whatever time is needed to do everything they felt they needed to do and could do to save their patient's life.
Unger: Hello and welcome to the AMA Update video and podcast. Today, we're talking about extreme risk protection order laws, or ERPO laws, and what physicians need to know about them. Here to discuss this topic are two guests from Johns Hopkins University.
Spencer Cantrell is an assistant scientist of health policy and management at the Johns Hopkins School for Gun Violence Solutions. She's also the co-lead of the National ERPO Resource Center. And Dr. Katherine Hoops is an associate professor of pediatric critical care medicine. She also represents critical care medicine on the AMA Firearm Injury Prevention Task Force. I'm Todd Unger, AMA's chief experience officer. Spencer, Dr. Hoops, welcome.
Cantrell: Great to be here.
Dr. Hoops: Thanks for having us.
Unger: Spencer, why don't we start with you? Give us a brief overview of what ERPO laws are and what states have them.
Cantrell: Sure. So ERPOs, or extreme risk laws, also commonly referred to as red flag laws, are civil court orders that restrict firearm access by removing firearms from someone who is at risk of harm to themselves or others and prohibiting them from obtaining firearms for the duration of the order. So 21 states, the District of Columbia and Virgin Islands have these laws in place. And six states and the District of Columbia physicians can file for an ERPO. So that's DC, Hawaii, Maryland, Connecticut, New York, Colorado and Michigan. And again, these are civil orders typically good for one year just to remove that firearm access.
Unger: Spencer, can you talk a little bit more about why these laws are such an important tool in preventing firearm injuries?
Cantrell: Sure. So ERPOs have been around for about 10 years now. And the research is overwhelmingly positive about what an effective intervention they are at reducing the risk of violence.
So research shows that for every 17 to 23 ERPOs issued, a suicide is prevented. But we also are seeing ERPOs being used in response to a variety of threats—to threats of mass shootings, political violence, domestic violence—in addition to suicide. And so these are great orders that are civil, not criminal, so that you can prevent violence before anything happens.
Unger: Now, Spencer mentioned in some states that physicians do have a role in ERPOs. Of course, that varies state by state. Dr. Hoops, can you tell us a little bit more about that role, another thing we're asking physicians to do?
Dr. Hoops: Yeah, sure. I think the first thing is that the role of a clinician is going to vary as the state's policy varies. So in any state with an ERPO law, a concerned clinician can work with law enforcement to petition. In states with family-initiated petitions, clinicians can work with a family member to petition. And in that handful of states that Spencer mentioned with clinician-initiated petitions, physicians or an assortment of other clinician types can also petition directly for an ERPO.
But I think if the question is what's a clinician's role in ERPO, I think maybe their most important role is actually their role as an educator once they themselves have sufficient knowledge and familiarity with ERPOs—or I think clinicians are really uniquely positioned to assess risk and to help patients and families understand and respond to risk. And sometimes, that'll include petitioning for an ERPO. But maybe much more often, that includes discussing safe and secure storage and heightened protections to restrict access to lethal means if there is a risk of suicide, for example.
So if a patient is at great imminent risk of harm in the states that allow clinicians to petition directly for an ERPO, clinicians can do so by following the guidance in their states to submit the necessary information and attend hearings. And as you can imagine, that requires some familiarity with the system and a substantial investment of time to attend, potentially, two or more hearings and complete the necessary documentation.
So I think the—what we see more commonly is that clinicians in their role as educator, as patient advocate—they're working with families to support a family member to be the actual petitioner for an ERPO if the state law affords that possibility.
Unger: Dr. Hoops, before we talk any more about this, I'm just curious—I speak with a lot of different physicians. They're on a lot of pressure, a lot of time pressure. How do you integrate something like this into the physician practice here? Do you have any advice or best practices to share about how physicians can navigate their role in ERPOs?
Dr. Hoops: I think it is a big investment of time, potentially. But at the same time, there isn't a clinician I know that wouldn't invest whatever time is needed to do everything they felt they needed to do and could do to save their patient's life. But we do want to find more ways to make this feasible for clinicians, especially as more states adopt ERPO laws that include clinicians as petitioners.
