ReducingHealthDisparitieswithInterpreterServices

AmyEllsworth

WesternWashingtonUniversity

1
ReducingHealthDisparitieswithInterpreterServices

MyinterestinthistopicbeganwhenIhadapatientfromadifferentcountryandspokeverylittle
englishtheassessmentswiththispatientwerenevertomysatisfaction.Iwouldaskquestions
anditwasonlyakindofunderstanding,withoutanyrealteaching.Hewastowardtheendofhis
lifeandaverystoicperson.Iattemptedtogethimincontactwithhisfamily,theywerelistedas
hisinterpreters.Weonlywereabletoleavemessages,anddidn'treceiveacallback.Hepassed
onadaywhereIhadafewdaysoff.Myperceptionisthatthetreatmentcouldhavebeenbetterif
communicationwasbetter.Sometimesitwasafrustratingexperienceforthepatientintryingto
figureoutawaytocommunicate.Itseemedoutsideofmyscopetoaccessinterpreterservices.
I'vesincethoughtofdifferentwaysforaccessinginterpreterservicesforthisfacilityandhave
alreadystartedusingthem.
Misunderstandinginhealthcareiscostly,costlyinthesenseoflives,andoftrustinthe
medicalsystem.Ashealthcareprovidersitshouldbeourgoaltoprovideequitablecare,andin
doingsowillfacilitatetrust.TherecontinuetobehealthdisparitiesamongLowEnglish
Proficiency(LEP)patientsandtheIOMpartiallycontributesthesedisparitiestohavinglanguage
barriers.Languagebarrierspromotemisunderstandinginhealthcareandonlycontributeto
disparity,mistrust,andavoidanceofthemedicalsystem.
Despitethefactthatusingprofessional
interpreterservicesismandatedbothlegallyandethicallybecausedoingsoleadstoequitable
accessandbetterhealthoutcomesforLEPpatients,practitionersarentusingprofessional
interpretersbecauseofinconvenienceandcost.
First,professionalinterpretersserveapurposebyfacilitatingbetterunderstandingof
medicaladvice.AccordingtoFloresG,LawsM,HardtE,etal.inthearticle
ErrorsinMedical

2
ReducingHealthDisparitieswithInterpreterServices

InterpretationandTheirPotentialClinicalConsequencesinPediatricEncounters
(2003)
Interpreterservicesdirectlycontributedtobetterpatientoutcomewithbetterunderstandingof
overallhealthandexpectationsofdiagnosisbyhavingareductioninmisinterpretation.
Professionalinterpreterserviceswereseentoreducepotentialmedicalerrors.Floressstudy
comparedtheuseofprofessionalinterpreterservicestoadhocinterpretation.Adhocinterpreters
arepatientfamilymembersorfacultymembersnotemployedasinterpreters.Thestudyfound
thatcommunicationerrorstendedtooccurmoreoftenwiththeuseofadhocinterpretersthan
professionalinterpretersandmoreoftentheseerrorswereofclinicalsignificance.Translating
medicalinformationiscomplexandwhenprofessionalservicesarenotemployedcriticaldata
canbelostintranslationcausingerrors.Theseerrorsofinterpretationwereprimarilyomissions
inmedicalinformationorincorrectsubstitutionswithinaccurateinformation.Thisinformation
couldbeportrayedasseeminglyharmlesstotheadhocinterpreterandhasclinicalsignificance.
Theomissionsincludeddrugallergies,andfrequencyofdruguse.Useofprofessionalinterpreter
servicesfacilitatesmoreaccuratecommunicationandincreasesbetterunderstandingofmedical
informationandyet,interpreterservicesarenotbeingused.
Ininvestigatinghowofteninterpreterservicesareusedthearticle
Patternsofinterpreter
useforpatientsinthehospitalwithlowenglishproficiency
tookatstudybetween20052008in
SanFranciscoof234patientsintheirhospitalstaythatcouldhavebenefitedfromuseof
interpreterservices.ThesepatientswereeitherChineseorSpanishspeaking.Thestudyfound
thatinterpreterserviceswereused17%ofthetime,andwhentheyareuseditisprimarilywith
physiciansduringthehospitalizationprocess.Insteadofusingprofessionalinterpreterservices

