Volume II: Video Remote Interpretation in Hospital Language Access Plans

November 21, 2019

Written By: By Paloma Peña, MSW, LSW; Sarah Stockler-Rex, CHI; Tatiana Cestari, PhD, CHI


This piece is the second in a new series, written by Cloudbreak Health’s quality and training leaders, that discusses medical language access and related topics.

In our last installment, we discussed how Video Remote Interpretation (VRI) is an important component in today’s world of language access. Like everything else in health care, language access requires some serious planning. In this volume, we will discuss exactly that: how to create a Language Access Plan that includes VRI to ensure your facility is not only compliant but providing appropriate patient care.

The What

So, what is a Language Access Plan? A Language Access Plan (LAP) is summarized as an effective written plan for providing interpreter services that are appropriate to the particular circumstances. Section 1557 of the Affordable Care Act (ACA) does not explicitly say when OPI, VRI, or onsite modalities should be used. Evaluation of what mode of language assistance is optimal will depend on length, complexity, context of communication, prevalence of the language, and frequency of the language encountered. Section 1557 stresses the importance of providing timely service while ensuring meaningful access and avoiding delay or denial of the service or benefit. A decision tree, such as the example below, can be incorporated into a LAP to help guide staff in providing the appropriate resource for commonly encountered scenarios.

The Who

Now that we understand the what, it’s time to consider the who. Health care administrators and other leaders are instrumental in developing LAPs. In both LAP development and revision, it’s important for administrators to consider different clinical and operational needs of each department. Section 1557 explicitly says all entity staff need to be trained on how to obtain language assistance and how to operate and use OPI and VRI if they are resources. All personnel should be thoroughly trained and provided proper scripting for answering what language services are available. This includes volunteers who frequently staff the points-of-entry desks as well as facility operators who triage calls and inquiries. In some cases, bilingual staff may even be incorporated into the LAP to provide language services directly, however, they should only interpret if they are qualified and it is a part of their official job duties.

For language access to be meaningful, the interpreter must be qualified, having demonstrated proficiency in speaking and understanding English and their other language(s), including any specialized vocabulary, terminology, and phraseology. In other words, qualified interpreters are those who have been specially trained and assessed for language proficiency needed for the profession and understand the code of ethics or professional conduct and standards of practice. Remote interpreting has grown so much in the last several years that while interpreters performing remotely have the same performance expectations as onsite interpreters, they may have greater exposure to some specialized topics. The VRI provider can answer questions regarding their requirements for qualification, ongoing training, as well as language availability.

Last but certainly not least, we must consider the patient. The patient’s preferences on how to communicate should be taken into consideration when choosing which interpreting modality is going to be used. For example, Section 1557 specifically says that Deaf individuals can specify how their communication needs should be met. And if a patient requests to use a companion as their interpreter, it is recommended providers have a qualified interpreter present (whether onsite or remotely) to ensure accurate and complete communication. It is never appropriate to work with an unqualified interpreter for informed consent, discharge instructions, diagnosis, treatment options, proper use of medications, or insurance coverage for health-related issues.

Section 1557 further specifies that minor children cannot interpret unless it is an emergency and there is imminent threat to the safety or welfare of the patient or public and no qualified interpreter is available. In yet other cases, the patient themselves may not need interpreting services but is accompanied by a family member, spouse, or partner who does. This individual should be provided access to a qualified interpreter even if the patient does not need one. One of the benefits of incorporating VRI and OPI solutions into your LAP is more timely access to qualified interpreters for all the above-mentioned scenarios.

The Why

LAPs are not mandated by Section 1557, but they are referenced throughout the document as a best practice. Whether or not a LAP exists would be taken into consideration if an investigation were to take place. Having one would show the entity took action to prepare to meet the needs of Limited English Proficient/Deaf/Hard of Hearing (LEP/D/HoH) patients. Even though LAPs are not mandated, language access is. Therefore, in most instances, VRI must be incorporated into the LAP because the interpreting demand exceeds the onsite resources available due to the frequency of request, language availability, or distance from the facility. If incorporating VRI, Section 1557 outlines specific video quality requirements that must be met.

The When

A LAP should be created as soon as possible so your facility is prepared to serve its LEP/D/HoH patient populations. Once in place, LAPs should be reviewed for effectiveness and updated at least annually, taking into account stakeholder feedback as well as any changes in demographics within the community. Any shifts or growth within community populations could shape demand and decisions around VRI or OPI services as part of the LAP. There should also be an active mechanism for renewing awareness and training of the Language Services policies within the organization.

The How

Throughout this article we have shared advisement on how to develop and revise a LAP that includes VRI. Below is a summary of the main steps for LAP implementation:

  1. Identify key stakeholders that will be involved in the creation of the plan.
  2. Complete a self-assessment of your organization to identify and assess the following:
    • LEP/D/HoH community demographics
    • How LEP/D/HoH individuals interact with your organization (via telephone for scheduling, written mailed documents, in-person, etc.)
  3. Based on the results of your organization’s assessment, document your plan to include:
    • Modalities of language interpretation (onsite, VRI, and OPI)
    • Decision tree to determine appropriate use for each interpreting modality
    • Resources such as internal staff and language service providers
    • Document and website translations
    • Process for monitoring and evaluating services
    • Staff training
    • Patient notification and outreach on available language services
  4. Develop a process to update the LAP regularly.

