Volume III: Video Remote Interpreting: General Setup and Preparation

April 22, 2020

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

This piece is the third in a 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 to create a Language Access Plan that includes Video Remote Interpreting (VRI) to ensure your facility is not only compliant but providing appropriate patient care. In this volume, we focus on what interpreters need for general setup and preparation to deliver a quality VRI experience.

The global pandemic has forced entire industries to convert to remote workforces, and medical interpretation is no exception. At Cloudbreak, we’ve been able to adjust to shifting daily needs through our many years of experience providing quality video interpretation and telehealth services.

For those new to video interpretation, or interpreting remotely, the following guide will help you pivot to remote work during these unpredictable times. Supervisors and Managers of interpreters will also find this information helpful before they begin supporting interpreters in a new environment.


Let’s assume you have the proper training and experience to interpret. Now, you need to translate those skills to a remote work setup.

The following list includes both items you need to have ready and tasks you need to complete to work as a video remote interpreter. While this list is written with the remote interpreter in mind, who may now be working from a home office during the pandemic, these guidelines apply to video medical interpretation whether it’s conducted at home or in an office.



Your work area should be compliant with the Healthcare Information Portability and Accountability Act (HIPAA), well lit, quiet, and well ventilated.


What it means

A HIPAA compliant space is a private and secure space. This means your home office has doors and if there are windows, that they have blinds and close. This is very important so no one else can see or listen to calls. No one else should enter or be in the room with you while you are interpreting.

You should have a computer connected to a high-speed, private and secured internet connection; and a desk drawer that locks, to store your notebook, or a way to destroy notes after every session such as a shredder.

Dedicated workspace

Your home office should be a room dedicated to your work. It should not be a room that also doubles as a laundry room, dining room, etc. 

Keep it quiet

Your home office isn’t just the room you work in, but also the surrounding environment. There shouldn’t be distracting noise from children, pets, or the surrounding area.


Start with a blank slate

It is recommended you use backdrops or mounts that are totally blank, to keep your image professional and not distracting. If you cannot obtain a backdrop or mount you should have a blank, untextured wall behind you, with no photographs or other decoration hanging on it.

Once you’ve set up your camera, the camera view shouldn’t show anything other than a blank wall or a professional backdrop that has been approved by your company (if applicable). The ceiling, floor, doors, or windows should not show.

Make it bright

Your workspace should be well lit, with no heavy shadows. Make sure your light source isn’t behind you, which will make you appear in silhouette.

 Ready your tools

Your space should have everything you need on hand. You should never have to get up from your desk during interpretation. Have your reference webpages saved on your browser and a notebook and writing utensils at your desk. Use an ergonomic chair and set it up to maintain good posture.



Attach your webcam

If you’re using an external webcam, affix it to the top of the monitor you’ll be looking at for interpretation. Make sure the webcam is centered on the monitor.

Attach your headset

Use a comfortable, noise cancelling headset with a microphone. It’s recommended you use a headset with a mic which will stay in place once adjusted rather than one where the microphone is built into the wire/cord. Test the speakers and microphone that are incorporated in the headset. All other microphones and speakers in your computer must be turned off.

Position yourself

When seated, with both feet flat on the floor, in a comfortable straight-back position, your head and shoulders should be fully in view on camera. Your eyes should be centered on screen. There should be space above your head. The camera should be facing you head-on not at an angle pointing up or down.

Check your surroundings

You should be well lit, without any heavy shadows. Angle your camera to only show you and your signing space (for signed language interpreters). The camera view shouldn’t show the ceiling, floor, a hallway, a door, a window or personal items. Again, the backdrop (or wall) behind you should be blank.


After you have set up of your space, test and ensure the following are working properly prior to taking any calls:

  • Internet Connectivity
  • Devices and software
  • Noise cancelling capabilities and lighting with test calls or with software testing abilities
  • Sound levels
  • Camera view


Be ready

  • Dress professionally and wear solid colors (reds are strongly discouraged for video).
  • Be on time by testing all settings prior to the beginning of your shift (see part III above).
  • Be seated, facing forward, and have your headset on before you answer a call.
  • Make sure you are sitting square in your chair with your shoulders back and centered in camera view.
  • Have all the appropriate computer settings and software open and ready as mentioned above.
  • Have information resources collected and ready to be used (online or not) prior to beginning interpretation to ensure accuracy and clarity. It is helpful to have medical dictionaries or other resources open and ready to go at the beginning of any interpretation.
  • Have a note taking method set up (online/pen & paper) and ready.
  • Have any scripting needed or assigned ready to be used.

