Case Objectives

• Understand the legal and regulatory obligations to provide language access services for patients with limited English proficiency.
• Recognize the risk of communication and clinical errors and how that risk can be mitigated by working with qualified professional interpreters.
• Weigh the advantages and disadvantages of different interpretation modalities.
• Learn best practices for working with an interpreter in clinical practice.

The Case

A 56-year-old Spanish-speaking woman with a complicated medical history presented to the preoperative clinic for evaluation in advance of a scheduled elective total abdominal hysterectomy and bilateral oophorectomy. The electronic health record indicated that the patient required a Spanish interpreter to communicate with health care providers. A non–Spanish-speaking physician met the patient and discovered that no in-person interpreter had been booked in advance of the visit.

The provider attempted to use the clinic's phone interpreter services, but the phone reception in the exam room was poor and the interpreter and patient could not hear each other. The patient tried calling her husband to interpret, but he was unavailable. Eventually, a Spanish-speaking medical assistant was able to interpret for the visit. The provider learned that the patient was having symptoms concerning for unstable angina and determined that the patient would require additional cardiac testing before proceeding with the elective surgery. The visit had been booked for a 30-minute slot but took more than 75 minutes. The patient obtained the necessary cardiac follow-up and her surgery was rescheduled.

After the visit, the physician investigated the situation further and discovered that the interpreter phone line receiver was located at the opposite end of clinic, which likely explained the poor reception in the exam rooms. Additionally, the interpreter phone shared a line with the fax machine. Although the physician had previously been able to use her personal cellphone to access the interpreter services company, the practice had recently switched vendors and she did not have their access number. Furthermore, the clinic did not have a formal process in place designed to identify non–English-speaking patients in advance of their visits and to ensure that in-person interpreters were booked for those visits.

The Commentary

Commentary by Leah S. Karliner, MD, MAS

Communicating across language barriers is a challenge for clinicians and health systems. In the United States, approximately 20% of the adult population speaks a language other than English at home; of this group, almost half report speaking English less than very well and are considered to have limited English proficiency (LEP).(1) For those with LEP, Spanish and Chinese are the most common preferred languages, but hundreds of additional languages are in use throughout the US. In health care, bridging the language barrier is necessary to avoid clinical errors, provide patient-centered care, and comply with legal and regulatory mandates.

Legal and Regulatory Requirements

Federal law requires linguistic services for patients with LEP. Title VI of the US Civil Rights Act states that people cannot be discriminated against as a result of their national origin, race, or color, which has been extrapolated to include primary language by the US Office for Civil Rights and Department of Health and Human Services. In addition, health care organizations that receive federal funds—most do in the form of public insurance payments (Medicaid or Medicare)—must provide services in a language that a patient with LEP can understand.(2) The Joint Commission, the main hospital accreditation body in the US, requires that hospitals collect and record patients' preferred languages for discussing health care and have included in their standards the use of qualified medical interpreters for patients whose preferred language is not English.(3)

Professional Interpretation

Poor-quality communication between patients with LEP and clinicians leads to decreased medication adherence (4,5), diminished patient satisfaction with care (6,7), less patient-centered care (8), and negative clinical experiences.(9) Poor communication contributes to errors and health disparities for this vulnerable population. Professional interpreters improve communication, promote appropriate use of resources, and significantly increase patient and clinician satisfaction.(10) The use of professional interpreters has been shown to result in fewer errors in communication (11), reduce disparities in utilization of services (12), and improve clinical outcomes.(10) Language interpretation requires a specific set of skills, including bilingual fluency and the ability to switch fluidly between two languages while interpreting the meaning and tone of what has been said from one language to another.(13) The challenges inherent to this task contribute to the potential for errors in interpretation. Multiple studies have demonstrated that the error rate for professional interpreters is considerably lower than that of ad hoc interpreters (untrained family, friends, or staff), and when errors are made, they are less likely to be clinically significant.(11,14-16) Clinicians can also help reduce the chance of errors by learning and practicing the skills needed for successful patient encounters when using professional medical interpreters (Table).

Interpretation Modality

The best modality for accessing professional interpreter services depends in part on the needs and resources of a particular health system or practice. In-person professional interpretation is the most studied interpretation modality and has been demonstrated to improve satisfaction, processes, and outcomes of care.(10) It allows the interpreter to incorporate visual cues to enhance communication. In fact, professional interpreters report better understanding of patients' social and cultural backgrounds and greater ease facilitating rapport when interpreting in-person.(17) However, in-person interpretation has drawbacks, such as limitations on the number of languages a health system can staff efficiently and time constraints on staff availability (particularly with fluctuations in demand and need to travel from one location to another between clinical encounters), which can hinder both access and efficiency. As a result, while solely relying on in-person interpreters will provide high-quality communication for patients who receive these services, it may actually reduce access for a large proportion of patients requiring services in the health system. Thus, mixed use of multiple modalities may be a more ideal strategy, particularly for larger health systems.

