James Fitzgerald Therapy PLLC

YOUR INFORMED CONSENT IS NECESSARY FOR RECORDING BUT NOT DICTATION

The 3 AI companies I use are Blueprint; UpHeal; and TherapyNotes™ (TherapyFuel and TherapyScribe)

Therapy Fuel™, is a suite of powerful artificial intelligence solutions designed to supercharge my documentation. Therapy Fuel simplifies my workflow and gives me more time to focus on what matters most—my clients. As with all the features in Therapy Notes, the company prioritizes privacy by design to safeguard my client’s health records and personal data. Therapy Notes is currently working on their own version of an AI recording, transcription, and writing software. Some AI is separate from my electronic health records system, Therapy Notes. You are not required to give me consent to use Therapy Notes or Therapy Fuel. You are required to provide consent if I use software that records the session.

Vermont Statutes prevent me from recording telehealth sessions at all. I will however be using AI to dictate observations and transcribe the handwritten notes from the session into progress notes that meet all the legal, ethical, regulatory and health insurance policy requirements.

Some professionals have chosen to use an AI assistant that turns the recorded content and discussion of any session with a client into a note. Basically, a dictation device, that saves time and energy for the professional and subsequently for the client. If I ever decide to use a service like this, I will endeavor to be sure that any record of the session after the note is generated is not stored or transmitted in any way. I will be sure that the service signs a business associate agreement to protect your information. And I will also get your expressed permission to use such a service.

Recording sessions without your express written permission is a violation of your privacy and is a breach of confidentiality. I will not record our sessions without your expressed written and verbal permission. During credentialing and certification for some types of in-depth therapy like DBT, CBT, or IFS, I may be required to submit recorded sessions. In certain instances, I may ask clients if the session can be recorded for the purpose of evaluation only. Every effort will be made to protect your identity and health information if I do record sessions. I will provide any client with a written agreement to sign if I want to record their sessions.

Safe Use of Artificial Intelligence in Mental Health Counseling:

In the rapidly evolving field of mental health counseling, artificial intelligence (AI) is increasingly being employed to enhance the efficiency of session documentation and administrative tasks. This technology offers potential benefits, including time-saving automation of progress notes, enhanced accuracy in record-keeping, and more time for clinicians to engage directly with clients. However, the integration of AI into sensitive areas such as therapy sessions raises significant concerns about privacy and security. Ensuring the confidentiality and protection of client information is paramount, particularly under the Health Insurance Portability and Accountability Act (HIPAA).

AI in Mental Health: Opportunities and Challenges

AI can be utilized to record therapy sessions and assist in generating progress notes, treatment plans, and other essential documentation. This approach can potentially improve the accuracy of clinical records and help therapists capture nuances that may be missed in manual note-taking. Despite these advantages, the use of AI must be carefully managed to ensure it aligns with ethical standards and legal requirements, especially concerning client confidentiality and data security.

Ensuring Privacy and Security: A Multi-Step Approach

To safely integrate AI in mental health practices, counselors must adopt a comprehensive strategy focusing on privacy, security, and compliance with HIPAA rules. The following steps outline this approach:

• Consent and Transparency: Before implementing AI tools, it is crucial to obtain informed consent from clients. This involves explaining how AI will be used, what data will be recorded, how it will be stored, and who will have access to it. Clients should fully understand the purpose of using AI and how their privacy will be protected.
• Secure AI Integration: Choosing AI solutions that adhere to robust security standards is essential. This includes using AI tools that encrypt data both in transit and at rest. Counselors should select vendors that comply with HIPAA regulations and have a proven track record of safeguarding sensitive health information.
• Access Controls: Access to AI-recorded sessions and documentation should be strictly limited to authorized personnel. This includes using secure authentication methods to ensure that only the counselor and approved team members can access the information. Regular audits and logs of access should be maintained to monitor compliance and detect potential breaches.
• Data Storage and Protection: AI-generated documentation must be stored securely. This includes employing encrypted storage solutions and backing up data in secure locations. Counselors must ensure that their data storage practices meet or exceed the standards set by HIPAA for the protection of PHI.
• Training and Policies: Implementing AI tools requires updating existing policies and training staff to handle new technologies responsibly. Training should cover the ethical use of AI, understanding the technology’s limitations, and recognizing the importance of maintaining human oversight.
• Ongoing Evaluation and Compliance: Regularly reviewing the use of AI tools is critical to ensure they continue to meet ethical standards and legal requirements. This includes conducting periodic assessments of privacy and security measures and staying updated with changes in HIPAA regulations.