Additionally, there are many resources available for further reading to help get you started with a LAP that would include VRI, which we have linked below.

Although this planning process might seem overwhelming, you are not alone; your language services department and vendors can provide expertise to help you with the process of developing or reviewing a LAP. We invite you to continue reading our ongoing VRI series as we dig deeper into more of the many related topics. If there is a topic you are interested in, feel free to contact us and let us know more about your questions about delivering optimal language access.

Further Reading:


12 Tips for Working with Interpreters

November 13, 2019

Written By: By Seth Lawton, Senior Manager of Marketing and Communications


Apart from our many highly qualified and certified language interpreters, the Martti team also has a group of skilled quality assurance and training professionals. Part of their job is to ensure that the providers and patients served by Martti are having the best possible experience, and that often includes making recommendations for how to best interact with our interpreters. Those interactions can be via video, over the phone, or in-person, and could be in spoken language or ASL.

So, we’ve distilled some of this wisdom and compiled a series of the top DOs and DON’Ts for providers working with interpreters across modalities, plus a few tips for interacting specifically with interpreters over video as well. We hope this helps you not only make the most of Martti, but also devote more valuable time and energy to patient care.

DO

Here are some of the best practices for providers when interacting with interpreters, whether via video, audio, or in person. Please DO:

  • Allow one person to speak at a time.
  • Plan and allow for more time when working with Limited English Proficient (LEP) or Deaf patients.
  • Be culturally aware with things like eye contact, personal space, and touching.
  • Know that the interpreter may take longer than the original speech. In some languages there may be no linguistic or conceptual equivalent of some words.

DON’T

By contrast, there are some things we encourage against because they may result in a sub-optimal interpretation or patient experience. Please DO NOT:

  • Make assumptions about the educational level of a patient who is LEP or Deaf. The inability to speak English or hear does not necessarily mean a lack of education or intelligence.
  • Write notes for Deaf or Hard of Hearing patients, as this is not the preferred form of communication. Instead, please request an ASL interpreter.
  • Use family members and friends. This is highly discouraged, as they often do not know medical terminology. They may also edit the information, resulting in an inaccurate or incomplete interpretation.
  • Say anything you do not want interpreted, as the interpreter’s job is to interpret everything.

VIDEO

And here are a few tips that we like to offer providers to help them get the most out of their video medical experience:

  • Adjust the camera so that the interpreter can see and hear the patient well and the patient can see the interpreter.
  • Don’t leave the interpreter over video alone in the room with the patient. Disconnect if you will be away.
  • Consider visual issues for a Deaf patient.
  • Be aware of background noise which could make the interpretation difficult.

For even more DOs, DON’T, and video best practices, the Martti team has prepared a quick tip sheet, which you can download here.


Why American Sign Language Interpreters are Bilingual, Bicultural, and Bimodal

October 21, 2019

Written By: By Fran Whiteside, Martti Interpreter, M.Ed., NIC/CI/CT, ASL VRI


When one thinks about being an interpreter between two languages, the first thing that comes to mind is listening and speaking. The definition of “bilingual” is a person that can speak two languages fluently. But that simple definition doesn’t fit the American Sign Language interpreter. The more precise definition for ASL interpreters would be the one involving or using two languages fluently.

Many American Sign Language (ASL) interpreters grew up in homes learning ASL as their first language and English as their second. They were depended upon to interpret in a myriad of situations, at times way beyond what they were capable of, because there was just nothing else. This practice of “family/friend” interpreting was routinely used before interpreting for the Deaf became a profession but in some instances continues today. These individuals are typically called CODAs, short for Children of Deaf Adults.

Like other interpreters ASL interpreters are also Bicultural. “Having or combining the cultural attitudes and customs of two nations, peoples, or ethnic groups.” Where the ASL interpreter is distinguished from other spoken language interpreters is in the “mode” that is used to carrying out the dialogue. Unimodal interpreters hear one language and speak another, therefore using two spoken languages. Bimodal interpreters are also spoken language interpreters, speaking in English, but they have the added change in mode from understanding not only speech but also sign language.

How does bimodal differ from unimodal? Bimodal (ASL) interpreters use spoken language that is perceived by the ears and produced by the vocal tract and also sign language which is perceived by the eyes and produced by the vocal tract. So let’s look at this definition—Visual language interpreting is the practice of deciphering communication in sign languages, which use gestures, body language, and facial expressions to convey meaning. But using visual cues for the process of interpretation is still bimodal using two different forms of processing.

There are other ways that ASL interpreters process communication. It might be from a written document that in not understandable to the Deaf client. It may be through tactile interpreting (hand over hand) for a DeafBlind client. Regardless of how it is done, ASL interpreters are still considered bimodal.

In addition to the way we communicate with individuals, there is also a continuum of language “types” that Deaf people use. To understand this language continuum a little history is required. ASL was brought over from France to the US back in early 1800s by Laurent Clerc and Thomas Gallaudet. Before this time there was no education of Deaf children and therefore most signs were made up or considered “home signs.”

