Transcript for Sign Language Interpreting and Video Remote Interpreting in Medical Settings

Tuesday, April 17, 2018


Communication is a critical element when interacting with medical professionals and providers whether it is in the doctor or dentist office or in a hospital setting. Often individuals who are deaf are denied effective communication based on a lack of understanding of the requirements or a concern about the cost of providing necessary services. Technology has expanded the options available for communicating with individuals who are deaf but it is not a situation of “one size fits all” and there are many variables that can go into whether or not one method of providing access to a sign language interpreter is more effective than another. Join this session for a discussion of these issues and to learn more about the resources that are available to assist an entity meet their effective communication obligations.



Shannon Montinho

Thank you for the introduction, thank you, everyone, for joining us.

In addition to the brief bio robin just shared about my experience, I'm also -- I have spent 10 years as a nationally certified sign language interpreter working freelance, working a lot in medical settings and so some of this information is coming directly from personal experience. The Agenda today will give a brief other Yen Tigers on deafness, mostly to give you a better idea of who your patients are, who the clients are and how best to serve them. We'll go over some legal requirements, required to achieve effective communication. We will define effective communication and auxiliary aids, discuss interpreter qualifications because those do differ state by state and the ADA and other laws regarding interpreter qualifications are intentionally vague about this. We'll try to clear up some of that, those issues.We'll define and discuss the sign language interpreters, deaf interpreters, video remote interpreting and video relay service. That can easily sometimes get confused on what accommodation is required and which one you need.

VRI versus live interpreter, sometimes you will -- a live interpreter refers to an on site interpreter versus an interpreter on a screen. Sometimes people will say an on site interpreter, an in-person interpreter, this is what they mean when they say those words. We'll go over some case law regarding VRI and the sign language interpreting as an accommodation and then give some of my personal, inside knowledge what I wish every provider knew in terms of going beyond reasonable accommodations, going beyond the ADA's minimal standards. This is a minimum standard. There is more that you can do if you're really going for equitable service to these patients.

All right.

Deafness, deaf people obviously are not a one-size-fits-all cookie cutter experience. There are some people with mild to moderate hearing loss. These people might use hearing aids and from, you know, based on judging what it looks like, they're keeping up with conversations, no problem, people with mild or moderate hearing loss may identify as deaf, they may identify as part of the deaf community. They judging by their communication methods they may present very different communication abilities than your next patient who shows up and has severe, profound hearing loss. Severe hearing loss, these are people who also often use sign language, they possibly have powerful hearing aids that allow them to still rely heavily only reading but be able to carry on a conversation. If the context of the situation allows for that.

If the situation is loud, if there are multiple people speaking over each other, if the conversation is bouncing between multiple members quickly then a person using hearing aids and depending on the meeting, they may not be able to keep up with a conversation so well. People with profound hearing loss, typically people that are born deaf or become deaf early on in life, they'll use sign language or other forms of non-vocalized communication such as queued speech or other systems. We'll get into that a bit more later.

I want you to keep in mind that you may have experience as a person that identifies as deaf, does not request accommodations,ly reads and carry areys on an appointment or an emergency room experience fine and the next person comes in, identifies as deaf, requesting sign language interpreter, does not lip read, et cetera. Keep that in mind. Every deaf person is different and they'll be the expert on how they best communicate.

Also late deafened individuals, this is people who we usually see become sometimes severely deaf with age and because we have lived most of their life as a hearing person, speaking, and listening, they typically do not learn sign language, they do not use sign language. So with these people, it is best to ask them what they prefer, but they might use CART, which is a captioning service or writing back and forth that kind of thing.

Just a note foregoing forward, in PC American culture, there's been an effort to say hearing impaired. There is some ideas that this is I guess less offensive than other labels, but deaf and hard of hearing people actually do not prefer that label. They prefer to be called deaf and hard of hearing. To call someone deaf when they are deaf, they know they're deaf if you say that they're deaf, you're not being offensive at all. Deaf and hard of hearing is what I suggest that you use going forward.

Just a note foregoing forward, in PC American culture, there's been an effort to say hearing impaired. There is some ideas that this is I guess less offensive than other labels, but deaf and hard of hearing people actually do not prefer that label. They prefer to be called deaf and hard of hearing. To call someone deaf when they are deaf, they know they're deaf if you say that they're deaf, you're not being offensive at all. Deaf and hard of hearing is what I suggest that you use going forward.

