With the continued and substantial growth of foreign-born and non-English speaking populations in the US, disparities in medical care may be further exacerbated by increasing language barriers. In response to this growing concern, many states, including California in 2006, have required that patient language be recorded routinely in medical facilities. However, compliance with these requirements is unknown. This study of cancer patients diagnosed at Greater San Francisco Bay Area hospitals and selected for their likelihood to have language barriers found that at least some information on language usage was present in the medical records for the vast majority of cases. At facilities where patient information on spoken language was not abstracted electronically, language information was most often found in admission registration/billing and admission assessment examination records, and most of those documents contained some information on the patient’s language. These findings indicate that language information is not only available in the medical records for most cancer cases but also is found consistently in specific locations regardless of the abstractor or facility. Language information was not found consistently in other medical record locations, however, particularly outpatient admissions, discharge/transfer summaries, and medical history/exam records. This is important for patients with diseases that are less likely to involve a hospital admission and who, therefore, may have incomplete admission documents.
In addition to discrepancies in the location of language information, availability differed according to hospital characteristics with greater availability found in larger, private, and teaching hospitals. This may be due to greater resources available at hospitals with these characteristics, which may include electronic records systems, more highly trained staff, more systematized protocols regarding data collection, better evaluation and reporting procedures, and possibly greater appreciation (particularly among teaching hospitals) for the value of patient language information.
While largely available, our kappa and positive predictive value statistics demonstrate that the language documented in the medical records may not consistently agree with language recorded in a research interview setting. As expected, disagreement was associated with being foreign-born, of Asian/Pacific Islander or Hispanic race/ethnicity, and of older age. Greater disagreement in the year 1998 may be due to decreased awareness of the importance of this information in earlier years. Disagreement was also associated with diagnosis at public hospitals, in part due to greater agreement at those private facilities where data were abstracted electronically.
Discrepancies in language usage between interview settings and medical records may be due partly to differences in the context and/or purpose of recording or reporting language usage between medical records and research study interview settings. In addition, differences may occur because a health professional records the patient’s language based solely on observation and without soliciting the patient directly (16
). Patients may also feel uncomfortable specifying a language other than English in a medical setting for fear of discrimination (10
). While such fear also may be present during research study interviews, it is likely that more accurate, or at least more objective, information on spoken language can be obtained through self-report than by health professionals, as is true with the collection of race/ethnicity data (17
Our results regarding language availability are similar to those of Polednak (37
), who found language information for 82% of minority patients sampled for medical record abstraction in Connecticut hospitals, although this information was most often found in locations different than those in the current study. These similarly high percentages of language availability in hospital medical records are encouraging; however, in both studies, it appears that the information is not collected in a consistent or uniform manner. Hasnain-Wynia et al. (16
) evaluated whether and how patient race/ethnicity and primary language were recorded in patient records and found that, while there appears to be a theoretical commitment to collecting such data, collection practices are inconsistent both across and within medical facilities. The results of these studies along with the present findings highlight the need for standardized protocols to collect information on language usage in medical records in order for this information to be useful for research purposes and to reduce language barriers in the delivery of medical care.
The present study has some limitations, including the difficulty in interpreting the meaning of the language documented in the medical records due to the inconsistency with which it may have been collected. For example, if a patient’s language is described as “Chinese” in his/her records, was this information obtained by asking the patient, by observing that the patient spoke Chinese but not English, or by observing that the patient spoke both Chinese and English? What does it mean if both “Chinese” and “English” are noted, but in different areas of the medical records? In the current analyses, cases with both English and another language noted in their medical record were categorized as “English” based on the assumption that their English proficiency would be sufficient to navigate the healthcare system. However, we were unable to determine which of the stated languages was considered the patient’s primary language. A second study limitation is the likely variability in searching methods used by the abstractors to collect language information from the medical records, given the lack of established protocols for collecting this information at the facilities studied. Because of the potential differences in searching methods used by abstractors, we are limited in our ability to generalize the findings regarding location of language information in the medical record to all facilities. A third limitation is the potential for selection bias in the sample of hospitals contacted to participate in the study. These facilities did not differ from those not contacted with the exception of being slightly more privately owned. Given that availability of language information and agreement with self-reported data were both greater for private hospitals, this limits our ability to generalize these results to all hospitals in the region.
The present study demonstrates that information on language usage is largely available in the medical records of Greater San Francisco Bay Area cancer patients selected for their likelihood to be foreign-born or to have poor English proficiency. However, our results indicate that, while language information may be available in the medical records, it may not always be accurate. Hasnain-Wynia et al. (16
) argue that inconsistencies in data collection practices demonstrate the need for state or federal policies to enforce complete and accurate data collection. On January 1, 2006, California implemented Assembly Bill 800 (AB800), which requires “all health facilities and all primary care clinics… to include a patient’s principal spoken language on the patient’s health records.” Existence of such a mandate significantly increases the likelihood that hospitals will now collect these data (16
), so that this new requirement in California should help to improve the availability of these data in the medical records. However, in order for the data to be useful for research and for reducing language barriers in medical care, the information needs to be collected in a consistent and accurate manner. To the extent that this information can then be included in data used for research and public health surveillance, our understanding of disparities in disease incidence and outcomes will be improved. However, until accuracy of medical records data on patient language can be demonstrated, it is not recommended at this time that these data be used for research and public health surveillance.