Remote interpretation (telephonic or videoconferencing) increases access and efficiency by allowing for economy of scale, whether utilizing a health system's own staff in a call-center type environment or with staff from a contracted service provider. Both approaches reduce travel time between locations, downtime for professional interpreters waiting for physicians to see a patient, and wait time for patients.(18) Remote interpretation also allows for on-demand access without scheduling, a particularly important component of a language access service program for emergency and hospital settings.

In addition to using a ubiquitous, familiar technology, telephonic interpretation greatly increases professional interpreter use, particularly in environments that previously had limited access to professional interpreters.(19,20) Patients also prefer telephonic interpreting over ad hoc interpretation.(21) However, the data on satisfaction with communication comparing telephonic and in-person interpretation are mixed, and greater satisfaction with one over the other may be related to other factors such as wait times and ease of access as well as professionalism of the interpreter.(22-24) Interpreters themselves report telephonic interpretation to be equally good as in-person interpretation for simple information exchange, but less satisfactory for interpersonal aspects of communication. In clinical encounters with extensive psychosocial or educational content, interpretation via videoconferencing is considered better than over the telephone.(17)

Videoconferencing, also known as video medical interpretation (VMI) or video remote interpretation (VRI), has the advantage over telephonic interpretation of preserving visual cues, and it provides the ability to conduct visually based teaching, such as for wound care or use of injectable medications. Both clinicians and patients report the quality of VMI/VRI as equal to in-person interpretation, although in-person may still be superior for understanding cultural nuances.(25-27) Interpretation error rates for VMI/VRI are significantly lower than for ad hoc interpretation and appear equal to rates for in-person interpretation.(15)

Technology

As videoconferencing technology has evolved to encompass sharper visuals and high-quality audio on less bulky equipment, the uptake of this technology for professional interpretation has increased. The development of VMI/VRI for shared public sector networks, along with the entrance of private service providers into this market, has begun both to expand the languages available and reduce the cost of videoconferencing interpretation. However, health systems still need to invest in high-quality equipment and should not rely on physicians using personal cellphones, for example, to attain the expected good outcomes from VMI/VRI use and to maintain privacy of protected health information.

Internet-based applications for smartphones and tablets continue to emerge in this space but remain remarkably understudied. For example, unidirectional mobile applications intended for rapid information gathering and simple communication have not been studied and require cautious use. Because the very nature of communication is bidirectional and much may be missed or misconstrued when clinicians are the only ones able to express themselves in an encounter, use of this type of application should currently be confined to emergency situations when no other options are available, or for brief use while awaiting a professional interpreter. Similarly, online translation tools, though promising, also require caution due to potential errors that may leave clinicians and health systems open to liability if the translated message delivered to the patient does not match the intended message.(28) However, there remains a need for technological advances to deliver reliably accurate translations that interface with electronic health records in order to provide visit and discharge summaries and instructions to patients in their preferred language.

Back to the Case

Reflecting on this case of the Spanish-speaking woman presenting for preoperative evaluation described above, there were significant opportunities to improve the care provided. First, while the health system seemed to provide access to both in-person or telephonic professional interpretation, neither form of interpretation was accessible to the physician at the time of this patient's visit. The physician then tried to reach out to the patient's husband who was not available and ultimately worked with a staff person who was not trained to interpret professionally. This use of ad hoc interpreters is not an adequate approach for clinical communication and is prone to error. In a more acute situation, using a staff member to interpret may be adequate for assessing urgent issues until a professional interpreter arrives.

Thankfully, in this case, the appropriate clinical assessment was made, and the patient's surgery was rescheduled due to concerning cardiac symptoms. However, the patient's symptoms could easily have been missed, and the lack of professional interpreter services could have contributed to an adverse outcome. In addition, the encounter with this patient took the provider a very long time. Even when interpreter services are easily available, it takes longer for a provider to communicate the clinical information via an interpreter to an LEP patient than it does to an English-speaking patient. Anticipating the need for extra time and scheduling longer visits for LEP patients can help facilitate clear communication necessary to care for these patients in a safe and patient-centered manner.

Take-Home Points

• Federal law and regulations require provision of language access for patients with limited English proficiency.
• There is a high risk of error when communicating with patients with limited English proficiency without a qualified professional interpreter.
• The choice of an in-person, telephonic, or video interpreter depends on the infrastructure and resource of the particular health care environment as well as the type of clinical encounter.
• Technology can facilitate access to professional interpreter services, but how the technology is utilized determines whether the care of patients with limited English proficiency is improved.
• Best practices for providers when working with a professional medical interpreter include talking in short units and pausing frequently to promote accuracy of interpretation.

Leah S. Karliner, MD, MAS Associate Professor of Medicine University of California, San Francisco

Disclosure: Dr. Karliner has declared that neither she, nor any immediate member of her family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

Table

Table. Best Practices for Working With an Interpreter in Clinical Practice.

References

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