3
ReducingHealthDisparitieswithInterpreterServices

adhocinterpretersareassigned.Inquestioningthe234patients,thepatientsreportedthat
interpreterserviceswereinfrequentlyusedinnursetopatientinteractionandthatinthese
interactionspatientswereeitherinfrequentlyspokento,orthatthepatientgotbyusinglittle
english.Themajorityofnursesarenotusinginterpreterservicesintheirdaytodaycare,andif
theyareusinginterpreterservicesoftenitisadhocinterpreters.
Notensuringpatientunderstandingiscontributingtomisunderstandingandencouraging
disparitieswithinthemedicalsystem.Inquestioningwhytherearehealthdisparitiesamong
racesareportfromtheInstituteofmedicine(2003)statesthatitispartiallycontributedtoa
lack
ofinterpreterservicesandavoidanceofthemedicalsystem.
Onereasontowhythereisavoidanceinthemedicalsystemisbecausetherearelanguage
1
barriers.Currently1in5latinoamericansavoidthemedicalsystemduetolanguagebarriers

Havinglanguagebarriersinhibitspatientsfromseekingmedicaladvice.
Accordingtothe
AmericanCollegeofPhysiciansreportof
RacialandEthnicDisparitiesinHealthcare
(2010),
pooroutcomesofLEPpatientscanberelatedtoavoidanceofseekingmedicalprofessionals,not
usingpreventativeservices,misunderstandingofdischargeandexpectationsofselfhealth
responsibilitiesandfollowup.
Therearemanyreasonsforwhyapersonavoidssomething,andoneaspectofthatis
becausetherewasmistreatment.
TheInstituteofMedicine(IOM)report,
UnequalTreatment:
ConfrontingRacialandEthnicDisparitiesinHealthCare(
2003
)
contributeoneaspectofthe

4
ReducingHealthDisparitieswithInterpreterServices

healthdisparityasahistoryofracismwithinthemedicalsystem.Thisracismwithinthemedical
systemresultedinageneralizedmistrustamongraces.
ThecontinuedmiscommunicationamongLowEnglishProficiencypatientshasonly
maturedtheconceptofsuspicionfortheUnitedStatesMedicalSystem.
Inseeingthisthe
governmentfeltitwastheirdutytofacilitatebetteraccesstointerpreterservices.
CurrentlyinthemedicalprofessiontheGovernmenthasoversightforfederalfundingto
requireinterpreterservicesinattemptstoeliminatemedicalerrorsamongtheLEPpopulation.
Since1980Itisapatientslegalrighttohaveinterpreterserviceswhilebeingmedicallytreated,
(accordingtotherevisionin1980ofthe1964CivilRightsActTitleVIasstatedbyTheUnited
StatesDepartmentofJusticeexecutiveorder12250).Arevisioncamein2000tomake
interpreterservicesmoreaccessible,toreexaminetheaccessibilityofinterpreterservicesandto
providemeaningfulaccesstoLEPpatients.Anotherrevisionin2002whichclarifiesthat
nonprofitandsmallorganizationsareexemptfromrequiringinterpreterservicesduetoitbeing
afinancialburdenuponthatbusiness.Dependingonthesizeofthemedicalpractice,interpreter
servicesmaynotbemandatory.
Althoughinterpreterservicesfacilitatebetterpatientunderstandingandtheyarerequired
forgovernmentfundedinstitutionstherecontinuetobebarrierstousageofinterpreterservices.
Forthesmallerpracticeandtoadoctorthatspeaksonelanguage,apatientwithLEPaddsto
inconvenienceandcostoftreatment.CostsofInterpreterservicesandreimbursementvary,and
areperceivedbytheprivatepracticeasbeinghigh.Thearticle
CaringforPatientswithLimited
EnglishProficiency:ThePerspectivesofSmallGroupPractitioners
(2007)didastudyonthe

