Video Conferencing Resuscitates Hospitals' Interpreter Services

Talk is cheap, unless it's helping doctors and nurses treat non-English-speaking patients in hospital emergency rooms and clinics. Then, it's a critical capability that can help save lives.

Just ask the IT staff at San Joaquin General Hospital in French Camp, Calif. They're hosting an innovative voice-over-IP (VoIP) system that provides audio- and videoconferencing to connect interpreters with patients at a trio of Northern California public hospitals. The system, called the Health Care Interpreter Network (HCIN), relies on a pair of Cisco Systems call center products, several types of video phones, and a Multiprotocol Label Switching (MPLS) network to provide shared translation services to the medical professionals and patients at the Contra Costa Regional Medical Center, the San Mateo Medical Center and San Joaquin General.

The first technology-based interpretation system of its kind anywhere, HCIN delivers two key benefits, according to Ken Cohen, San Joaquin General's director of health services. First, it reduces by half the cost of providing interpreters in the admitting, emergency and clinical environments at the three hospitals. Second, it significantly enhances the quality of medical care the patients receive, Cohen says.

The project was funded by a $500,000 federal grant divided among the hospitals. Cohen calls the $180,000 his hospital received for its share of the overall HCIN project "frankly, a small investment." Small, that is, considering San Joaquin General's $250 million annual budget, the 160,000-plus patients it treats each year, and the fact that 60 percent to 70 percent of those patients speak little or no English, Cohen says.HCIN is vital to meeting the needs of the involved hospitals, he says. The voice and videoconferencing system lets interpreters at each hospital communicate more quickly with patients and health care professionals in different locations on the premises. In addition, all three hospitals can share their interpreter resources over the voice/video system, which is essential due to the variety of languages spoken by patients. The real-time link significantly extends the reach of the interpreters available at any one moment.

Language Barriers

The hospitals in the HCIN serve diverse populations that speak a variety of languages, including all the Hispanic dialects as well as Asian-Pacific languages and dialects. Although each hospital has several full-time, medically trained interpreters on staff, no one hospital can necessarily cover every language. "Having interpreters [at each hospital] for all those languages is almost impossible," Cohen says. "It would take an army."

In addition, due to the high volume of patients, interpreters at each hospital are also constantly moving from one area to another: to the ER, to admitting and back. This results in downtime as patients and staff wait for an interpreter to arrive.

These conditions put considerable strain on the hospitals. "When we don't have interpreter services, or [medical] providers who speak the patient's language," he says, "we're left to rely on family or relatives. That's not appropriate or acceptable." Family members untrained in medical terminology often commit interpretation errors, leading to faulty diagnosis and incorrect treatment, Cohen points out.

Another option is on-demand interpretation services, but these can be expensive and there's no guarantee that the interpreter will have medical training.

So what's to be done? Enter Melinda Paras, the Oakland, Calif.-based consultant who built and manages the HCIN system for the three Northern California hospitals. Paras thought of the idea of delivering video-based interpretation about six years ago, when she was a commissioner at San Francisco's Highland and General hospitals. There, she worked with Cohen to develop a pilot project that delivered limited videoconferencing capabilities for a clinical trial.

When Cohen moved from Highland Hospital to San Joaquin General in 2003, he became a "champion" of the videoconferencing model and agreed to work with Paras to develop a more comprehensive interpretation system at San Joaquin General. That partnership landed a federal grant in October 2004, to develop what would become HCIN (see "The Hard Sell").

HCIN consists of three primary components. At its heart is a call center at San Joaquin General, which is based on the Cisco Unified Contact Center Express and the Cisco Unified CallManager. Cisco Unified Contact Center Express provides the basic call center capabilities, such as call routing and contact management, for HCIN, while the CallManager is the call-processing component of Cisco's communications systems.Paras went with the Cisco products, "because we couldn't find any other products offering both video and voice IP with call-center functionality. We heard there were open source products such as Asterisk, but two years ago, Cisco had the only products that could do what we needed--delivering video to someone's desk."