I would suggest that you not initiate, you know, an appointment by asking the deaf person to lip read. You're going to get yourself into some deep water real quick. Lip reading also depends on the deaf person's contectual knowledge of the subject. If you switch subjects on them real quick, did you let them know, now we're talking about X, Y, Z instead of something else and do they know about the subject well enough to keep up with lip reading. It is definitely beneficial if they are lip reading to have a one on one setting. When communication bounces around from a circle of people quickly, trying to figure out whose talking and turn your attention to them, without hearing where the conversation is going, it is a problem. Deafly you need eye contact, if you have a doctor, a nurse, something that's talking to a person that is trying to lip read them and immediately they Burry their face in the chart or turn around to the machine behind them. Obviously that cuts off any kind ever successful lip reading. Things like having a clean shaven face, is your facial hair covering your lips, standard mouth shape, speech production, do you have an accent and it just requires -- it is slow. There will be a lot of miscommunication and asking for clarification. It requires a lot of patience and also keeping in mind that it probably will fail and when that does, you need written communication as a back up.

Deaf people who identify as culturally deaf usually also identify as a visually-oriented people. If you're not hearing the world around you, you're depending on your eyes for all incoming information. So culturally deaf means typically people who use sign language and there is a set of social beliefs, behaviors, art, lit area tradition, history, values and shared institutions of communities that are influenced by deafness and this idea of a visual world. Bottom right-hand corner, you see the image I have labeled Eyeth, it is an image of the globe as a eyeball, there is a cultural joke I guess that earth is spelled Earth, earth and deaf people live on Eyeth, keep that in mind when going tore ward with deaf patients, think of how can you make this experience, this medical experience as visual as possible so if you know that somebody is coming in to discuss a knee replacement, do you have posters, pictures of knee replacements, the equipment, the procedure? Do -- can you pull up a video on YouTube right there in your office that's going to more visually explain to this person what actually is going to happen. That's an example of an equitable service.

Just thinking, how best to serve your patients, and then sometimes -- some deaf people have a tradition of more straightforward communication. This is often a cultural treat. It comes from legacy or I guess decades of being misunderstood, of having this communication and, you know, there is a cultural trade of not wanting to beat around the bush, just get me the information that I need to know. Keep this in mind as you work with deaf patients, but then also sometimes if there are comments that are coming from the deaf patient, maybe there's a frustration of some kind, keep this in mind, this is a cultural difference, and there are two cultures, a hear agriculture, a deaf culture, that may be part of what's going on with this style of communication.

Slide 15. Other issues to consider as you serve this population. Again, this is not every deaf person out there. Some deaf people, their literacy levels are low or non-existent in terms of reading and writing English. As an interpreter from experience, I know that when a nurse has said, you know, do you read English or Spanish, because they're preparing to give them some kind of paperwork. A deaf person response, it is something lighter with I'm not so great with English, ASL is my primary language. I want to caution you when you get this kind of response, it may be that it is not that they're not so great with English but they may not be literal at all. If you have patients, whether deaf or hearing who are illiterate, how do you best serve these patients, what type of resources are you able to give or reach out to to supplement information that they may need.

Limited peripheral learning, a professor of mine who is a deaf professional, has a master's degree, highly successful, lives in Washington D.C., she had told me a story that simple things like dentists that tell you you should replace your toothbrush every three months, this is something I remember learning as a child and I heard it kind of in my periphery, repeatedly, and it is just something that I always knew, you replace the toothbrush every three months.

Nobody had taken the time to actually communicate that to her until she was about 37 years old. She went to the dentist, she was, you know, her how many hundreds time at the dentist and it was only then that the dentist took the time to write out to her, replace your toothbrush every three months, floss morning, evening, so keep that in mind. When you're serving this population health information that sees common sense to you and I may not be accessible to this population and just to make sure that there is effective communication holistically around that. Family networks, I can't remember the exact statistic, it is something like 60% of hearing parents who have deaf children never learn to sign. That may sound extreme or unbelievable, but it is the truth. It is confirmed, definitely, by my own experience and for that reason I have that in here. I know that as medical professionals, many people are used to family networks being comprised but when you have hearing family members coming in with deaf family members speaking tore a deaf familiar member I would caution to know what is this relationship, how fluent is that person, parent, family member in sign language, are they kind of taking over that communication? I had a situation one time where a sister was legal guardian of their family member, did not know sign language at all and the patient had severe pain for a month and the sister did not even know the sign for pain and was really unable to communicate that to doctors. Family members, to you, family members as interpreters for their deaf family members, it is a struggle sometimes and a word of caution there.

