Feature Story

August 7, 2006

by Charles Waltner, News@Cisco

A small group of California hospitals is tapping Internet technologies to address one of the most daunting challenges faced by the healthcare industry in the United States.

Known as the Health Care Interpreter Network (HCIN), the program is using Internet protocol (IP) networking equipment and software from Cisco Systems to connect remote medical interpreters with patients who have little, if any, English language skills.

While the industry has previously considered video conferencing for facilitating interpreter services, until recently the necessary technologies were neither financially or logistically viable. But with the continued expansion of Internet communications, now the same infrastructure that runs the World Wide Web can also deliver high-quality video and audio communications. The success of the HCIN program has wide-ranging implications for the healthcare industry; extending far beyond the need for interpreters into telemedicine and in-home medical services.

Results from the initial trial of the HCIN system are highly promising, according to participants and industry observers. Most importantly, the system is offering a way to significantly improve healthcare services for millions of individuals. Some experts estimate that as many as one in every four U.S. residents could benefit from interpreter services. In the California public hospitals where the trial took place, administrators say that up to 50 percent of their patients require such translation support.

"It sounded like a good idea for addressing a problem that has been daunting us for many years, so I was interested in participating in the trial," says Nancy Steiger, chief executive officer for the San Mateo Medical Center. "But I underestimated the impact of the technology. In my career this is one of the single best steps we have taken to improving the quality of our patient services."

The trial, which started earlier this year and is funded by federal, state and private grants, connects three hospitals over a broadband, IP network that provides high-grade video and audio communications to Cisco video phones and portable video conferencing devices from Tandberg ASA, Lysaker, Norway. With such a system in place, each hospital can share their staff interpreters, regardless of an interpreter's location, creating a much broader pool of interpreters while making such services much easier to manage and less expensive to offer. Even within each hospital, the system is much more quickly connecting interpreters with patients than by other means.

The California healthcare organizations participating in the trial include San Joaquin General Hospital, the San Mateo Medical Center, and Contra Costa County Health Services. The organizations own and manage the program.

Dr. William Walker, director of Contra Costa County Health Services, says he was skeptical of the concept, since it made his group dependant on new technology, but the pilot program allayed his fears with virtually glitch-free performance. He says the quality of the video is excellent and on par with typical television images.

Consultant Melinda Paras, the organizer of the pilot program and president of Paras & Associates, Albany, Calif., says Cisco's call routing technologies, adapted from the company's IP telephony systems, make it easy to connect the right type of translator with the right patient.

While other organizations worldwide are starting to test and use video-conferencing technologies for various telemedicine applications, this is the first known use in the United States of a networked, IP-based video interpreter system with full call management capabilities. Video equipped with automated call management allows the system to easily expand to include many different entities without increasing the complexity or hindering the performance of the network.

Paras says in addition to Cisco's creation of IP-based call center software, Cisco's innovative multi-protocol label switching (MPLS) technology for large telecommunications networks paved the way for the HCIN by making it viable to conduct video conferencing among dozens, even hundreds, of locations. Paras & Associates, working in conjunction with Cisco channel partner and networking specialist, Quest Technology Management, Sacramento, Calif., designed, installed and manages the HCIN infrastructure.

While hospitals participating in the trial have not fully analyzed the long-term costs of the technology, initial results indicate that it can provide major savings with relatively modest investments.

Most importantly, the video interpreter network has greatly increased patient safety, making it far easier for patients with limited English proficiency to explain their medical problems and for them to understand instructions from doctors, says San Mateo's Steiger. Without proper interpretation, patients can, for example, misunderstand a doctor's instructions and take the wrong prescription doses or fail to follow through with proper home treatment. Such communications problems are particularly critical in emergency rooms, where doctors must act quickly and have little time to wait for an interpreter to be found among the staff or patients.

