Despite a largely unfunded mandate for federal fund recipients to provide language services,38
few studies have compared the acceptability and effectiveness of different modes of interpretation.25
Our study helps address this gap by comparing quality ratings of in-person, video conferencing and ad hoc
interpretation from the clinician’s perspective. We found that clinicians perceived the quality of in-person and video conferencing interpretation to be similar, and that both were felt to be superior to ad hoc
interpretation. Mode of interpretation did not have an independent effect on clinicians’ perceptions of the quality of communication or their satisfaction with the visit. These results suggest that when language-concordant clinicians or in-person professional interpreters are not available, video conferencing increases access to professional interpreters without compromising the quality of the interpretation and communication, and clinician satisfaction with the visit. These findings also support the use of professional over ad hoc
interpreters whenever possible. Shared, centralized videoconferencing technology could help health care systems expand language access while containing costs, especially in the case of less common languages.
Studies comparing satisfaction with and the quality of interpretation across modes of medical interpretation are few, and those that do exist are limited for several reasons. First, most studies compare two types of interpretation or one type with usual or no interpretation. For example, compared with ad hoc
interpretation, use of professional interpreters was associated with greater patient satisfaction with clinicians and quality of care,23
and fewer interpretation errors.24, 39
In another study, patients randomized to remote simultaneous medical interpretation reported greater respect by physicians and satisfaction with interpreters when compared with usual interpretation through telephone language lines and ad hoc
interpretation combined. 28
Simultaneous interpretation, however, requires a higher degree of training and skill compared to consecutive interpretation, and thus, may be less feasible and more costly in practice. This study was also limited in that remote simultaneous interpretation was compared to a group that included both professional interpreters via telephone and ad hoc
in-person interpretation combined.
Although clinicians often must depend on ad hoc
interpretation, evidence has accumulated that interpretation mediated by a professional results in better physician-patient communication, greater clinician and patient satisfaction, and fewer errors of interpretation with adverse clinical consequences.21, 24, 26, 40–42
Our findings are consistent with these studies and suggest that these results extend to video conferencing interpretation. Thus video conferencing may increase access to professional interpreters and limit use of ad hoc
interpretation to a method of last resort.
In-person professional interpretation appeared to offer an advantage over video conferencing with respect to clinicians’ understanding of patients’ cultural beliefs. Clinicians were almost 2.5 times more likely to indicate a better understanding of the patient’s culture with a professional interpreter in the room as compared to video conferencing interpretation. Certain types of visits, such as those involving a serious illness or end-of-life care may be at especially high risk of miscommunication when the clinician’s and patient’s culture differ. In these cases, using the interpreter as a cultural broker to bridge differences between the patient’s and clinician’s explanatory models of illness and cultural and spiritual beliefs, may be critical to providing the best quality care. 43
For example, in one study, an interpreter working with an East Indian patient conveyed to the physician the need for sensitivity to a cultural belief that talking about death hastens its occurrence. 43
Having an interpreter in the exam room may facilitate an exchange of cultural information that is more challenging under video conferencing conditions. Previous studies have suggested that professional interpreters function as cultural brokers,43, 44
a function that appears to be consistent with clinicians’ expectations.40
Further studies are needed to determine whether the extent of cultural brokering varies with type of interpretation, and possible explanations. However, about half of the clinicians had never been trained in the use of interpreters and perceived their understanding of patients’ health-related cultural beliefs as poor or non-existent. These findings are consistent with other studies indicating that clinicians need more training to care effectively for an increasingly diverse patient population.32, 45, 46
The strengths of our study are that we were able to include a large number of visits (relative to other studies), a variety of languages, three interpretation modes, and the clinician’s perspective. An additional strength is that the in-person and video conferencing interpretation were delivered by the same professional interpreter staff, which makes it more likely that the observed differences were due to mode effects, not individual interpreter effects.
The inability to randomize patients to mode of interpretation and a focus on a single county health care system limit the generalizability of the study and the causal inferences that can be drawn. Selection of interpretation type was driven largely by system factors such as availability, time constraints, and convenience of a specific interpretation mode for a particular visit. Because these system-related factors were not measured, it is difficult to assess the extent of bias these factors may have introduced. Furthermore, we were unable to assess the extent to which clinicians’ selection of their preferred interpretation method might have biased the ratings of the quality of interpretation. However, it should be noted that all interpretation modes tended to be rated highly and system changes were implemented to make video conferencing interpretation as accessible as other interpretation modes. Additionally, we were unable to assess interpretation via telephone language lines because they were either infrequently used or unavailable in these settings.
We were unable to obtain patients’ perspectives on interpretation due to the diversity of languages spoken and our resource constraints; thus, we had to rely on physician-reported data. However, a study that used parallel physician and patient instruments to assess visit-specific quality of communication found that item agreement was >80% (± 1 on a 1–5 scale), and that patient ratings actually tended to be higher than physician ratings.47
Relying on clinicians who may not be fluent in the patient’s language to rate the quality of interpretation and patients’ understanding of explanations may be problematic. This problem may be further compounded by differences in cultural norms. In certain cultures, patients may be inclined to assent with a nod even though they may not understand, or may prefer an “expert-learner” dynamic to collaborative care. Nonetheless, clinicians make daily judgments in clinical practice about patients’ level of understanding based on patients’ responses and nonverbal cues. Even though what constitutes high quality communication and visit satisfaction to a clinician may not coincide with what patients rank as high quality communication, clinicians’ perspectives are important and should be combined with other data sources in determining the value of interpreter services.
We were also unable to capture cost data in our study and could find no published data on the costs of video conferencing interpretation. A 2002 Office of Management and Budget (OMB) report estimated the cost of telephone interpretation at $132 per hour 48
compared to a cost of $234 per patient for in–person interpretation in a public hospital inpatient setting.13
Another study estimated the average cost of professional interpreter services in a health maintenance organization as $79 per interpreted visit, although these costs do not differentiate between in-person and telephone modes.15
Data on the costs of interpretation by mode are sparse, indicating the need for more studies that factor in potential net savings achieved through better communication, adherence, and use of recommended preventive and treatment services.
Although legislative intent to address language discrimination is evident in Title VI of the Civil Rights Act of 1964, the looming question is who will pay for language services. Health care systems and insurance plans must address the growing need for professional interpretation services to enhance quality of care and decrease disparities. However, significant gaps in the availability of professional interpreter services exist due to inconsistent government mandates and public and private reimbursement policies.22
While Medicaid and the State Children’s Health Insurance Plan (SCHIP) allow for reimbursement of interpreter services, state reimbursement policies vary; in 2007, only the District of Columbia and 12 states were directly paying for the cost of language services.49
It is up to individual commercial and Medicaid Managed Care Plans to negotiate reimbursement rates for interpreter services, but a notable gap is the lack of reimbursement provided by Medicare. The lack of comprehensive reimbursement practices for interpreter services operates as a de facto
disincentive for clinicians to see LEP patients or for LEP patients to seek care when they need it. 50
Failure to address language barriers restricts access to quality care, increases the risk of medical errors, and impedes the elimination of health disparities.48
Our study supports wider use of video conferencing to increase access to professional interpretation, especially where institutional resources or demand make it impracticable to hire on-site interpreters for a specific language. Future studies should further examine patient and clinician preferences for language services and the health outcomes and costs of providing such services. These studies are critical to elucidating best practices for providing quality health care to an increasingly diverse patient population.