Greet the partner

Make sure to smile and use an appropriate scripted greeting. For example, “Hello, my name is Cat, interpreter ID 1234. I will be your Spanish<>English interpreter”, followed by your interpreter pre-session. Your presence should be professional yet reassuring.

Make eye contact

This is another area where onsite interpreting differs from video remote interpreting. Video remote interpreters look directly at the camera to show professionalism. Eye contact lets the user know you are engaged. Focusing on the video also helps you read additional context clues like body language. Set your viewing window directly below your camera to help maintain eye contact.

Try these tips. They should help you feel more prepared and confident with your video interpretation. Stay safe!

Interpreting for Spiritual Care: Importance, Controversy and Solutions

February 19, 2020

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

Presenting the case

Visualize the following scenario:

“Good morning! We are calling from the prepping area in the operating room,” a nurse says to the video remote interpreter on the screen. The interpreter, a professional accustomed to the fast-paced environment of remote interpreting, is already thinking and processing, within the few seconds available, what areas of medical vocabulary to focus on and picturing in her head what kind of complicated procedure she will be interpreting for. The nurse continues, “Our patient is about to have a very important surgery and has requested someone to talk to and receive a blessing from, so here is our chaplain who came to pray with him.”

The interpreter quickly realizes that the vocabulary and context of the interpretation that is going to happen has NOTHING to do with what she had just formulated in her mind. In only milliseconds, the interpreter needs to make a decision (which is a process we always go through, but we don’t think about the fact that WE, the interpreters, are making that decision before we accept every session and in many times during the interpretation). The interpreter’s options are:

  1. to adjust to the new scenario and proceed with the interpretation;
  2. to ask more questions or clarify that this is going to be a challenging experience, but she is still willing to give her best during the encounter;
  3. to refuse to interpret based on the terminology and scenario.

Option ‘c’ is definitely one I would not recommend and one that would make the interpreter part of a problem and not a solution. So, how could interpreters be prepared to choose ‘a’ or ‘b’? Believe it or not, very little of this scenario is different from other interpreting sessions.

Scenarios like the one described above are common. This has been a controversial topic among interpreters, language service organizations, and providers (both medical and spiritual) for multiple reasons, and the worst part is that only few people talk about it. The debate seems to be limited because human beings have made this subject so taboo or because many would like to be respectful of people’s different beliefs. By not talking about it, we may think we are being more respectful, or that we are in a better place because we don’t have to deal with a potential conflict, or all of the above!

Digging deeper

As with many other things, I have come to the realization that NOT talking about it doesn’t really make the problem go away. My personal and professional way of thinking about this topic is that it is OK to have different spiritual beliefs or faiths, and it is also OK to have no spiritual beliefs at all. We must respect that. Bottom line is, as interpreters, we are called to serve our patients and healthcare communities, and spiritual care may be an important part of a patient’s healthcare.

Looking for answers to some questions about this topic, my team performed a survey in which 80 video healthcare interpreters from  different U.S. states participated. The main purpose of the survey was to determine how video healthcare interpreters felt about interpreting for spiritual care. In addition, we wanted to make data-derived suggestions to the remote interpreting community on how to enhance training for these types of sessions and obtain preliminary data for potential further research.

More than 63% of the participants agreed with the statement, “I like to interpret for spiritual care,” because of the importance it has to the patient or the patient’s health. About 23% were neutral and 14% did not agree with this statement.

More than 48% of participants feel confident when interpreting spiritual care because they are familiar with the subject; 20% were neutral and 31% did not agree with the statement.

When asked if they liked having fixed vocabulary or more from-the-heart prayers to interpret, we found an almost equal number of respondents liking one type of vocabulary over the other.

It was surprisingly good to observe that only 10% of the interpreters in this pool feel uncomfortable when interpreting a spiritual session if it involves a faith that they don’t follow because it is disrespectful to their own faith. And almost 80% of them did not mind interpreting in a spiritual care session even if it is a faith that they don’t follow.

