The near universal use of smartphones and health-related applications (apps) has begun to revolutionize patient-centered care. Many of these apps have a common ultimate goal, improved physician-patient communication. Whether it is indirect dissemination of information (such as test results) or direct communication, effective interaction between health care providers and patients is essential to quality patient care. Language barriers significantly impact communication and can increase risk of poor patient satisfaction, but can also lead to more catastrophic patient outcomes including death. Although the use of smartphone technology can break down these barriers, positively impact patient outcomes, and reduce risk to patients, validating such technology is essential to ensure accurate communication and minimize risk to health care providers. We present a case of a unique communication challenge with a foreign deaf family, discuss how simple smartphone technology facilitated effective communication, and elaborate on the development and use of this technology in health care with an emphasis on the need for validating these communication tools. Written Health Insurance Portability and Accountability Act (HIPAA) authorization was received from the patient’s mother to publish this case report.
A 13-year-old deaf Russian boy and his mother, for whom communication was limited to Russian Sign Language (RSL) and written Russian, underwent a left radical plantar medial release, calcaneal slide osteotomy, and medial cuneiform plantar opening wedge osteotomy. A communication challenge was encountered in 2 different phases of care—during the in-hospital perioperative period and following discharge. Perioperatively, we utilized a hospital-based American Sign Language (ASL) interpreter and a deaf close family friend, who could sign in both RSL and ASL, to facilitate face-to-face communication with the patient. Following successful surgery, the boy was discharged home on postoperative day 1 with both popliteal and saphenous peripheral nerve catheters in place for pain control.
When sending a patient home with a peripheral nerve catheter, our standard practice includes educating families via in-person discussion, providing a pamphlet, and daily phone calls after discharge. The phone calls are intended to follow up with the patient about pain control and potential complications associated with the peripheral nerve catheters by asking a series of standardized questions. For this particular patient, as previously mentioned, our in-person communication was accomplished using a translator; and our standard pamphlet was translated into Russian. Postdischarge, given the unique double-language barrier of Russian and sign language a “text & translation” method was used for further communication. This communication method required a member of the acute pain service to send the mother the aforementioned series of questions in English daily via text message. Using the mobile application, Google Translate(GT), the mother would translate this message into Russian and then reply in Russian via text message. Using the same application, the acute pain service staff member then translated her reply back into English. Communication was continued in this manner until postoperative day 4, at which time the patient’s mother removed the nerve catheters. The patient had excellent postoperative pain control with no complications.
Language barriers present a significant communication challenge in health care. The non-English-speaking patient population in the United States is estimated between 30 and 45 million people. According to the American Community Survey Census statistics, at least 350 different languages are spoken in homes around the United States.1 While English is obviously the most common language, spoken in 80% of households, other common languages include Spanish (12.4%), Indo-European (3.7%), and Asian/Pacific island (3%).1 Interestingly, there are also multiple different sign languages spoken in addition to ASL including: Hawaiian, French, Australian, and RSL to name a few.
Understandably, much of the focus on potential hazards of communication within health care is on HIPAA compliance and the importance of risk mitigation when it comes to private patient information. However, accurate communication in the context of a language barrier is perhaps even more important. This is highlighted by a couple of eye-opening examples of patient harm due to inaccurate communication. The first can be found in a report published by the University of California, Berkley School of Public Health, in which medical malpractice claims due to poor communication are examined.2 The pivotal case presented is that of a 9-year-old Vietnamese girl whose death was partly attributed to mistaken communication between an emergency department physician and her parents. Unfortunately, the patient herself and her 16-year-old sibling were used as interpreters between the physician and her parents. The case ultimately cost a total of $340,000 dollars in combined settlement and legal fees. An equally alarming case occurred in 1980 when an 18-year-old Hispanic man presented to a Florida emergency department with a complaint of “intoxicado” (“nausea” in Spanish). Physicians caring for the man did not use an official Spanish interpreter and incorrectly treated the man for acute intoxication. Ultimately, the young man was found to have suffered an intracerebellar hemorrhage, the effects of which left him quadriplegic, and a lawsuit resulted in a 71-million-dollar settlement.3 These shocking stories highlight the need for validated communication tools in the health care setting.
