Documenting How Patient Language Needs Are Met Using the Electronic Medical Record

International Medical Interpreters Association Conference

October 11, 2008

Helena Santos-Martins, MD - Medical Director

Jacquelyn Caglia, MPH – Research Associate

Cambridge Health Alliance

• Academic Public Healthcare System – Safety Net• Harvard and Tufts Teaching Affiliate• Three acute care hospitals with 300 total beds• 25 primary care sites • Public Health Department • Medicaid Managed Care Health Plan• Uncompensated Care Program

Cambridge Health Alliance

In Massachusetts we are •The 10th largest healthcare system•The LAST public acute care hospital system •The largest acute care hospital provider of inpatient mental health and addiction services

1. Boston Business Journal's Annual Top 100 Hospitals list Healthshare One

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CHA’s Primary Communities

The mission of the Cambridge Health Alliance is to improve the health of our communities.

• Total population of seven primary communities is 366,450

• Estimated 34% speak a language other than English in the home

• Estimated 15% have limited English proficiency and require language assistance1. US Census 2006 Estimate; CLARITAS Market Place

2. US Census 2000.

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Language needs of our patients

• A third of our patients come from outside our primary communities

• Our linguistic and cultural capabilities are a big draw

• Result – 45% of our patients have a preferred language other than English

1. CHA Primary Care Panel (FY 2006 and FY 2007)

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Important Questions

• Should we develop a standardized system for documenting how patient language needs are met?

• How does accurate language identification affect clinical operations?

• How is the Electronic Medical Record used to document how patient language needs were met?

• How can documentation then foster quality improvement initiatives, aimed at improving patient-provider communication?

How does language effect healthcare disparities?

Language Barriers Negatively Impact Patient-Provider Communication

Note: Percentages are adjusted for non-response based on how many of the four questions had a response.

Source: Agency for Healthcare Research and Quality. National Healthcare Disparities Report. 2006.

Adults who report their health providers sometimes or never listened carefully, explained things clearly, respected what they had to say, and spent

enough time with them, 2003

9.3 8.9

1112

8.3 9

16

12

1816

No

dataNo

data

Total White, non-Hispanic

Black, non-Hispanic

Hispanic AmericanIndian/Alaska

Native

Asian

P referred language-EnglishP referred language- other

Percent of adults age 18 and over

Non-English* speakers have more difficulty understanding information

from their doctor’s office

* English is not primary language spoken at home

Source: The Commonwealth Fund 2001 Health Care Quality Survey, chart 15.

Percent of adults reporting it is 'very easy' to understand information from their doctor's office

16%

47%

37%

51%

57%

Total U.S. Hispanic EnglishSpeaking

Hispanic SpanishSpeaking

Asian AmericanEnglish Speaking

Asian American Non-English Speaking

Risk factors associated with LEP population:

• Persons with LEP experience disproportionately high rates of infectious disease and infant mortality.

• Persons with LEP are more likely to report risk factors for serious and chronic diseases such as diabetes and heart disease.

Source: Office of Minority Health, “Eliminating Racial and Ethnic Disparities,” http://www.cdc.gov/omh/AboutUs/disparities.htm (25 April 2007)

Language barriers affect patients’ quality of care

• Language barriers are associated with less health education, worse interpersonal care, and lower

patient satisfaction. Source: Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality care for limited English proficient patients: The importance of language concordance and interpreter use. J Gen Intern Med 2007. 22(Suppl 2):324–30

• Hispanics who do not speak English at home are less likely to receive all recommended health care services.

Source: Cheng EM, Chen A, Cunningham, W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med 2007. 22(Suppl 2):283–8.

Language barriers affect patients’ quality of care

• LEP patients who are hospitalized are less likely to have documentation of informed consent before undergoing invasive procedures.

Source: Schenker Y, Wang F, Selig SJ et al. The impact of language barriers on documentation of informed consent at a hospital with on-site interpreter services. J Gen Intern Med 2007. 22(Suppl 2):294–9

• LEP populations are less likely to receive preventative

health services such as mammograms. Source: Woloshin S, Schwartz LM, Katz SJ, et al. Is language a barrier to the use of preventive services? J Gen Intern Med. 1997;12:472–477.

Language Assistance

• Federal requirement for all hospitals • Federal funding to provide competent language services to ensure equitable care for LEP patients (Title VI)• Massachusetts law requires interpreters in Emergency Department and Inpatient Psychiatry

Competent language access should be provided by:• Trained, tested interpreters• Providers who are fluent in the patient’s language• Bilingual employees using their language to do their job (not interpreting without training)

How do hospitals respond to the language needs of their patients?

Hospitals use a variety of resources to provide language services

Source: Health Research and Educational Trust, 2006

Methods Commonly Used in U.S. Hospitals to Provide Language Services

68%

63%

66%

82%

74%

18%

92%

0% 20% 40% 60% 80% 100%

Staff interpreters

Independent freelance interpreters

External interpretation agencies

Bilingual clinical staff

Bilingual nonclinical staff

Community language bank

Telephonic services

Trained Medical Interpreters vs. Ad-Hoc

• Competent medical interpreting requires a high degree of fluency in English and the patient’s language (tested), as well as training in interpreting, medical terminology, and cross-cultural health care. Professional skill level is assessed.

• Ad hoc interpreters are bilingual employees, friends, or family members unlikely to have had fluency testing or medical interpreter training. Skill level is questionable.

