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.

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.



(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



  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.

Strategies for Providing Better Care through Telemedicine

April 30, 2019

Written By: By Bruce Hensel, MD, FACEP, Cloudbreak Chief Medical Officer; Former Medical Correspondent, NBC; Full Professor of Medicine, UCLA

In my 27 years as a health, science, and medical correspondent for NBC, I received an average of more than 500 “pitches” and questions per week. The pitches—mainly from medical organizations or their marketers—were mostly about touted tests, treatments, or “cures.” The questions came from viewers, readers, and listeners, and often asked about some of these vaunted methodologies and how to choose among them.

There is no doubt that there are more choices now than ever before. That should mean medical care is less expensive, better, and more accessible. We all know the opposite is often true. It is more difficult to choose, more expensive and, in some cases, more dangerous. Yet we are living longer and better than ever before. It is clear that, properly chosen (which is why I had a long career explaining the choices), these options can improve and lengthen life.

But many factors influence the ability of these to have the proper effect, such as:

  • The use of the internet for what we call Cyberchondria—searching for answers and solutions that may be misleading because the sources are sponsored and have agendas
  • Around 23% of Americans live in rural areas and say access to quality doctors and hospitals is a major problem1
  • About 21% of Americans speak a language other than English at home2

Those are three reasons I chose to join Cloudbreak Health a few years after doing a story on its use for interpretive services at Sloan Kettering Memorial in New York. It simply struck me that video interpretation and telehealth could help overcome two of the most severe impediments to good health care: distance and language. Yet since that time, the two modalities have been challenged by restrictions due to cost and other obstacles.

Dr. Bruce Hensel
Dr. Hensel reporting on Martti and its use in a hospital environment. (Original story licensed by NBC.)

In 1996, four years after I first did a story on telehealth, the Institute of Medicine (IOM) defined telemedicine as “the use of electronic information and communications technologies to provide and support health care when distance separates participants.”3

Currently, the exploding trend of medical cost absolutely demands we increase value to sustain revenue and improve lives. Yet many companies resist spending the time and money on these modalities, fearful that the cost would make their bottom lines bottom out. In many cases they look at overall cost without considering whether quality of care or length and number of visits were affected using these modalities. Many studies suggest that when these aspects are considered, cost decreases and patient and provider satisfaction increase.

The telehealth interventions that are most likely to achieve these goals will be those that ensure quality as outlined by the IOM in its landmark report, Crossing the Quality Chasm—namely, health care that is safe, effective, patient-centered, timely, efficient, and equitable. 4 As the IOM noted, “health care is undoubtedly one of the most, if not the most, complex sectors of the economy. Sizable capital investments and multi-year commitments to building systems will be needed.”

Studies have outlined some critical moves that can help organizations best take advantage of these modalities, including:

  1. Adjusting to patients’ understanding and needs
  2. Providing help, resistance, and training to improve the use of these modalities
  3. Changing how we look at revenue streams
  4. Changing the provider-client interaction
  5. Addressing privacy, security, and space considerations
    All of which are not only crucial to the patient but also to the provider who has little time and needs the space and opportunity to use these innovations.
  6. Focusing on prevention and detection as well as treatment
    The use of these modalities in pre-hospital settings, offices, clinics, companies, and, believe it or not, retail outlets.

Revenue and excellence of care don’t always go hand in hand in traditional settings. The provider is pressed for time and income. The patient/client is fearful and not as informed as he or she would like to be or need to be. Traditionally that equates to visits that are too short and unfocused. Preparation, video interpretation, and telehealth can address all those issues. And while it may seem costly when looked at in bulk, when shorter and fewer visits and improved outcomes are factored in, it is often cost effective and can deliver significant savings.

Deciding when to use video interpretation and other telehealth strategies, and when not to use them can be crucial to this formula. They should not be used just because they seem progressive and new. When chosen and used properly they can:

  • Improve flow
  • Reduce readmissions
  • Improve outcomes
  • Increase revenue
  • Improve data collection (thus providing better future care as well as itemizations that prove the modalities’ usefulness and cost-effectiveness)
  • Improve patient and provider satisfaction

More study is needed to know what is best for our systems overall, but in the meantime, each health system should choose based on the evidence within their organization. Some questions to guide those decisions:

  • How large is your non-English speaking population?
  • What percentage of visits is with patients who live in distant areas or have work or other responsibilities that make in-person visits difficult?
  • Where and how do you set up time, space, and training for those who will use these services?
  • Does the telehealth organization you choose provide assistance in each of these areas?