5
ReducingHealthDisparitieswithInterpreterServices

perceptionofmedicalpracticesanduseofinterpreterservicesandstatedthatfewofthe
physiciansormanagershadexperienceusingandpayingforprofessionalinterpreter
services.andestimatedcostsvariedfrom$30to$200pervisit.(p344)Notknowingthecost
ofinterpreterservicesmakeevidentthatuseofinterpreterservicesislow.
Inthesamearticle,
onemedicalofficemanagerdirectlystatesthat
...[T]thedoctorswouldjustratherthatpatient
[LEP]gosomewhereelse[and]findasolutionsomewhereelse.Thenewdoctorjuststartingout
......(they)dealwithit.Anyestablishedpracticeisgoingtotrytoavoidthat.
(p345)Although
thisseemsabitunethicalaprivatepracticeisabusiness,anddependingonthesizeofthe
practice,interpreterservicesmaybeafinancialburdenandnotarequirement.
ThesizeofthepracticeinfluencesuseofinterpreterservicesandalsopopulationofLEP
patientsdetermineaccessibilityofinterpreterservices.DependingonpopulationsizeofLEP
patientsuseofinterpreterservicescouldbeabusinessstrategy.
Therearephysiciansthathave
foundwaystoeliminatethecostofinterpreterservices.Onecouldapplyforfederalfunding.
Otherdoctorsusedthehospitalwheretheydidtheirsurgeriesandwereabletoaccessinterpreter
6
services
.Thisemphasisesthatalthoughcostisalargeconcernforrunningabusiness,thereare

alternativewaysforobtaininginterpreterservicestoreducethefinancialburdenandincrease
interpreterserviceusage.
Measurestakentoincreaseinterpreteruseincludeincreaseoffederalfunding.In
Februaryof2009Obamaincreasedthefederalfundingofuseofinterpreterservicestocover
75%ofthecost,thisisanincreasefromthegovernmentcovering50%ofthecostofinterpreter
3
services
.
Reductionofthecosttotheprivatepracticewillhopefullyallowincreasedinterpreter

6
ReducingHealthDisparitieswithInterpreterServices

usage.
Alongwithreducingthecostofinterpreterservicesreducingtheneedforinterpreter
servicescanincreasepatientoutcomes.Decreasingtheneedforinterpreterserviceswouldbe
employedbyhavingproviderswhospeakthesamelanguageasthepatient.
Accordingtothe
AmericanCollegeofPhysicians

reportof
RacialandEthnicDisparitiesinHealthcare
(2010)
bilingualphysicianandinterpreterserviceshadbetterpatientoutcomes,thisincludedbetter
adherencetomedicalregimens,andsimilarhealthoutcomestothosewhodidnotrequire
1
interpretationservices
.Thisevidenceshowsthatspeakingthesamelanguageandeliminating

thecommunicationbarrierallowsforbetterpatientunderstanding,betterpatientoutcomes,and
thepotentialtoreducehealthdisparitiesamongracesbyprovidingequitablecare.Yes,caringfor
LEPpatientshasunseencostsandcomplexities,hopefullybyfocusingonreducingthecostand
complexityofaccessinginterpreterservicesbettercarefortheLEPpatientisfacilitated.
Waysthatthegovernmenthaspromotedinterpreterserviceusageisthroughuseof
rewardsystems.In2006theNationalCommitteeofHealthAssuranceandtheJointCommission
createdtheRecognizingInnovationinMulticulturalHealthCareawardprograminattemptsto
decreasehealthdisparitiesamongtheLEPpopulation.Likehavingmagnetstatusinhospitals
thisawardsystemcanbeavectorforchange.Twentyfiveyearsagothegovernmentmade
interpreterservicesapatientslegalright,andtherecontinuestobealackofinterpreterservice
usageindaytodaycare.
Thegovernmentisdoingtherepartbymakinginterpreterservicesarequirementinareas
wheretheLEPpopulationislarge.Irregardlessoftheaward,orthatLEPpatientsaddtothe
complexityofthecase,asanurse,andasahealthcareprovidertherearesolutions.Accessing