So one way to do that, like I mentioned, is to work with another eligible petitioner, such as a family member, to do the petitioning. But another way that members of our team in Baltimore are studying and implementing is the role of, essentially, an expert consult service for ERPOs.
So in a model that's based on child protection teams devoted to child abuse and neglect in pediatrics, those teams serve as consultants in the hospital and in outpatient settings to assess cases of suspected child abuse and neglect and then work with local child protection agencies and the courts to provide expert clinical knowledge that will inform decisions about child welfare and safety. And in the case of ERPO, a qualified clinician with special training on implementation of ERPOs can be consulted by a concerned clinician or a clinical team to assess the degree of risk and then provide those necessary services.
So they come in. They can establish a clinical relationship with a patient and ascertain the imminence of the risk and the potential risk posed by access to firearms. And they establish a clinical relationship with that patient in order to do that. And in some cases, there isn't a grave imminent risk of harm to a patient and there's a less restrictive means of lethal means safety that can be safely recommended.
So in our program, these clinicians are trained to offer that full spectrum of services, from safe storage counseling, including providing safe storage devices to patients, up to and including petitioning directly for an ERPO and then following through with whatever next steps are needed for the petitioning process, including hearing—participating in those hearings. And we think this is a really a really promising model that will help to support clinicians through this process.
Unger: Dr. Hoops, if physicians want to learn more about ERPO laws, where should they go?
Dr. Hoops: Oh, man. There's a lot of great resources. Spencer mentioned a lot of the emerging evidence supporting the use of ERPO. But certainly, I would want to highlight the incredible work of Spencer and the whole team in compiling and creating resources for erpo.org for the National ERPO Resource Center.
There's a special field, a special page, dedicated to clinician materials. And I think if I could highlight just one resource, I think, that really responds well to a lot of clinicians' concerns about privacy, there's a link to a summary of the HIPAA privacy rule specifically as it relates to ERPO that I think is maybe of interest to a lot of listeners who might have heard or experienced some degree of concern about that. But just as a spoiler, it is lawful to disclose information in response to a court order or if you suspect that there's a great risk to your patient's health or safety.
Unger: And we'll include information about that resource in the description of this episode. Spencer, before we wrap up, I'd love it if you could tell us a little bit more about the Johns Hopkins Center for Gun Violence Solutions and some of the work that you're doing there.
Cantrell: Sure. So at the Center for Gun Violence Solutions, members of the center work on firearm policy and implementation and research around the country—so channeling that research into policy solutions.
Within that umbrella, we have the National ERPO Resource Center, where we work to provide training and technical assistance to ERPO implementers around the country. So I am often on the road, working with judges, law enforcement, prosecutors, attorneys, behavioral health providers, physicians, working on ERPO implementation. So we are here to be a resource.
If folks have questions, I encourage them to go to erpo.org. We're happy to provide free training and technical assistance, webinars, presentations, to be a resource and support implementation, and share best practices in this ERPO work.
Unger: Thank you. And Dr. Hoops, tell us a little bit more about your involvement with the AMA Firearm Injury Prevention Task Force and how that work supports the efforts that we've been talking about today.
Dr. Hoops: First, just a tremendous gratitude to the AMA for convening the Firearm Injury Prevention Task Force, leveraging the reach and impact of the AMA to amplify this message that gun injuries and gun violence are a public health crisis in which clinicians play a critical role.
So the task force is this awesome collaborative group of leaders in the field representing numerous disciplines and professional organizations. And so, my personal expertise is in developing tools to support clinicians implementing safe and secure storage counseling and programs.
But I get to work closely with my colleagues, like Spencer, on that spectrum of lethal means safety and safe storage, up to and including ERPO at times. And so that work I get to share on the task force, especially the ERPO National Resource Center, so that all of these tools, like the ones we've talked about today, can be made more widely available to clinicians across the country.
Unger: Well, Spencer, Dr. Hoops, thank you so much for joining us today and for everything that you're doing to educate physicians on this important issue. If you found this discussion valuable, you can support more programming like it by becoming an AMA member at ama-assn.org/join.
That wraps up today's episode. And we'll be back soon with another AMA Update. Be sure to subscribe for new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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