March 2007 | Back to Table of Contents
Quality Rounds
Open to Interpretation
Having qualified interpreters is important to patient safety. But who's to say what makes an interpreter qualified?
Any physician yet unconvinced of the importance of using trained medical interpreters in hospitals and clinics should talk with Cinda Velasco, J.D., an attorney with Midwest Medical Insurance Company, a Minnesota malpractice insurer.
Her claim reviews are a chilling reminder of what can happen when care gets lost in translation (see end of story). “Being able to communicate across cultures effectively is especially important to health care providers. Using interpreters is even more important if patients don’t speak English,” says Velasco, who specializes in risk management.
The issue of interpreter services has gained importance with Minnesota doctors, as the state has seen an influx of people with limited English proficiency. In Minnesota, about 437,000
(9.4 percent) of residents speak a language other than English at home, and about 185,000 (4 percent) have limited English proficiency, according to U.S. Census figures.
The number of patients needing interpreters has also increased nationwide. Between 1990 and 2000, the number of Americans with limited English proficiency increased by 53 percent to 22.3 million, according to Glenn Flores, M.D., director of the Center for the Advancement of Underserved Children and a professor of pediatrics and population health at the Medical College of Wisconsin and Children’s Hospital of Wisconsin in Milwaukee. He cited those statistics in an article about the link between medical errors and language barriers that was published in the July 20 issue of the New England Journal of Medicine.
Flores said in a phone interview that language barriers between patients and doctors can lead to impaired health status; reduced access to medical care; lower rates of mammography, Pap smears, and other preventive screenings; less likelihood of attending a follow-up appointment after an emergency room visit; an increased risk of harm because of drug complications and medical errors; a greater chance of intubation for children with asthma; longer medical visits; greater utilization of diagnostic testing; lower patient satisfaction; and poorer adherence to medication schedules. “This is increasingly going to be an issue that we can’t avoid and sweep under the rug,” he says.
Guidelines Needed
Some hospitals that are admitting a growing number of patients who speak limited, if any, English are making interpreters integral members of the care team. Those interpreters should meet certain standards, says Sidney Van Dyke, manager of interpreter services for Regions Hospital in St. Paul.
But who’s to say what qualifications and skills interpreters should have and what an effective interpreter service program should look like? Currently, there are no agreed-upon standards for regulating interpreters or measuring their abilities in the United States or Minnesota. And a lack of benchmarks makes it difficult for hospitals and clinics to evaluate their interpreter programs.
Regions and Hennepin County Medical Center (HCMC) are taking part in an initiative funded by the Robert Wood Johnson Foundation to create national standards and benchmarks. The project, which involves 10 hospitals, was launched in December. The hospitals will track five measures of language service and two clinical measures over 16 months to assess the effectiveness of their interpreter services.
Regions’ interpreter team is composed of staff, contract workers, and interpreters from Language Line Services, a telephone interpretation service. About 12 percent of the hospital’s patients have limited English skills. Spanish, Hmong, and Somali are the languages for which interpreters are most often requested.
Hennepin County Medical Center has one of the largest interpreter staffs in the country, with more than 70 interpreters, according to Anthony Gardner, director of interpreter services. Like Regions, it supplements its staff with contract interpreters and a phone service. Last year, it started using MedBridge, a computerized system that allows for immediate communication with a patient in his or her language. The hospital arranges for about 120,000 interpreter sessions a year.
All hospitals taking part in the Robert Wood Johnson Foundation project will track these measures: 1) whether staff asked the patient about his or her preferred language and documented that preference (Van Dyke notes that the gold standard is to conduct the medical interview in a patient’s preferred language, even if he or she is proficient in English); 2) how often patients received intake and discharge instructions from a bilingual provider or a qualified interpreter; 3) whether patents waited more or less than 15 minutes for an interpreter; 4) how much time interpreters spent actually interpreting during an appointment; and 5) how much time interpreters spent waiting for providers.
Hospitals can choose the clinical measures they’ll study. The two being evaluated at Regions are whether use of interpreters affects the 30-day readmission rate of diabetics and the number of depressed patients with limited English proficiency who complete a PHQ-9 screening. HCMC will use the same depression measure but will track HbA1c levels instead of readmission rates.
The participating hospitals will also develop methods to assess the proficiency of their interpreters and bilingual providers, and quantify the amount and type of training they have received. “The thought is that when the 10 hospitals start talking about this, we may be able to come up with a common definition of what an assessed and trained interpreter has done to get that title,” Van Dyke says.
Legislating Language
Creating such a definition would not be an academic exercise. Some believe that Minnesota needs to follow Washington’s lead and become the second state in the nation to certify interpreters.
A bill establishing a certification process and requiring private health plans to reimburse providers for interpreter services was introduced in February. Minnesota is one of about a dozen states that reimburses physicians for providing interpreter services to patients on public programs. However, its private insurers rarely pay for the service.
Passage of the bill would address the two paramount barriers to providing patients with interpreter services: finding qualified interpreters and paying for them. Van Dyke says interpreter services can cost from $1.25 to $2 a minute for a telephone session and $35 to $75 an hour for an in-person session.
Flores says requiring health plans to pay for interpreter services would go a long way toward preventing the need for more costly care, and even lawsuits, later on. “They can pay a little bit up front for high-quality care or a lot more later when these patients show up in emergency rooms or hospitals.” MM
Scott Smith is a staff writer for Minnesota Medicine.
Claim Review
By Cinda Velasco, J.D.
Specialty: Family medicine
Allegation: Failure to diagnose tuberculosis
Risk Management Focus: Communication failure, inadequate clinic policies and procedures
Facts of the Case: Immigrant Bosnian parents brought their 2-year-old to a family medicine clinic because of fever, cough, and a runny nose. The parents spoke virtually no English, and communication was difficult. The physician diagnosed the child with an upper respiratory infection (URI) and bilateral otitis media (BOM), and prescribed Amoxicillin.
One month later, another family physician at the clinic saw the child for fever, cough, and a sore throat. A strep screen was negative. The physician prescribed Tussis for five days. The next month, a third physician in the group saw the boy for a dry cough and fever. This physician diagnosed BOM and prescribed Amoxicillin.
Six days later, the child was seen in the emergency department for vomiting, fever, and decreased appetite. The emergency physician diagnosed URI and BOM and prescribed Augmentin. The little boy returned to the clinic three days later with a higher fever. His WBC was elevated, and his chest X-ray revealed a miliary infiltrate; a pediatrician admitted him for testing. The differential diagnosis on admission was tuberculosis, histoplasmosis, coccidial blastomycosis, and pertussis.
Four days later, the child developed seizures and was moved to pediatric intensive care, where he was intubated. An infectious disease physician was consulted, and a lumbar puncture revealed TB in the meningeal fluid. The child became comatose with decerebrate posturing and remained in a coma until his death six months later. The family sued the family physicians and the clinic, alleging negligent failure to diagnose and treat tuberculosis in a timely manner.
Disposition of Claim: Settled for more than $300,000.
Risk Management Perspective: The medical experts who reviewed this case concurred that the family practice clinic lacked adequate procedures to provide comprehensive care for this child. The language barrier prevented the physicians and clinic from obtaining an adequate medical and family history. They did not know whether the boy was receiving well-child check-ups and appropriate immunizations. The experts criticized the lack of a policy and procedure for treating patients with limited English proficiency. During some of the visits, a 12-year-old relative translated. At others, no interpreter was available. The clinic failed to obtain an adequate history and didn’t know that the boy’s father had been diagnosed with active TB in California prior to coming to the Midwest.
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