Electronic Health Reporter

Eric Munz, vice president of business process crowdsourcing at Lionbridge Technologies, where he manages and leads the delivery of in-person, telephonic and video crowd-enabled interpretation solutions to meet the unique needs of customers across a broad range of industries, discusses here the need for interpretation services in health systems.

He also touches upon interpretation mandates for hospitals, the struggles large and small health systems face with interpreting to ensure the best patient care; he discusses the benefits of using a secure interpretation solution; and provides advice for implementing such a solution.

What are interpretation mandates for hospitals? How has equal access to language changed recently with ACA?

There are about 10 different places in the Affordable Care Act (ACA) that require hospitals to develop and implement a system that provides interpretation services to patients with limited English proficiency (LEP),  to have equal access to healthcare. For example, Section 1557 of the Patient Protection and Affordable Care Act focuses on non-discriminatory policies and procedures, including those based on the grounds of language and national origin.

Now, healthcare facilities are facing a renewed struggle to provide such interpretation services because of the influx of LEP patients newly enrolled in insurance plans under the ACA. According to the UCLA Center for Health Policy Research, 36 percent of newly insured individuals under the ACA in the state of California are LEPs — compared to only 9 percent of LEP patients prior to the ACA enactment. That is a dramatic increase in non-English speaking patients to serve.

Other states facing a jump in patients speaking foreign languages include Texas, Arizona and Florida. Across the nation, healthcare providers must be at the ready to interpret more than 300 languages to remain compliant. Otherwise, they risk incurring monetary penalties.

Why is it often a struggle to deliver interpretation for patients in large and small hospitals alike?

A big city hospital could serve patients representing a dozen different languages or more on any given day. That presents a very practical logistical problem for facilitating so many different conversations in so many different languages. This is why many facilities partner with vendors to provide on-site interpretation, but these interpreters often work on an on-call basis, delaying treatment. They also often charge two-hour minimum rates for their service even if it’s a 30-minute conversation. In a rural hospital, there simply may not be someone with the skillset to speak a particular language within the geographic area.

For these reasons, the biggest challenge for hospital management is determining how to efficiently meet the demand for interpretation services, which are required by law, while remaining cost conscious throughout the process.

Now, the power of the crowd is being leveraged by forward-looking facilities to provide unprecedented, equal and immediate access to even the least commonly spoken of languages. These crowd-powered services give both healthcare facilities and patients a range of real-time interpretation options, including video and telephonic services. With these technology enabled solutions, hospitals only pay for minutes used, as opposed to a costly, often unnecessary hourly rates.

Talk about the benefits for the patient of being able to communicate in real-time in their primary language? How does it affect treatment and decision making?

With immediate access to a knowledgeable, trained language specialist through a video interpretation service, such as Lionbridge, patients can quickly, privately and confidently engage their physician in any media discussion, no matter what level of sensitivity. Medical terminology, which is often difficult to understand in layman’s terms, can be thoroughly explained in the patient’s preferred language, and patients won’t hesitate to ask on-the-spot follow up questions if they don’t understand. This easy, real-time access can lead to faster diagnosis, treatment, and ultimately help improve a patient’s overall healthcare experience.

How have smartphones and tablets changed the delivery of video interpretation? What was it like 10 years ago and what can a Limited English Proficient patient expect to encounter today?

The proliferation of tablets and smartphones now allows service providers to combine the speed of in-person interpretation with the affordability of telephonic interpretation. Video interpretation utilizes a smart crowd of remote interpreters, either at video call centers or even their own homes, available for a face-to-face discussion in about 30 seconds, all from a handheld device.

Ten years ago, video interpretation was administered through equipment such as the “Rover,” or a similar assortment of video monitors, microphones and additional transmitting equipment that would sit atop a large cart, requiring significant space within a hospital’s crammed emergency room. Along with the inconvenience of the size of such equipment, these services often required a sophisticated, and expensive, network structure to support the high bandwidth needed to send and receive signal.

Today, smartphones, tablets and laptops make delivering high-quality video interpretation more portable and cost-effective than ever before. Hospital staff can now securely connect through a standard 4G LTE network, making the process as fast and seamless as a phone call, but with the face-to-face connection of a trained professional.

What happens when interpretation isn’t available? Is it true that doctors and nurses sometimes depend on the patient’s relatives, and even total strangers, to help bridge the language barrier?

In the past, it was not uncommon for doctors and nurses to turn to unskilled and unqualified interpreters, such as staff members who speak a second language, the patient’s family members, and even from time-to-time, strangers who may be present. This doesn’t mean the facility doesn’t have an interpretation infrastructure in place, but often times, it’s quicker and easier, especially as you think about how many interactions a doctor or nurse may have with a patient during an ER visit or a hospitalization.

As hospitals and healthcare providers realize they don’t have the budget to deal with the influx of Limited English Proficient patients, a risk is that they may turn back to this approach, which puts both the patient and the institution at great risk.

This must raise serious safety and privacy implications, right?

From a safety perspective, it only takes one misunderstanding by the interpreter to put the patient at great risk. When you take a minute to think about all of the medical terminology which is shared in this setting, it is sometimes hard for someone who speaks English as a primary language to keep everything straight. Now, insert an unskilled interpreter, such as a family member, who may not understand everything which is being said. In an emergency situation, an error can have life or death implications.

Institutions are also in violation of HIPAA when they rely on ad hoc interpreters to bridge the language gap. From an ethical viewpoint, patients have an absolute right to privacy and confidentiality, but from a business perspective, failure to comply with HIPAA can result in expensive financial penalties.

Here’s the different between using anyone with multilingual skills to provide interpretation and using a reputable service provider such as Lionbridge’s crowd: All of our interpreters are trained to work in the medical setting. They understand medical terminology and receive very specific instructions to ensure HIPAA compliance. Our crowd interpreters sign three agreements: a code of conduct, a confidentiality agreement and a Business Associates Agreement (or BAA), which is a HIPAA document. They have deep understanding and respect for patient privacy, and also a contractual obligation to follow HIPAA standards.

Should interpretation be approached from the perspective of patient satisfaction, risk management or some other viewpoint? Why?

At minimal, an infrastructure to provide equal access of language is needed to satisfy compliance mandates spelled out in multiple sections of the Affordable Care Act, but the ramifications of an effective interpretation strategy are really wide sweeping for healthcare institutions. This is why it should be approached from multiple viewpoints.

Take a hospital which effectively leverages tablets to provide video interpretation: the real-time dialogue that takes place between doctor and patient helps improve the quality of care, which in turn improves patient safety and satisfaction. This helps improve risk management, which in healthcare can equate to costly penalties. The instant, 24/7 availability and on-demand nature of the crowd ensures the cost is more affordable than having a staff of interpreters who may or may not be expected to be in multiple places at once. This satisfies budgetary requirements. So, as you can see, from the CEO and CFO to the doctors and nurses, to the compliance officer, everyone has an active stake in implementing an effective interpretation strategy.

Can you share best practices for implementing and executing video interpretation services used by high performing hospitals and medical centers?

There are several questions a healthcare institution should ask potential partners when vetting any interpretation service. These include:

• Is your interpretation crowd really available on-demand?
• Are your interpreters qualified to work in the medical field?
• What steps are taken to ensure interpreters comply with HIPAA regulations?

From a technology perspective, avoid being lulled into a false sense of security by a provider that offers an HTTPS connection. Anyone can deliver interpretation over a webcam, so you want to make sure you are working with a service provider that can provide truly secure VPN access between language workers and the hospital to ensure patient information or data is never in an unsecure environment.