To: Dr. Howard A. Zucker
From: Warveen Othman
Date: July 18, 2021
Re: New York State Mandate Requiring Translation Services in All Healthcare Settings
Statement of Issue: Should there be a state mandate requiring the use of professional translation services with patients with limited English proficiency (LEP) in all healthcare settings? Although access to translation services have increased in the last few years, there is still a dangerous lack in the use of professional translators due to pressures of efficiency and metrics. Appropriate use of these services by all healthcare providers is necessary to avoid detrimental medical errors. And situations that have risen amidst the COVID-19 pandemic have further exacerbated difficulties with access to translation services.
- Poor communication due to language barriers is still a big issue today. This leads to consequences like misdiagnosis, poor patient compliance due to misunderstanding of medical instructions, lower use of preventative care, increased admissions and readmissions, increased length of hospital stays, and many other preventable problems (Masland) (Fetterolf).
- Family and friends are too often used for translation. Potentially due to poor experiences in the past with lengthy waits for an interpreter, many providers think it is more convenient and efficient to use family members or friends to translate for patients. They may also find that the family/friend may be culturally preferable than a 3rd party, unknown translator (Masland). However, comfortability should not outweigh the importance of adequate translation. Family/friends often do not translate accurately; they may omit information, summarize, and inject opinions. The patient themselves may also not be comfortable opening up in front of these companions (Moch).
- Many providers feel their limited proficiency in a language may be enough to effectively communicate with patients without a translator. (Masland) They’ll attempt to use hand gestures and insufficient language skills to communicate and get by, which can lead to miscommunication and dangerous consequences (Panayiotou). Even though professional translation services may be readily available to providers, many still fail to use them.
- New York State Diversity. In 2019, about 22% of NYC residents were limited English speaking individuals. (Keeping Track Online). This means that about 1.7 million people could be receiving poor quality care secondary to miscommunication if adequate translation services aren’t provided. Title IV of the 1964 Civil Rights Act requires all federally funded facilities to provide free language assistance to those who request it (Masland); however, not all LEP patients will request translation! This brief will discuss options to require providers to use interpreter services with all LEP individuals, regardless of whether or not they request this service.
Policy Options
- 1 – A state mandate that would require all health facilities in New York to carry and use adequate video translation services with all patients with LEP. In the case that video cannot be used, phone or voice translation services may be utilized. These services will be provided by professional translators through a state-approved company of the health facility’s choice. Providers will be legally prohibited from using the patient’s family members or friends for translation. The translator’s ID number must be included in the clinician’s note for each specific encounter in order to prove appropriate use and for tracking purposes.
- Advantages: Provider higher quality care to LEP individuals and avoids miscommunication, medical errors, and malpractice lawsuits. (Moch) For services provided over video, patients and providers benefit from non-verbal communication (Fetterolf). Requiring use of these services would also increase demand, thus creating more jobs. Requiring ID # in the charts of all LEP patients will hold providers accountable.
- Disadvantages: Healthcare providers, especially those in small offices, may be reluctant to sign a contract with a company and implement these virtual services due to extra costs (Jacobs). Clinicians may also be opposed to this if they feel this is a time-consuming task, with obtaining the translation devices, calling the interpreter, and adding yet another item to document. There is always a risk of privacy breach with these virtual services, especially because there are more people involved (the translators) that are expected to comply with HIPAA. Although relatively rare, human error on the translators’ part is always a risk to take into consideration as well (Allen). Specific dialects may not be available. These services may be uncomfortable for emotional and sensitive patient-provider conversations (Fetterolf).
- 2 – A state mandate requiring all employees of New York health facilities to use secure, private translating apps on their cellular devices, similar to Google Translate, with all LEP individuals.
- Advantages: This option would be cheaper than the above. More efficient and convenient, as the device would be in their pockets and there would be no wait time. Virtually all employees would have access to this service, even front desk staff, transporters, etc. Patients may feel more comfortable with this service, as it does not involve an unfamiliar 3rd person in the conversation.