Consent to Record Psychotherapy Sessions for Creating Clinical Documentation

I am steadfastly committed to providing you with the highest quality of mental health services. This document outlines the policy regarding the use of audio or video recording during your counseling sessions and the subsequent transcription by artificial intelligence (AI) technology. Please read it carefully and let us know if you have any questions or require further clarification.

Purpose of Recording:

• To enhance the accuracy of clinical documentation needed for treatment planning and review.
• To comply with legal and professional standards governing our practice.
• Documentation is required for processing insurance claims and ensuring appropriate billing.
• For professional supervision and ongoing training to improve therapeutic skills and outcomes.

Technology and AI Utilization:

The recordings will be transcribed using advanced AI technology designed to convert speech into text. This technology assists in creating detailed and accurate clinical documentation promptly, which is essential for effective therapy management and compliance with regulatory requirements.

Confidentiality and Data Protection:

• All recordings and transcriptions will be handled with the utmost confidentiality and will be stored securely in accordance with HIPAA regulations and state laws.
• Access to these recordings will be restricted to authorized personnel only, such as your therapist, supervising clinicians, and administrative staff involved in billing and compliance.
• No third party will have access to your recordings without your express written consent, except as required by law.
• Recordings will be retained as long as legally required and then securely destroyed.

Privacy Policy

James Fitzgerald, LCMHC (“we”, “us” or the “Healing Professional”) provides mental health services to clients (“you”). To provide consultations (our “Services”), we need to collect some of your personal data. We act as a data controller and processor of your personal information. This Privacy Policy (the “Privacy Policy”) is intended to inform you about our practices regarding the collection and use of your data that you may submit to us through our website or Zoom integration.

We process your data with due care, in accordance with all applicable laws and regulations, including the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), regulation (EU) 2016/679 of the European Parliament and of the Council, the General Data Protection Regulation (the “GDPR”), the California Consumer Privacy Act of 2018 (the “CCPA”), the Personal Health Information Protection Act (the “PHIPA”) and any applicable data protection regulations.

What Personal Data is Processed by James Fitzgerald Therapy and the AI software?

• Identifying data: Name and pronouns
• Recording: Audio recording of the in-person session. Digital transcription of hand written notes.
• Usage data: Session date and time, length
• Health data: Session transcript & insights, audio of in person sessions, and clinical notes
• Treatment plans: Problems, assessments, long term goals, objectives, interventions
• Progress notes: progress toward goals, completion of objectives, assessments, and outcome measures
• Specific data: themes, topics, experiences, and events processed and discussed with the Healing Professional in the provision of services

Why is your data used?

The audio recording process lasts for the duration of the session. The audio recording is then transformed into text data with speech to text technology. The data is the processed and analyzed, then turned into a transcript, session notes, analytical data, and progress notes. The data is used to make the documentation process easier for the clinician, which benefits you as the client, so your clinician is not trying to write notes during the session. This can sometimes be a distraction for some clients. The software collects limited identifying data, personal details discussed in the session, and usage data. The data adheres to legal standards as it pertains to the performance of the therapy agreement. Protected Health Information (therapy session transcript & insights, progress notes, treatment plans, assessment results) is collected and stored for documentation purposes.

This process can only be implemented legally speaking, with your signed written consent, and verbal consent before each session starts. Your failure to provide such data will result in the inability of me to use the software application and provide you with the enhanced counseling service, but in no way affects the therapeutic relationship. The audio recording is erased immediately and the text data is stored in the AI servers for 6 years, or until deleted by the clinician. The data is typically transferred to the clinician’s electronic health records management software within two weeks and deleted from the AI servers.

It is always optional to provide the consent for the storage of the audio recording. The data is stored in the AI servers for 6 years. But you can always withdraw your consent at any time during sessions and the recording will be deleted immediately.

How is your personal data used?

During the provision of Services, the Healing Professional collects and processes the following data:

• Identifying data and any other data that identifies you, provided by you voluntarily, to provide the service.
• Session insights including notes based on what’s discussed during sessions is stored in analytical data.
• Using AI, a transcription, session summaries, treatment plans, analysis, and insights of the conversation will be generated.
• As a benefit, your clinician will not spend time writing notes in the session and can focus on being there for you, present and attuned.
• The recording of the session will not be stored unless you express your consent before starting each session.

