Transcript Document

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
1. Boston Business Journal's Annual Top 100 Hospitals list Healthshare One
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
1
• Estimated 34% speak a language other than
English in the home
2
• Estimated 15% have limited English proficiency
and require language assistance
1. US Census 2006 Estimate; CLARITAS Market Place
2. US Census 2000.
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
1. CHA Primary Care Panel (FY 2006 and FY 2007)
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
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
Percent
of adults
age 18
and over
16
12
9.3
To tal
18
16
12
11
8.9
White, no nHispanic
9
8.3
No
No
dat a
dat a
B lack, no nHispanic
Hispanic
A merican
Indian/A laska
Native
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.
A sian
P referred languageEnglish
P referred language- o ther
Non-English* speakers have more
difficulty understanding information
from their doctor’s office
Percent of adults reporting it is 'very easy' to
understand information from their doctor's office
57%
51%
47%
37%
16%
Total U.S.
Hispanic English
Speaking
Hispanic Spanish
Speaking
Asian American
English Speaking
* English is not primary language spoken at home
Source: The Commonwealth Fund 2001 Health Care Quality Survey, chart 15.
Asian American NonEnglish 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
2007. 22(Suppl 2):283–8.
Med
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
Methods Commonly Used in U.S. Hospitals to
Provide Language Services
Telephonic services
92%
Community language bank
18%
Bilingual nonclinical staff
74%
Bilingual clinical staff
82%
External interpretation agencies
66%
Independent freelance interpreters
63%
Staff interpreters
68%
0%
Source: Health Research and Educational Trust, 2006
20%
40%
60%
80%
100%
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 crosscultural 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
English Preferred by Patient Today
Face to Face Interpreter
38%
37%
Family or Friend Preferred
No Interpreter-Patient Declined
Phone Interpreter
5%
2% 1%
17%
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