Elba Nazario, former hospice chaplain and current video remote interpreter, comments about the topic: “I think people interpreting in cases of pastoral care should be genuine and show compassion […]. Body language is very important. People can tell when you are being sincere or when you are just playing a part or doing your job. People that are in distress want to know that other people care. For me, as a chaplain, it was more important to show compassion than to say the right words, but I understand that as an interpreter, both things are important.”

A non-spiritual view

Apart from the spiritual aspect of things, we healthcare interpreters may not believe in many things in life, but we still interpret about them and we do a terrific job at it. Thus, we interpret for many things we may not share, follow or practice, such as:

  • Abortions
  • Bottle or breast feeding
  • Sex change
  • Diets
  • Circumcisions
  • Profanity
  • Hormone replacement
  • Gastric bypass
  • Birth control
  • Natural family planning
  • Blood transfusions
  • Breast augmentation
  • Liposuction

And there are many others. We have to focus on the fact that the content of the interpretation has nothing to do with us as interpreters; we are there to serve others and convey the message following our professional guidelines.

Responsibility and outcomes

Any interpret who abides by the NCIHC Code of Ethics must practice:

  1. Impartiality: The interpreter interprets everything without allowing their own thoughts and beliefs to affect the interpretation in any way, even when they conflict with the interpreter’s beliefs.
  2. Transparency: The interpreter makes all parties aware of any challenges or struggles that the interpreter faces during the encounter.
  3. Professional Development: The interpreter strives to continually further his/her knowledge and skills and spiritual care is included in this.
  4. Accuracy: This must be the star in any interpretation. However, I believe it is fair to say that interpreting in spiritual care is an area that is slightly more flexible when it comes to accuracy of the message. Allow me to explain: A prayer, if prayed/interpreted with the heart, even if it is not 100% accurate, will NOT cause harm as other accuracy errors in healthcare terminology may. Of course, it is important to be as accurate as possible but minor edits or omissions may be even “lighter in weight” when it comes to a prayer.

The goal of healthcare providers, including interpreters, must be the well-being of the patient. Refusing to interpret for a spiritual care session can have deleterious effects on the patient. On the contrary, helping to communicate in those circumstances may be what a patient needs to make a recovery, cope or feel peace (the most precious prize a human being can have in life!) (Puchalski, 2001).

In addition, spiritual care is the main reason chaplains and priests call for interpreters. If interpreters refuse to help, these providers get the impression that interpreters never want to serve. No healthcare interpreter acting as an exemplary professional deserves that reputation.

Toolkit and resources

Let’s be ready! Below are some ethical principles and tips to keep in mind to help navigate some scenarios when interpreting for spiritual care sessions—


  • As with any other interpretation, the patient’s words are their own and not the interpreter’s. On the other hand, shared beliefs could make the encounter very emotional for the interpreter.
  • Debriefing with a trusted colleague after one of these encounters may be needed.


  • Let the chaplain/patient know that a specific term or concept is unfamiliar and if clarification is needed.

Professional Development:


  • The tools under Professional Development (above) will help you enhance your accuracy.

MarttiNext Has Arrived

January 30, 2020

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

This month Cloudbreak Health announced the nationwide release of MarttiNext – the most advanced version of Martti ever. MarttiNext is built on a new architecture and delivers enhanced HD video, multi-party calling, a sleek user interface, and some sought-after features for users.

The Martti team has spent a long time developing the next generation of our flagship language access software. With MarttiNext, we’ve incorporated the best practices in user experience design, along with input from our very own users. Some of the updates will be obvious and others will be more subtle, but we wanted to highlight a few of the elements that will really improve the experience for our users:

  • Call handling: MarttiNext’s call routing engine enables resources on demand, allowing a telemedicine call to bring in an interpreter or an additional resource such as a family member or remote caregiver to be added to a video medical interpretation. These calls can be cross-platform, utilizing MarttiNext’s video interoperability engine.
  • Enhanced support for HD video: MarttiNext is designed to work with the latest hardware in providing a high definition video experience. This is especially important for ensuring that patients who are Deaf or Hard of Hearing can interact with an ASL interpreter with clear video and minimal lag.
  • Expanded reporting capabilities: A newly updated code base will allow us to expand our analytics and reporting capabilities. We’ve heard from several of our users who increasingly want to visualize and manipulate their data.
  • In-demand features: MarttiNext delivers a streamlined interface and provides new features like an interactive whiteboard for iPad users. With a focus on simplicity, we think the expanded features and improved design will make Martti even more intuitive than before.