Use of untrained medical interpreter or no interpreter impairs communication

• Ad hoc interpreters misinterpreted or omitted up to half of physicians’ questions.

Source: Ebden P, Carey OJ, Bhatt A et al. The bilingual consultation. Lancet 1988, 1:347

• Errors committed by ad hoc interpreters were significantly more likely to be errors of potential clinical consequence than those by hospital interpreters.

Source: Flores G, Laws MD, Mayo SJ et al. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 2003, 116:6-14.

Effects of Language Services on Patient Care

LEP patients’ understanding of disease and treatment plans were significantly more likely to be poor or fair compared to those who were provided an

interpreter or patients who did not need interpreter.

Percent of patients

* p< 0.01; Source: Baker DW, Parker RM, Williams MV et al. Use and effectiveness of interpreters in an emergency department. JAMA (1996); 275: 783-788

The Challenge for Hospitals

• All hospitals are required to provide competent language services (interpreters, phone services, or video link) to LEP patients at no charge

• Minimal federal guidance is provided

• No uniform standards are established for assessing the effectiveness of language services

• Hospitals need to know if current services are meeting patient needs

How can hospitals know if language services are meeting patients’

needs?

Step One: Identify Language Need

• What is primary language spoken at home?

• What is preferred language for clinical care?

• What is preferred language for written materials?

Language Identification at CHA

• Patients screened upon registration

• Preferences documented in medical record (paper & electronic)

• Language needs confirmed with clinical providers

• System for correcting language preferences

Step Two: Address Challenges to Identifying How Language Need Met

• Need documentation to be quick and easy

• Required IT assistance for programming

• Providers may need reminders that patient is LEP

• Providers may need reminders that they need to document how language needs met

• Some types of language assistance are not optimal

Language Services at CHA

• Multilingual Interpreting Service started in 1979• Service is offered 24 hours a day, 7 days a week.• Main languages are Portuguese, Spanish and Haitian Creole• Employed 160 employees in FY08, with approximately 185 projected for FY09 • Also work with approximately 75 per diem employees in FY08, project 100 in FY09• Provided 200, 000 interpreted encounters in FY08• Focus on Quality Improvement, internally and in collaboration with clinical departments

Interpreter Database

•Interpreters enter visit information•Generates management reports•Does not capture unmet need

Documenting Language Assistance in Medical Record

•Lack of clarity about language definitions (primary, language of care, preferred)•No QC on listed language•Only the provider and patient actually know

•What the language need was•How it was met (or not met)•Why

•Data needed for process improvement, program design and development•Interpreter use must be documented anyway, but encounters when interpreter not present are not•To get this data…more clicks

How can language needs be met?

• Face-to-face interpreter

• Phone interpreter

• Bilingual provider

• Bilingual employee

• Patient’s friend or family member

• LEP patient speaks some English

Solution in EMR

Developed EPIC Quick Questions for Provider Documentation of How Patient Language Needs Are Met

Pilot at Ambulatory Health Center, East Cambridge Health Center, for office and telephone encounters for adult medicine providers and nurses

• Provider documents how language needs met

• Records language of encounter

Critical to Success was Provider Buy-In

EPIC Quick Question Pilot East Cambridge Health Center Jan-July 2008

N=7012 Completed Questionnaires

38%

17%

37%

1%2%5%

English Preferred by Patient Today

Face to Face Interpreter

Family or Friend Preferred

No Interpreter-Patient Declined

Phone Interpreter

Provider Fluent in Patient's Language(Not English)

Data Outputs and Uses

We can now begin to…•Understand unmet need•Identify, assess & certify providers using a second language•Understand the added value of such providers•Correlate approach to language needs with

•Patient satisfaction•Clinical outcomes•Efficiency

•Manage interpreter service scaling and deployment•Correlate with interpreter activity reports•Reduce liability

Data Outputs and Uses

• Reports at the provider and site level

• Represent True Need and True Service Delivery

• Establish best practices for clinicians and staff

• Connection to other QI efforts and interventions by linking how language needs met to clinical service delivery and patient outcomes

• Monitor cost-effectiveness of various ways of meeting patient language needs

Solution using EPIC

Why would providers answer more questions without complaining (or worse)?•Clear understanding of the importance of this data for patient care•For interpreter visits, this replaces a smart phrase•It is quick – 7 seconds (range 2-11)•Soft stop•Non-punitive

How can data be used to improve services?

• Monitoring and improving language access requires collaboration• Engaging leadership and technology brought success• Listening to providers and addressing their concerns created buy-in• Ability to now document all of the ways in which language needs are met

Next Steps #1

•Develop reports•Analyze impact on quality and cost•Develop provider assessment and certification process•Prospectively manage interpreter services to demand, provider change•Make the case for meeting language needs well

Next Steps #2

• Continued feedback to providers to improve documentation• Identify and close gaps in language access•Leadership support for expansion of documentation to other sites• Design a system for assessing the language skills of bilingual providers• Staff training to improve the accuracy of patient language fields

Why Should Interpreters Support Provider Documentation?

• Patient Safety• Reimbursement• Advocacy for more language services• Ultimately, to better meet the patient’s needs!

Thanks to ECHC staff (above), Loretta Saint-Louis, Carleen Riselli, Jenny Azzara, Dr. Hilary Worthen and the CHA Epic Team, and the

RWJF Speaking Together Program