Paras has used several different end-point videoconferencing systems since first deploying HCIN in 2005. "We started with a Polycom product--I don't recall its name--that had a Web camera and a laptop, with a proprietary high-quality video codex that delivered boardroom quality video," she says.

She later migrated to a Tandberg 1000, an integrated camera/VoIP unit that offered compatibility with the Skinny Client Control Protocol (SCCP), the proprietary protocol Cisco uses to communicate between CallManager and VoIP phones. A year later, Paras deployed Cisco's 7985 videophones, an OEM offering from Tandberg that is also SCCP-enabled. They're located in interpreter stations around each hospital.

HCIN also relies on a variety of other videophones as well as audio-only phones--seven different end-point devices in all, Paras notes. For instance, a Polycom wireless speaker phone on a rolling cart is located in emergency rooms, where it can be wheeled into a trauma bay to allow a nurse or physician and patient to talk with an interpreter located elsewhere. Dual-handset VoIP phones allow an admitting nurse and a patient to both talk with an interpreter. "A videophone might be too intrusive in a chaotic situation" such as an ER, she explains.

Finally, Paras elected to deploy an AT&T (then SBC) MPLS network to connect the three hospitals. SBC got the call because, "all of the hospitals had existing contracts with SBC, so it was familiar ground, and SBC had just completed development of a similar MPLS network for another hospital in northern California."She needed a "secure network, and we didn't want a series of point-to-point connections between the hospitals--pretty soon, we'd have had a grid of criss-crossing T-1s between the hospitals," she says. Instead, she wanted them all connected to a "cloud," so each hospital would have a T-1 connected to the MPLS network. "When the [Cisco CallManager] software sets up a call, it determines where the call should be routed, and the two hospitals link in an ad hoc, point-to-point connection," Paras says.

Challenges Ahead

Developing a call center that could handle both audio- and videoconferencing, as well as route calls between hospitals, was the most important and difficult part of the process. "We didn't have a model of how to build this," Paras says. "We weren't looking to be first in anything but, as we began building what we thought we needed, we couldn't find anyone who had done it before."

For instance, there were no widely accepted techniques for linking the Cisco Unified Contact Center Express product to the various videoconferencing stations within the three hospitals, she says. Most notably, Paras ran into problems related to Network Address Translation (NAT), in which the firewalls at each hospital essentially "hid" the videoconference stations from those at the other hospitals. Paras lucked out, however, and discovered a Cisco gold partner, Quest Systems in Sacramento, that had worked with another Bay Area hospital to resolve similar problems. Says Paras, "We developed a work-around to get things temporarily working, knowing that Cisco was about to release an upgrade to its firewall that would allow [video] transversal of the network."

Dealing with cautious systems administrators at each hospital was another barrier. They were reluctant to connect their networks to external sources, no matter how trustworthy the sources. "It's their jobs to protect their networks," Paras says.The "political will" of the hospital administrators went to work, however, to overcome their reluctance. "We showed them how urgent the staff at the hospitals needed the services, and [closing off their networks] wasn't the way the hospitals wanted to operate," she says.

Miraculously, the HCIN infrastructure has seldom disappointed, Paras says. "We've never experienced network congestion, or noticeable latency or video problems" with the MPLS network, a private system used only for the interpreter services. "We've had a couple of outages due to loss of MPLS service and, on one occasion, telephone work in a closet disconnected the network.

There have also been occasional challenges with audio volumes in various hospital units. For instance, physicians and nurses in the neo-natal intensive care wanted the volume on the speakerphones lowered, while those in the emergency rooms, which have extensive background noise, wanted the volume turned up. Those issues have been resolved.

Jim Carr is an Aptos, Calif.-based freelance business and technology writer. Write to him at [email protected].