These modalities should deliver care that—after evaluation of the client and patient population—considers patient needs, is consistent in quality, and helps reduce inequalities in care.

We all know remote monitoring can prevent and treat problems early. Properly used it can also reduce waste of equipment, redirect personnel, and dramatically reduce costs of transportation and energy while helping patients and providers make better use of their time.

  1. https://www.pewresearch.org/fact-tank/2018/12/12/how-far-americans-live-from-the-closest-hospital-differs-by-community-type/
  2. https://www2.census.gov/library/publications/2013/acs/acs-22/acs-22.pdf
  3. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.1021#B1
  4. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.1021#B4

4 Thoughts on Telemedicine and Robot Doctors

March 21, 2019

Written By: James "Jamey" Edwards

Occasionally we’re fortunate enough to share the perspectives of others on this blog, along with our own. This post is co-written by Dr. Ben Panwala, a hospitalist and founder/CEO of Telshur.

Earlier this month, there was a stir about a ‘robot doctor’ giving the family of a terminally ill man some difficult news about his condition. Evidently, a remote physician appeared on a screen and was positioned at the patient’s bedside to discuss his case. The family took to social media to share the experience and state that this is no way to tell a patient he’s about to die.

The team at Cloudbreak use the phrase “humanize healthcare” a lot, and along with Telshur, we both believe that technology has tremendous potential to help us meet that goal. So, what went wrong in this situation? Likely several things.

Quite a few physicians have spoken out to defend the doctor in this story (and technologists have defended the tech as well). But maybe this misses the point. We sympathize with the family but also acknowledge the challenges of the remote doctor in delivering high quality care over distance and pushed by time constraints. Scenarios like this can happen anywhere and do happen numerous times a day across the country, and around the world—whether it’s in-person or remotely.

When these events occur, we should always look at opportunities they present to look for insights and areas of improvement. We suggest four takeaways to ponder—

  1. Core to a clinician’s role is talking to the family and delivering news. This is true regardless of whether the doctor is in the room or hundreds of miles and two iPad screens away. With demanding clinical assignments, it can be tempting to take shortcuts and not engage patients on a deeper level. In this way, a doctor may not fail medically, but may still fail the patient. But care providers need to connect with their patients and their families over media just as we would in person.
  2. There is a “digital etiquette” that’s different from face to face interactions. This one should be obvious. Think of two friends hanging out together. One utters a sarcastic comment but does so with a smile and a wink. While the words on their own may offend, there’s an understanding that this is sarcasm and no real offense is intended. Now think about that same remark uttered in an e-mail to a colleague (and no emojis allowed!). The perception would be very different. Fortunately, it’s certainly possible for doctors to ‘read the room’ virtually, but it takes a different set of skills and steps.
  3. Training is needed to ensure clinicians make the best use of the technology provided. Imagine you started a new job and your first assignment was to lead a webinar with multiple participants, on a platform that you’d never used before. Without some foundational training, how likely are you to conduct that webinar without a hiccup? Remote physicians, mental health professionals, language interpreters, and others need to be trained on things like: positioning the equipment for the best view and sound; coaching the person(s) on the other end who may be incredulous; and acting with intention, knowing that some of the non-verbal cues may not make it across the ether. Such training should be built into any robust telemedicine program. When you do this, it results in more precise communications, often shorter interactions, and improved patient and provider satisfaction.
  4. Telemedicine, or “distributed healthcare” if you prefer, is the future. Actually, it’s the present, but the future promise is even greater. The facts are plain. We’re facing very real doctor shortages, with the gaps in some practice areas much wider than others. And for patients remote from large metro hospitals or who arrive in the ER or ICU before a specialist can be on-site, the promise of telemedicine is that we can deploy more expertise to the patients who need it, and in a timelier manner. We hope both doctors and patients shift from tolerating this reality to embracing it.

When we say “humanize healthcare” it means that technology is at its best when it’s enabling or improving personal medical interactions. We believe the key to this is not focusing on the technology alone, but also the protocols, procedures, and workflows that are being employed by caregivers when using the technology, and then ensuring the technology is supportive of those things that make the difference. Or, put another way, the culture is more important than the communication modality.

We believe, if given the opportunity, being in person to inform patients and families of serious health issues is optimal. But sometimes that’s simply not possible, and for urgent life and death situations, worried families are looking for timely answers and guidance to make decisions.

