Critical Partnerships: Ethical Medical VRI & Sign Language Interpreters

May 31, 2017

Danielle Meder discusses the responsibility of sign language interpreters when working in medical VRI environments. Since VRI is here to stay, partnering with ethically responsible VRI providers is the most effective way to improve the medical VRI experience.

In her article, Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters, Shelly Hansen discussed her perceptions of the ethical implications of VRI. In addition, she explored the most common assumptions about VRI, at times upholding stereotypes while also utilizing extreme examples of patient experiences with VRI. However, by exploring how sign language interpreters and VRI providers can work together to raise the standards and improve the patient experience, VRI will be seen as one viable option for communication access.

[View post in ASL.]

If You Can’t Beat ‘Em, Join ‘Em

It is undeniable that VRI is here to stay. As a result, hospitals see the opportunity to provide immediate access, increase the availability of interpreting services when on-site interpreters are not available, in addition to seeing the cost-saving benefits of VRI–and as a result, they are making it a permanent part of their language access plans. However, many hospitals are misguided when it comes to the proper use of VRI for Deaf patients. It is unrealistic to imagine all ASL interpreters refusing to work for VRI providers in an effort to drive VRI out of medical environments. Therefore, it becomes the practitioner’s responsibility, when exploring VRI employment, to take positions with ethically responsible VRI companies; VRI companies where sign language interpreters have a voice and Deaf patients are respected.

Ethically Responsible VRI

It may seem like an oxymoron, but ethically responsible VRI companies do exist. Just as sign language interpreters vet any number of companies/organizations they work for, purchase from, or have relationships with, they can also do so with VRI companies. This vetting is not only from the perspective of potential employees but also as allies to the Deaf community. If local hospitals and clinics are going to use VRI, then it is imperative that VRI providers in local hospitals are working with Deaf patients.

As professional sign language interpreters, we should be asking VRI providers if they do the following:

  • Offer CDIs on-demand
  • Empower VRI interpreters to advocate for onsite when VRI is not effective or appropriate
  • Hire experienced and trained sign language interpreters in both medical and mental health vs. general practitioners
  • Provide training to hospital staff on how to utilize the VRI equipment
  • Offer cultural sensitivity training for providers when working with Deaf patients
  • Adhere to all national and state licensure laws for sign language interpreters
  • Provide readily accessible tech support to sign language interpreters and providers

If a VRI provider cannot answer ‘yes’ to the full list above, then practitioners are faced with two options: to not accept work from them or to accept work in an effort to help develop ethical business practices from within the company. Further, it’s important to include local Deaf communities in the conversations in order to limit the ill-prepared VRI provider’s presence in local medical facilities until they change their practices.

VRI Does Work/VRI is Not One Size Fits All

Unfortunately, there are a number of cases where VRI hasn’t worked, and the fallout has been devastating for patients and their families. There are also cases where unqualified onsite sign language interpreters have been hired, as well as medical encounters where no sign language interpreter (onsite or via VRI) has been procured. These situations create equally damaging results. Communication disasters are not exclusive to VRI, and while onsite is best, it’s not a guarantee of quality or effectiveness.

Most commonly, it is said that VRI ‘will do’ until an interpreter shows up on-site or only in a dire emergency room visit, yet there are plenty of times where VRI does work beyond the emergency room. It’s also important to note that VRI is used at the patient’s request, too. Patients are requesting VRI when they want privacy from their local interpreting communities; when they want an appointment this week instead of in two weeks when the first available onsite interpreter can be booked; when their local interpreters aren’t experienced enough; or when they want a CDI for their appointment and their local community doesn’t have or has a limited number of CDIs.

Frozen Screens and Dropped Calls Do Happen

One very real and unacceptable aspect of VRI is that frozen screens, heavy pixelation, and weak internet connections make communication cumbersome, at best, and often impossible. This can also lead to potentially dangerous health care results. It is the responsibility of the hospitals to provide a stable, secure, and strong internet connection. When sub-par internet connections are used, VRI providers, sign language interpreters, and Deaf patients must demand medical facilities invest in fortified internet services for VRI to even have a chance at providing effective, quality communication access. Without a robust Internet connection, even the best sign language interpreters will, in essence, have their hands tied. Again, if VRI is not going away, then it must be properly deployed on all fronts, and sign language interpreters can have a strong influence on that deployment.