But along the way many hearing teachers felt the only way for Deaf children to learn English was either by trying to sign in English word order or not being allowed to sign at all using what is known as the “oral method.” Even today there are schools across the United States that don’t allow children to sign, accepting only the use of their voice for communication.

As you can gather, the way a child is taught language can have a major impact on their language use as an adult. ASL interpreters must be prepared in all situations to match the “language” that the consumer is using. From those that were raised with the fluidity of American Sign Language to those that use their voices and “sign” in English world order including everything in between.

Sign language is also referred to as a visual gestural language. It not only incorporates signs but also uses facial expressions and body movements as part of the grammar and vocabulary of the language.

The most popular Manually Coded English (MCE) sign systems are as follows:

  • Pidgin signed English is a combination of English and ASL. While using ASL signage it more closely follows English syntax.
  • Signed English is simplified English-based code with grammatical markers added.
  • SEE, or Signing Exact English, uses English word order but uses more “signs” than signed English. This system has invented signs that are not used in ASL.
  • These are sometimes referred to as speech-supported sign.
  • The Rochester method is comprised solely of fingerspelling.
  • Cued Speech, while used infrequently, is not a signed language but a system to use lip reading combining handshapes and locations around the face to phonetically represent English.

And while all of these methods are bimodal they are not all specifically bilingual since they do not involved two languages but some are between a “system” and a language.

With the complexities of the language itself, numerous sign systems, varieties within the estimated 100,000 to 300,000 Deaf individuals that use ASL and the ever changing and growing technological and medical advancements being introduced being a sign language interpreter is a constantly evolving profession.

So maybe our exact description should be Bilingual/Bicultural/Bimodal/Visual Interpreter!

 

Selected References

Oxford Living Dictionary, Bicultural definition, 2017 Oxford University Press,

https://en.oxforddictionaries.com/definition/bicultural

Emmorey, Karen, Borinstein, Helsa B., #ompson, Robin and Gollan, Tamar H. 2008. “Bimodal bilingualism.” Bilingualism: Language and Cognition 11 (1): 43–61.

Swabey & Nicodemus, Bimodal bilingual interpreting in the U.S. healthcare system, 2011.

Schofield & Mapson, Dynamics in interpreted interactions: An insight into the perceptions of healthcare professionals, 2014.

Sign Language Continuum, https://prezi.com/rr345zssbr5p/sign-language-continuum/

Greene, Daniel, Bimodal interpreters, not just sign language interpreters, 2014.


Volume I, VRI in Healthcare: An Important Component of Language Access

September 24, 2019

Written By: By Paloma Peña, MSW, LSW; Sarah Stockler-Rex, CHITM; Tatiana Cestari, PhD, CHITM


This piece is the first in a new series, written by Cloudbreak Health’s quality and training leaders, that discusses medical language access and related topics.

Chances are if you work in healthcare you have seen or even worked with an interpreter. If not, it is likely that you will in the near future.

The population of Limited English Proficient (LEP) patients is rapidly increasing; there is a growing need for access to quality interpretation. The unfortunate reality is that it is nearly impossible for healthcare systems to meet these around-the-clock needs through on-site interpretation only. Video Remote Interpretation (VRI) services can provide on-demand access to interpretation services 24/7/365 when on-site interpreters may not be readily available (Burkle et al. 2017; Marshall et al, 2019).

Nowadays, VRI is likely to be part of any solid holistic Language Access Plan which helps health systems care for patients as soon as needed and remain compliant with language access regulations. While becoming increasingly popular as a solution to interpreting demands and hospital compliance needs, it’s important to note that research is still relatively limited surrounding VRI standards and best practices for spoken language interpretation.

The purpose of this series is to provide guidance on best practices in VRI based on our experience and data, national standards, and any research available. In addition, we aim to open a discussion on what research has taught us and what needs to be implemented in VRI.

Through this series, our goal is to communicate with interpreters, language service providers, VRI users, and hospital administrators about VRI practices to further advance the healthcare interpreting profession and serve our patients.

THE BASICS:
What is Video Remote Interpretation?
Video Remote Interpreting (VRI) is a video telecommunication service to access real-time sign or spoken language interpretation through interpreters who are located in a satellite call center or remotely. While VRI is most commonly used within medical settings, it can also be an effective communication tool in a variety of settings such as educational, legal, business, etc.

When referring to video communication services, VRI is occasionally confused with Video Relay Service (VRS), which is a separate service for Deaf/Hard of Hearing individuals that is governed by the Federal Communications Commission (FCC). This service “enables persons with hearing disabilities who use American Sign Language to communicate with voice telephone users through video equipment” (https://www.fcc.gov/consumers/guides/video-relay-services).

What about Over the Phone Interpretation (OPI)?
In addition to on-site and video remote interpretation, telephonic interpreting services, also called Over the Phone Interpretation (OPI), is a popular solution used by healthcare teams to help meet the increasing demand for interpreting services.

While OPI is a commonly used and essential component of an effective Language Access Plan, OPI is limited to providing spoken language interpretation only and does not give interpreters access to non-verbal cues or the human connection of working with someone face-to-face.

