When patients speak limited English, be wary of online translation tools

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Ursula Tice-Alarcon (in pink) surrounded by her team of interpreters at Lahey Hospital and Medical Center in Burlington

Patients who are not proficient in English — growing in number in Massachusetts and nationally — are more likely to experience medical errors and to misunderstand diagnoses. But experts warn that technologies like Google Translate and smart-phone medical interpretation apps are often unreliable and potentially dangerous ways to communicate with patients with limited English proficiency (LEP) in clinical settings.

"I would not use those programs to communicate with a patient, and at Lahey we don't use them," said Ursula Tice-Alarcon, manager of interpreter services at Lahey Hospital and Medical Center in Burlington. "We provide medical interpreters in person primarily, with minimal to no wait time. We aim to do that for the vast majority of our non-English speaking population of patients. When an in-person interpreter is not promptly available, we resource immediately to provide the highest-quality services via video remote and phone interpretation."

Tice-Alarcon and others point to dozens of cases in which medical interpretation (spoken) and translation (written) programs have been severely and almost comically wrong, leading to adverse events like patient misidentification and improper invasive procedures.

Google Translate has proven especially unreliable in medical communication, and was the focus of an advisory last year from the Quality and Patient Safety Division of the state Board of Registration in Medicine (QPSD). The advisory noted that patients with limited English skills “make up a significant proportion of patients in acute care hospitals and emergency departments’’ and warned against use of services like Google Translate, Babel Fish and Bing Translator for clinical interactions with patients.

Examples of errors with Google Translate

  • “Your wife is stable” was translated to “your wife cannot fall over.”
  • “Did he have a high fever at home?” was translated to “your home temperature was high.”
  • “Your husband had a cardiac arrest” was translated to “your husband’s heart was imprisoned.”
  • “Your child will be born premature” was translated to “your child is sleeping early.”

Source: July 2016 Clinical Translation Advisory, QPSD

Even as they try to hold down costs, many health care providers in Massachusetts say they rely on what is considered the best and safest option: interpreters who have been trained and certified for medical work in face-to-face conversations with patients and their clinicians.

Tufts Medical Center, which treats a high volume of Asian-language patients, devised a “clustering strategy” because it had “so many requests to book interpreters and only a limited staff to draw from.” Doing so involved asking clinics to schedule most of their Chinese and Vietnamese patients in close proximity to one another.

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“In this way, one or two interpreters could report to a certain clinic during the clustering time and meet the needs of 20 to 30 patients in a much more efficient manner,” according to Heidi Waitkus, the executive director of patient care services.

How a small provider in Massachusetts is revising its policies

After an incorrect procedure was performed on a non-English-language patient last year, a medium-size Massachusetts health center submitted the following corrective action plan to the state Department of Public Health after a root-cause analysis of the event.

“The OB/GYN department performs a high volume of invasive procedures, often with patients who face language/cultural barriers. To optimize patient engagement in the pre-procedure verification process, we evaluated the need for in-person interpreters for these procedures.

  • A determination was made that in-person interpreters should be available in the invasive procedures listed below to assure face-to-face interpretation and preserve visual cues: Bartholin’s cyst I&D, colposcopy, ESSURE (hysteroscopic sterilization), hysteroscopy, LEEP, vulvar biopsy.
  • Block scheduling of in-person interpreter services department interpreters was instituted in the OB/GYN department. The assigned interpreter, once the procedure begins, must remain for the entire duration from consenting to completion.
  • Contingency plan when in-person interpreter not available: Certified Auxiliary Interpreter or Video Remote Interpreter.
  • Standardize documentation of interpreter use in the consent process.

Measures of Success: Conduct chart review of 10 randomly selected procedures every month for 4 months. Charts will be assessed for interpreter use and corresponding documentation.”

Interpreter Md
Dr. Eric J. Hardt

And Boston Medical Center (BMC) has a team of 60 professional medical interpreters or language facilitators who can provide face-to-face support in Spanish, Haitian Creole, French, Cape Verdean Creole, Portuguese, Vietnamese, Cantonese, Mandarin, Somali, Albanian, Amharic, Tigrinya, Russian, Arabic and Ukrainian, as well as American Sign Language. 

Dr. Eric J. Hardt, who has spent more than 30 years as a formal medical consultant to the Interpreter Services Department at BMC, says the days are long gone when patients would or should rely on their children or other family members to describe their conditions, or when hospitals can turn to employees who speak a bit of Albanian or Creole. (For more on Dr. Hardt's research into medical interpretation as it relates to patient safety, see “Five Questions.”)

Ad hoc interpreters may be bilingual, but most lack medical training and education, he noted. “How do I know how good the person’s language skill really is, and how do I know how much real info I am getting?” 

Subtle and challenging situations, such as a suicidal patient, are better dealt with through a face-to-face interpreter, he said. And while remote interpreters can be an urgent and necessary emergency option, they can easily miss important body language and social cues. 

Many smaller practices, with limited staffs and budgets, use telephonic or remote-video medical interpreters to assist with non-English patients. A 2012 study in the journal Patient Education and Counseling explored the topic from the interpreters’ perspective.

“Most interpreters find telephonic interpretation adequate for administrative, ancillary, and follow-up care clinical scenarios,” the authors wrote. “For other scenarios with substantial educational or psychosocial components, telephonic interpretation may not suffice, and video-conferencing offers improved communication … because it improves access and quality of care.”
Cynthia

Cynthia Schenck, a member of the board of the International Medical Interpreters Association who founded Medical Interpreters of the North Shore in 1995, said she understands that smaller practices might choose telephone or video interpreters for convenience and to save money. But, she believes, using certified, on-site interpreters can actually cost less than over-the-phone interpreters who charge by the minute.

“If you are getting a medical interpreter who is live, it’s much more cost-effective and infinitely more reliable,” Schenck said. “And you have to think about the human component, too. Do you want to take someone who is seriously ill or going into surgery and put them on the phone?”

In its advisory, QPSD urged providers to assess their translation capabilities in light of their patient populations and to: 

  • Educate staff and providers on the use of simple language and avoidance of idioms, jargon, and nuance in both interpretation and translation.
  • Use standardized forms prepared by certified medical translators.
  • Use experienced and/or certified medical interpreters and vendors.
  • Develop and follow a comprehensive translation process.
  • Educate staff and providers about the goals and risks of communication through translation and interpretation.

How to find an interpreter

The International Medical Interpreters Association, which is based in Massachusetts, offers information on access to trained interpreters and translators.

http://www.imiaweb.org/def

Its database is searchable by state:

http://www.imiaweb.org/corporate/corporatememberdirectory.asp

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