Overcoming Documentation Challenges

In this video taken at the 2024 Psych Congress NP Institute, Julie Carbray, PhD, PMHNP-BC, APRN, Co-Chair, Psych Congress NP Institute, and Desiree Matthews, PMHNP-BC, Steering Committee, Psych Congress NP Institute, talk about the challenges that can arise in a clinical setting when it comes to documentation. Noting that maintaining proper documentation can be the cause of burnout for many clinicians, Julie and Desiree consider what role AI may play in managing clinical notes in the future.

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Julie Carbray, PhD, PMHNP-BC, APRN: Hi, I am Julie Carbray. I'm a clinical professor of psychiatry and nursing at the University of Illinois--Chicago, Department of Psychiatry and College of Nursing. Desiree?

Desiree Matthews, PMHNP-BC: Thank you, Julie. My name is Desiree Matthews. I'm a board certified psychiatric nurse practitioner. I'm owner and clinical director at Different MHP in Charlotte, North Carolina.

Psych Congress NP Institute: What are the major challenges in documentation, and what do you do in your practice to overcome these challenges?

Julie: Desiree, you know that one of the largest areas of burnout for us as mental health clinicians is the time we need to spend documenting what we do. It can be a real challenge trying to juggle our presence with the patient along with those challenges. We have some new things in the pipeline, and I know that you speak on this topic for us at Psych Congress and have some expertise helping us to think about how we can better do that, both to care for ourselves as well as to have the excellent documentation that we need for our patients. So some thoughts on that?

Desiree: Certainly Julie. I'd love to talk about that. So in my career, I've had a lot of opportunities to be able to help shape our electronic health record (HER) and notes and community mental health. I think we had gone through, while I was in community mental health for 8 years, we'd gone through 4 or 5 revisions of our template on our EHR, because collectively we would listen to the voices of our NPs, our PAs, and our doctors, and to really try to streamline and fix some of these issues. I laugh, I'm like, how many clicks does it take to send in a prescription? In fact, one doctor, he did count, he said 56 clicks.

Julie: It was that many?

Desiree: he counted, yes, he came on a meeting, he counted how many clicks, 56 clicks, how many clicks does it take to discontinue a medication?

Julie: Wow.

Desiree: Exactly. So certainly I think we've all been there, right, Julie, where we are in the afternoon, if we have to chart one more thing on the computer, we're at the end of our rope. It happens to us. But I do think there's some opportunities, again, when we consider our EHR, we really want that to work for us.

Julie: It should be a helper to us.

Desiree: We don't want to be working for the computer. So my biggest advice, whether you are in a large organizational system or maybe you're a solo entrepreneur, is really take the time to consider your own documentation style to consider the patients that you see, the operations, the support staff, and make sure when you're interviewing those EHR companies that you are asking questions, that you're not agreeing to the first phone call to sign up with them.

Julie: Right. Some of us are stuck with the EHR program that our systems have purchased, and what would you think about helping others to be able to capitalize on that system? I loved what you said about know your patient population, know what helps you to expedite your workflow with your EHR. How might you do that just in terms of things like smart phrases or getting to know that system that you're stuck with and getting it to work to maximum capacity for you as a clinician, what might you do?

Desiree: Certainly. So first, I would encourage clinicians to really, if there's somebody that you feel like, wow, they're always getting their notes done on time, they're leaving the office at 5:00 PM you don't see their notes outstanding. I would really encourage reaching out to that person and just seeing if you can get any tips or tricks. And I've done that a lot in my career and too, gave tips and tricks on what works for me. Because a lot of times we learn to document in terms and really the constraints that we have in the EHR, but also our experience with our preceptorship, like our clinical rotations--

Julie: That’s where we learn.

Desiree: Right, so we kind of get stuck in kind of maybe one mode if that's what we've seen. But also, as you mentioned, smart phrases. Some of these EHRs have macros. In some cases, check boxes and dropdowns can be our friend, in some cases. I think if it's just a bunch of check boxes, again, it's going to on cause some fatigue.