- Disadvantages: Risk of privacy breach with online services. Specific dialects may not be available. Translation may not be accurate; a study done with discharge instructions interpreted with Google translate found a small portion of mistranslations that could have done harm to the patient (Carroll). Professional human translator may be better at interpreting culturally specific linguistics/phrases. Risk of contamination; employees’ phones will need to be disinfected before and after every encounter, adding time to visits. Many employees may not carry phones that can support these apps. Because no ID # attached to the service, accountability will be hard to track in order to prove this app was used with all LEP patients.
- 3 – Implementing in-person translation centers in every county. The number of translators in every center would depend on population size of LEP individuals in that county. In non-emergency situations, a translator will be scheduled at least 24 hours ahead of time to come into the office and interpret for an LEP individual.
- Advantages: Creating more jobs. Nonverbal cues are easier to access. In-person translation has been shown to lead to better patient satisfaction (Fetterolf). Provider will have an ID number to prove use for accountability.
- Disadvantages: The most expensive of the three options. Scheduling conflicts. Patient may be uncomfortable with another unfamiliar person in the room. Unrealistic to expect every center to have employees that speak every language. Not an option for emergency situations. Increased risk of HIPAA violations.
Policy Recommendation: Like stated previously, although federally funded facilities are required by law to offer language assistance when requested by patients, not all LEP patients will request these services. Although imperfect, the best option here is the first mentioned – to mandate all health facility employees use video or phone translation services. Although implementing these services may seem costly, the increase readmissions and health costs secondary to miscommunications are actually a heavier financial burden (Jacobs). While the extra documentation and increased time required to use these services may seem to decrease efficiency, improving communication through adequate and accurate translation will decrease the rate of misdiagnoses and misunderstandings in the LEP population. Employees of these interpreter companies will need to be adequately trained for HIPAA compliance. These healthcare facilities will need to increase the number of devices available in order to accommodate for the LEP population in their area, in order to avoid having employees needing to wait for devices to become available to them. Video is preferred in all cases, however, in emotional/sensitive situations, phone may be used over video.
Sources:
Allen, M. P., R. E. Johnson, E. Z. McClave, and W. Alvarado-Little. 2020. Language, interpretation, and translation: A clarification and reference checklist in service of health literacy and cultural respect. NAM Perspectives. Discussion Paper. National Academies of Medicine, Washington, DC. https://doi.org/10.31478/202002c
Carroll, L. (2019, February 25). Google Translate mostly accurate in test with patient instructions. Retrieved from https://www.reuters.com/article/us-health-translations/google-translate-mostly-accurate-in-test-with-patient-instructions-idUSKCN1QE2KB
Jacobs, E. A., Shepard, D. S., Suaya, J. A., & Stone, E. L. (2004). Overcoming language barriers in health care: costs and benefits of interpreter services. American journal of public health, 94(5), 866–869. https://doi.org/10.2105/ajph.94.5.866
Keeping Track Online – Limited English Proficiency. (2019). Retrieved from https://data.cccnewyork.org/data/map/1256/limited-english-proficiency#1256/210/1/1446/62/a/a
Masland MC, Lou C, Snowden L. Use of communication technologies to cost-effectively increase the availability of interpretation services in healthcare settings. Telemed J E Health. 2010;16(6):739-745. doi:10.1089/tmj.2009.0186
Moch, R., Nassery, H. G., & Fareed, M. T. (2014, April 01). Incorporating Medical Interpretation Into Your Practice. Retrieved from https://www.aafp.org/fpm/2014/0300/p16.html
Panayiotou A, Gardner A, Williams S, et al. Language Translation Apps in Health Care Settings: Expert Opinion. JMIR Mhealth Uhealth. 2019;7(4):e11316. Published 2019 Apr 9. doi:10.2196/11316