7
ReducingHealthDisparitieswithInterpreterServices

interpreterserviceswhenneededrequirecommitmentandhastobeapriority.Useofinterpreter
servicesisoneaspectofreducingthehealthdisparityamongraces.Beingabletoaccess
interpreterservicesisacriticalaspectofequitablecareandfacilitatingtrustinthemedical
system.Notonlydoesbettercommunicationfacilitatetrustinthemedicalsystemitalsoallows
betterpatientunderstandingofdiagnosisandempowersthepatienttotakecontroloftheirhealth.
Theresultofbettercommunicationandbetteroutcomeisequityamongraces.Thisneedstobea
reasonforobtaininginterpreterservices.

8
ReducingHealthDisparitieswithInterpreterServices

ReferenceList:
AmericanCollegeofPhysicians.RacialandEthnicDisparitiesinHealthCare,Updated2010.
Philadelphia:AmericanCollegeofPhysicians2010:PolicyPaper.(AvailablefromAmericanCollegeof
Physicians,190N.IndependenceMallWest,Philadelphia,PA19106.)Retrievedfrom:
https://www.acponline.org/advocacy/current_policy_papers/assets/racial_disparities.pdf
)
Anderson,K.M.,Roundtable,O.T.P.O.H.,&Board,O.P.H.A.P.(2012).HowFarHaveWeComeinReducing
HealthDisparities?:Progresssince2000:WorkshopSummary.Washington,DC,USA:NationalAcademies
Press.Retrievedfromhttp://www.ebrary.com
ChenAH,YougelmanMK,BrooksJ.Thelegalframeworkforlanguageaccessinhealthcaresettings:TitleVIand
beyond.JournalofGeneralInternalMedicine.200722:362367.
Diego,H.,Hicks,L.,Lopez,L.,Rodriguez,F.,UseofInterpretersbyPhysiciansforHospitalizedLimitedEnglish
ProficientPatientsanditsimpactonpatientoutcomes.JournalofGeneralInternalMedicine.June2015,Vol.
30(6),p.783(7).Retrievedfrom:http://link.springer.com/article/10.1007%2Fs116060153213x
FloresG,LawsM,HardtE,etal.ErrorsinMedicalInterpretationandTheirPotentialClinicalConsequencesin
PediatricEncounters.
Pediatrics
[serialonline].January2003111(1):6.Availablefrom:HealthSource:
Nursing/AcademicEdition,Ipswich,MA.AccessedNovember22,2015.
GadonM,BalchGI,JacobsEA.CaringforpatientswithlimitedEnglishproficiency:Theperspectivesofsmall
grouppractitioners.JGenInternMed.200722(Suppl2):3416.doi:10.1007/s1160600703114.

GerrishK,ChauR,SobowaleAandBirksE(2004)Bridgingthelanguagebarrier:theuseofinterpretersinprimary
carenursing.HealthandSocialCareintheCommunity12:40713.

Rice,S.(2014).Languageliabilities.
ModernHealthcare
,
44
(35),16205p.
Smedley,B.,Stith,A.,Nelson,A.,(2003).UnequalTreatment:ConfrontingRacialandEthnicDisparitiesinHealth
Care.InstituteofMedicine.Retrievedfrom:
https://iom.nationalacademies.org/~/media/Files/Report%20Files/2003/UnequalTreatmentConfrontingRacialan
dEthnicDisparitiesinHealthCare/PatientversionFINAL.pdf
Schenker,Y.,PrezStable,E.J.,Nickleach,D.,&Karliner,L.S.(2011).PatternsofInterpreterUsefor
HospitalizedPatientswithLimitedEnglishProficiency.
JournalofGeneralInternalMedicine
,
26
(7),712717.
http://doi.org/10.1007/s116060101619

TheInstituteofMedicineReportandItsPublicHealthImplications.(2003)."UnequalTreatment":TheInstituteof
MedicineReportandItsPublicHealthImplications.
PublicHealthReports(1974)
,
118
(4),287292.Retrieved
from
http://www.jstor.org/stable/4598854