Hundreds of Martti customers have already made the switch and upgraded to MarttiNext. Fortunately, the process is easy. Hardware and software running the previous version of Martti will generally support MarttiNext. In some cases, a few adjustments to network settings will be necessary, but the Martti team has resources available to guide that process. And we’ve created a series of training and reference materials to ensure that upgrading to MarttiNext will be a breeze.

The future of video medical interpretation is here, and its name is MarttiNext.

2019: Year-In Review and Looking Ahead

December 31, 2019

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

As we wrap up the year, it’s time to reflect on some of 2019’s highlights and begin to look ahead to what’s in store for 2020.

The Cloudbreak Health team kicked off 2019 with CEO Jamey Edwards taking the stage as a Health Transformer Spotlight presenter at StartUp Health. Jamey set the tone for the year by speaking about innovation in digital health and asking the question “What if?…” when it comes to connecting patients to care independent of location and language. Shortly thereafter, a contingent of the Cloudbreak team descended on Orlando to take part in HIMSS 2019. As part of our theme to #humanizehealthcare, Jamey presented to a crowd on the themes of the power of language, driving adoption, and supporting culture change. Sure, technology was discussed as well, but we thought that a health tech conference of 45,000 people was a terrific opportunity to underscore the human element as central to achieving our mission.

Part of supporting innovation includes taking new approaches to the way we structure our team. So, in 2019 we recognized seven-year veteran team member Tatiana González-Cestari with a new role of Director of Language Service Advocacy. This shift for Tati – who had worked in interpreter education, compliance, and other roles over the years – reflects the continued emphasis we place on engaging the interpreter community and sharing our thought leadership at conferences and with customers across the country.

Probably the most significant news of 2019 is the arrival of Martti Next – the newest generation of Martti software and the most substantial enhancement to the platform in years. With Martti Next, provider users and patients have noticed a more streamlined navigation of the software, plus support for enhanced resolution and improved call handling. Here’s what one of our users at a large health system recently had to say about the Martti Next experience:

Patients and providers are extremely happy with the high video resolution that allows the interpreter to relay the message in real time, including working with deaf patients that use ASL for their communication. The hand movement for ASL interpreters is so clear that our patients are able to easily read the finger spelling while simultaneously interpreting for providers. Because of this high technology, their talented and experienced interpreters are able to showcase their skills in order to effectively facilitate communication between staff and community members.

And those advancements come with recognition. Over the summer Cloudbreak Health was recognized with a number of awards for the company’s innovation and achievements in healthcare technology. Cloudbreak was awarded Best Overall MedTech Software in MedTech Breakthrough’s 2019 Awards Program. MedTech Breakthrough is an independent organization recognizing the top companies and solutions in the global health and medical technology market. Around that time, the Los Angeles Business Journal named Cloudbreak Health the 2019 Health Care Supplier of the Year at its annual Health Care Leadership Awards. These awards recognize the top medical professionals, community health programs, medical teams and providers throughout the Los Angeles area, highlighting the accomplishments of individuals and organizations that have made great strides in providing better quality of health care in Los Angeles and beyond. And co-founder and COO of Cloudbreak Health, Andy Panos, was named an honoree of the Columbus Smart 50 Awards by the Smart Business Network. The Central Ohio Smart 50 list recognizes leaders who are passionate about the work they do and make a noticeable impact on the communities, industries, and organizations in which they work and live.

Finally, we’ve made updates to the way we communicate to our users and the broader community. We’ve launched a monthly newsletter to share updates, not only about Cloudbreak, but about developments that are relevant to language access and telemedicine. And we’ve greatly expanded our social media presence, finding new ways to engage with our extended community, wherever they are.

As we look back on 2019, we’re grateful for all the patients, providers, administrators, team members, and others who made the journey with us. As we look ahead to 2020, we expect to see continued innovation, both in our product offering and in the way we serve and support our partners. We can’t predict what the future will hold, but the mission to #humanizehealthcare will continue as ever in 2020.

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.


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.


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.


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,


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.

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.