The addition of video capabilities makes VRI accessible to be used for sign language interpretation needs and provides all language interpreters access to non-verbal language which is unseen through OPI solutions.

Additionally, VRI can provide a better human connection between provider, patient, and interpreter (Marshall et al. 2019), which reduces communication errors, interpretation time, readmission, and improves overall patient satisfaction.

Providing VRI services: What do I need to know?
Short answer: a little bit about a lot!

To provide effective VRI services, healthcare systems must follow Language Access Plans, compliance requirements, and VRI best practices. We will delve into these topics later in this series but for now, we will outline the basic foundation for providing effective VRI services:

  • Review national compliance requirements and guidelines in Language Access
    • Title VI of the Civil Rights Act of 1964
    • The Affordable Care Act (ACA), including Section 1557
    • The Americans with Disabilities Act (ADA)
    • The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS Standards)
    • The Joint Commission publications
    • The National Health Law Program publications
    • Any additional national, state, and local requirements
  • Implement or revise a Language Access Plan
    • Plan VRI deployment and implementation
    • Train hospital staff on the use of VRI and best practices
    • Develop a decision-making tree tailored to your Language Access Plan
    • Track VRI utilization and performance
  • Understand protocols regarding
    • working with the interpreter
    • staff training requirements
    • technical requirements
    • environmental control
    • quality control
  • Work with highly qualified interpreters who have proven
    • language proficiency and interpreting skills
    • an understanding of the code of ethics or professional conduct and standards of practice
    • knowledge of specialized vocabulary, terminology, and phraseology
    • completion of national certification requirements
    • ability to navigate cultural sensitivities

Establishing the basics is critical for effective communication when providing care to Deaf/Hard of Hearing and LEP patients. Equally important is knowledge and frequent review of your organization’s Language Access Plan, specific policies/procedures, and designated contact for language services matters.

Armed with this knowledge you are well on your way to improving patient outcomes through effective communication. Support by your language service provider(s) will be key in the implementation and success of this process as it requires ongoing collaboration and education.

Whether you are new to the discussion of VRI or are a seasoned expert, we welcome you to follow our series which will provide a glimpse into VRI-centered topics including best practices, scripting, common challenges, their solutions, and more.

 

Resources:

(ADA – https://www.ada.gov/effective-comm.htm)

(RID VRI SOP – https://drive.google.com/file/d/0B3DKvZMflFLdTkk4QnM3T1JRR1U/view)

(NAD Position Statement –https://www.nad.org/about-us/position-statements/minimum-standards-for-video-remote-interpreting-services-in-medical-settings/)

(ACA, Section 1557) – https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html

 

References:

  1. Burkle CM, Anderson KA, Xiong Y, Guerra AE, Tschida-Reuter DA. Assessment of the efficiency of language interpreter services in a busy surgical and procedural practice. BMC Health Serv Res. 2017 Jul;17(1):456.
  2. Marshall LC, Zaki A, Duarte M, Nicolas A, Roan J, Colby AF, Noyes AL, Flores G. Promoting Effective Communication with Limited English Proficient Families: Implementation of Video Remote Interpreting as Part of a Comprehensive Language Services Program in a Children’s Hospital. Jt Comm J Qual Patient Saf. 2019 Jul;45(7):509.

What Variations in Dialect Can Teach Us about Better Interpretation

September 18, 2019

Written By: By Seth Lawton, Senior Manager of Marketing and Communications


When I moved from the northeast to central Ohio a couple years ago, I expected some amount of adjustment. I had heard that I might have to order ‘pop’ instead of ‘soda.’ And somewhere along the way I learned that New Englanders lacing up their ‘sneakers’ are in the minority; most of the country puts on ‘tennis shoes.’ Even when, inexplicably to me, they are not playing tennis. But one linguistic format I wasn’t prepared for is when folks say: the dishes need washed; the car needs fixed; the dog needs walked. My adoptive state, I decided, needs infinitives.

But then, as a native Bay Stater, who am I to be prescriptive about language? Where I come from, it sounds the same whether folks refer to their tan pants or the jangly vehicle starters in their pockets. And a listener needs context clues to know whether one is referring to a silky fabric or the sixth planet from the sun. (When new acquaintances ask why I don’t talk like that, I tell them the truth—I take after my mother, not my fah-thuh.)

Confusing ‘car keys’ for ‘khakis’ is matter of accent, which is part of our regional dialects. More than just pronunciation differences, regional dialects also include lexical differences such as your word choice for a ‘rotary,’ a ‘traffic circle,’ and a ‘roundabout.’ These are just some quick examples from the automotive realm—think about all the language variations that exist and have the potential to cause miscommunication.

Sarah Stockler-Rex is a colleague of mine who specializes in training and quality assurance, and who recently presented a session on the variations in English language dialects at the Texas Association of Healthcare Interpreters and Translators annual symposium. It’s an important but easily overlooked topic; companies that support medical language services tend to focus mainly on interpretation and cultural differences between different languages. But it’s also necessary to explore those English dialect variations, including those Englishes used by our providers from other parts of the globe, and how a deeper understanding of this can enhance interpreter comprehension, and thus support better outcomes.

