As the population of our nation continues to grow, age, and become more diverse, physician practices are more likely to encounter patients with limited English proficiency (LEP) or hearing disability. The number of foreign-born residents in the United States is already at an all-time high of 40 million people,1 and more than 19 percent of the population speaks a language other than English at home.2 Depending on the definition used, between 1 million and 8 million are considered hearing impaired, a number expected to rise as older Americans experience functional deafness.3
This poses a major challenge for primary care providers. Accurate and effective communication between patients and clinicians is essential for quality care and patient safety. Language barriers can increase the chance of unnecessary or repeated testing, inappropriate treatment resulting in serious errors, and liability for malpractice.4 It is important that primary care practices identify effective strategies to overcome communication barriers and consider the financial, social, and legal consequences of ignoring them.
Take the example of Willie Ramirez, an 18-year-old all-star baseball player who was taken to a Miami emergency room after developing a sudden headache in 1980. He was comatose on arrival, and his history was obtained from friends and family who were not fluent in English. They used the Spanish word “intoxicado,” which can mean poisoned, as they felt he was having a reaction to something he ate. The physician did not understand the context of the history and presumed the patient was intoxicated. The misdiagnosis of a cerebral hemorrhage resulted in the patient becoming a quadriplegic and a $71 million settlement.5
There are five main steps practices should take to develop a strategy to overcome language barriers and improve the quality of care for LEP and hearing-impaired patients:
1. Determine the need for services in your practice,
2. Develop a policy,
3. Determine the method of communication to be used during the patient encounter,
4. Seek financial support for medical interpretation,
5. Provide language-appropriate patient forms and educational resources.
1. Determine the need for services in your practice
Title VI of the Civil Rights Act of 1964 establishes that those receiving federal assistance, such as Medicare reimbursement, must take reasonable steps to provide meaningful access to LEP persons. The U.S. Department of Health and Human Services (HHS) has issued its own guidance on whether a provider is obligated to provide language access services. Some states have also passed their own laws mandating language assistance in health care situations, said Chicago-based health care and disability rights attorney Andrés J. Gallegos.
He said that there is no “bright line” determining what number or percentage of LEP patients triggers the HHS mandate. Recipients of federal assistance should consider the following:
The number or proportion of patients with LEP who are likely to be encountered at the practice,
The frequency with which LEP individuals are seen at the practice,
The importance of the interpreter services to patients' lives,
The resources available to the practice and their cost.
Physicians should document their analysis of these four factors and, if they decide the mandate does not apply to them, review that analysis every six to 12 months, or earlier if patient requests for language assistance increase, Gallegos said.
If you don't know or find it difficult to assess how many LEP patients are in your practice, determining the prevalence in your region can help determine how great the need for those services may be and identify the languages you are most likely to encounter in your practice. To do this, you can review census data for your region or connect with community organizations, such as civic organizations or agencies that oversee state or federal benefit programs, that have already done this type of assessment.
Gallegos said that physicians who violate Title VI can face civil penalties from private lawsuits, including “compensatory damages” in cases of intentional discrimination. In some circumstances, individuals can also recover reasonable attorneys fees and expenses.
As for patients who are deaf or hearing-impaired, the Americans with Disabilities Act (ADA) requires any “public accommodation,” such as a hospital or physician's office, to provide sign language interpreters to individuals and their companions, Gallegos said. The Justice Department enforces the ADA, meaning that violations can result in fines if taken to court.
2. Develop a policy
When a patient presents to your medical practice and cannot speak English or is hearing impaired, the staff and clinicians should be prepared to handle the situation. If you don't already have a policy in place relating to language access and LEP or hearing-impaired patients, you should develop one. A sample policy for communicating with LEP patients can be viewed at the HHS website. You can also obtain samples of policies that other practices are using through organizations like the National Council on Interpreting in Health Care. Your policy should be written down so that staff can refer back to it if necessary and you can document your compliance with Title VI and other laws. The policy should help staff members understand their roles and responsibilities in caring for LEP or hearing-impaired patients and prepare them for these encounters.
