Tag: Video

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Critical Partnerships: Ethical Medical VRI & Sign Language Interpreters

Ethical Medical VRI & Sign Language Interpreters

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?

References:

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.” Www.rid.org. N.p., 2005. Web. 21 April. 2017.

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Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters

Behind the Screens: The Ethics of Medical VRI & Sign Language Interpreters

Shelly Hansen explores the ethical implications of VRI in medical settings, especially the impacts of dropped connections during sensitive consultations and loss of consumer choice regarding live, on-site sign language interpretation.

It’s all the rage. Those smooth little carts with satisfying clicks and keys. Sweet control, right here at my fingertips for your eyes. No more waiting for a live interpreter to arrive. No more scheduling…it is on demand 24/7/365. No more incorporating another breathing human being into the interaction; we’ve gone high-tech and modern, happy to share our space with a “machine interpreter”, the term used locally by health care provider staff for Video Remote Interpreting/VRI. The medical facility loves this kind of sterile control.

[View post in ASL]

The patient, on the other hand, may have a mixed response to the cyber–signer. Like cafeteria food and military MRE’s, this is a one-size-fits-all solution. If a person has vision issues, is not a strong signer and/or struggles with the style, speed or information from the “machine interpreter”, if they are dizzy, lying down awkwardly, giving birth, going into a radiology department, are from a foreign country and need a specialized sign language, are elderly and prefer a familiar interpreter, are an active child with attention issues or a CODA utilizing the interpreter, would benefit from techniques used by CDIs such as physical movement, drawings or references to visual aids in the immediate environment (including the current meds list on the computer charting screen), or struggle with paperwork and literacy challenges, they are out of luck. Not only are these individuals out of luck, they now need to self-advocate against a large medical institution or physician who has already invested in a “solution” to this communication barrier, and who feels that due diligence has been satisfied.

Communication in Context

When I step back and consider these experiences as a whole, the impact of VRI appears to be greatest on vulnerable adults. We can all find ourselves vulnerable at times, and some individuals may consistently interact as vulnerable adults. I have noticed that communication is most effective in the context of relationship when interpreting for these encounters. The negotiated meaning within a tangible human relationship provides a context for effective communication that mitigates barriers for vulnerable adults and provides a level of comfort needed to genuinely engage with others. While it may seem an overstatement, trust in the interpreter allows for depth of conversation that is not possible for some clients via technology which has an “outside, looking-glass” quality. I consistently hear feedback about “not remembering what they said”, “not understanding but agreeing anyway” and being told there “weren’t any live interpreters available” when those facilities aren’t calling live interpreters any longer as a standard procedure.

“Do No Harm”

RID Certified sign language interpreters historically have been vigilant to “do no harm”, maintaining high professional standards of ethical conduct, creating ethical codes of conduct, establishing ethical review boards and making every effort to provide quality service to the Deaf, Hard of Hearing, DeafBlind, Late-Deafened, and Hearing communities as allies and professionals. This commitment to the profession has enabled increased access to places of public accommodation throughout society and is a source of quiet pride and job satisfaction for many sign language interpreters who are committed to increased equality, autonomy, and self-actualization.

As a freelance community sign language interpreter, I have seen a dramatic shift in medical interpreting assignments from live interpreting to VRI supported interactions. As I sit on the cyber-fence, wanting to continue the work I love and provide services to people who need, want, and are requesting live interpreters, I am faced with an ethical dilemma. Do I participate in a flawed and “do some harm” medical VRI system because my livelihood is being affected by marketplace shifts?

Sample Scenario of a Botched VRI Appointment

A patient goes to a medical appointment in a facility to discuss the results from a recent scan with a specialist. The office uses a VRI system. The patient is optimistic about VRI, despite prior frustrations with freezing screens and dropped connections resulting in re-scheduled appointments with a local, familiar, RID certified “live” sign language interpreter. The doctor begins to review the results of the scan along with the possible issues that may be causing symptoms of concern. The “worst case scenario” is discussed and then the VRI starts to cut out, freezing. The tech issues cannot be resolved, again. The doctor, exasperated says, “This is not a service, it’s a DIS-service.” The appointment is abruptly curtailed and a follow-up appointment is scheduled for next week with an onsite, “live” interpreter.

When the appointment begins the following week, the “live” interpreter is unaware of the previous snafu. The doctor begins again to explain the medical condition, and informs the patient that s/he does NOT have the fatal condition. The patient breaks down. For an entire week, the last message about the fatal flaw and partially explained scan image had left the person believing that they had the dreaded malformation and the condition was terminal. The visible relief on the face of the patient is combined with frustration and anger. Both the patient and doctor commit to no further VRI appointments, expressing relief to have an in-person sign language interpreter on site. They agree that using VRI just isn’t worth the frustration, miscommunication and emotional duress.

