Language access in the era of the Personal Health Record – shadowing at La Clinica del Pueblo, Washington, DC

I was semi-recently asked a question about how an innovative community health center in Washington, DC, would support patients with multiple languages when they brought up their personal health record in the coming year.

That medical center is La Clinica del Pueblo, I am always interested in patient access in the safety net, and as I always say, if I can walk to it, I’ll do it, so I asked if I could shadow for an afternoon to learn more, and luckily, the answer was “yes.”

I went to see Meredith Josephs, MD, who’s the Chief Medical Officer, a family physician, and champion of the electronic health record at La Clinica (produced by eClinicalWorks). I also went to see Isabel van Isschot, who’s the Director of the Interpreter Services Department at La Clinica.

It turns out that La Clinica is a strategic place to learn about language access, because the Department that Isabel directs provides interpreter services across the community, for other safety net organizations, in specialty care visits and emergency room visits.

When asking the question, “How will we support personal health records for people who do not speak English or have other language access hurdles?” it might seem simple to respond with, “well, why don’t you just do what you do in in person care delivery?” As in life, sometimes the simple answer is not the right answer, read on…

For those of you who work in multilingual care environments all the time, please excuse any appearance of naiveté on my part as I explain what I learned, I have a feeling many others do not know how this world works :).

I learned that “Language access” has several components, which includes:

  • The populations that need language access in an environment – at La Clinca del Pueblo, there is relatively good proficiency in Spanish, so “language access” for the people who receive care here means “languages other than English or Spanish”
  • Interpretation, which is verbal communication, and translation, which is written communication, which are two different things. A physician that is a good at interpretation (“communicating in the language of the patient”) may not have the same skill level for translation (“writing in the patient’s language”). This is an important distinction when we are talking about changing care from a spoken art to a written one.

These issues are considered and documented in a language access plan, which includes, policies, plans, and procedures, and as Isabel explained to me, there are good templates available from the US Governement ( which actually has an entire web site which covers limited english proficiency at http://www.lep.gov ). Isabel also told me that Kaiser Permanente is supporting La Clinica in creating a language access plan, which I didn’t know about previously (and was of course happy to hear about).

When I shadowed Lorena and Meredith as they cared for patients, I was exposed to the challenges the population faces in receiving routine care.

As Meredith explained to me, patients who previously were not covered for health care services now receive them through the DC Healthcare Alliance. At the same time, there are occasional service disruptions such as the closing of nearby pharmacies.

Meredith is a pretty good Spanish speaker (interpreter). She is not as skilled a Spanish writer (translator), which is common in the provider community. Editorial comment from Ted – this is actually the case among English speakers too, because when heath care is a verbal art form prior to the PHR, you will discover deficiencies in writing English, too….

In addition, the legal medical record for patients here is appropriately in one language (English), which means that additional work needs to be done to integrate patients’ written notes into the flow of care. This is not to say that this is not desired – it is just to say that it needs to be understood and supported properly. If physicians and nurses are skilled at interpretation and the translation skill becomes more important, there could be a gap in access, which could delay care. This gap would need to be mitigated differently in different organizations, depending on the mix of interpretation and translation skill sets of both patients, families, and staff.

Hi everyone, I seem to have gotten confused in my confusion about language access, so rather than trying to re-type my definitions again and again, here’s a quote from Meredith Josephs, MD, that will help (and thank you!))

An interpreter is a 3rd party in the room assisting with a verbal exchange and a translator is a 3rd party changing a document from one language to another. With the advent of the PHR the physician may actually be tasked with translating a Spanish email to English, but as you correctly picked up during your visit, THIS physician is not skilled enough with reading/writing Spanish to be able to do a good job with translation.

Before you say, “Google translate,” Meredith showed me a humorous/maybe a little scary Google translation of an e-mail written in spanish about a health care issue. Let’s just say we should understand that this is not good enough/respectful of the communication, just as we learned many years ago that less-than-professional in-person interpretation in health care is not respectful, either.

The facility itself is modern, using an advanced electronic health record (with funny artifact of desktop computers in exam rooms that are no longer used, since every provider now uses a wireless laptop), and has culturally supportive touches like a non-denominational chapel right off the waiting room (see photos below). One thing I really appreciate that La Clinica del Pueblo has done is to spend time to document its “essence.” I am going to copy that below because I think where people come from is important to respect as they move forward:

1. La Clínica was created by the Latino community for the Latino community: a large proportion of the staff has similar backgrounds to and “look” like the patients.
2. La Clínica staff deeply care about their patients and clients; they are committed to going the extra mile to meet their needs.
3. Patients and clients at La Clínica are treated as equals; with dignity, and respect. Part of treating them with dignity and respect is seeking out, listening to, and acting on their feedback and suggestions.
4. La Clínica provides a refuge, a secure and trusted place; for many, La Clínica is like a second family.
5. La Clínica provides health care that is culturally sensitive, relevant, and that evolves to meet the changing needs of its patients and clients.
6. La Clínica approaches its patients in a holistic manner: as beings that have physical, mental, emotional, spiritual, socio-cultural, and political needs.
7. The staff at La Clínica go out of their way to do everything possible to ensure that every patient/client knows that s/he has the right to adequate health care as well as the responsibility to make sure her/his health needs are met.
8. La Clínica’s philosophy is based on the premise that advocacy, making one’s voice heard, is fundamental: as a means of pushing for change, providing patients and staff with a vehicle for exerting their rights, forming community, and providing a therapeutic vehicle for many individuals whose rights have been violated.

From spending time with patients and staff, and reading the history of La Clinica del Pueblo, it’s clear that this is not an organization that is averse to innovation.

They are in fact an early adopter of health information technology, and I believe will be similarly ahead of their peers when they launch their patient portal in 2012. I learned during my time with Meredith that language access planning requires great care in the interest of providing the most empowering experience, consistent with an organization’s values (see above). I think La Clinica del Pueblo will achieve success in incorporating this experience in the development of their patient portal. I’m really excited to see this happen here in Washington, DC, and for their patients to achieve the huge empowerment and access benefits from doing this well.

Of course I want to walk back here and see it in action!

With great thanks to Meredith, Isabel, and the staff and patients at La Clinica del Pueblo for taking the time to teach a community colleague about the care they provide within their walls and beyond. Photos below, click to enlarge.

 

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