“We have a large immigrant population, and people sometimes have no English. This program has been a godsend.” –- Winnipeg pediatrician Stan Lipnowski
Obtaining a good history is the most important thing in practising medicine, so being able to get that history about the children of new immigrants has made a “humungous difference”, says Stan Lipnowski, a pediatrician who practices at the Manitoba Clinic in downtown Winnipeg.
The Winnipeg Regional Health Authority (WRHA)’s language access program, launched in 2007, offers language interpreter services on a no-fee basis to hospitals, clinics, long-term care facilities and, unusually, even in the offices of doctors like Lipnowski who practice medicine on a fee-for-service basis.
Before the interpretation program, “gestures and guesswork” were often used in attempts to obtain medical histories for children—frequently high needs children in need of specialized care— whose parents didn’t speak English, says Lipnowski. “We were never quite sure… and there were often unnecessary tests.”
It’s generally acknowledged that the ability to communicate is the cornerstone of medicine for making a diagnosis and explaining management options.
However interpretation services have historically been considered an “add on” cost supported only by “soft” social science evidence, says Sarah Bowen, an associate professor of public health at the University of Alberta. (“Intepretation” refers to oral translation, while “translation” is used with reference to written text, Bowen explains.)
People in positions of power “don’t know much about this issue”
As well, “people in positions of power and authority don’t know much about this issue…and many do not have lived experience with it,” she says.
Bowen did background research to establish the framework for the WHRA language access program, and is the author of numerous reports on the subject, including a landmark 2001 Health Canada document on language barriers in access to healthcare, a Canadian Institutes for Health Research Knowledge to Action project, and a 2011 presentation to Accreditation Canada on the language barrier issues.
Recently, however, the importance of professional interpretation services has moved up the policy agenda because of a mounting body of international evidence about the risks associated with the use of untrained interpreters.
Interpretation services are increasingly understood to be part of risk management, the patient safety agenda, and strategies to address disparities in access to health and health care, Bowen says.
When the Toronto Central Local Health Integration Network (TCLHIN) surveyed healthcare organizations within its boundaries, all respondents identified a need for enhanced language services, said Rachel Solomon, senior director of performance measurement and information management at TCLHIN. A 2011 equity consultation report with stakeholders also revealed a considerable variety of hospital and healthcare institution policies and services for interpretation services.
“Bulk buy” of telephone interpretation initiated by Toronto Central LHIN
The WRHA’s program , developed on a regional basis, has been designated a “leading practice” by Accreditation Canada.
In Toronto, one of the most ethnically diverse cities in the world, the TCLHIN last fall launched an initiative to facilitate the bulk buying of telephone interpretation. (Historically, interpretation services in Ontario have developed on an institution-by-institution basis.)
The bulk buy led to better rates but still, because language interpretation services are a “spend”, health care administrators want hard facts about risks of inadequate interpretation and benefits of professional interpretation, notes Solomon.
Solomon says her LHIN’s focus is on the importance of interpretation from a “quality, equity, and sustainability of care” perspective, but she acknowledges that there is “absolutely a risk management lens … and we have heard from some organizations that there is a fear of liability” when something goes wrong because a service was not provided in a way that a patient could understand.
Canada lacks enforceable national standards for healthcare interpretation
Canada lacks enforceable national standards for healthcare interpretation for people with limited English and French proficiency and is behind other jurisdictions such as the United States, the United Kingdom and Australia, in providing such services.
The WHRA developed its own standards, ethics and policies for its program and, around the same time, the Ontario-based Healthcare Interpretation Network developed a set of national standards.
More recently, a National Coalition on Community Interpreting has formed and, at a Critical Link International Conference this coming June, TCLHIN chief executive officer Camille Orridge is scheduled to speak on “interpretation as a critical healthcare service.”
The notion that “any interpretation is better than none” to facilitate communication with patients has been overwhelmingly disproven, says Bowen, who points to numerous published studies based on transcription analysis.
“The error rate of untrained interpreters (including family and friends) is sufficiently high to make their use more dangerous in some circumstances than no interpreter at all” because of the false sense of security it provides, the U.S. Office of Minority Health concluded back in 1999. (As well as using family and friends of patients, many hospitals have traditionally used staff, sometimes from unrelated departments, to interpret.)