If an incident has precipitated the need for a policy, it can be a powerful opportunity to have an open discussion with your staff about expectations. What do your staff expect from patients? What do you expect from your staff? What do patients expect from your staff? And, most important, what do your patients expect from you? A really robust discussion may reveal some biases that surprise you. It is always helpful for staff to hear about these issues in a safe setting, like a staff meeting, instead of during patient care. This discussion may be particularly useful as your patient demographics change over time.
Employed physicians should have input to their organization's policy. Mayo Clinic, for example, used a physician committee to develop its interpreter policies.
The policy should specify how each staff member should respond to assist the LEP or hearing-impaired patient. It should also list the method of interpretation used in your practice. LEP or hearing-impaired patients should be notified that interpreter services are available to them at no cost. For instance, the Mayo Clinic has information for patients on its website detailing the interpreter services available.
Collecting primary language data from patients during registration is a valid method to verify the number of LEP or hearing-impaired patients and the languages you need to accommodate. Asking how well individuals believe they speak English, what their preferred language is, and what language is spoken at their home are all questions that could be incorporated into the registration process. This information can be recorded for each patient via your electronic health record, scheduling system, or the patient database your practice uses.
The policy should also reflect an awareness of the need to provide written materials in the language of the patient.
If a language group constitutes 5 percent of your practice or 1,000 patients, whichever is smaller, you need to provide vital documents in that language, according to Title VI. Vital documents can include consent forms for procedural services, living wills, and others. If the 5 percent is less than 50 patients, you can simply interpret the materials orally.6
Train each staff member according to your policy. Verify that staff members understand their role in assisting patients. One way of doing this is to role-play an LEP or hearing-impaired patient encounter, document the staff person's competency, and provide feedback.
3. Determine the method of communication to be used during the patient encounter
The options for obtaining medical interpreter services in urban areas may differ from those in rural areas, but you want to choose a method that is practical, economical, and readily available for you based on your needs:
Face-to-face interpretation provided by professionally trained interpreters. Professional medical interpretation is a specialized skill and can be expensive for a medical practice to employ. This method, however, has been proven to be more effective than improvised interpretation and has been demonstrated to be superior to all other means tested for providing health care services to LEP patients.7 Similar improvements have been seen with hearing-impaired patients as well.8
If you have a large LEP or hearing-impaired population in your area, you may want to contract with a professional interpreter or an outside professional interpreter service to provide face-to-face interpretation. Professional medical interpreters have been trained on medical terminology, communication skills, cultural issues, ethics, and confidentiality. The Certification Commission for Healthcare Interpreters has a listing of credentialed health care interpreters on its website.
Although interpreter services are provided to one patient at a time, when the Grady Health System in Atlanta began caring for a new group of Nepalese patients who had been resettled in the area, staff made a concerted effort to schedule all of the patients in blocks of time. This made it easier to schedule an interpreter who could come in for that period.
The Office of Management and Budget estimates that the cost for professional interpreters varies from $20–$26 per hour,4 but that can fluctuate based on your location and the experience of the interpreter.
Employed bilingual staff members. If professional interpreters are not feasible for your practice, you could hire trained and competent dual-role bilingual staff members for roles such as receptionist or medical assistant, or you could train an existing employee. These staff members can provide interpreter services in addition to performing their regular duties in the clinic, saving you the cost of paying an outside provider and making the service more accessible.
If you have current staff members who are interested in helping out as interpreters in your practice, you should ensure that they are trained to be competent in the languages your practice encounters most. Their own English proficiency and knowledge of medical terminology must also be considered. There are a variety of interpreter training programs ranging from three-day, beginning programs to graduate-level university programs. You can search for programs in your area or contact a national program that trains medical interpreters, such as the Cross Cultural Healthcare Program.