Some of the examples I offered above focus on dialectal differences among regions of the country. But apart from geography, gender, ethnicity, and socioeconomic status can all have an impact on the dialect an English speaker uses as well. Oh, and don’t forget age. Do generational differences have an impact on dialect? You can bet your britches on it.

To ensure optimal coverage and flexibility, the network of professionals supporting Martti comprises eight different language centers in regions across the United States. So not only do the patients and providers who we interact with represent different dialects, but so do our interpreter staff. On a daily basis, our team encounters words or phrases that may cause a person to lean in and may require clarification.

That’s why training on these topics is so important—when interpreters know what to listen for, it makes comprehension easier. A primary goal of training interpreters in English dialects is to help them become better listeners and more keenly attuned to detecting patterns.

But at the core of dialectic differences is the concept of respect. As a former Bostonian, I still find it incomprehensible that some folks from the region can drop their ‘r’s in one place and yet manage to add them where they don’t belong: “Building a pah-king garage on this lot would be a terrific i-dear.” It’s head-scratching, to be sure, but it underscores the key point. There are undeniable variations in accents and dialects, and languages have always and will always shift and evolve. It’s not a bad thing; it’s just a thing. And it’s an opportunity to learn more from each other, see other perspectives, and pave the way for improved communications.

Ultimately, we should focus on the ways that language can bring us together. Depending on your background, some folks say ‘pill bug’ while others say ‘roly poly.’ Let’s get beyond our differences and instead focus on a term we can all agree on: ‘exterminator.’


The ‘Why’ Behind Continuing Education

August 20, 2019

Written By: By Seth Lawton, Senior Manager of Marketing and Communications


Cloudbreak Health has built the award winning Martti solution, and we hire and train the very best medical interpreters to support our clinical users and their patients. We’ve pioneered video medical interpreting for years, serving hundreds of large hospitals and thousands of clinicians and patients. So why do we engage in administering continuing education?

It’s certainly not for profits—paid online trainings like this are hardly lucrative. And it’s not some facile hobby; in fact, creating the curriculum and maintaining status as an issuer of continuing education units (CEUs) is a big lift indeed. It takes a dedicated training and quality assurance team, comprising seasoned language experts and focused on staying ahead of the curve.

We maintain a training and CEU program because we see the issues that come up every day and that often span different cultures. We do it because we’re so well positioned to deliver training like this, and we frequently address topics that aren’t covered elsewhere. Just look at some of the training topics we’ve tackled recently—

Interpreting Bad News
Sometimes our interpreters are the first ones to break some very difficult news to a patient about their situation. That initial moment – along with the worry and uncertainty that can follow – is so pivotal in the patient’s care journey that it merits a standalone session. It’s no easy task when everyone is speaking a single language, so imagine the importance of the role an interpreter plays in that scenario.

Interpreting Profanity
Many reading this have probably seen it before: an ASL interpreter being goaded by the puckish presenter on stage who wants to know how a curse word is signed. Sure, it gets a chuckle from the crowd, but in a medical situation, a patient’s use of profanity – be it spoken or signed – is a non-trivial part of the interaction. It can convey frustration or perhaps the intensity of the patient’s pain or emotional state.

Work / Life Balance
File under earth-shattering news: we’re not the first company to address this subject. Most businesses and every self-help section blares advice for workers on the topic of work / life balance. But work / life balance for medical interpreters is a category unto itself. Many in the interpreter community who take part in our training sessions work more than one job. But regardless of employer count, medical interpreters frequently encounter grave or stressful situations in the course of their work. So, some guidance on best practices for self-care and avoiding burnout go a long way, and in turn make trainees better interpreters.

An upcoming webinar addresses domestic violence topics for medical interpretations—a topic that is frankly difficult to address, which is why so few are doing it. Just try doing a web search for “medical interpretation domestic violence” and see what comes up. Very little, actually, that’s both recent and relevant. But domestic violence is unfortunately a factor in a number of medical situations and more and more interpreters are going to be called on to aide in these encounters, so we should be preparing them for those unique demands.

We speak on these topics at conferences and present continuing education sessions on these subjects because we have a wealth of experience and learnings to share. When the community of interpreters is performing better, patients are likely to do better too.


Language Access Alert: Changes Proposed for the ACA Section 1557

July 31, 2019

Written By: By Lauren Werstler, NIC, CoreCHI, Language Service Advocacy Specialist and Tatiana Cestari, PhD, CHI, Director of Language Service Advocacy


We believe in equal access to communication and quality healthcare for all. With this in mind, we would like to provide information about The Department of Health and Human Services’ (HHS) proposed changes to Section 1557 that would change its scope and could impact the healthcare community.

Section 1557 of the Patient Protection and Affordable Care Act is the civil rights extension of nondiscrimination protection to persons participating in healthcare programs/activities receiving funding from HHS, programs/activities administered by HHS, and to all plans offered by issuers through Health Insurance Marketplaces.

