Reducing Language Barriers in Health Care: Is Technology the Answer?

In this issueof JAMAPediatrics, Lionandcolleagues1 describe findings from their well-designed randomized clinical trial of videovstelephonicmodesofdeliveringSpanish-language interpretation in the pediatric emergency department (ED). They foundthatparentswhowererandomizedtoreceivevideo interpretationduring their child’s ED stayweremore likely toname their child’s diagnosis correctly than those who received telephonic interpretation (74.6% vs 60.0%, respectively) and reported a lower percentage of frequent lapses in interpreter use (1.7%%vs7.7%,respectively);videointerpretationwasalsomore costly by amean of $30 per patient. No significant differences were found between the 2 modes of interpretation in selfreportedqualityofinterpretation,EDlengthofstay,orEDcharges. This work makes a substantial contribution to the literature. Many health care systems are making decisions about whether touse technology toprovide interpreter services, and this work provides data to allow for a better-informed decision about which type of technology to use. The question remains whether technology, in any form, is the best solution to reducing language barriers in the health care setting. Althoughnothighlightedassignificant findingsbecausethe authors foundnodifferencesbetween themodesof interpretationdelivery, 2 other findings are quite striking. First, the quality of interpretationwas rated as high only 47.2%and50.0%of the time in the telephone and video arms, respectively, and almost two-thirds of patients in both groups experienced some lapsesintheprovisionof interpreterservices.Thesefindingssuggest that there is stillmorework to do to develop interventions toprovideconsistent,equitable,high-qualitycommunicationto patientswithlimitedEnglishproficiency(LEP)despitetheadvent of technological advances in communication. Akey limitationof thisstudy is the lackofcomparisonswith in-person interpretationandprovisionof language-concordant care. The preponderance of extant evidence suggests that language-concordant health care professionals are superior to any other method of provision of care to LEP patients.2-5 Language-concordant health care professionals and in-person interpretersmay be superior to video and telephonic interpretation,making expansion of access to in-person interpretation andbilingual clinicians thebestmethodofprovidingequitable, high-quality care to LEP patients. However, few head-to-head comparisonsof telephonic,video,andface-to-face interpreting have been performed. In addition, lack of comparison with to face-to-face interpretationprohibited theauthors fromexploring a key stated hypothesis—that the lack of ready access to inperson interpretationmay contribute to lapses in use of an interpreterwhenneededandthatmakinginterpreterserviceseasier to access, especially throughvideo interpreting,would reduce these lapses.However,most of the patients in this study experiencedlapses,andwhethertheselapseswouldhavebeengreater if oneof the groupshadbeenassigned to face-to-face interpretation remains unclear. OperationsatSeattleChildren’sHospital, thesetting for this study,arebasedonthesekeyconceptsbecausetheyhaveapolicy inplaceprohibitingcliniciansfromusingnonnativelanguageskills formedical communicationunlesscertifiedasproficientby the hospitalthroughtheClinicianCulturalandLinguisticAssessment (avalidated, telephone-basedtest).6Thiskindofpolicy,present atan institutional level, isanadditional importantsteptoensure thatpatientshaveaccesstohigh-qualityinterpreterservices.Even in this settingand in this study,duringwhichparticipatingclinicians were aware that use of interpreter services was being tracked, lapses in interpreteruseweresignificant,withclinicians againoptingtogetbywithouttheuseofanyinterpreterservices. Thepracticeofgettingbywithout interpreterserviceswhencaringforLEPpatients iscommonamongcliniciansandevenmedical students.7,8 This finding is oneof themost important in this study and should be explored further. The reported lapses in interpretationmay have little to do with accessibility to the interpreter services orwith the lack of apolicyregardingcareofLEPpatients.Thelapsesreportedinthis studylikelyhadmoretodowiththeclinicians’ lackof insight into keyconcepts: the importanceofusing interpretation if theirpatientscannotunderstandthemandthatequitablecareofpatients at risk for languagebarriers is an issueofqualityof care.Thebig question iswhat itwill take for clinicians tocommit tousing interpreter services appropriately. We think the commitment shouldstartearlywithappropriateeducationofcliniciansonequityasaquality issueanduseofpolicy to implement important safeguards, followed by a systematic evaluation of clinicians’ practices targeting the care of LEP patients. Futureworkalsoshould focusonpatients’experienceof interpretedencounters.Wewerestruckbyhowhealthcaresystem– centered themain outcomes of this studywere—that is, length of stay in theED, cost, andknowledge of diagnosis vs the experience of care and understanding of treatment and follow-up. These outcomes are certainly relevant to making a policy argumenttohealthpolicymakersandleadersofhealthcaresystems,butpatient-centeredoutcomes are also important. Future investigative efforts should expand outcomes tomeasure the quality of communication in interpreted encounters andhowdifferentmodes of interpretationdelivery, inpersonorvia technology,buildtrust inandcomfortwith the health care professionals anddelivery systems. As theLEPpopulation in theUnitedStates continues toexpand in sizeandgeographic reach, investigations intoeffective and efficient communicationwith LEP populations should informpolicy andpractice. Technologymaybe an important adjunct inimprovingcommunication,butteachinghealthcareprofessionalsabout theexperienceofpatientswithLEPwhodonot get access to interpreter servicesmust be emphasized, and the patientsand their experiencemust remain theprimary focus in research and practice. Related article page 1117 Opinion Editorial