Speaking the Language of Health Care

Translation apps and other technology seek to eliminate language barriers for patients uncomfortable with English.

LAKEWOOD, CO - DECEMBER 01:   Physician's assistant Erin Frazier checks a young boy at a community health center for low-income patients on December 1, 2009 in Lakewood, Colorado. The Metro Community Provider Network (MCPN), which has 11 health centers in the Denver area, has seen a 138 percent increase in patients during the last year of recession. Community health centers such as MCPN could play a major role nationally if health care reform is passed, with increased subsidies from the federal government as well as millions of newly-insured low-income citizens seeking care.  (Photo by John Moore/Getty Images)
National Journal
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Sophie Quinton
March 19, 2014, 12:53 p.m.

There’s an app for re­lay­ing ba­sic med­ic­al in­struc­tions in Fukienese, a group of dia­lects spoken in south­east­ern China. Need a way to help bedrid­den non-Eng­lish-speak­ing pa­tients in­stantly alert a nurse for as­sist­ance? Touch-screen soft­ware ex­ists that al­lows pa­tients to click a pained face — per­haps marked “pain” in Rus­si­an — to in­stantly alert a nurse. Both were cre­ated by New York City-based Tran­scend­ent En­deavors to im­prove com­mu­nic­a­tion between pa­tients and health care pro­fes­sion­als who speak dif­fer­ent lan­guages.

But while today’s di­git­al tools can help com­mu­nic­ate ba­sic in­form­a­tion across lan­guage bar­ri­ers, there’s not yet a di­git­al sub­sti­tute for a trained med­ic­al in­ter­pret­er or a fully bi­lin­gual prac­ti­tion­er. And some ex­perts say that trans­la­tion apps and oth­er tools can even be dan­ger­ous if they lead to in­com­plete com­mu­nic­a­tion.

“The med­ic­al en­counter is in­cred­ibly com­plex and nu­anced,” says Dr. Glenn Flores, dir­ect­or of the gen­er­al pe­di­at­rics di­vi­sion at the Uni­versity of Texas South­west­ern and Chil­dren’s Med­ic­al Cen­ter in Dal­las. Pa­tients and doc­tors need to com­mu­nic­ate about the pre­cise nature of symp­toms, past med­ic­al his­tory, pre­scrip­tions, and pro­ced­ures. “If you just have a simple tab­let that asks, do you have pain or not, that’s go­ing to give people a false sense of se­cur­ity,” Flores says. “You’re go­ing to end up put­ting people at risk.”

About 21 per­cent of people liv­ing in the U.S. speak a lan­guage oth­er than Eng­lish at home, and some 9 per­cent of U.S. res­id­ents aren’t flu­ent in Eng­lish, ac­cord­ing to 2011 census es­tim­ates. Eld­erly people are most likely to say they don’t speak Eng­lish very well, and speak­ers of some Asi­an lan­guages — like Chinese, Korean, and Vi­et­namese — are par­tic­u­larly likely to lack Eng­lish flu­ency.

These lan­guage bar­ri­ers can make it more dif­fi­cult for pa­tients to re­ceive ef­fect­ive med­ic­al care. People who don’t speak Eng­lish well are more likely to be hos­pit­al­ized for pro­longed peri­ods or to ex­per­i­ence ser­i­ous med­ic­al events while they’re in the hos­pit­al, Flores says. Stud­ies show that poor com­mu­nic­a­tion can hinder everything from colon-can­cer screen­ings to care for asth­mat­ic chil­dren.

Fed­er­al law re­quires all health care fa­cil­it­ies that re­ceive fed­er­al fund­ing of­fer lan­guage ser­vices to pa­tients who need them. Most hos­pit­als ac­com­plish this by re­ly­ing on a mix on staff in­ter­pret­ers, bi­lin­gual staff, out­side in­ter­pret­a­tion agen­cies, and phone-based ser­vices. Yet many fa­cil­it­ies don’t do a good job con­nect­ing pa­tients with lan­guage ser­vices. Less than half of pa­tients who need an in­ter­pret­er say they usu­ally get such as­sist­ance, ac­cord­ing to 2001 sur­vey from the Com­mon­wealth Fund.

Each dot represents 100 Spanish speakers who say they speak English less than "very well." (U.S. Census Bureau's 2011 Language Mapper) U.S. Census Bureau's 2011 Language Mapper

Each dot rep­res­ents 100 Span­ish speak­ers who say they speak Eng­lish less than “very well.” (U.S. Census Bur­eau’s 2011 Lan­guage Map­per)Bill Tan, founder and CEO of Tran­scend­ent En­deavors, be­lieves that there are lots of points of con­tact in health care — from home vis­its to emer­gency de­part­ments — where tech­no­logy can make lan­guage ser­vices bet­ter and more ac­cess­ible. Foun­ded in 2002, the com­pany uses Na­tion­al In­sti­tutes of Health grants to de­vel­op di­git­al com­mu­nic­a­tion tools. Sev­er­al small busi­nesses have been launched by suc­cess­ful products.