The Federal Court Interpreters Act of 1978 established standardization and validation of interpreters for US court proceedings. However, no such federally mandated certification exists for health care interpreters.4 The most qualified among federal court interpreters, “certified interpreters,” must pass a written and oral examination process that has been independently validated.4,5 Interestingly, this level of certification is currently only available for Spanish interpreters. Two lower tiers of court interpreters exist and include “professionally qualified” and “language-skilled.” Language-skilled interpreters represent the lowest of the 3 levels of interpreter in the judicial setting and are the current requirement of medical interpreters nationally. In the health care setting, there are 2 independent organizations that provide certification: the Certification Commission for Healthcare Interpreters and the International Medical Interpreters Association both of which have their own standards for examination, certification, and validation.6,7 Although in-person hospital interpreters must meet a standard set by these independent entities, the use of smartphone technology is becoming increasingly common in the health care setting, which begs the question of whether or not similar standards should be required of such technology when used for interpretive services.
A Pew Research Center survey in October 2015 found that 68% of American adults own smartphones, which is an increase from only 35% in 2011.8 When accounting for age, smartphone ownership is even greater, with more than 80% of 18 to 49 year olds having these devices.8 The surge in ownership of this technology has lead to the emergence of the mobile health (mHealth) solutions market, which is estimated to reach a global value near $59 billion by the year 2020.9 One common goal of many mHealth products is to facilitate communication, whether it is indirect communication (laboratory results or prescription refill reminders) or direct communication among health care providers caring for the same patient or between providers and a patient (or family). mHealth developers must follow regulations set forth by the HIPAA and the Health Information Technology for Economic and Clinical Health act relevant to the privacy of protected health information when developing new applications.10 Many HIPAA-compliant applications are currently available and can be separated into 2 categories: (1) those used for communication among health care providers and (2) those used for communication between providers and patients. As anesthesiologists, we would be remiss to not acknowledge the impact of this technology on our patients’ lives and how we can capitalize on it to improve perioperative patient care. But we must not lose sight of the validity of these applications especially when it comes to using them to bridge the communication gap in the setting of a language barrier.
Although ensuring the privacy of protected health information is an important aspect of using mHealth technology for communication, ensuring the accuracy of communication when using this technology in the setting of a language barrier is equally important. There is no universal standard being developed for validation of this technology for use in language interpretation in health care. Furthermore, simple translation applications have been shown to be variably accurate.11–14 For example, one evaluation of GT showed that its accuracy was comparable to professional human translation with respect to preservation of information and meaning when translating patient educational materials into Spanish.11 However, a more comprehensive evaluation of the accuracy of GT for 50 different languages found it to be accurate when translating between European languages, but accuracy faltered when it came to Asian languages.13
Multiple software development companies are embarking upon bridging the language gap with specific focus on health care communication. Examples include Canopy Apps, eCaring, and Starling Health. Unfortunately, there is little information on these developers’ websites about how their translation applications have been validated for accuracy.
Although the impact of mHealth technology will touch various aspects of personal health and health care, none is more important than communication. Its impact on breaking down language barriers is likely to be revolutionary and will significantly impact patient safety. Our case provides one example of how these tools can be successfully used perioperatively to help navigate a complex language barrier. However, perhaps more importantly, our case highlights the fact that there is no standard for validating the accuracy of these communication tools. In an edition of Fortune magazine published in 1950, American journalist William H. Whyte focused on improving communication in business saying: “the great enemy of communication… is the illusion of it.”15 The importance of effective communication in health care cannot be overstated. Creating a standard for validating the accuracy of mHealth language translation tools is essential to providing the best possible patient care and mitigating risk to health care providers with a common goal of avoiding the illusion that communication has taken place.
Name: Patrick G. Fernandez, MD.
Contribution: This author helped research, write, and edit the manuscript.
Name: Megan A. Brockel, MD.
Contribution: This author helped write the manuscript.
Name: Lisa L. Lipscomb, CRNA, MS.
Contribution: This author helped write the manuscript.
Name: Richard J. Ing, MBBCh, FCA(SA).
Contribution: This author helped write and edit the manuscript.
Name: Muayyad Tailounie, MD.
Contribution: This author helped research, write, and edit the manuscript.
This manuscript was handled by: Raymond C. Roy, MD.
4. 28 U.S.C. § 1827. Interpreters in Courts of the United States
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