Be cognizant of the extra work that interpreting places on the staff member and how it may affect his or her regular role and duties. Practices that have a frequent and regular need for interpreting services may want a staff interpreter whose sole responsibility is to provide medical interpreter services. Many employers pay extra to attract bilingual staff.
Remote interpreter services. Telephone interpreter services can be a quick and convenient way to accommodate LEP patients when in-person services are unavailable. This method is also a great option for languages that are infrequently encountered or for practices that have only an occasional need for services. With this option there is no need to employ someone or have a contract with an interpreter. Many telephone services offer instant access that's available 24 hours a day, seven days a week. Dual handset phones or speaker phones can be used in these situations to accommodate both the patient and medical personnel. Most telephone interpreter services charge by the minute. For more information on telephone interpreter services, you can visit Language Line Solutions.
For hearing-impaired patients, you can subscribe to a sign language interpreting agency that provides remote services via a computer and webcam. The hearing-impaired patient watches the computer monitor while the physician listens through the computer's speakers.
Family members or friends. Some patients adamantly refuse to use a professional interpreter, preferring to use a family member or friend instead. In other instances, a qualified medical interpreter isn't immediately available because of geography or time of day. Generally, it is best not to rely on an individual's family member or friend to provide interpreter services, and clinical staff should strongly encourage the use of a professional interpreter. Not doing so could lead to errors or omissions of vital health information affecting treatment and compromising patient safety. Adult family members or friends often do not interpret accurately. They may not understand the need to interpret everything the patient says and may summarize the information instead. They may also inject their own opinions and observations, or impose their own values and judgments. They too could have limited English abilities and may be completely unfamiliar with medical terminology. Receiving incomplete information could prevent a correct diagnosis and compromise treatment for that patient.
Be particularly careful when female patients insist that their husband will act as an interpreter; they may have information that they will not reveal in front of their husbands. This may be related to abuse or intimidation, or simply a reluctance to speak of taboo topics in front of a male.
Minor children should never be allowed to interpret for their parents when the parents are the patients. Children may have trouble understanding medical terminology and may incorrectly interpret information between patient and the physician. Some may be fluent in English but quite limited in the language of their parents. Relying on a child for interpretation has an increased probability for medical error.
Relying on adult friends and family is sometimes unavoidable, especially in emergencies and in rural areas without adequate or easily accessible sources of qualified medical interpreters, but also when patients refuse interpreter services. The physician has the legal duty to ensure that the translation is accurate, Gallegos said. Having solid procedures in place can help to minimize risk. Those should include clearly documenting in the patient's record his or her refusal or other reason why a qualified interpreter was not provided, the patient's request to use an adult friend or family member to translate, and the friend or family member's consent. Some practices ask patients to sign a form indicating that they are refusing interpreter services.
After the encounter, immediately following up with written information and instructions in the patient's native language should be standard procedure.
Pitfalls. Even certified medical interpreters can make errors. One example at Grady Health System involved a patient from Cambodia who was being seen for a routine visit. Using a telephone interpreter, she was asked about her sleep habits. She had chronic insomnia. In obtaining a social history, the patient was asked how many children she had. She spoke for more than a minute, and the physician heard her say “Pol Pot” (the brutal dictator of Cambodia in the 1970s). When the patient finished speaking, the interpreter simply said, “She has no children.” The physician spoke directly to the interpreter and stated that she had heard the patient say “Pol Pot.” The interpreter then revealed that the patient had four children who had been murdered by the Khmer Rouge, and that she had also lost both of her parents and her husband. It was later established that the patient was suffering from post-traumatic stress disorder.
It is important to note the identification number of the interpreters in your progress note so that you can give their agency feedback on their competence.
STEPS FOR USING AN INTERPRETER IN A PATIENT VISIT
Provide adequate additional time for the visit.