Some of the provisions HHS is proposing to change include those regarding:

  • Taglines, notices, and language access plans
  • Compliance coordinator requirements and written grievance procedures
  • Enforcement-related provisions and changes remedies
  • The role insurance companies play in providing language access
  • Remote video interpreting service requirements, making them more closely resemble those for audio-only services

We believe that these changes may limit access to quality health services and create additional cultural and linguistic barriers for non-English speakers. In addition, healthcare providers would lose guidance on providing language access and blur the lines of what defines discrimination.

Added communication barriers increase the risk of miscommunications, leading to less effective treatment, higher readmissions rates, and less successful outcomes for all.

It is important to note that should these proposed changes become regulation, the relevant provisions of Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973 will remain. Additionally, Video Remote Interpretation requirements for Deaf/Hard of Hearing persons as defined in the Americans with Disabilities Act would not be affected by the proposed changes.

We strongly encourage you to familiarize yourself with these proposed changes and how they could impact your organization. As part of the process to review the proposed changes, members of the public have the opportunity to share your comments and concerns with HHS.

HHS is accepting comments through August 13, 2019. Comments can be made electronically at http://www.regulations.gov by searching for the Docket ID number HHS-OCR-2019-0007. Comments including the ‘why’ and ‘how’ along with detailed information are most beneficial in making a positive impact.


Why Speaking the Language Isn’t Enough: How Interpreter Location Affects Interpretations

June 25, 2019

Written By: By Tatiana Cestari, PhD, CHITM, Director of Language Service Advocacy


Being bilingual and trained in healthcare interpretation are the cornerstone requirements to perform as a medical interpreter. However, it’s also necessary to possess certain other skills, which are pivotal in each encounter, such as: having an attitude of service to patients and providers while maintaining the interpreting profession’s boundaries; being culturally aware; understanding the ethics and standards of practice that rule this profession; knowing how the US healthcare system and insurance/billing process work; and knowing idioms and regionalisms or how to recognize them.

Since we understand the impact of our services, we follow a model in which interpreters are based in the US. Over the years, we have identified crucial implications regarding the location of video or audio interpreters:

A. Customs and Cultural Aspects

Remote interpreting raises the issue of how flexible interpreters can be when it comes to knowing location-specific customs, terminology and idioms, and cultural differences of where the physician or provider of care resides when delivering their services.

Coming from a Latin American country that has a healthcare system very different from the US, I have had to learn about the US system as a patient, provider, and interpreter. Having that familiarity with the US healthcare system has helped me tremendously in my interpretations. Many examples on this topic come to mind. It is common to interpret for a patient or a parent asking the doctor “how much do I owe you, doctor?” because in many other countries the healthcare provider may be more involved in the financial aspects of the practice. It is shocking for patients to receive care without having to pay cash up front or before they leave the hospital. It is also surprising for US healthcare providers, based on my experience, to receive financial questions from patients. As expected, all these questions are interpreted but, if the interpreter does not identify these differences as reasons for lack of conversation flow, the interpreter may not act appropriately, thus s/he may not intervene and empower patient and provider to talk about it for the well-being of the patient.

B. Interpreting Regulations

Interpreters’ location also affects what rules they abide by. Auditing interpreters and ensuring compliance with the US Code of Ethics/Professional Conduct and Standards of Practice as well as with privacy and security of data are simply not possible if they don’t reside within US territories.

C. Ability to Monitor, Mentor, and Maintain Oversight for Quality

Another factor that may be related to location is whether interpreters can be employees or simply contractors for an interpreting company. This affects the ability to perform quality controls, obtain and provide feedback, perform research, train, and work on enhancing processes and performance. Having interpreters on US soil who are employees allows for ways to ensure quality and invest in cultural awareness and professional development.

Our company has been able to develop quality assurance processes and identify how location may affect cultural awareness and thus accuracy in interpretations. Furthermore, having a network of interpreters from multiple countries in our language centers and a support system with quality assurance and training allow interpreters to grow and learn. Not only do they expand their vocabulary for multiple regions, but their awareness of cultural differences enhances their interpretation work and improves the patient and provider experience.

An example – shared by one of my colleagues who is an interpreter and Quality Assurance expert – explains that: “Even a native Spanish speaker may not realize the importance of the words ‘agua fresca’ (literally fresh water) if they’re not trained to look for their contextual meaning. In certain regions, agua fresca is a beverage made with fruit, flowers, or herbs mixed with sugar and water. A diabetic patient who reports drinking this vs. its literal interpretation will be provided with much different instructions that may affect treatment and outcome.”

D. Security of Data

Just as we use remote interpreting to help care for patients and save lives every day, expanding our communication possibilities brings questions about the privacy of the information being shared or how the data are being handled and stored. At a macro-level, data recorded and stored in other countries may not be subject to the same data protection and privacy rules that apply to US-based operations. Interpreters processing calls are considered to have access to non-public health information and the transmission, transportation, and storage of such non-public information is generally prohibited.

