Urgent message: Using interpreters in the urgent care setting can help you provide quality healthcare and save time and money.
Bruce Merley
Imagine that it is late Friday night and you and a nurse are the last remaining staff on duty at your urgent care center. A couple arrives and the woman appears to have several facial cuts and bruises. When you greet them, the man responds in a language you do not understand. You turn to the woman and she only says one or two words, also in a language you do not know. Finally, the man says in very limited English that they are from Russia, his wife has fallen, and asks you to fix her wounds – he will tell her to do as you say. You immediately suspect domestic violence but have no way of communicating with the woman. Now what?
In the United States today, there are over 45 million people who speak a language other than English as their primary language at home. Even more people are considered by government to be “Limited-English Proficient” or LEP, which means that they do not understand instructions about their healthcare. Amazingly, there are over 325 different languages spoken in the Untied States, with the number growing almost every month, and over 6,000 languages spoken in our ever-so-mobile global population. Linguists tell us that because English is a complicated language fraught with exceptions to its grammatical structure, it takes the average non-English-speaking person 7 years to become sufficiently fluent to communicate about and understand instructions about their healthcare in English.
While immigration to the United States from Central and South America continues at high rates, less noticed but even more challenging are the large numbers of immigrants, both voluntary and refugee, arriving on our shores from all over the world. In recent years, we have seen large numbers of new immigrants from Africa and Southeast Asia. Refugees from Myanmar (formerly Burma) who speak a number of languages new to the United States, are settling in towns and cities all across the country. As air transportation takes the dominate role for global travel, many new cities are appearing as immigration gateways. Atlanta, Buffalo, St. Louis, New Orleans, and Dallas, among others. New immigrants need work to survive, so they go where the jobs are – often to growing suburban communities.
When you combine the immigration trends above with the socio-economic demographics (new immigrants are, as a group, underinsured and on the lower end of the socio-economic scale), and add to that a generalized social mistrust of authority and government, it is not surprising that the LEP population tends to keep a low profile and seek healthcare in community health centers, local walk-in clinics, and small hospital emergency rooms. If you aren’t seeing them already, it is only a matter of time before they find you. The U.S. LEP population represents an enormous healthcare market if you can successfully meet the challenges. Urgent care centers are ideally positioned to serve this community.
But why do you have to use interpreters? After all, insurance companies don’t cover the cost, it’s really expensive, and a lot of your patients bring their children to interpret for them, right? Well, not exactly. Let’s look at some of the facts and some reasons why using interpreters makes good sense.
Why Use Interpreters?
First, there is the law. Title VI of the Civil Rights Act of 1964, and President Clinton’s Executive Order 13166 of August 16, 2000 (www.justice.gov/crt/cor/Pubs/eolep.pdf) make it clear that it is illegal to discriminate against someone because of national origin, and language is specifically identified as an indicator of national origin. Furthermore, the National Standards on Culturally and Linguistically Appropriate Services (CLAS standards) mandate that healthcare organizations receiving Federal funds must offer and provide language assistance services at no cost to each LEP patient. In addition, the Joint Commission now has very specific requirements about language services for LEP patients that hospitals must meet to maintain their accreditation. The federal government, most states, and the Joint Commission discourage the use of family members, friends, and ad hoc strangers as interpreters. Also, they prohibit the use of minor children as interpreters except in dire emergencies. (The reasons are fairly obvious, but you need only consider a teenage Arab boy interpreter who must explain to his mother that she has sexually transmitted disease to understand the inappropriateness of this idea.)
To supplement the Federal laws, several states have passed regulations regarding language services. New York State’s Patient’s Bill of Rights gives patients the right to communicate with providers about their health care in a language they can understand, and healthcare facilities are expected to provide language assistance within 20 minutes or less. In Massachusetts, Emergency Rooms now require by law to provide interpreters. California now requires that health insurance companies provide interpreting services for non-English-speaking customers, and many other states have regulations requiring healthcare entities to provide language services.
The cost of a lawsuit for discrimination or the loss of accreditation over language service dwarf any concerns about the cost of providing the service. However, these are only the compliance reasons for using interpreters. There are much better reasons, the most obvious of which is to provide the best health care you can as a responsible medical professional.
