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Service Delivery Innovation Profile

Remote Interpretation Delivered via Simple and Inexpensive Videoconferencing Technology Generates High Satisfaction Among Patients and Clinicians at Outpatient Clinic


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Snapshot

Summary

An outpatient clinic pilot tested use of inexpensive, widely available, easily implemented videoconferencing technology to provide Spanish-speaking patients with interpretation services from an offsite translator during appointments. Instead of purchasing costly equipment specifically designed for medical applications, clinicians used a tablet computer with preinstalled videoconferencing software and the clinic's existing wireless network. The program generated very high levels of satisfaction among both patients and clinicians, with nearly all of them rating it "good" or "excellent," and most saying they would use it again. The pilot test ended after 6 months, as program leaders wanted to test the approach's acceptability to patients and clinicians and not use it permanently since the clinic had an adequate number of onsite interpreters. Program leaders hope that this successful pilot test encourages other providers to adopt this approach, particularly in areas where interpreters are in short supply.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation feedback from participating patients and clinicians through a five-question multiple choice survey administered immediately after the appointment.
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Developing Organizations

Downtown Health Plaza, Wake Forest Baptist Health
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Date First Implemented

2011
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Non-english speaking/limited english proficiencyend pp

Problem Addressed

A large, growing number of patients do not speak English. Clinicians' inability to communicate effectively with these patients during medical encounters can lead to suboptimal care, and onsite interpreters are not always available.
  • Growing number of non-English speaking patients: In 2010, nearly 9 percent of U.S. residents reporting speaking English "less than very well," up from 8.1 percent in 2000.1 About 5 percent of patients who visit the Downtown Health Clinic speak only Spanish.
  • Leading to suboptimal care: A patient's inability to speak English can adversely affect his or her safety, medication compliance and adherence, and satisfaction, and in some cases can prevent the clinical encounter from occurring at all. Not having a language interpreter increases the risk of a subsequent emergency department visit, additional outpatient appointments, more frequent use of diagnostic resources or invasive procedures, and overprescribing of medications.2
  • Few onsite interpreters: While onsite interpreters have advantages over remote interpreters providing an audio translation, they often are not available because of factors such as cost and a shortage of qualified interpreters in many areas.3

What They Did

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Description of the Innovative Activity

An outpatient clinic pilot tested use of inexpensive, widely available, easily implemented videoconferencing technology to provide Spanish-speaking patients with interpretation services from an offsite interpreter during office encounters. Instead of purchasing costly equipment specifically designed for medical applications, clinicians used an Apple iPad tablet computer with Facetime, a preinstalled videoconferencing software, and the clinic's existing wireless network. Key elements of the pilot test are described below:
  • Identifying interested patients: When patients requiring Spanish interpreters came for an office visit, one of the two physicians running the program asked if they would be willing to have an interpreter present via the videoconferencing technology.
  • Low-cost, easy-to-use videoconferencing: If the patient agreed, the clinicians activated the videoconferencing system, which made use of two tablet computers with preloaded videoconferencing software. The interpreter used one tablet computer, while the other rested on an adjustable stand in the examination room, allowing clinicians to change the camera angle if necessary so as to ensure that both parties could see each other. (During the pilot test, the interpreters worked out of another office inside the clinic, as the clinic's purpose was to test the feasibility of the approach.) The system transmitted video images over the clinic's existing wireless network, making use of a 2.0 Mbps bandwidth connection on a router. The software and the network are encrypted, ensuring that audio and video cannot be intercepted by outside sources.
  • As-usual interview: The office visit generally proceeded as it would have if the interpreter were in the room. Because the devices pick up sound well, participants did not need to speak directly at the device or raise their voices. If the doctor needed to examine a sensitive part of the body, he or she adjusted the stand so the device faced the wall.

Context of the Innovation

A community health center affiliated with Wake Forest Baptist Health in Winston-Salem, NC, Downtown Health Plaza handles more than 28,000 visits from adult patients each year, including many Medicaid and uninsured patients. Roughly 5 percent of patients speak only Spanish. The clinic employs 10 full-time Spanish interpreters across all departments, enabling it to provide onsite interpretation to all Spanish-speaking patients who require it.

The impetus for this program came from two clinic physicians affiliated with the Wake Forest University School of Medicine who already used tablet computers to provide patient education during office encounters. Aware that the device's videoconferencing application had advanced significantly in recent years, the physicians decided to test whether it could be used to provide remote Spanish-language interpretation as part of routine clinical care. Their goal was to determine if the approach could be used in areas without an adequate number of interpreters and/or by providers who could not afford to hire onsite interpreters on a part- or full-time basis.

Did It Work?