We know humanized telemedicine can work because we’ve seen it. We’ve experienced provider teams specifically requesting telemedicine interactions on behalf of family members who can’t make it to the bedside in time. They want what’s best for the patient and family, and so do we. And that’s what we hope to achieve with a distributed healthcare future.

Relying on Dr. Google for Medical Interpretation

March 11, 2019

Written By: James "Jamey" Edwards

JAMA recently published an article on using mainstream translation software in a health care setting, which was also picked up by Gizmodo. Researchers used Google Translate to translate emergency department discharge instructions prepared in English into Spanish and Chinese.

The results were then retranslated into English by bilingual translators, and lo and behold Google Translate handled the lion’s share correctly—92% of Spanish instructions were rated accurate. Not surprisingingly, Chinese was more difficult and about 81% of instructions were spot on. In each language, a small percentage of the faulty translations were deemed clinically significant with the potential to cause harm.

The punchline: “While GT can supplement (not replace) written English instructions, machine translated instructions should include a warning about potentially inaccurate translations.” The study also noted that the authors “cautiously support its use” in a clinical encounter.

Medical interpretation is the trickiest and most nuanced form of interpretation—we see it every day. To make it more complex, interpretation (the spoken word) and translation (the written word) are different disciplines and the danger is that the public most often doesn’t recognize there is a difference, nor do most clinical personnel who use those words interchangeably. Interpreters are often painting a picture of understanding vs. doing word for word translation, because in many languages a phrase will not directly translate into the same meaning in the other language. In addition, the context or the situation in which the words are spoken matter and needs to be taken into account.

For example, the English-language phrase “my wife is going into labor” becomes “mi esposa va a laborer” in GT (pictured), which, translated back into English is more like “My wife is going into work.” The contextual meaning is lost. Or when a Spanish speaker complains of “mal de orina,” the literal interpretation of the words they are saying is “bad urine,” but in context a skilled interpreter will recognize they may be trying to say they have a UTI. Even short phrases present a huge potential for error.

“Why should I care?” is most often the next question to be asked when considering and how Google Translate or other computerized translation tools might affect outcomes. We all should care for many reasons. First off, we need to assume that a clinician reading JAMA may start using such a tool for all their interpretation and translation needs even though it hasn’t been recommended for such usage. This would lead to significantly increased risk for the patient, as well as potential physician liability. We also need to contend with the fact that no one is QA-ing or supervising tools like Google Translate in the field to measure its effectiveness as has been done in this study and therefore “miles may vary” in terms of its true accuracy and effectiveness.

The study simply tested Google Translate’s ability to handle a sentence or two of fairly clear-cut instructions. An error rate that high on straightforward text is something to be concerned about. It’s a far cry from interpreting through a full medical exam or procedure. Cloudbreak’s average provider/patient video interactions last 10 minutes, and they benefit from non-verbal cues oftentimes communicated. Furthermore, nearly 20% of our encounters are in American Sign Language for the Deaf and Hard of Hearing community, and browser-based transliteration simply can’t address that.

We get it – care teams may like the idea of using a computerized tool such as Google Translate because it’s fast is available at their fingertips, but that’s the experience that Martti users have always had.

But even more important is the quality of the interpretation. Martti is health care-specialized and it’s underpinned by interpreters who are not only specially trained and certified by CCHI, but also participating in the US health care environment rather than being based in another country. In many other nations, the idea of things like co-pays or certain advanced technology may not exist, so U.S.-based interpreters are not only adept at handling the language piece, but also speak the language of health care as its delivered here.

Now, if you’ve read this far, look back on the blog post and consider how many idiomatic English-language phrases were used. Phrases like:

lo and behold
lion’s share
spot on
far cry

Certified interpreters unfamiliar with these phrases would know to look them up and apply context, or perhaps ask the speaker for clarification. That’s what effective (and ultimately accurate) medical interpretation looks like.

We believe in the power of technology and its power to solve thorny problems such as building a virtual medical interpretation tool. We love Google and use it every day. That being said, the technology isn’t quite there yet to “cautiously support its use” for the root of good healthcare: communication. As a patient, would you want to be one of the statistics of the studies acceptable error-level window? As a doctor, would you want to put your medical license at risk or see one of your patients harmed?

Currently Martti offers our health care partners the ability to instantly access at the push of button Certified Medical Interpreters in U.S.-based language centers who speak over 250 languages, delivered over a reliable and scalable telemedicine infrastructure. We believe this is currently the gold standard offered in the market and remain committed to building patient and provider trust through our more than 85,000 encounters per month at over 1,000 health care venues.