In­spir­a­tion for one such product, Starling, came from Tan’s per­son­al ex­per­i­ence. When his fam­ily moved to the U.S. from China in 1992, Tan was 15 and knew just a hand­ful of Eng­lish words. He picked up Eng­lish quickly, but his grand­par­ents — who were in their six­ties when they left China — struggled. To­ward the end of her life, his grand­moth­er was hos­pit­al­ized for a heart con­di­tion. She took to draw­ing on a note­pad to tell her nurses what she needed. “Luck­ily, she was a good artist,” Tan says.

Starling is soft­ware that an in­pa­tient fa­cil­ity like a hos­pit­al can load onto a touch screen and put at a pa­tient’s bed­side. By se­lect­ing a pic­ture — of a toi­let, say, or food — de­scribed in one of eight lan­guages, pa­tients can send an alert straight to a nurse’s mo­bile device. The soft­ware also helps nurses track what ser­vices pa­tients are re­quest­ing and when. “It can im­prove the com­mu­nic­a­tion pro­cess, and has the abil­ity to im­prove health care de­liv­ery as well,” Tan says. Since Starling launched in 2012, about six health care fa­cil­it­ies have li­censed the soft­ware.

Tan’s com­pany has also cre­ated a trans­la­tion app and med­ic­al Span­ish on­line train­ing pro­gram, both called Can­opy. The app — which can be down­loaded for free — in­cludes au­dio clips of about 1,500 routine med­ic­al phrases (like: “I’m go­ing to listen to your heart and lungs”) in 11 lan­guages. A but­ton on the app al­lows doc­tors to call a phone-based in­ter­pret­a­tion ser­vice when the con­ver­sa­tion gets com­plic­ated.

“Something like that is use­ful if you need to look up a word, a single word,” Dr. Den­nis Cle­m­ents, pro­fess­or of glob­al health and pe­di­at­rics at the Duke Uni­versity School of Medi­cine, says of trans­la­tion apps. He’s a big­ger fan of Can­opy’s on­line lan­guage-learn­ing pro­gram, which med­ic­al school stu­dents at Duke are now us­ing. “In the United States in their life­time, [health-care pro­fes­sion­als] are go­ing to be at a great dis­ad­vant­age in be­ing able to see pa­tients and in be­ing able to be cul­tur­ally ap­pro­pri­ate with pa­tients” if they can’t speak Span­ish, Cle­m­ents says.

Call­ing in a trained med­ic­al in­ter­pret­er is still the safest way to bridge a lan­guage gap between pa­tient and health care pro­vider. In a 2003 study, Flores found that ad-hoc in­ter­pret­ers — like nurses, so­cial work­ers, or a pa­tient’s sib­ling — were much more likely to com­mit ser­i­ous er­rors than pro­fes­sion­al in­ter­pret­ers. Er­rors in­cluded mis­steps like for­get­ting to ask about drug al­ler­gies and giv­ing in­com­plete in­form­a­tion about med­ic­a­tion dosages.

The best in­ter­pret­ers can also re­lay cul­tur­al tra­di­tions that can help im­prove dia­gnos­is or treat­ment plans. For ex­ample, Flores says, in some Mex­ic­an-Amer­ic­an com­munit­ies, loc­al heal­ers sell powders to aid in­di­ges­tion that can con­tain tox­ic con­cen­tra­tions of lead. On the oth­er hand, doc­tors might want to in­clude harm­less tra­di­tion­al treat­ments for in­di­ges­tion, like rub­bing the stom­ach with warm oil, in their treat­ment plans in or­der to set pa­tients at ease.

For now, phone-based in­ter­pret­a­tion ser­vices are the best tech­no­lo­gic­al sub­sti­tute for hav­ing a trained in­ter­pret­er in the room. Some hos­pit­als have made it their policy to use phone-based ser­vices in emer­gency rooms, be­cause it’s faster to call than to wait for an in­ter­pret­er to ar­rive, says Cath­er­ine West, seni­or re­search sci­ent­ist at the George Wash­ing­ton Uni­versity School of Pub­lic Health and Health Ser­vices.

“What I think is ex­cit­ing, but it’s prob­ably a num­ber of years away, is we may at some point have a smart­phone that’s able ac­tu­ally to provide state-of-the-art, spoken-lan­guage trans­la­tion,” Flores says — a tool that ac­cur­ately trans­lates spoken lan­guage in real time. Google Trans­late’s speech-en­abled smart­phone apps, an early at­tempt at this, aren’t al­ways gram­mat­ic­ally ac­cur­ate, he says, and shouldn’t be used in a health-care set­ting.

As the num­ber of truly bi­lin­gual doc­tors and nurses grows, di­git­al tools may be­come less ne­ces­sary. “Four of the last five pro­viders I have hired — I’m in charge of the whole sec­tion, with 30 doc­tors — all speak Span­ish nat­ively,” Cle­m­ents says of Duke’s primary care pe­di­at­rics de­part­ment. In the two Durham hos­pit­al nurs­er­ies he over­sees, doc­tors must be bi­lin­gual: Half the ba­bies there are born to moth­ers most com­fort­able speak­ing in Span­ish.


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