In summary, knowing the language is not enough and location of your interpreters does affect interpretation encounters. The benefits of staffing interpreters who are based in the US are numerous and impactful. Here is a partial list to keep in mind:

  • Ability to monitor, mentor, and conduct oversight for quality
  • Professional development in a diverse learning environment for interpreters
  • Multi-cultural, multi-nationality environment to learn from
  • Familiarity with the healthcare system that both the patient and provider at the other end of the encounter are experiencing
  • Security of data, and the vendor’s control thereof
  • Enterprise-level internet connection, which directly relates to quality of service

Certification vs. Qualification: Considerations for Your Language Services

May 16, 2019

Written By: By Tatiana Cestari, Ph.D., Manager of Interpreter Education and Compliance


From our more than 15 years of supporting hospital staff and experts in the healthcare interpreting industry, we know there can be a lot of confusion around the terminology used or some definitions that are unclear. So, we thought it might be valuable to provide answers to those terms that are routinely used to help you make informed decisions that lead to improved clinical and financial outcomes.

What do interpretation companies mean when they say “qualified”?

Have you ever asked that question? Generally, a person “qualified” for a job is one who meets the job description criteria set by the company. Therefore, this term can be relative and depends on the quality standards set by each vendor.

At Cloudbreak, we take quality and compliance very seriously, and thus don’t use our own definition, but meet and exceed the definition of qualified interpreter shown in Section 1557 of the Affordable Care Act. To us, a minimally qualified interpreter is a bilingual individual who has proven:

  • language skills proficiency;
  • interpreting skills proficiency (able to interpret effectively, accurately, and impartially);
  • they understand the code of ethics or professional conduct and standards of practice;
  • they have any necessary specialized vocabulary, terminology, and phraseology;
  • they have completed all requirements to apply for national certification as a healthcare interpreter, which includes passing a nationally recognized qualifying medical interpreter training

What’s more, many “qualified” interpreters who may know the language are not trained in interpreting virtually or in the complex and emotionally charged context of medical terminology and practices. Our required onboarding and continuing education programs dive deep into the implications of interpreting remotely as well as understanding terminology and healthcare.

What’s the difference between qualified and certified?

Many interpretation companies stop at “qualified,” and yet others loosely use the term “certified.” But certified against what criteria?

At Cloudbreak, a certified interpreter is one who has successfully obtained national certification for spoken or sign language. National certification for healthcare interpreters is achieved by passing one or two independent, professional exams (the number depends on the non-English language that the interpreter uses) developed and provided by the corresponding organizations. The certification process is like that of other professions in the US such as nursing, engineering, dentistry, etc. as they need to take and pass a professional exam to obtain it.

As a result of our training efforts and commitment to quality, Cloudbreak’s passing rate for the CCHI national certification written exam is 90.1%, which is greater than the passing rate nation-wide (see national passing rate for this exam in CCHI’s Annual Reports).

What continuing education is necessary to maintain certification and relevance?

As healthcare is a dynamic industry, initial training is only enough to get started. While some companies may “certify” they interpreters upon hiring, they may do very little to maintain skills and certification, depending on what certification framework they employ. Conversely, ongoing education is a core process at Cloudbreak to ensure continued skill building and contextual familiarity to improve outcomes.

As proof of our commitment to the education of our interpreters and the interpreting community at large, we offer more than eight webinars per year that are pre-approved by RID/ACET, CCHI/CEAP, IMIA, and Washington State DSHS. The topics included in our webinars vary from healthcare and medical terminology to cultural awareness, interpreting skills onsite and remotely, ethics, etc. With the number of Continuing Education Units (CEUs) pre-approved, we surpassed the minimum requirements for most certifying bodies to renew national certification in the US. In addition, we require our video interpreters to complete more CEUs per year than the number needed for national certification renewal, ensuring that they aren’t only the best in the industry, but that they remain so.

What types of ongoing training, testing, and other quality measures are available for interpreters in addition to the third-party certification?

The potential for ongoing professional development is limitless, yet often-times an investment that independent interpreters or interpretation companies are unwilling to make while keeping rates below market value. These can be particularly challenging for healthcare institutions opting for support from interpreters who are not specialists in the needs of healthcare. At Cloudbreak, we’re not willing to compromise on quality. At a minimum, Cloudbreak Health requires the following from all video interpreters prior to performing interpretations:

  • Pass a criminal background check and drug screening
  • Pass a bilingual fluency and/or medical interpreting assessment given by a neutral third party, in both English and non-English language(s)
  • Pass a medical interpreting training that meets the eligibility requirements to apply for national certification
  • Make a commitment to further develop his or her skills and knowledge in healthcare and in interpreting
  • Successfully complete Martti’s comprehensive on-boarding training, which focuses on:
    • HIPAA Compliance and Confidentiality
    • Professionalism
    • U.S. Healthcare System
    • Camera Presence and Basic Troubleshooting
    • Customer Service
    • Cultural Competency
    • Quality Assurance Guidelines
    • Code of Ethics/Professional Conduct and Standards of Practice

In addition, Cloudbreak’s ASL interpreters are required to pass our Medical Screening Assessment prior to hire to ensure quality medical interpretation. This screening was created in collaboration with the faculty of Columbus State Community College’s Interpreter Education Program, a nationally recognized ASL Interpreter Training Program.

Why do we insist on such rigorous qualifications when others don’t? What does service look like when provided by non-certified interpreters?

