Rheumatology: Improving communication with limited English proficiency patients at LVPP and throughout LVHN
Marie Spevak O’Brien, DO, who practices in rheumatology at LVHN, and is a Clinical Assistance Professor at USF Morsani College of Medicine, became interested in how well health care providers were communicating with patients having limited English proficiency.
Research showed that Spanish speaking patients have less access to health care and are at a higher risk of adverse outcomes and decreased patient satisfaction. Fortunately, they are protected by the Title VI of the Civil Rights Act of 1964, which prevents discrimination by any organization receiving federal funding. Since virtually all health care providers accept Medicare, Medicaid, or another form of federal funding, this applies to physicians, and further requires that providers and hospitals “supply an interpreter for limited English proficiency patients.”
Dr. O’Brien found that the type of interpretation matters. A 2012 study in emergency departments that appeared in the Annals of Emergence Medicine reports that, “The use of trained interpreters resulted in 10 percent fewer errors with potential medical consequences than using untrained interpreters, and that using untrained interpreters could be just as dangerous as using no interpreters.” Multiple studies showed that phones and iPads are not as effective as live interpreters, because they are minus the advantages of body gestures and nonverbal cues, and are shown to not alleviate anxiety or improve patient cooperation.
Further, “When limited English proficiency patients do not have professional medical interpreters or bilingual providers available, they have to resort to the use of ad hoc interpreters, which are family members, friends, and people from the waiting room or strangers pulled from the street. This can introduce a host of biases, such as when a family member withholds information to try and protect a loved one, or when a speaker uses slang or idioms unique to their country. Such errors can lead to misdiagnoses, unnecessary tests, and misinformed treatments that put a patient's health at risk.”*
Dr. O’Brien decided to measure interpretation differences. She and her team launched a pilot study to demonstrate increased patient and provider satisfaction with live medical interpreters for Spanish speaking patients seen in Lehigh Valley Physicians Practice (LVPP) rheumatology fellow’s clinic compared to other resources (electronic devices mainly VRI, iPads and or ad hoc) over six-month period. In this population, 30 to 35 percent of patients are Spanish speaking only. The nature of LVPP is longstanding patients on injectable, intravenous, or oral therapies with extensive toxicities, and a need for precise communication involving medical terminology
Communication options at LVHN include live interpreters, the iPad Stratus Video Remote (VRI) program, and “ad hoc” interpreters such as family members or noncertified staff. However, in a survey of current status, it was found there was an existing limited use of live interpreters. The survey showed that iPads and ad hoc interpreters used more frequently even though iPads disconnect frequently, and time with patients can be limited since staff are often pulled away from current tasks to assist in rooms.
The following is an outline of the pilot program:
- A sample of patients from rheumatology AM LVPP sessions are chosen.
- Supervising LVPG rheumatology attendants oversee three rheumatology fellows.
- Time in minutes of each session is documented from start time in room to check out time.
- Surveys are provided to each patient and fellow at end of each visit with two questions. (The questions were adapted from Consumer Assessment of Healthcare Providers and System Hospital Survey (www.cahps.ahrq.gov))
- Lkert scale for response categories is utilized with 1 indicating “very satisfied” or “very easy” and 4 being “very dissatisfied” or “did not understand at all.”
- The survey data is collected into an Excel spreadsheet with de-identified data.
- Statistics chosen in SPSS Statistics software are discussed with faculty at the USF RISE office to assess differences in patient and provider satisfaction.
With results of this pilot, Dr. O’Brien is hoping to demonstrate significant improvement from both patient and provider with use of live medical interpreters. Study results will be submitted to the LVHN QI Team so that more funding can be provided to support an increase in LVPP specialty medical interpreters to utilize in all specialty clinics and possibly LVPP Medical clinic. The study will be expanded to other specialties with the assistance of a USF SELECT student, who will be using this topic for a Capstone Project and to obtain larger numbers to calculate cost benefits.
* Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters