Lost In Translation: The Need for Interpreter Certification

It's a Tower of Babel out there.

I'm not referring to the fact that more than 8% of the U.S. population has limited English reading or speaking proficiency, or that in America, residents speak languages from more than 172 countries.

What I'm referring to is that there is no uniform accreditation or certification process to guarantee the competence of language interpreters in healthcare settings. It seems that for the most part, everyone is speaking in tongues.

But that may soon change.

A large for-profit provider of interpretation solutions, Language Line Services has teamed up with the International Medical Interpreters Association to create just such a national medical certification program.

It is being run as a non-profit organization, The National Board of Certification for Medical Interpreters, and 12 members of its board were named earlier this week. The effort includes employers, physicians, health advocates and regulators.

Although the nonprofit effort is just getting off the ground, the entities hope to launch a written test to determine the translator's knowledge of ethical standards, privacy laws, medical terminology, and an oral exam to measure proficiency and sensitivity.

Martin Conroy, Language Line Services senior manager, says the groups will seek the blessing from The National Commission for Certifying Agencies, an organization that certifies professional competence.

Yes, there would probably be a fee. And existing translators will probably fret about whether they will be able to pass. For a time, they will oppose any constriction on their work or any training they may have to undergo.

But qualified translators are essential to convey a non-English speaking patient's symptoms and circumstances to English speaking providers. They are needed to make sure the patient understands the process of diagnosis, and the instructions for medications and follow-up care to get better. Occasionally, a translator is required to help a provider, for whom English is not the native tongue, communicate with English-speaking patients.

They need to be people that patients and providers can trust. Because if the patients can't understand the doctors or the doctors can't understand them, much that is provided in the way of medical care will be useless, misguided, and potentially harmful. And there may be a bottom line reason for having such certification.

According to a recent report by Language Line Services President Louis F. Provenzano, Jr., "Breaking the Language Barrier," the consequences of relying on haphazard interpretation services "can be deadly—and costly" because language barriers are a major factor in misdiagnosis and instances of poor hospital treatment as well as delays in service or access to preventive care.

"Limited language proficiency hospital patients are more likely than their English-speaking counterparts to experience adverse events that result in harm, and the severity of that harm is often greater," according to a report by the Joint Commission.

Another study in Health Affairs (http://content.healthaffairs.org/cgi/content/abstract/24/2/435 ) in 2005 documented that patients who don't speak English are more likely to defer medical care, leave the hospital against medical advice, miss follow-up appointments, and experience complications from medications.

"Whether they simply fear a difficult medical encounter due to language issues, or whether they are receiving substandard care due to miscommunication and delays caused by language gaps, the end result is the same: language barriers are clearly resulting in the unequal delivery of medical care, and in physical harm," according to the 2005 report.

In fact, Provenzano wrote, "The argument in favor of . . . coverage for language interpretation is very similar to the argument for coverage of preventive care, something that insurance companies are beginning to actively promote and embrace."

Yes, Language Line Services, which has 8,000 medical interpreters, wants to market its business. But I spoke with Martin Conroy, the company's senior manager, and he makes some excellent points about the true need for such a national certification standard.

Today, health providers, including physician practices, clinics, and hospitals, often rely on the patient's family members or on untrained members of the staff to provide interpretative services, Conroy says. Each hospital has different ways of handling the issue, each physician practice and each clinic. Some are formal and include contracts with translation services by phone or on site while some are far more haphazard, he says.

Among the many large companies similar to his that offer translation services for medical settings, there are usually established criteria that employees are required to meet. But among the many companies, the criteria can have wide variation, he says.

The only state with a true certification process for medical translators is Washington, which has it for eight languages, Conroy says. "All states have some regulation and oversight, but they use terms like 'competent' or 'quality' that are not very well defined. What we're trying to reach to is have a certification, have a national credential that would apply to all."

Without a national testing or certification process, he says, "there's no way to assure that a person who has worked for three years in Nevada and then goes to California will have the same level of skills."

He gave some examples of how healthcare can go terribly wrong when provider and patient can't understand each other:

• A doctor told a Spanish speaking patient he should take the medication "once" a day, and then wrote down "once a day." But in Spanish, the English word "once" sounds like the Spanish word for number 11. So the patient took the medication 11 times a day.
• After a child rode her bike into a wall and ended up in the emergency room, the parent tried to explain what happened. But a misunderstanding led hospital personnel to call social services and investigate the parent for child abuse. The emergency staff thought the mother said she had hit the girl.
• A Spanish-speaking patient told paramedics he was "intoxicado," which was interpreted as being high on drugs. What the patient meant was that he was sick to his stomach from food poisoning. As a result, his care was delayed and he is now a quadriplegic. The mistake resulted in a $71 million malpractice settlement.

There's another reason to have a national certification program. By federal law, health providers who accept federal reimbursement must offer language interpretation services for their patients. But federal funding to pay for such services is partial and spotty.

The federal government offers states matching funding up to 75% for interpretive services for patients eligible for Medicaid and the Children's Health Insurance Program.

According to Provenzano's report, 12 states and the District of Columbia have implemented such programs. These states have developed mechanisms for reimbursement, along with qualifications and standards for interpretation and translation services. "Federal matching funds ensure that states can achieve these goals in a way that is cost-effective for their own fiscal health."

Few private health insurers reimburse for translator services, such as Kaiser Permanente and Group Health Cooperative, which provide the services for their members.

If providers are to make a solid case that they deserve reimbursement for providing quality translation services, they should be able to measure the quality of those services. Certification is one way to accomplish that.

"Right now in any clinical, hospital or physician setting, people on a team are assisting a non-English speaking patient, such as a physician, nurse, ultrasound tech—and all of these people have a license and are certified," Conroy says.

"The only person who is not is the medical interpreter."