Current Research Initiatives

Remote Simultaneous Medical Interpreting (RSMI)

OVERVIEW
Over one million immigrants arrive in the United States each year. 2000 Census data indicate that over 30.5 million United States residents are foreign-born. These newcomers speak over 150 different languages. Forty-five million people over age 4 speak a language other than English at home. A significant proportion has Limited English Proficiency (LEP). LEP is “a limited ability to listen, speak, read, and write in English, and speak English less than 'very well'.” About 50% of LEP individuals speak Spanish, followed by Indo-European languages. As many as one in four immigrants in New York City demonstrate LEP, and in effect, are unable to adequately communicate with their health care providers in English. To considerably improve on current practices, a Remote Simultaneous Medical Interpreting (RSMI) system was implemented at Bellevue Hospital Center. Cutting edge technology allows patients and doctors to utilize the services of interpreters, located offsite, who are trained in simultaneous medical interpretation.

The primary purpose of the RSMI Outcomes Study is to document differences in medical outcomes experienced by LEP patients who use the RSMI system as compared with LEP patients who use Usual and Customary interpreting practices. The term Usual and Customary refers to the range of other methods in which interpretation is available, including trained volunteers and staff, commercial over-the-telephone interpreting services, and ad hoc interpreters such as a patient’s relatives and untrained staff.

This pioneering study is the first conducted on the impact of the RSMI system on medical outcomes among LEP patients in a primary care setting, as well as the first study to document RSMI costs as compared to costs of alternative methods. This study is being conducted in the Primary Care and Cardiology Clinics at Bellevue Hospital Center in New York City. In addition, a sub-study was conducted in the Bellevue Emergency Department to examine patients’ knowledge of exit instructions when various interpreting modes are utilized.

Additional studies focus on accuracy of information and education and patient/provider/interpreter satisfaction. The collective results will provide critical new information regarding interpreting methods. This body of knowledge will be available for health policymakers and hospital administrators in New York City’s and the nation’s health care facilities, thereby enabling more informed choices about interpreting practices.

OUTCOMES STUDY
This randomized control study is being conducted in the Bellevue Hospital Center Primary Care Clinic and the Cardiology Clinics. The experimental and control groups consist of newly enrolled Spanish-, Mandarin-, and Cantonese-speaking patients. Experimental patients and their primary care providers use the RSMI system at Bellevue. Control patients employ Usual and Customary interpreting practices in the same clinics. Two additional comparison groups include English-speaking patients matched for demographic characteristics apart from language, and Spanish-speaking LEP patients with Spanish-speaking providers. Patients are being followed for one year.

Patients study including chronic disease management indicators(hypertension, diabetes, and hypercholesterolemia); new diagnoses (depression); and adherence (follow-up appointment keeping, adherence to immunization, and adherence to screening guidelines).

Research Questions:
Does RSMI improve timely and accurate diagnosis of depressive disorders for LEP patients?
Is RSMI effective in enhancing initiation into appropriate follow-up care?
Does RSMI improve adherence to screening and immunization guidelines?
Does RSMI improve routine management, and, hence, outcomes, for chronic diseases including diabetes, hypertension, and hypercholesterolemia?

EMERGENCY DEPARTMENT SUB STUDY
The Sub Study conducted in Bellevue Emergency Department compared RSMI and Usual and Customary encounters in the Bellevue emergency room

Research Questions:
Does knowledge of exit instructions differ by mode of interpreting (RSMI, RCMI, and PCMI)?
Does provision of instructions vary by interpreting mode?
Does patient satisfaction vary by interpreting mode?

COST STUDY
To obtain data on the efficiencies of various modes of interpreting, a separate study is being conducted. Scripted encounters in several languages were recorded and timed. The timing analysis will also be augmented by visit length information gathered during the Outcomes study. An econometric analysis will also be performed

ERROR ANALYSIS STUDY
Four patient-provider scripts were prepared spanning different medical conditions and issues that arise in an outpatient setting, including diabetes mellitus, tuberculosis, depression, and menopause. The encounters in the study’s languages are recorded, all across four modes of interpreting in each language: Remote Simultaneous, Remote Consecutive, Proximal Consecutive/Trained, and Proximal Consecutive Ad Hoc. An error analysis tool is used to record both linguistic and medical errors. This tool allows the errors to be identified, classified, deemed significant or not, and further classified as to their potential medical significance. The Error Analysis is being conducted in Spanish, Mandarin, and Bengali.

FUNDERS
Thank you to our study funders, the Commonwealth Fund and the California Endowment.

THANK YOU
The RSMI study is being conducted with cooperation from Bellevue Hospital Center and New York City Health and Hospitals Corporation

Language Enhancement Activation: Responding to Needs (LEARN)

The LEARN Program is being developed by the Center of Immigrant Health to allow a systematic assessment of hospitals to determine how they are meeting or missing their language assistance service needs. Based on this assessment, practical suggestions can be made on how hospitals can improve on their current practices.

The goal of the LEARN Program is to assure that LEP patients obtain meaningful access to all programs and services provided by hospitals in New York City.
The specific objectives of the LEARN program are
1. To develop a tool to assess the readiness and needs of hospitals in providing language assistance services
2. To apply this tool at two hospitals providing care to a significant number of LEP patients (“pilot sites”)
3. To refine and finalize the tool based on the findings at the pilot sites
4. To offer a Roundtable for health care facility management to highlight the LEARN

21 million U.S. residents are limited English proficient (LEP), a growth of 50% over the last decade. Over one in four New York City immigrants is LEP. LEP is an important service barrier before a patient arrives at the clinical visit. A New York City Comptroller’s report, “Getting in the Door: Language Barriers to Health Services at New York City’s Hospitals,” determined that limited English proficiency may impede medical services information receipt, appointment-making, understanding payment terms, and obtaining publicly-subsidized insurance (Thompson, 2004). The Report evaluated four access points: main hospital telephone numbers, and those of the clinic, billing office, and ER. Nearly 75% of the City hospitals were unequipped to respond to Spanish-speaking callers’ needs in one or more of these departments. Billing offices were the weakest, while frequently the uninsured are overwhelmed by large medical bills.

Regulatory concerns mandate hospitals to bridge the language gap for their LEP patients. Numerous federal and state laws require “meaningful language access” in health care settings. Any recipient of federal funds is required to take reasonable steps to ensure access to their programs and activities by LEP persons. 98% of hospitals receive federal funds, and almost all large and mid-sized hospitals are subject to compliance with federal guidelines to provide LEp access. In addition, health facilities in New York State are further subject to N.Y. Public Health Laws, which require them to provide skilled interpretation services and translations or transcriptions of significant forms, instructions and information to ensure effective visual, oral and written communication with all patients, regardless of their language. The past four years have seen increased enforcement of federal and state statute on the provision of language assistance services. Failure to provide adequate interpretation and translation services to LEP patients has resulted in civil rights complaints filed against hospitals.

Increasingly, hospitals are actively seeking to meet their language assistance services needs. Such an effort must necessarily be preceded by a comprehensive assessment of these needs. However, hospitals find themselves ill-equipped to systematically assess their current policies, procedures and practices. In the absence of this comprehensive assessment, they are unable to undertake appropriate remedial actions to address deficiencies. Consequently, hospitals are struggling to appropriately serve their LEP populations.