Who can access your personal data?

Your data can be accessed or communicated to:

• Processors: hosting providers, suppliers of IT services and application software public or private bodies to whom it might be necessary to disclose the data provided there is a business associate agreement between the parties. The non-exclusive sub-processors of your data include: Upheal AI, Inc.; Blueprint AI; Zoom Pro Workspace; and Therapy Notes LLC (TherapyFuel™)
• Disclosure for Law Enforcement: your personal data can be disclosed outside the scope of these provisions only as required to do so by law or compelled by court, government or administrative agency of competent jurisdiction. Personal data from users may be subject to federal and local laws that require the disclosure of data in certain circumstances.
• 3rd parties upon your request: your personal data, including medical and behavioral information, can be shared with other healthcare providers or any other individual or entity that you instruct me to inform via a signed authorization to release HIPAA protected health information.

Where is Your Data Processed?

Some suppliers (IT services, hosting providers) operate in Europe and others in the US. Therefore, It is possible that your data will be processed outside of your country/region. The Healing Professional only utilizes suppliers who meet adequate security safeguards, and therefore if a data transfer only takes place in the presence of security and data protection standards provided for by the applicable law.

How are You Supported in Dealing with Data Subject Rights?

If you are from the European Union, Switzerland or UK remember that you can:

• access and correct your data
• obtain the erasure of your personal data under certain circumstances
• restrict the processing of your personal data
• withdraw your consent at any time
• receive a copy of your personal data or ask your Healing Professional to transmit that data to another controller, where technically feasible
• lodge a complaint with the supervisory authority of your country in case you think that your rights have been breached.

If you wish to exercise one of these rights, you can write to

• James Fitzgerald at vttherapist@jamesfitzgeraldtherapy.com.
• James Fitzgerald Therapy, PLLC
• 86 Lake Street, Suite 311
• Burlington, VT 0540

Remember that under HIPAA you can always request access and amendment of your data.

If you are from California, remember that the CCPA provides California consumers with specific rights regarding their personal information. This section describes your CCPA rights and explains how to exercise those rights.

The Right to Know:  You have the right to request the disclosure of the personal information collected, used, disclosed or sold about you in the previous twelve (12) months. You may also request a copy of the personal information collected on you over the past twelve (12) months.

The Right to Deletion: You have the right to request the deletion of any of your personal information collected from you and retained, subject to certain exceptions. Once your verifiable request is received and confirmed, your healing professional or entity will direct service providers to delete your personal information from any records, unless an exception applies.

AI Transcribed Notes

All the software I use offers advanced transcription services tailored to meet the rigorous documentation standards required in the mental health care industry. This service is invaluable for clinicians who need to convert their session notes into detailed and insurance-compliant progress notes, ensuring accurate and thorough records without the burden of extensive manual documentation.

For sessions that are not recorded, whether conducted via telehealth or in person without the client’s consent for recording, the AI provides transcription services for handwritten or typed notes. Clinicians can upload these notes, and the AI will transform them into comprehensive progress notes that adhere to industry standards. This process ensures that all necessary details are captured and documented properly, facilitating smooth insurance claims and maintaining high-quality clinical records.

When it comes to recorded audio from in-person sessions, the AI offers a secure and efficient solution. Clinicians can upload the audio recordings of their sessions, and the AI transcribes these recordings into detailed progress notes.

Importantly, once the transcription is complete, the audio recordings are immediately deleted from the clinician’s devices and the AI’s servers. This practice ensures the confidentiality and security of client information, aligning with best practices for data protection and privacy.

Similarly, for audio recordings from the clinician alone, the AI provides a secure transcription service. After the clinician uploads the audio recording for transcription, the service generates detailed progress notes. As with client session recordings, these clinician-only audio recordings are promptly deleted from devices and the servers after transcription. This approach guarantees that sensitive information is not stored longer than necessary, maintaining the privacy and security of both client and clinician data.

The service ensures high standards of documentation while maintaining strict confidentiality and security protocols by deleting audio recordings immediately after transcription. This solution allows clinicians to focus more on client care, confident in the knowledge that their documentation needs are being expertly managed.