Although using a recognized program such as The Community Interpreter International or Bridging the Gap as qualifying medical interpreter trainings teach the basic skills, due to the shorter program durations, they may not cover all ongoing aspects of the interpreting profession. We use these great trainings to get new interpreters ready to perform as interpreters, but by also requiring our interpreters to have continuing education and national certification, we make them grow and learn to their own benefit, that of our partners and their patients.

In other words, national certification is the most comprehensive way to demonstrate that an interpreter has all the skills needed to be a professional interpreter. Someone who has passed the national certification exam(s) can prove they have:

  • language skills proficiency;
  • interpreting skills proficiency (able to interpret effectively, accurately, and impartially);
  • comprehension of the code of ethics and standards of practice;
  • any necessary specialized vocabulary, terminology and phraseology;
  • a commitment to continue to improve and be up-to-date on things related to the field by taking CEUs (this is a requirement to renew certification; similar to other healthcare providers need to complete);
  • proven interpreting experience as it is also mandatory, in some cases, to complete a minimum of interpretation hours to renew certification.

The impact of these investments in our interpreters includes everything from greater patient and provider satisfaction, to shorter encounters which speeds patient throughout and reduces the total cost of interpretation services.

Remember, always ask what “qualified” or “certified” means to those talking to you about it!


How Language Brokering Shapes Professional Interpretation

May 7, 2019

Written By: By James “Jamey” Edwards


At Cloudbreak Health, we are passionate about ensuring that we deliver the highest quality of interpretation services. Much of the “heavy lifting” in this regard is performed by our Quality Assurance (“QA”) team. They train, monitor, share best practices, and improve processes, so our team is always staying ahead of the curve, handling minor issues before they become larger problems and constantly learning from our experience.

QA is more than just monitoring calls and handling complaints when and if they arise. The team also participates in and conducts research around topics that are relevant to our staff, as well as to the partners who we serve. We don’t just read about the latest and greatest trends and standards; we also help shape them. So, a member of our team recently presented at the American Association for Applied Linguistics (AAAL) with researchers from The Ohio State University and The University of Texas, Austin.

The research set out to find, among professional interpreters, how prevalent is previous experience as a language broker and how has that experience shaped interpreters. “Language broker” is a term that typically refers to children of immigrant families who are relied upon in a variety of situations to interpret and/or translate. It’s a role—often challenging—they didn’t choose but are called upon to do in the context of shopping, education, travel, and yes, healthcare.

Our video medical interpreters certainly encounter this regularly—family members of non-English speaking patients often accompany their kin to help broker the discussion in the doctor’s office. But even so, those discussions can be difficult and interpreting medical terminology requires precision and mitigation of any potential bias, which is why our interpreters are so often called upon to join these brokered conversations.

We know language brokering looms large among the populations we serve. So, the researchers conducted a survey and followed that up with a focus group to find out more about the interpreter’s brokering experience. There were a whole host of findings, but here are just a few to highlight:

  • The average age participants started brokering language was 14, though there was some variation
  • About half the participants reported brokering daily or weekly
  • Overall, positive feelings about the brokering experience were about twice as prevalent as negative ones

The findings are significant, but just as impactful can be the qualitative information shared in free form by some of the interpreters who took part in the research. Here are a few of the quotes that struck us:

“I grew up in an area … South Texas to me is a different world. I can say that because I lived there from the age of seven all the way to the age of 25. The Spanish that I spoke just a few years ago is not the Spanish that I speak nowadays because the area is very close-minded when it comes to traditions, culture, when it comes to some of the Mexican and even Mexican-American things there. … I wish I would have been exposed to more correct Spanish as a kid.”

“…as Dominicans we have a lot of Spanglish so I think there’s a struggle there of having to really push myself to learn proper Spanish.”

“…I have two different types of feelings. There was more fear then than now. I feel less scared than I did when I didn’t have training, so I think that fear is no longer [there]. And I think with the background knowledge of professional interpreting I push back when people say we don’t have [an] interpreter. I am more of an advocate now.”

“…In the preteen years I started to notice that my parents deserved more. I would see the unfairness, I would see the treatment. It would make me upset but when I think of the fact that I was only a kid, to me it was not of the magnitude that it is today as an advocate. Some providers seem to have cultural diversity training; you can see the sincerity but others you just think ‘what planet are they from?’”

Because we know that many of our current and future interpreters have some background with language brokering, these findings and insights have some implications for our training and professional development. Among the most tangible takeaways from this research:

  • Brokering can come with feelings of shame and experiences of injustice.
  • In training, there is often a focus on more standard language situations, which is understandable; but this also has the potential to introduce bias in the interpreter testing process.
  • Language brokers have keen intuitions. Current industry training sometimes focuses on suppression of these intuitions.
  • Interpreters viewed previous brokering experiences as both an advantage and a disadvantage.

So, what can we do with these insights? We can incorporate some of this thinking into ongoing instruction programs. At Cloudbreak, we are constantly revising training protocols, so we can focus more attention on developing the instincts of language brokers more appropriately. Professional development is about making our interpretation staff the best they can be, and sometimes that means providing opportunities for processing emotions and learning from their experiences. It’s one more way we are shaping the trends in language services and ensuring the highest levels of quality for the patients and families we serve.