If the “live” sign language interpreter left the room at the moment of diagnosis, s/he could lose her/his certification for ethical malpractice. The patient could file an ethical complaint with RID stating that the interpreter violated NAD-RID Code of Professional Conduct tenets 6.2 and 6.4 (see below).

Unintended Consequences

In my area, an older gentleman took his own life after receiving a terminal diagnosis. His family found him alone in the backyard. To my knowledge, this was not an interpreted interaction. However, it is possible that someone could react with serious consequences to a misunderstood partial-diagnosis. A scenario like this happened January 2017 at the Limerick Hospital in Ireland. A man received a terminal cancer diagnosis and took his own life in the hospital chapel.

Codes of Professional Conduct

Let’s look at some pertinent codes of conduct for medical sign language interpreters.

IMIA (International Medical Interpreters Association)

“Responsibility Toward Ensuring Adequate Working Conditions” The interpreter shall strive to ensure effective and productive communication in any professional situation and make every effort to have working conditions in place that will allow him or her to provide quality interpretation services.

“Right to equal treatment” Patients have a right to receive treatment in a language they understand; these rights are governed by federal anti-discrimination laws and the ADA.

“Informed consent” Patients should be aware of treatment options and consent to treatment only after understanding these options. Communicating information accurately is essential to informed consent.

“Beneficence” The health and wellbeing of patients is a core value in all health care professions, as well as in medical interpreting.

The NAD/RID Code of Professional Conduct

4.0 Respect for Consumers

4.1 Consider consumer requests or needs regarding language preferences, and render the message accordingly (interpreted or transliterated).

4.4 Facilitate communication access and equality, and support the full interaction and independence of consumers.

6.0 Business Practices

6.2 Honor professional commitments and terminate assignments only when fair and justifiable grounds exist.

6.4 Inform appropriate parties in a timely manner when delayed or unable to fulfill assignments.

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

Similarly, the National Code of Ethics for Interpreters in Health Care includes “beneficence” and “do no harm,” along with “fidelity”:

“The essence of the interpreter role is encapsulated in the value of fidelity. The American Heritage Dictionary of the English Language describes fidelity as involving the unfailing fulfillment of one’s duties and obligations and the keeping of one’s word or vows.”

More Questions than Answers

How can a career medical interpreter agree to work as a VRI medical interpreter with the knowledge that predictable and unresolved VRI technical issues, including consistently disrupted and poor quality connections and communications, are occurring throughout the healthcare system and political practice issues in which “one size fits all” approaches that dictate language use without options for live on-site sign language interpreters are creating barriers for consumers that violate medical and RID certified interpreter ethical standards? Does the interpreter ignore these issues and shift that duty to the health care system and VRI employer, and ignore the systemic impact of complicit participation in a flawed approach to health care interpreting?

At the moment, I am working triage. Those failed VRI encounters, re-scheduled appointments, miscommunicated partial diagnoses are creating a clean-up tier of work for live interpreters. I’m holding out for “live” interpreting, despite the economic uncertainty of increased VRI use and the lower hourly wages those positions offer. Do I want to be part of the machine interpreter phenomenon? How can I ethically participate in quality healthcare interpretation in 2017 and beyond?

Questions to Consider:

  1. What protections are in place for consumers of medical VRI? Are there rating or feedback mechanisms available to track customer and provider satisfaction post-appointment?
  2. What alternatives are available or recourse do consumers have in the event a VRI appointment fails and are there systems in place to allow patients to pre-select live or VRI preferences especially for sensitive or technical appointments?
  3. What duty does an RID certified interpreter have in medical VRI settings and is that duty usurped by VRI companies and medical facilities choosing to eliminate live on-site interpreting in favor of machine interpreting?

References:

The National Council On Interpreting In Health Care, and Working Papers Series. A NATIONAL CODE OF ETHICS FOR INTERPRETERS IN HEALTH CARE (July 2004.): 8. Web. 21 Mar. 2017.

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

“International Medical Interpreters Association Code of Ethics.” IMIA – International Medical Interpreters Association. International Medical Interpreters Association, n.d. Web. 21 Mar. 2017.

Collins, Pamela. “Bringing Scheduling Into View: A Look at the Business of Sign Language Interpreting.” Street Leverage. N.p., 17 Aug. 2016. Web. 21 Mar. 2017.