Julie: Yes, it depends on how many clicks.

Desiree: It also doesn't give context a lot of times to the actual patient. But I also think that things like artificial intelligence or AI might be able to come into play.

Julie: We all have a lot of hope for this, don't we? Wouldn't that just help so much if we were able to speak to something that then would be able to create our documents for us? Probably some advantages and then some concerns.

Desiree: So certainly with some of these new healthcare tech companies, they're really flourishing. They're popping up everywhere now. But I would say some of the advantages to AI is that at this time, it's fairly accurate. However, the problem is that these are two different pieces of software. So we have that AI and it's listening to your conversation, it's spitting out that note for you in real time. However, you still have to get that information into the EHR. If they're not able to talk to each other and integrate, then you're having to then maybe take what the AI more

Julie: Take more time to then integrate within your system, your templates.

Desiree: Exactly. You're kind of copy and pasting that into your template. And again, your template for your EHR really needs to be set up in a way that you can have a narrative note, because that AI is not going to, at least at this time, be able to check those boxes. So like a review of systems, the MSE, the AI is, not checking that box. So it would really, ideally for me, if I was going to solely use some of this ambient listening as they talk about for the AI to write your note, I would really honestly just have a blank page as my psych eval or my follow-up. And an ideal situation, I would have full integration. So that way I have my microphone, I'm talking just as I would with you with a patient, and I go back and, oh look, my note is there. That's the ideal situation.

Julie: Imagine a world, again, like the old days for myself, where I would see a patient jot some good note, put it away and done. Boy--

Desiree That would be wonderful

Julie: Wouldn’t it?

Desiree: I think there are some certainly concerns. I think a lot of my colleagues have brought up HIPAA concerns, privacy—are these things safe? Are patients going to be concerned about their privacy? So I would say that when you're looking at implementing AI, there's a few things to look for. Certainly reputable companies that have been in the game in terms of dictation for a long time. But if you also look in the backend, kind of the about, there should be a place where it talks about how that company is going to safeguard the information

Julie: From data breaches in this world of cyber hacks and data breaches, just how will those be managed and addressed so that there's confidence that confidentiality will be assured.

Desiree: Exactly. Is this going to be encrypted? Are the employees at that company trained in HIPPA? Do they have background checks? What happens to this data? Is it stored? Is it deleted? So these are some things to consider, and certainly looking through formal contracts, so business agreements between these companies so that from an operational standpoint, that you're covered and that you're keeping that patient's information safe.

Julie: Excellent points. Yeah, a lot of hope, but then also some caution,

Desiree: Certainly. So I hope this was helpful for your practice in terms of learning how to make sure that we document in a way that helps provide excellent patient care communication to other healthcare professionals, as well as to help support your billing and coding to ensure that you are getting reimbursed for the work that you're doing with your patients.

Julie: Yeah. Thank you so much for joining us. Look forward to hearing more tips and tricks from our experts in this area. Really trying to help us to be able to not only provide that excellent care, but attend to billing coding that really makes it necessary for us to continue to be there for our patients in meaningful ways.

Julie Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana. A clinical professor of psychiatry and nursing at the University of Illinois Chicago and the director of the Pediatric Mood Disorder Clinic, she has been practicing as a Psychiatric Nurse Practitioner for over 35 years.

Desiree Matthews, PMHNP-BC, is a board certified psychiatric nurse practitioner with expertise in treating patients living with severe mental illness. Beyond clinical practice, Desiree has provided leadership in advocating for optimal outcomes of patients and elevating health care provider education. Desiree is the founder and owner of Different MHP, a telepsychiatry practice founded with the mission of providing affordable, accessible precision focused, integrative psychiatry to patients through a rich and comprehensive mentorship of the health care providers within the company.

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