Costs of inadequate interpretation a “hidden problem”
The costs of inadequate interpretation—costs resulting from misdiagnosis, unnecessary tests, and lack of preventive health care—have largely been “a hidden problem,” Bowen notes. Poor interpretation has also resulted in the violation of patient confidentiality and inadequate informed consent.
The WHRA initiative was driven by careful documentation of the risks associated with inadequate interpretation, and by champions at the upper levels of administration, says Jeannine Roy, WHRA manager of language access.
Demand for interpretation services within the WRHA increased from 1,851 requests in its first full year to 13,187 requests in the year ended March 31, 2013, she says. About 5% of requests went unfilled. Despite the uptake, many of the WHRA’s 29,000 employees are not yet familiar with the service, she adds.
The WHRA has a centralized scheduling and dispatch service and the program emphasizes face-to-face interpretation, which is offered by the region’s 60 interpreters who are unionized casual employees and receive free training from the WRHA.
WHRA policy spells out when to “at least attempt” to have face-to-face interpretation
The region’s policy says that health care providers must at least attempt to secure professional face-to-face interpretation services for matters such as diagnosis, mental health questions, discharge planning and informed consent.
Telephone interpretation is considered appropriate for more routine interactions and, as well, as a back up service. About 25% of the program’s services involved telephone interpretation, Roy says.
The program’s operating budget is slightly more than $1-million, which covers interpreters, telephone interpretation and administration staff, says WHRA media officer Bronwyn Penner Holigroski. The service costs are covered by the WHRA although there is some cost recovery when other government departments or regions draw on the service.
In Toronto, the TCLHIN also found that the cost of telephone interpretation services varied considerably (from $1.70 to $8 a minute) and that community organizations such as community health centres were largely unable to afford telephone interpretation services.
In Ontario, Excellent Care for All Act helped push for better ways to provide interpretation
At the same time, the province’s Excellent Care for All Act, which underscored patients’ rights to understand the care provided to them, helped to push the LHIN to consider better ways to provide services.
The LHIN arranged a bulk buy of telephone interpretation services from the Toronto based RIO Network and backup services through the California-based Language Line Services (recently renamed Languageline Solutions).
Nineteen hospitals and 14 community organizations now participate in the bulk buy, which was launched in last October. The TCLHIN has opened up participation in the bulk buy to other LHINs and organizations within those LHINs. For the first month, 22,000 minutes of interpretation were used. In February this year, 37,000 minutes were used, a level of uptake which has already brought costs to the lowest pricing tiers of less than $1.50 a minute, Solomon said.
Hospitals are charged back for the service but the LHIN has also, as a pilot project, budgeted $200,000 for the provision of telephone interpretation to certain community organizations. Based on the experience of this pilot, community health centres (CHCs), which already have a budget for face-to-face interpretation, will know better how to budget costs for telephone interpretation, says Angela Robertson, executive director of Central Toronto Community Health Centres.
A big advantage of the telephone interpretation service is that it doesn’t require purchase of new equipment, Robertson notes. (Video interpretation, offered through the non-profit Health Care Interpreter Network in California, is widely used in hospitals. While it requires substantial investment in hardware and technology it has, as promotional material notes, the advantage over in-person interpretation that interpreters do not run into travel delays.)
In-person interpretation used for more complex interactions
Robertson says that at CHCs in-person interpretation (by multilingual CHC staff who treat patients, as well as services purchased from a provider) will continue to be used for longer, more complex interactions, while telephone interpretation (either through speaker phone or, more privately, with two handsets) is for more routine communication.
The entire TCLHIN bulk buy initiative is to be evaluated by the Centre for Research on Inner City Health (CRICH), which is based at St. Michael’s Hospital in Toronto. (St. Michael’s Hospital itself is not participating in the bulk buy because it signed a three-year contract for telephone interpretation before the bulk buy was offered.)
Robertson says the CHCs, which in Ontario specialize in providing services for marginalized communities, have been pushing for hospitals to improve language interpretation services in order to provide continuity of service for clients.
Asked if the TCLHIN has contemplated a bulk buy of in-person interpretation services, Solomon says the LHIN “tries to leave the operational use and implementation to the organizations themselves and thus far, has not contemplated a policy around use of [in-person] interpretation services. That said, it is the LHIN’s expectation that the organizations are meeting the needs of ALL of its patients.”