Dr. Dyron Jue, an endocrinologist at the San Mateo Medical Center, says his initial experience with video-based medical interpretation was positive, noting that the video-conferenced interpreter seemed to be just as good as having the translator in the room. HCIN's most significant benefit was an improvement in workflow, Jue says. Typically, it would take 20 to 30 minutes to find a hospital employee who could help translate for one of his patients. With the video system, Jue says it only took a couple of minutes to set up and get an interpreter online.

Jue says most patients seemed comfortable with the technology, though a few initially worried about the privacy of the Internet-like communications devices. Overall, the HCIN improved patient care while streamlining the management of interpreter services, Jue says. "I was a little hesitant to try it at first, but the system definitely enhanced our ability to help patients."

The HCIN comes as a much-welcomed aide to addressing a long-standing challenge for healthcare providers. Though various state and federal laws mandate equal healthcare access regardless of language barriers, few healthcare providers have been able to meet these directives.

"Despite the laws, it simply hasn't been viable for healthcare organizations to supply one interpreter for each patient. It simply would cost too much money," says Cindy Ehnes, director of the Department of Managed Healthcare for California. "So our hope has been that technology would help us better address this pressing need, and the HCIN looks like it can do just that. I think technology like this has to be the answer because, otherwise, nothing will change."

Steiger says ad hoc interpreters from hospital staff and family members simply cannot match the quality of trained, professional medical interpreters, which not only need fluency in a foreign language but also in medical terms and procedures. Hospitals have also relied on telephone-based interpreter service bureaus, but such services have innate limitations compared to video conferencing. Being able to see the interpreter, for example, helps interpreter and patient use visual clues to communicate, says Kenneth Cohen, director of the San Joaquin Healthcare Services Agency. "There's something reassuring for patients to be able to see the interpreter," he adds.

Paras estimates that a larger 250-bed hospital might spend roughly $200,000 in the first year of installing and using the HCIN system, with the majority of costs from the video conferencing units. Depending on a hospital's existing data network, the HCIN would require some equipment upgrades as well. The annual costs for the network would be primarily for high-speed connections among other participating hospitals.

Such an investment, however, means far greater efficiencies, Steiger says. San Mateo's dedicated staff interpreters can now work with up to 30 patients a day, both at her hospital and others on the network. Previously, interpreters averaged only eight sessions a day.

More hospitals on the network will bring greater economies of scale, making a good thing even better by sharing costs and increasing the pool of interpreters, program managers say. Already several hospitals have expressed interest in joining the network and the HCIN organizations are working on a management model for such expansion. HCIN representatives hope that a large enough pool of interpreters will provide 24-hour support for virtually any of the approximately 35 languages needed to serve California's diverse population.

Ehnes hopes a network of larger hospitals will be able to provide cost-effective interpreter services to the myriad of small community hospitals and specialty clinics, which simply don't have the means to provide any formal interpreter services.

Dr. Jeffrey Rideout, the executive who leads Cisco's healthcare initiatives, says the HCIN program is but one dramatic way IP-based broadband, multimedia communications networks can significantly improve healthcare for individuals while also reducing the nation's medical bill.

"Internet communications technologies are helping the healthcare industry move away from physical boundaries and move toward providing the right information or services at the right time and place," Rideout says. "Whether its interpreter services, telemedicine, or home-based care, new network technologies are making it easier for hospitals and doctors to provide services that are more convenient and effective."

Certainly, the initial HCIN trial has inspired plans for expanding this new communications system. Program managers say they are working on bringing sign-language interpreters into the network, another patient need hospitals have had difficulty addressing. And HCIN executives are also looking at ways to extend the interpreter network to help with many other related healthcare services, such as mental health and substance abuse programs, and even into broader governmental services, such as for welfare, employment, and justice departments.

Ehnes believes that the HCIN video conferencing system could be the first step in developing a wide-range of new telemedicine programs, such as remote medical examinations and consultations for patients in rural areas, which suffer from a shortage of doctors and medical services. "This system could be the foundation for broad advances in healthcare services," Ehnes says. "We are eager to see what more it can do."

Charles Waltner is a freelance journalist in Oakland, Calif.