Speak briefly with the interpreter outside the exam room to explain the purpose and goals of the visit.
Sit facing the patient and speak to him or her, not to the interpreter. If using an interpreter over the telephone, conduct the visit in a private room with a speakerphone or with a second handset to preserve confidentiality.
Use short sentences and speak slowly and clearly, avoiding jargon and including adequate pauses to accommodate the interpreter.
Expect the interpreter to interpret everything. If the patient and interpreter have an extended conversation that doesn't seem to include you, interrupt and ask the interpreter to tell you everything being said.
Ask the patient to repeat key information back to you to ensure understanding.
After the patient visit, debrief with the interpreter.
4. Seek financial support for medical interpretation
The cost of interpreter services – and widespread lack of reimbursement to medical providers for these services – is a great concern for many practices and is often the largest barrier to language access for LEP or hearing-impaired patients. Even though covering the costs of these services may create a financial hardship for the practice, patients themselves are under no obligation to pay for them. Many practices absorb the charges as a cost of doing business, but there are some options to ease the financial burden, depending on your community and your state's reimbursement policies.
Medicaid and the State Children's Health Insurance Program (SCHIP) have indicated that language services are eligible for federal matching funds, but each state determines whether and how its Medicaid program provides reimbursement for interpreting. The District of Columbia and 13 states currently cover interpreters for Medicaid/SCHIP plans: Hawaii, Iowa, Idaho, Kansas, Maine, Minnesota, Montana, New Hampshire, Utah, Vermont, Virginia, Washington, and Wyoming.9 In some cases, the state reimburses the provider directly. In others, it contracts directly with interpreter organizations to provide services and may offer a specific telephone number for practices to call to access interpreter services for eligible beneficiaries.
Another option is to use time-based evaluation and management coding, which may result in higher reimbursement for visits dominated by counseling or coordination of care. Language barriers often extend the visit duration and present coordination of care challenges. What might otherwise be a 15-minute follow-up visit may be a 25-minute discussion with an LEP patient, even with the involvement of an interpreter. For example, some immigrant patients are not familiar with the concept of medication refills and will simply take their medicine until it runs out. They do not realize that the prescription has refills, and that they can request these from their pharmacy.
Identifying and rectifying issues like these can take considerable time. Be sure to document the time you spent addressing language and cultural barriers, and if counseling or coordination of care accounts for more than 50 percent of the total length of the face-to-face encounter, you can code the visit based on time (to learn more about time-based coding, see “Time Is on Your Side: Coding on the Basis of Time,” FPM, November/December 2008).
Other strategies to reduce the financial impact to your practice include the following:
Treat the cost of interpreter services as an overhead expense for accounting and tax purposes. In the case of sign language interpreters, the Internal Revenue Service provides a tax credit of up to 50 percent of eligible business expenditures greater than $250 but less than $10,250 during the tax year if those business expenditures helped you comply with disability access requirements of the ADA.10
Negotiate for discounted rates with local hospitals that provide interpreter services.
Collaborate with physician practices in your region to negotiate a more reasonable rate for using telephone interpreter services.
Contact community organizations in your area for possible volunteer interpreter services, and offer them medical interpreter training in exchange for a service commitment.
5. Provide language appropriate patient forms and educational resources
In addition to offering vital documents in the languages most often spoken by your patients, other forms and patient education materials should also be available. For instance, the U.S. Census Bureau provides free “I Speak” cards that practices can post in service areas and patients can use to identify the language they speak and need help with. Websites such as FamilyDoctor.org and MedlinePlus.gov have dozens of free, easy-to-read patient education materials translated into Spanish. The Multicultural Health Communication Service also has hundreds of translated health promotion documents on their website.
Providing interpreter services to your patients helps your practice provide quality care and avoid medical errors that could lead to malpractice lawsuits – and for many practices it is required by law. Accurate communication ensures the correct exchange of information between you and your patients and is a must for every medical practice.