The second reason to use interpreters is to improve healthcare outcomes. Without verbal communication with patients, you cannot ask them for a medical history, assess their degree of pain or distress, ask them to show you where it hurts, how they feel, or whether they are dizzy or nauseated. Medical schools tell us that 70% of a doctor’s diagnosis comes from direct verbal communication with a patient. In addition, if a patient can understand you, he or she is more likely to follow your instructions, use medication appropriately, appear for appointments on time, and so forth. Numerous studies have shown that LEP patients who have been provided with interpreters have better healthcare outcomes than those who were not given language assistance. Consequently, using an interpreter significantly lowers your risk exposure as a provider.
The third reason to use an interpreter – and this is a big one – is that the service they provide saves money in several ways:
- Using an interpreter to provide verbal communication with the patient avoids the cost of otherwise unnecessary diagnostic testing and longer-term observation. A 1988 study by Lee, Rosenberg et al, showed that an Emergency Room doctor was 70% more likely to order additional testing and overnight stays for LEP patients, when the doctor could not verbally communicate with the patient.
- Using an interpreter improves provider and support staff productivity. You waste less time trying to communicate inadequately with an interpreter than without one.
- Better compliance from LEP patients with your healthcare instructions means fewer unnecessary return visits and improved payment histories. A recent study at a Massachusetts medical center showed that providing easy access to language services at every point of patient contact reduced the cost of care, improved staff productivity, enhanced patient satisfaction, and reduced the LEP inpatient length of stay by 1.3 days. To read the entire study, visit http://www,innovations.ahrq.gov/content.aspx?id=2656.
Currently, most health insurers do not cover the cost of interpreting services. However, it is worth noting that some insurers are considering it, and 17 states have plans in place or in progress to offer some reimbursement for interpreting expenses for Medicaid patients.
Telephone Interpreting
So the healthcare industry has taken to using interpreters to communicate with the ever-growing number of LEP patients. Many hospitals have staff interpreters, especially for frequently needed languages when you need them is not easy. Even more challenging is finding interpreters who understand our healthcare system, know the vocabulary needed for medical conversations, have the skills to manage an interpreting encounter, abide by a code of ethics and confidentiality agreement, and qualify under HIPPA regulations. The cost of recruiting and training qualified interpreters is high and few facilities can afford the luxury of on-site interpreters for more than a couple of languages. An agency interpreter might cost upwards of $100 for a 2-hour minimum call where the actual encounter with the patient might only take 10 to 15 minutes. Enter telephone interpreting.
Launched by AT&T in the 1980s, telephone interpreting has grown into a $1 billion industry that serves multiple industries and worldwide markets. With its economics of scale and ability to source and deliver interpreters anywhere in the country where there is phone service, telephone interpreting has transformed language services in health care from an expensive luxury to an indispensable everyday tool. Using a telephone interpreter or an over-the-phone interpreting (OPI) company, obtaining an interpreter on-demand in over 200 languages can be easy as picking up the phone. The cost is equally accessible – in many markets, OPI costs approximately $1 per minute. Furthermore, you can access interpreters who are skilled and experienced in healthcare interpreting and who have qualifications to ensure compliance with federal laws, state laws, and accrediting agencies.
How It Works
Several vendors provide telephone interpreting (OPI) services in the United States, and some offer services specifically for the healthcare industry. With most, you can easily open an account, after which they will provide you with a toll-free phone number to call and an account code to access the service. Once you indicate the language needed, typically in a minute or less, you will be connected to an interpreter who will facilitate the communication between you and your patient. The interpreter will introduce her/himself to both parties in both languages and you are ready to go.
Once on the phone with the interpreter, if you are using an ordinary phone, you will have to pass the handset back and forth with your patient while the interpreter consecutively interprets the conversation in both directions. Good telephone interpreters are skilled at helping set the rhythm of this process to make it easier for you, and once you have done it a couple of times, you’ll find it relatively easy. If you have privacy (for confidentiality), using a speakerphone eliminates the need to pass the phone back and forth and offers the added benefit of leaving you hands-free. However, speakerphones, depending on the physical environment, often make it more challenging for the interpreter to hear all parties clearly. Another option is a dual-handset phone, which provides a handset for both parties, a modicum of privacy, and good hearing capabilities for all parties. Cordless dual-handset phones often are more convenient in an urgent care or clinic environment where multiple exam rooms may not have phones lines installed, and they avoid the complication of extra wires in technology-congested areas. These devices can normally be purchased for $50 to $100 per set.