ACA Section 1557

“Covered entities are prohibited from using low-quality video remote interpreting services or relying on unqualified staff, translators when providing language assistance services.”

“Providers’ required to give ‘primary consideration’ to the choice of an aid or service requested by the individual with a disability.”

These two statements are linchpins in the Affordable Care Act when it comes to language access. The first statement is the provision that holds providers responsible for quality and effective language access while the second statement is the provision that is most misunderstood and misused when defending the right to an onsite interpreter.

At one point last year, social media sites were ablaze with the phrase “primary consideration” and what that meant for patients. What many thought it meant was providers had to honor the patient’s preference for onsite sign language interpreters. What it means is that providers must consider a patient’s preference, however, if VRI offers effective communication access, then VRI can be used in lieu of an onsite interpreter (ACA Effective Communication). While a patient may want an onsite interpreter because they prefer it to VRI, preference is not a protected right; quality and effective communication is a right. Reasons onsite interpreters must be arranged, and VRI should not be used are when a patient is:

  • Low vision and/or blind
  • Experiencing a highly traumatic incident
  • Experiencing a psychotic episode
  • In a physical position or condition that prevents them from easily seeing and communicating with the interpreter
  • Case sensitive pediatric encounters
  • Not able to communicate because technology is not working reliably
  • Participating in group therapy

There are also case-by-case instances where VRI is not suitable.

I highlight this to further make a point; although VRI is not appropriate for all situations, it is not going away. Therefore, medically experienced video remote interpreters have a multi-layered responsibility. They must provide clear and effective interpreting, while also skillfully explaining to the provider, using healthcare terminology, why VRI is not appropriate for a given situation. Finally, the interpreter must advocate for onsite sign language interpreting services.

In Need of Standards

Currently, the only provisions in place for VRI are the terms ‘quality’ and ‘effective’ as put forth by the Affordable Care Act (ACA) and the Americans With Disabilities Act (ADA). No industry-wide screen size minimums exist, no mandatory medical interpreter certifications, nor experience requirements are in place. Additionally, no internet standards for medical facilities, nor protocol where VRI should not be used are set. At this time, the National Association of the Deaf (NAD) has written a position paper, and each VRI provider has their own business practices that may or may not align with NAD.

Much like courtrooms across America that have policies, rules, or laws in place which require sign language interpreters to be trained, vetted, and certified to work, medical facilities need to take the same approach when it comes to language access. The ACA made great strides when it stated that family, minors, and bilingual staff may not work as interpreters with patients. However, there is still work to be done to standardize what it means to be a medical interpreter whether onsite or in a VRI setting.

VRI and the CPC

All of the CPC tenets below can be honored and maintained while working in VRI with ethically responsible VRI companies. Sign language interpreters can assess the consumer needs and advocate for effective communication from the moment a VRI call begins through its completion.

2.0 Professionalism:

2.2: Assess consumer needs and the interpreting situation before and during the assignment and make adjustments as needed.

3.0 Conduct:

3.1 Consult with appropriate persons regarding the interpreting situation to determine issues such as placement and adaptations necessary to interpret effectively.

6.0 Business Practices:

6.3 Promote conditions that are conducive to effective communication, inform the parties involved if such conditions do not exist and seek appropriate remedies.

6.5 Reserve the option to decline or discontinue assignments if working conditions are not safe, healthy, or conducive to interpreting.

Further, advocacy should also extend to the leadership and management of the VRI company which, if their priorities are properly placed, will work with the medical facilities to educate them on the proper use of VRI.

Final Thoughts

The VRI industry is booming right now, and sign language interpreters are faced with the choice to accept employment opportunities within VRI or resist on principle. If we, as sign language interpreters and allies to the Deaf community, want to protect communication access in medical environments, then it is our duty to hold providers responsible for ethical practices. We know VRI is going to be one of the communication tools medical providers use, so we must work with ethically sound VRI providers to ensure quality and effective communication access is the top priority for all parties involved.