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Results

The program generated very high levels of satisfaction among both patients and clinicians, with nearly all rating it "good" or "excellent," and most saying they would use it again.
  • Favorable views from patients: In a survey administered to 25 patients immediately after their visits, almost all patients rated the overall quality of the videoconferencing as "good" or "excellent" and favored using it again during future visits. A large majority also rated the technical quality of the audio and video as "good" or "excellent," and felt that videoconferencing took the same or less time than having an inperson interpreter.
  • Favorable views from clinicians: In a survey of 18 clinicians, almost all rated the overall quality of videoconferencing as "good" or "excellent," and a large majority favored using the same approach in the future.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation feedback from participating patients and clinicians through a five-question multiple choice survey administered immediately after the appointment.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Securing approval and clinician support: In early 2011, the two physicians gained approval from the medical center's institutional review board to launch the pilot program at the clinic. They described how the pilot program would work to clinic staff, including physicians, physician assistants, and a medical student.
  • Prelaunch testing of technology: In advance of the pilot's launch, physicians tested the videoconferencing technology by having clinicians act as model patients in simulated appointments with a clinician and interpreter. During these simulations, the physicians worked out details such as the ideal placement of the tablet and communication protocols.
  • Pilot test: The pilot test commenced in August 2011, after physicians had been satisfied that the technology worked well. Initially, the interpreter introduced himself/herself in person to the patient and explained how videoconferencing worked, giving the patient the option of whether to participate. Once clinicians became comfortable with the technology, this interaction generally occurred via videoconferencing.
  • Pilot test termination: The pilot program lasted 6 months, during which 25 patients and 18 clinicians used the videoconferencing technology with 5 interpreters. Based on the positive reactions from both patients and clinicians, program leaders hope this approach can be used in areas in which interpreters are in short supply by enabling multiple clinics to access one or more offsite interpreters.

Resources Used and Skills Needed

  • Staffing: Downtown Health Plaza hired no additional staff for the program, as existing clinicians and interpreters participated as part of their regular duties. Organizations without an adequate number of in-house interpreters, however, would have to hire and/or contract with individuals to provide translation services.
  • Costs: Downtown Health Plaza incurred few expenses during the pilot test, since participants used two tablet computers already in use at the clinic and an existing wireless network. The clinic made only one minor purchase—the adjustable stand for the tablet computer used in the examination room. Would-be adopters might also have to purchase tablet computers for the program, as each participating interpreter needs one.

Adoption Considerations

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Getting Started with This Innovation

  • Partner with other sites: Medical clinics interested in this program likely need to identify other facilities in the area that also require interpreters. If the demand becomes large enough, the partnering entities can then set up dedicated office space in a remote location where a group of interpreters provide translation to multiple sites.
  • Develop brief explanation designed to allay patient concerns: Clinicians using videoconferencing need to strike a balance between making sure patients understand how the technology works and going into so much detail that patients become intimidated and decline to use it. Program leaders found a 1-minute explanation from the interpreter to be effective.
  • Purchase and use adjustable computer stand: A swiveling stand helps to ensure patient privacy during sensitive physical examinations.

Sustaining This Innovation

  • Minimize ambient noise: It can become difficult for offsite interpreters to provide translation services when more than two people are in the examination room (e.g., additional clinicians, family members). In these situations, the clinician should take steps to minimize extraneous noise, either by asking those present to speak one at a time or having everyone but the patient leave the room. Similarly, the interpreter should situate himself/herself somewhere free from noise and distractions, and/or should wear headphones to block outside noise.
  • Be sensitive to interpreters' changing role: Videoconferencing alters the standard dynamic of interpreting in which the clinician, patient, and interpreter are in the same room. Some interpreters may feel they cannot be as effective when not present, or that videoconferencing threatens their job safety. To help overcome these concerns, listen to their perspective, give them time to get comfortable with the technology, and emphasize that videoconferencing has the potential to expand their job opportunities by enabling them to provide translation services to more patients over a broader geographic area.
  • Assess need for other types of interpretation: Clinics that successfully implement videoconferencing for interpretation services in one language may want to consider using it for hearing-impaired patients and/or those who require interpreter services in other languages. Partnerships among multiple clinics might make it feasible to offer services to those who speak less common languages.

More Information

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Contact the Innovator

Claudia L. Campos, MD
Assistant Professor, Internal Medicine
Department of Internal Medicine
Wake Forest University School of Medicine
Winston-Salem, NC 27157
Phone: (336) 716-2011
E-mail: ccampos@wakehealth.edu

James L. Wofford, MD, MS
Clinic Director, Downtown Health Plaza
Associate Professor, Internal Medicine
Department of Internal Medicine
Wake Forest University School of Medicine
Winston-Salem, NC 27157
Phone: (336) 716-2011
E-mail: jwofford@wfubmc.edu

Innovator Disclosures

Campos and Wofford reported no financial interests or business/professional affiliations relevant to the work described in this profile.

Footnotes

1 Limited English Proficiency Rates in the United States, 2000 and 2010. Available at: http://www.us-english.org/userdata/file/LEP2000to2010.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Ku L, Waidmann T. How race/ethnicity, immigration status and language affect health insurance coverage, access to care and quality of care among the low-income population. Washington, DC: Kaiser Family Foundation; 2003. Publication No. 4132. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/01
/how-race-ethnicity-immigration-status-and-language-affect-health-insurance-coverage-access-to-and-quality-of-care-among-the-low-income-population.pdf
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3 Price EL, Pérez-Stable EJ, Nickleach D, et al. Interpreter perspectives of in-person, telephonic, and videoconferencing medical interpretation in clinical encounters. Patient Educ Couns. 2012 May;87(2):226-32. Epub 2011 Sep 17. [PubMed]
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Original publication: November 21, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.