[15 minutes]Melinda Paras

San Joaquin General Hospital, French Camp, Calif. Melinda Paras, 52, is the CEO of Paras and Associates, an independent consulting firm that develops and implements language access systems in hospitals. Paras has worked to integrate computer and communications technologies into medical language interpretation systems for seven years.

Best part of working as a technology consultant within the health-care industry: "I get to focus on innovation--it's what I love about my job, doing something that no one has ever done."

Worst part: "We work with leading-edge technologies, and the problem when you're doing something that's never done before is that it never works right the first time. We have to go at it from lots of directions to make it work."

How I got into providing technology and interpretation services to hospitals: "I was on the government health commission for the City/County of San Francisco and president of the county board of hospitals in Alameda County and I became aware of the lack of availability of interpreter services for patients. I've been involved in health advocacy, and I was determined to find a solution, so I launched my business this year."What my clients don't know about me: "I play center field for an adult softball team. That's my passion."

Subject that makes me rant: "Inefficiency."

What keeps me awake at night: "Technical problems that have not been resolved yet."

Favorite hangout: "Sunnyside Cafe (in Albany, Calif.). It has great muffins."

Comfort food: "Macaroni and cheese."Favorite team: "New York Mets."

Wheels: "2000 Toyota Camry."

In my car CD player right now: "My own mix of jazz."

Must-see TV: "Grey's Anatomy."

White wine or red: "Red (cabernet sauvignon)."First career: "Activist in the Philippines, fighting the Marcos dictatorship."

Next career: "I hope to retire and become a philanthropist."

The Hardsell

When the federal government speaks, hospitals that need interpreter services listen, especially when the feds talk about awarding grants. Such was the case when three California medical facilities needed funding to implement innovative language interpretation technology to improve communication between health-care professionals and patients.

With the help of two California congressmen, San Joaquin General Hospital, the Contra Costa Health Services and San Mateo Medical Center in 2004 landed a $500,000 grant from the Department of Commerce. It covered the costs to develop, deploy and maintain the Health Care Interpreter Network (HCIN), says Ken Cohen, San Joaquin General's director of health services.

Sixty percent to 70 percent of the hospitals' patients speak little or no English, putting a strain on existing interpreter services. The congressmen, Rep. Richard Pombo, D-Calif.,, and Rep. Dennis Cardoza, D-Calif., played a key role in getting HCIN funded by "telling us about the grant and acting as advocates for us with the U.S. Department of Commerce," Cohen says."The Department of Commerce was looking to provide grants to hospitals to help them study the feasibility of and to implement new technologies to solve their business problems," Cohen recalls. In the HCIN case, it made the grant "to see if technology improvements could be made in the provisioning of interpretation services, and whether interpretive services could be provided as part of a shared network."

Cohen says the HCIN has met the goals of the grant and more. "It helped us improve the productivity of our interpreter services--and we've validated this by an outside review--by as much as 200 to 400 percent. And the costs of providing interpreter services is significantly less than what it would be if we had to purchase it through other alternatives."

Alternative interpreter companies such as Language One typically charge $1.90 to $2 per minute, according to Melinda Paras, the consultant who built and manages the HCIN, who says that fee is not a major issue "if you're using five minutes here or there. But if you're using hundreds of thousands of minutes annually, a per-minute charge is just not feasible."

With HCIN, San Joaquin General's per-minute costs have dropped to about 80 cents to 90 cents per minute. That includes the cost of the MPLS circuits linking the three hospitals, Cohen says.

Cohen expects the hospital's investment in the project to "come back to us within six to eight months, and that includes the cost of adding two more interpreters at its own expense. It's an extraordinarily good project. It's given us the ability to create a network that we can add facilities to and, as we add more facilities, the cost of operation improves as well."Most important, however, is HCIN has enhanced the productivity of the entire staff and improved the quality of health care the hospital provides. By delivering interpretation services quickly, hospital staff treating non-English-speaking patients no longer have to wait for an interpreter to arrive. "The patients like that," Cohen says.

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