When your budget so dictates, you can often simply add a splitter to your business phone base unit, and plug in two handsets, basically creating your own dual-handset phone for about $15 – $20. If you are fortunate enough to have some of the more advanced communications devices like the voice-activated Vocera lapel communicator, telephone interpreting services are easily accessed through these devices, again improving your communications with your patients and your productivity.
The LEP Population and Culture Collisions
As you might expect, with the arrival in the United States of people from throughout the world – from countless different cultures, faiths, and social systems – there are inevitable conflicts where, through ignorance or misunderstanding, either our behavior or the LEP’s behavior offends, conflicts with, or makes no sense to the other party. Issues of gender, modesty, spiritual beliefs, and social authority all can contribute to misunderstandings and embarrassment at a minimum, and even to treatment failures and catastrophic healthcare outcomes at the other end of the spectrum. This is where a qualified interpreter is an invaluable resource; the qualified interpreter brings a sound, first-hand understanding of both cultures to each encounter. Professional medical interpreting allows for the interpreter to intervene with either party to explain a potential cultural roadblock and recommend solutions for addressing the issue. The reputable telephone interpreting for addressing the issue. The reputable telephone interpreting companies in our industry make a point of hiring interpreters with qualified cultural competence that can help you avoid the pitfalls of practicing your best Western medicine with people of other cultures.
Interpreter Qualifications
Reputable telephone interpreting companies have strict qualification requirements for interpreters, particularly in healthcare, and are normally prepared to address all the quality compliance obligations of government and regulatory agencies. Some telephone interpreting companies require interpreter candidates to take tests that measure bilingual fluency, cultural competence, knowledge of ethical dilemmas and conflicts of interest, and the ability to manage both; demonstrable interpreting skill; knowledge of HIPPA, Joint Commission and Centers for Medicare & Medicaid Services (CMS) regulations as they relate to language services; the ability to intervene appropriately when required, among other protocols. In addition to passing the aforementioned tests, ideal interpreters would have at least 2 years of college-level education, professional interpreter training, and 2 years of previous interpreting experience.
The Joint Commission, CMS, and several states now have specific guidelines about the qualifications they expect for people providing language services for healthcare professionals. You may wish to visit the resources section of the websites of the National Council on Interpreting in Healthcare or the International Medical Interpreters Association for additional information. In addition to source documents on compliance issues and links to primary sources such as the Office of Civil Rights and CMS, there are a number FAQ documents and recommendations for language access program for your facility that addresses your resources and the needs of both your patients and your organization.
Recently, the community of medical interpreters across the country has pushed to develop a third-party professional certification for medical interpreting. At this point in time, there are two very new bodies offering certification in medical interpreting in Spanish: The Commission for Certification of Healthcare Interpreters (CCHI) and the National Board for Certification of Medical Interpreters (NBCMI). As of this writing, there are approximately 450 Certified Spanish Medical Interpreters in the United States, divided between the two bodies. Over time, both organizations will offer certifications in additional languages, but there will always be a need for qualification assessments of interpreters, either for specialty skills (pediatric interpreting, for example) or for languages where the demand does not justify the tests development costs for the certifying organizations.
In the next few years, as the number of certified interpreters grows to a meaningful number, it will be in your best interest to work with OPI vendors that have a clear strategy toward the offering of Certified Medical Interpreters whenever possible.
The Global Community
Living in a global community is something we have talked about for years. Now it appears we are actually experiencing it. Our discoveries may be amusing, terrifying, and even catastrophic. However, we must accept and embrace the reality of our world. Language is key to understanding culture and an anchor to our social stability. Using interpreters where language skills are missing can open doors of success in providing quality health care and of personal discovery that enrich our lives beyond measure. Oh, and yes, it will actually save you time and money.