Guest Translator – Mistie Owens, BA, CDI, QMHI, YMHFAI, has been serving the local Deaf community as a CDI since 2011, although she remembers interpreting from her early youth. Dedicated to the healthcare field, she is employed by InDemand Interpreting and holds certifications as a Qualified Mental Health Interpreter and Youth Mental Health First Aid Instructor; her work in Mental Health and related disciplines are her passion. She resides near Salt Lake City, Utah with her husband and rescue dogs.

Questions to Consider:

  1. What committees or advocacy groups are in place that are working to create industry standards for language access and VRI?
  2. Who is holding VRI providers accountable when they negatively contribute to ineffective and unsuccessful medical encounters?
  3. How can ASL interpreters work within their own communities and with existing VRI providers to raise standards in language access in ways that honor Deaf patients while respecting legal and fiscal considerations?


Hansen, Shelly. “Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters” StreetLeverage. N.p., 22 March 2017. Web. 24 April 2017.

Registry of Interpreters for the Deaf, Inc. “NAD_RID Code of Professional Conduct.pdf.” N.p., 2005. Web. 21 April. 2017.

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15 Comments on "Critical Partnerships: Ethical Medical VRI & Sign Language Interpreters"

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Hi all, I am in disagreement with many aspects of this article. Please understand that my tone is out of concern and not anger. If you sense that I am angry, I am not going to apologize. As a deaf client myself, this is something that holds absolutely dear in my heart. I outline my concerns below: -“If You Can’t Beat ‘Em, Join ‘Em” implies that we have no choice but to embrace VRI. I truly feel this statement gives dangerous premise that we have no other avenues to effective communication and that we have to accept VRI as sin… Read more »
Danielle Meder
TH, Thank you for your thorough response to my article. I can understand and appreciate your perspectives. There is one issue you mentioned that I’d like to address: The deaf community continue to resist VRI so the mantra of if “we can’t beat em, we have to join them” is a tautological message to the deaf community that their concerns are moot. To trivialize their voices and dismiss their concerns with a “nothing we can do” approach is one of the worst forms of oppression. We have an obligation to leverage, and this type of “if you can’t beat em,… Read more »
Danielle, Thank you for your response and clarifications on my points. I’d like to suggest a different word than “advocacy” because many hospitals appear to comply with the NCIHC National Standards for Practice for Interpreters in Health Care Settings. While this is specifically for foreign language translations, many confuse to also include ASL interpreters. In their standards, they define advocacy as: “as an action taken on behalf of an individual that goes beyond facilitating communication, with the intention of supporting good health outcomes. In general, advocacy means that a third party (in this case, the interpreter) speaks for or pleads… Read more »
Hi TH! While I appreciate your points, I cannot sit by without asking what you would suggest for those Deaf and HofH folks who live in coastal or rural towns where a certified interpreter is hours away? What happens when my mom, nearing her 80’s, is sent to the ER via ambulance? Must she wait the time it takes to contact an agency, find an available interpreter, and wait for that interpreter to drive the two hours it takes to get to her small town? Or what happens when she needs to make a last minute, urgent appointment? Does she… Read more »
Hi Tami – Deaf people who live in these rural or coastal towns are even at greater risk of not getting immediate services; therefore, it is imperative that the local deaf community in those areas build a strong relationship with their direct healthcare provider/hospital and to identify possible interpreters that would be readily be available. Theoretically, VRI in rural areas seem the optimal solution, but these rural hospitals are often the most in need for formal training on how to set up VRI and do not have the technical requirements.. Your mother nearing in her 80’s, I’d be concerned on… Read more »
Eloisa Williams

Thank you Danielle for providing knowledgable and balanced perspective to VRI access. There is much growth to be recognized within the VRI; by involving the Deaf community and educating medical providers, VRI can provide another viable option for immediate and effective communication access.


