Artificial Intelligence (AI) is an electronic tool that can be used for a variety of purposes, including to create progress notes from data it is given about the session. AI programs include ChatGPT, Orchid, Mentalyc, SessionAid, Clinical Notes AI, Berries, Blueprint, Yung Sidekick, and Upheal.

Since I know almost nothing about using Artificial Intelligence (AI) for documentation, I turned to Maelisa McCaffrey Psy.D., founder of QAPrep.com, and author of Stress-Free Documentation for Mental Health Therapists, a fellow documentation expert who has researched AI programs.

According to McCaffrey, there are a few ways to use AI for progress notes. Either the AI program kind of logs in and listens to your telehealth session, or you record your session, upload the recording, then AI writes a note. Or you can just enter the information from what happened in your session, and then AI writes a note from that. Some programs also offer dictation.

“People who are struggling with paperwork are really excited about AI,” says McCaffrey. “I hate to shatter their dreams, but AI is not going to be your silver bullet to getting progress notes written magically, quickly and perfectly … it isn’t going to do your notes for you.”

“And it’s just not going to save you the time you thought it would,” she says. McCaffrey states she was surprised how long AI these programs took, often taking as much as 10-15 minutes to create a note (though she noted the exception of ChatGPT, which at the time of this writing is not HIPAA compliant). “If you have to enter that session data into an AI platform, you have already taken up as much time as you would just writing the note on your own. Then you have to wait for the program to produce the note. And then you have to review and edit each note, because every single one I have tested so far has added things that did not happen in the session. Then you might be copying and pasting the note into your Electronic Health Record. And I can teach therapists to write a note faster than that.”

Another concern McCaffrey expresses is that AI may not be able to weigh the complex factors necessary to write a progress note to please insurance. When writing the note, can AI consider how the session aligns with the client’s treatment goals, symptoms, and diagnosis, defend the medical necessity for treatment, and comment on therapy progress? “While some AI programs are ‘trained’ to look out for medical necessity, they may then create inaccurate or false information to meet that criteria,” she says.

McCaffrey stresses that “an AI platform doesn’t take the place of an Electronic Health Record (EHR) or other client record-keeping system that keeps track of a full client record.”

McCaffrey also points out that you need a HIPAA-compliant AI platform, and some AI platforms that claim HIPAA compliance really aren’t. Be sure to get a Business Associate Agreement (BAA). It’s also important to note that you may ethically or legally be required to advise clients if you are using AI to create your notes. “And if the AI platform is recording the session, some states require separate consent related to recording sessions,” she says. “Most ethical guidelines would direct us to at least review this fact with clients, along with what we plan to do with the recording once the note is completed.”

Also, she says, “consider what happens to the information in the AI platform. Now you have progress notes, and potentially full transcripts and/or recordings of sessions, located in a different electronic system. Does the AI platform delete that information, or do you?” It is likely clients will have access to that if they request their records, so “make sure to ask how long information is kept in the AI platform, how to delete information, and have a policy around this for your practice.”

But overall, McCaffrey says this: “if it works for you, it works for you. It’s still so new, and changing constantly. I think we will see more and more AI platforms integrated into our EHRs. And AI programs will only get more sophisticated and perhaps able to better reflect a therapy session.” So, her advice? “AI is here to stay. So, don’t shy away from it. See if it works for you, figure out if you feel comfortable with it and how to use it, and how to do that in an ethical way.”