When telehealth visits increased exponentially during the pandemic, patients at Mount Sinai Health System with limited English proficiency, or LEP, were at a great disadvantage to receive equal access to services because of the language barrier.

THE PROBLEM

Telehealth platforms were not originally set up with LEP patients in mind. And Mount Sinai's patient population in New York City is very diverse – the health system needs to be prepared to deliver healthcare in more than 200 languages.

"Our pool of in-house interpreters is limited; it only covers a few languages," said Silvina de la Iglesia, associate director of language assistance at The Mount Sinai Hospital. "As a health system, we rely primarily on phone and video interpreter vendors to cover the demand.

"One of the most challenging problems we faced was not having interpretation services integrated into the different telehealth platforms that were being used," she continued. 

"Each platform offered different capabilities for three-way communication, and we needed to explore which one would work best for our patients. We chose to tackle Epic/MyChart in the first place and work in partnership with our language vendor, Language Line Solutions."

On this platform, an invitation to join the encounter could only be pushed via email or text message in real time. This was possible when aligning the encounter with a staff interpreter, but not with the organization's phone or video vendors, as those interpreters operate in an enclosed environment on an on-demand basis.

"Providers were initially calling Language Line and placing the interpreter on speakerphone or holding cell phones in their hands and hoping that the video platform would pick up the sound," de la Iglesia recalled. "This was a very frustrating experience for providers and patients as the audio quality was poor, with lots of residual noise and echo on the line."

"And as with all technology and use-cases, rarely is there a one-size-fits-all solution. It is important, whether interpreters or caregivers, to have as many options as possible for flexible technology to allow another party to join."

Natalya Sholomyansky, Mount Sinai Health System

Video visits are heavily utilized at Mount Sinai and a great option for patients who do not want to come into the office; they can be accessed via a mobile app or on a computer with a webcam. Neither needed the ability for the patient or other individuals joining the video visit to be called via phone number since this was accessed via login credentials.

"Our in-house interpreters could be invited to and join a video interaction with our patients using the existing platform," said Natalya Sholomyansky, director, IT digital health, at Mount Sinai. 

"However, external vendors that supplement cannot leverage this workflow or join video visits. Providers can only access those external Language Line partners by dialing out to an 800 number, a capability that did not exist in the video visit platform. This left only the in-house language interpreters able to support patients who needed them during the video visit."

PROPOSAL

Mount Sinai turned to health IT vendor Caregility for help. Caregility offered the option for the provider to dial a phone number to Language Line and have the external vendor join the video visit with audio.

"Our providers and non-English-speaking patients needed instant, seamless access to language interpreters to communicate effectively," de la Iglesia said. "Language Line has a pool of 14,000 interpreters in more than 200 languages operating 24/7. Caregility offered the option for the provider initiating the encounter on the telehealth platform to dial out to a toll-free number to connect with Language Line within seconds."

Mount Sinai leveraged this capability by building a call-routing architecture behind the scenes. With the help of Language Line, the provider organization created dedicated toll-free telephone lines for the top five languages – Spanish, Mandarin, Cantonese, Russian and Bengali – and another one for the remaining languages. The dedicated telephone lines are answered directly by interpreters, reducing the connectivity time to less than 10 seconds.

MEETING THE CHALLENGE

This new solution went live on October 26, 2020, with the more robust integration features. Mount Sinai expanded utilization 100-fold in three days.

"When the provider is ready to start a video visit, they can have an external interpreter join," Sholomyansky explained. "They do so by selecting one of our language lines and the language that is needed. The interpreter will then join the visit by audio only."

The IT teams from Mount Sinai, Language Line and Caregility worked together to place the patient at the center of this initiative and find solutions to address the language and technology barriers, de la Iglesia said. The focus was to find a solution for Epic/MyChart, the telehealth platform most widely used by the health system for ambulatory services.

"We achieved integration of interpretation service into the platform via audio in a very short period of time and with minimal testing," she noted. "The sound quality has greatly improved as it comes from a single source.

"The most important feature to highlight is that it is provider- and patient-friendly," she added. 

"The provider simply clicks on the Add Interpreter button and selects a desired language. The patient can receive the link on any mobile device and simply click on Begin Encounter to join. Once on the encounter, the patient can see the provider on the screen but only hear the interpreter, which fosters a more direct patient-provider rapport supported by the invisibility of the interpreter."

RESULTS

From the time Mount Sinai implemented this solution to date, more than 600 telemedicine encounters have taken place using the Add Interpreter button. To ensure the health system was going in the right direction, it surveyed non-English-speaking patients and obtained feedback from providers using the service.

"Some quality metrics that indicated success were connectivity time, audio quality, ability to understand the interpreter and availability of interpreters," de la Iglesia reported. 

"We also identified some opportunities for improvement, like educating providers to add the interpreter before the patient joins an encounter. Patients reported they feel more welcome when they are greeted in their preferred language. A total of 88% of surveyed patients would recommend telehealth services to family and friends."

ADVICE FOR OTHERS

The ability to have a third party join a telehealth session in general is an important one, Sholomyansky said.

"And as with all technology and use-cases, rarely is there a one-size-fits-all solution," she noted. "It is important, whether interpreters or caregivers, to have as many options as possible for flexible technology to allow another party to join."

From the language access and patient experience perspective, de la Iglesia would encourage stakeholders to work together, in a creative and agile manner, and explore all possibilities the telehealth platform offers. Oftentimes, it does not require a lot of financial investment or bringing a completely new vendor into the picture, she said.

"Knowing the different communication needs of the patient population your hospital or health system serves also will provide great guidance to build a roadmap," she said. "When we first launched this technology solution as audio, we assumed our patients expected to see the interpreters on video; however, 86% of the surveyed patients indicated satisfaction with audio interpreting as it is.

"Providers also reported that seeing an interpreter on the screen could be very distracting," she concluded. "Video is imperative for patients who are deaf and/or hard of hearing, but not for spoken languages. Patients are driving the way we deliver healthcare, and we need to keep them engaged when implementing solutions."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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