Thank you Eloisa! It’s a necessary conversation and one where all stakeholders need to be present.

Teresa Blankmeyer Burke
Thank you, Danielle, for this helpful analysis — this is an issue I have been thinking about in my own work as a Deaf bioethicist and philosopher, presenting my views at various medical schools around the country. I am not a lawyer, so the following should not be viewed as legal advice. That said, I’ve been watching the ACA/ADA/EEOC wrangling, and think we should continue to pay attention to this (so long as we still have the ACA). I think it is important to note that the ADA distinguishes between Title II and Title III providers; publicly funded hospitals, such… Read more »
Great article! I appreciate exposure to both the positives and negatives of VRI. I will say, however, there seems to be some irony here… We all agree that Deaf people need to be equal participants as these interpreting situations arise; yet those Deaf individuals who LIKE VRI seem to be disregarded. I don’t think it is wise for ANYONE to speak on behalf of anyone but themselves. When I read responses that push only one view, I feel frustrated and somewhat defeated. As we know, having only one perspective brought to the table isn’t productive. The fact is, some Deaf… Read more »
Rhi, I think I am not clear. I agree that interpreters can intervene if they feel that there is not effective communication access being mediated – this would be where a CDI may be successful. To be very specific, advocacy within the CPC is not to assess the deaf person but rather the collective context of communication access. As you know, advocacy has many different definitions and I don’t want the layperson reading the article to be confused as to what “advocacy” means. I’d prefer a different word. Also, many hospitals appear to comply with the NCIHC National Standards for… Read more »
Shelly Hansen
Hi Danielle! So glad to be discussing this topic because it deserves to be debated, addressed, improved and resolved. Love it!. Two thoughts: The most concerning part of the above article to me is the reality of ZERO standards. The ADA and ACA (which is at the moment a less reliable standard as the ACA is under revision by Congress) provide the legal requirements for equal access. But the implementation is without standards. People do not tend to consistently follow standards that lack consequences for not following those standards. Thus, we now see lawsuits. Check out The Daily Moth 5/11/17… Read more »
Danielle Meder
Hi Shelly! Glad to see read your perspective on my approach to VRI. I’ve been following the lawsuits and hope standards come of them. But you are right-there are no standards in place and without potential financial or legal consequences. In regards to your idea about a consent form: while I agree, patient involvement in their communication method is critical, it creates the opportunity for absolute denial leaving it to onsite only which depending on location and supply of onsite interpreters may not be available. Further, and it isn’t a consumer friendly reason, the fiscal advantages to VRI are clear… Read more »
Shelly Hansen
Hi Danielle! The argument of cost is secondary to the federal laws requiring equal access AND ethical duties to do no harm. The basis of the ADA is access that is equal. We would all agree not using an interpreter and not needing an interpreter because all parties use the same language is the best case scenario. The next best level of access available is a qualified, competent interpreter. VRI falls below that standard for many many reasons. Without direct patient involvement and choice of communication access, the patient’s access to equal care is sub-standard. VRI screens freeze. VRI screens… Read more »
Debbie Lesser
In response to Shelly Hansen’s comments on June 4th: To address Shelly’s first point “The next best level of access available is a qualified, competent interpreter. VRI falls below that standard for many many reasons. “ You’re making the assumption that VRI and qualified, competent interpreter are dependent on one another. However, there are extremely competent/qualified interpreters who provide medical services via VRI. Rather, I’d argue that another component of providing remote interpreting services is the ethical decision of the interpreter to ensure it is being used appropriately. To address Shelly’s second point “Without direct patient involvement the patient’s access… Read more »
Shelly Hansen
Hi Debbie and all~ Just checked in on this post. Here are some brief replies to your bullet points: 1. The patient needs to be able to participate in the choice to use VRI or a live interpreter, not the interpreter. The resistance to allowing patient consent and input compromises the ethical use of VRI and the interpreter is not the primary player: the patient is the primary player. The onus is not on the interpreter. (qualified or not) I am not arguing that VRI terps are not qualified/competent. I am arguing that VRI has limitations that live interpreters do… Read more »

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