Facing ramped-up federal requirements and new accreditation standards, hospitals are taking a closer look at how to best use interpreters to meet the needs of patients with limited English proficiency.
Patients hindered by language barriers with clinicians are more likely to be the victims of medical error and more likely to suffer related harm, said Dr. Alexander Green, associate director of the Disparities Solutions Center at 945-bed Massachusetts General Hospital, Boston.
Research has repeatedly demonstrated the benefits of professional interpreter services for limited English-proficient patients, or LEPs, as they are commonly known. A May 2012 study in the Annals of Emergency Medicine, for instance, found that hospitals' use of well-trained medical interpreters can reduce the risk of errors and improve patient outcomes.
Increasingly, many hospitals are choosing to contract with companies that offer remote medical interpretation services, usually provided by telephone. These services, which typically cover more than 200 languages, are often more cost-effective for budget-strapped hospitals. But questions persist about whether telephone interpreters are as effective as on-site employees and how outsourcing such services affects patient care.
On Jan. 7, Monterey, Calif.-based Language Line Services, an interpretation services company that covers a number of industries, including healthcare, government and manufacturing, announced it had acquired rival Pacific Interpreters, Dallas, from Sterling Capital, a Northbrook, Ill.-based private equity firm, for an undisclosed sum. The two companies, whose combined annual revenue totals nearly
$300 million, are leaders in the medical interpretation market, a sector that is expected to expand rapidly in coming years. According to U.S. Census Bureau data, LEPs accounted for more than 25 million people in 2010, or roughly 9% of the nation's population over age 5.
“It's a fast-growing area,” said Scott Klein, Language Line Services' CEO, adding that hospitals face mounting pressure to ensure interpretation services are adequate.
In January 2010, the Joint Commission issued new and revised standards for effective patient-centered communication, including more specific provisions for hospital interpretation services. They require that hospitals document patients' language needs in their medical records and ensure interpreters' qualifications and proficiency through training and education. The standards were piloted through 2011, and as of January 2012 are considered as part of the Joint Commission's hospital accreditation process.
“The Joint Commission usually puts a toe in the water first, but when they do get involved, it raises a lot of interest among hospitals, to say the least,” said Green, of the Disparities Solutions Center. The Patient Protection and Affordable Care Act also put greater emphasis on care for LEPs, including provisions that require hospitals to collect data on patients' race, ethnicity and language, he added.
Green said telephone interpreters can serve an important role, particularly when it comes to serving patient populations that are not well-represented in a hospital's community. Ideally, though, hospitals should have some on-site staff who maintain services for the racial and ethnic groups that constitute the largest percentages of their patient population, he said.
“Telephone interpretation is best as a backup for less-represented groups,” Green said. “There is such an important role for live interpreters because they can carry out certain functions that phone interpreters cannot, like working as part of the care team.”
Stanford Hospital and Clinics, Palo Alto, Calif., relies on a combination of on-site and remote services. The 477-bed hospital's interpreter services department, regarded as a model for other healthcare facilities, has a staff of 37 who are tested for language competency and familiarity with medical terminology, said Luis Alberto Molina, Stanford's assistant director of interpreter services. Molina called phone interpretation “complementary and an essential part” of Stanford's program. But he cautioned that telephone interpreters can miss important body language cues and facial expressions.
“Someone who is really trained in the field needs intermediate or advanced knowledge of anatomy and physiology, diagnoses, therapies, procedures, names of medical equipment—all of these come into play in these conversations,” he said. “The challenge is knowing how these companies are training their interpreters. Are they selecting the best ones or are they hiring just to meet the increases in market demand?”
But Klein, Language Line Services' CEO, defended his company's practices, saying LLS required interpreters to be fully trained in medical issues and terminology.
Telephone interpreter services are attractive to hospitals because the price is low, comparatively, said Teresa Reyna, Stanford's director of operations for guest services.
Brunilda Torres, former director of the Office of Multicultural Health at the Massachusetts Department of Public Health, acknowledged that cost pressures are increasingly pushing hospitals toward remotely provided options, though she called face-to-face interpretation “the gold standard.”
Like Green, she said the best arrangement is one in which hospitals meet their primary language needs with staff interpreters and use telephone services as a backup. “Financially speaking, telephone interpreters have made it much more feasible for hospitals to provide these services,” said Torres, who is now retired. “But we have to be clear about what we're trading for those savings.”