A critical look at current interpretation tools and new approaches on the horizon.
It will come as no surprise to the emergency medicine (EM) physician that the linguistic and cultural barrier in healthcare is a monumental obstacle to providing competent care. The last two censuses reveal that from 1990 to 2010, the limited-English-proficient (LEP) population has increased by 80%; currently, there are over 26 million people who are LEP in the US. The Pew Research Center reports that if current trends continue, immigration will account for a full 82% of US population growth through 2050.
In comparison to the English-speaking patient, the LEP patient experiences more testing, longer stays, higher rates of readmission, lower adherence to treatment, and subsequently higher costs. The provision of language assistance services (LAS) to bridge the communicative impasse remains a significant challenge for health facilities, posing an extreme threat to the safety and health outcomes of the patient as well as an enormous financial and operational burden. Beyond the increased cost of care for each of the millions of LEP patients, medical misunderstandings present liability and have lead to millions of dollars of settlements and legal fees.
Canopy Innovations, a NYC digital health startup, was awarded a Pilot Health Tech award to work in Mount Sinai Hospital’s Emergency Medicine (EM) residency program. Their goal was to better understand providers’ perception of available language assistance tools and systems. Canopy also sought to gauge an emergency physician’s reception to mobile technology solutions. The need for communication aid is especially amplified in EM due to the high caseload of patients in a context characterized by urgency. The Sinai EM residents, specifically, rotate between hospitals in Manhattan and Queens, environments of extreme diversity, providing an ideal location to examine the landscape of LAS. Some linguistic experts believe as many as 800 languages can be found in New York City. In fact, Queens has been claimed to be the most diverse urban area in the world.
Language Assistance Services, In Reality
Despite an acutely heterogeneous patient population, the LAS tools and systems at EM residents’ disposal are wanting. Current interpretation options tend to rely on antiquated technology and are scattered and cumbersome to use. Remote over-the-phone interpretation (OPI) and video remote interpretation (VRI) offer critical solutions that scale, however, providers consistently report logistical difficulties accessing those solutions, rendering them less efficacious. Some residents described the dual-handset interpreter phone as “grimy,” and its usage did not fit into their workflows: locating it, knowing which access code to use, and connecting to the voice on the line. Remote interpretation can feel abstract—elderly patients get confused, and if they’re hard of hearing, lack of body language cues creates difficulty. Additionally, about a third of residents questioned the qualifications of the remote phone interpreters and perceived the resource to be inaccurate.
Aside from OPI and VRI, EM residents can request a trained in-person medical interpreter, the coveted gold star resource. The approximate ratio of 3,000 nationally certified medical interpreters to an LEP patient population of almost 30 million, equates to about 10,000 patients per interpreter. Facilities may have their own internal qualification and allocation processes for interpreters, but residents nonetheless reported great difficulty in accessing qualified in-person interpretation through approved channels.
It’s this inadequate access and availability of approved, appropriate interpretation resources that causes people to turn to ad hoc, unqualified interpreters and family members. These inadequate tools and resources lead to adverse events for the patient. Furthermore, this behavior takes a toll on the provider: when working across the language barrier, residents reported feeling “frustrated” and “powerless” or doing more guesswork, testing, and omitting conversations. One resident expressed that with certain patients that speak a rare language, there seem to be no available resources and, “It’s pretty much a veterinarian visit at that point.”
Enter the Smartphone
Given its ubiquity and immediacy, there is a palpable opportunity to safely harness the smartphone as a mobile access point to scalable technology platforms. Study shows that 88.6% of healthcare employees report they bring and use their device irrespective of hospital protocol. It is second nature for providers to turn to apps, especially given the high rates of smartphone ownership among staff. However, different apps differ in their approaches to the communication issue. Some promote access to qualified interpreters, while some like Google Translate, avoid people all together. According to a study by the British Medical Journal in 2014, an app like Google Translate is inaccurate 43% of the time in medical contexts—so safety and practicality are wanting when providers turn to this unapproved tool. In late 2016, the new Google Translate morphed from using large scale statistical machine translation to neural machine translation. Though Google Translate may have experienced improvement, (the magnitude of which has yet to be elucidated for the medical context, specifically) the extreme nuance, frequent necessity of cultural brokerage, and sensitivity of medical conversation should convince the reader that faith and reliance on this refurbished digital tool is unwise.
Canopy offers a different way to harness the smartphone, not with real-time translation capability as the beacon but as an access point for other systems and processes that can strategically improve interpreter service delivery. Through qualitative interviews and in-depth discovery, the Canopy team has prioritized a new digital approach that uses the smartphone as an access point to a more complex interpreter services platform. Pilot feedback and exploration influenced the development of Canopy Connect, an interpreter services delivery and analytics tool that is currently going through its own pilot programs with a small handful of facilities. Canopy believes in user-driven innovation to mold its technology development priorities.
Relying on smartphones for communication has barriers, though. About half of the participating residents reported using their smartphone in close proximity with patients feels “unhygienic” and “unprofessional.” Although cellphone use while in the hospital is common, it may not feel normalized or accepted yet. This perception, amongst others, is important to understand when developing nuanced, appropriate and adoptable solutions.
With the changing landscape of healthcare and a shift from quantity-of-care delivery to quality-of-care delivery, hospitals will need to optimize the delivery of LAS services to effectively support encounters between providers and LEP patients. Performance-based reimbursement programs offer financial incentives and impose penalties to health facilities based on their ability to meet quality benchmarks such as readmission rates, patient satisfaction, and other metrics that are directly affected by the quality of clinical communication. Accessible and appropriate LAS tools are key, so providers aren’t tempted by more immediate yet subpar methods, like getting help from the 9-year-old, kind-of-bilingual child at the bedside.
Because use of LAS and language barriers are often underreported, LAS coordinators and departments face the challenge of justifying funding of LAS. In this framework, teamwork and awareness are key. However, given the increasing financial implications, facilities are pressured to prioritize proper and efficient LAS. Feedback from providers through each step of implementation is key as well. If providers’ perceptions of tools and systems are not taken into account, there may be another “EHR situation”: a necessary evolution that promised to revolutionize delivery and efficiency but that has added significant frustration and burden to providers’ daily practice.
How can hospitals and tech innovators leverage the power of technology to better improve communication across linguistic and cultural barriers? How can one reap the benefits of mobile apps — scalability, immediacy, tracking and automatic data collection, familiarity, and ubiquity—while taking provider perceptions and workflow constraints into account? These questions frame Canopy’s pilot program, in recognition that the success of its digital approaches depend upon insight from different user groups and iterative development. Moving forward, facilities will need to make better use of all of their interpretation modalities: access to over-the-phone interpreters, video remote interpreters, and the efficient deployment and effective use of in-house, in-person interpreters. And now, the smartphone can serve as yet another access point for immediate, accessible and accurate interpretation.
Three Apps to Help Bridge the Language Gap
–Nicholas Genes, MD, PhD
- Canopy Speak: Look up 4000+ medical phrases in 15 languages. Categorized by encounter phase (greeting, history, exam, procedures) or by specialty. Also one-button access to your hospital’s medical interpreter service.
- CyraCom Interpreter: 24/7 mobile access to a trained interpreter over HIPAA-compliant video. Dozens of languages, including ASL. Not free, but free trial available, with both individual and enterprise rates to choose from.
- Google Translate: OK, you’re not supposed to trust this kind of communication. It’s better to look up a curated medical phrase like Canopy does, or use a real interpreter. But sometimes Google Translate is your only choice. And its new capability to “read” and translate live text through the camera is amazing, and can help with foreign pillboxes or documents.