Other things to consider too, this community is -- this population is not just deaf. A lot of times we'll have deaf people who are also blind, deaf people who have low vision. There is deaf immigrants whose first language is not English, it is not American sign language, it is something completely different. How do we serve that population. How do we work towards effective communication. This word deaf plus, it is not quite a standard vocabulary, it is in the field yet, but I have heard it a few times. Basically it means deaf plus other disabilities. Does this person, does this deaf person have C, if P, does this person have -- you name it.

And to make sure that we're accommodating for that as well.

Slide 16. These are the laws that cover medical facilities and that require effective communication, the American disabilities act, titles II and III, Affordable Care Act, section 1557 and the Rehabilitation Act section 504. A lot of the language in these laws specifically about effective communication and providing exile area aids, providing accommodations to effective communication is very similar. The ADA defines disability as a person with a disability is a person who has a physical or mental impairment that substantially limits one or more major life activity. This includes people who have a record of such impairment, even if they do not currently have a disability. It also includes individuals who do not have a disability but are regarded as having a disability. The ADA also makes it unlawful to discriminate against a person based on that person's association with the person with disability. Deafness, being hard of hearing, it is usually no argument there, it is usually a given. This falls within that definition of disability under the ADA.

I want to bring your attention also to the last line of that definition that it -- the ADA makes it unlawful to discriminate against a person base odden that person's association or the person with the disability. Sometimes we see it as -- in terms of companions, if there is a deaf patient, and their family member, their friend, who is there as part of the care team, as a visitor, et cetera, often needs accommodations, accommodations extend to the companions.

Going forward, so what is effective communication. When is communication effective? This is Slide 17. So you know communication is effective when the patient understands the information. This may seem like common sense. How do you know that you've Clevelanded effective communication? How do -- that you've achieved effective communication and that the patient understands the information.

The only way to really, truly know for yourself, if the patient has understood the information given effective way for you to confirm that communication has happened, that that patient understands.

If you have a patient who is unable to understand maybe because they need a deaf interpreter, we'll get into that in a minute, then, you know, further research needs to be done on how to effectively communicate with this patient. They may need more than just a sign language interpreter or just a VRI or CART or lip reading, whatever it is that you have tried for thus far.

Sometimes people have asked a hired sign language interpreter, we have hired the deaf interpreter and they still don't understand. Sometimes you have patients who are not going to understand. When you have a hearing patient who doesn't understand you after you have made various attempts to make that communication understood what do you do? In those situations, how do you mark that down? That is obviously within your professional practice.

In terms of -- you know, most people effective communication, it is when the patient understands and the best way to ensure that for yourself is to ask.

Qualified interpreter, the laws we just named, the ADA, rehab act, the Affordable Care Act, they have very familiar language around qualified interpreter and it is intentionally vague. It says a qualified interpreter is one who is able to interpret effectively, accurately and impartially both receptively and expressively using any necessary specialized vocabulary. An individual does not have to be certified in order to meet the standard. A certified interrupter may not meet the standard in all situations where the interpreter is not familiar with the specialized vocabulary involved in the communication. Be aware that state laws may require certified interpreters superseding the ADA and be sure to check those local laws.

Certified does not mean necessarily qualified. Vice versa. However, state laws, certain states, they have very strict state licenser laws that require interpreters that work in highly nuanced situations or situations with more liability such as medical, legal, requiring a specific state licensure.

Check that before you hire an interpreter. In Illinois we have these laws. In states like New York, there is no state law yet. In terms of medical, it is still best practices to find an interpreter with some kind ever credentials and experience in what you need them for. Each state is different. Check that.

Family members are not considered appropriate interpreters because of their emotional or personal involvement. In the is situation and because it would be difficult to maintain that impartiality especially if a situation may starts out very simple, you think simple and then a surprise diagnosis is found and suddenly your interpreter is emotional and trying to straddle the duties of being an interpreter and a supportive family member at the same time. It is best to just rely on the professionals.

That's a fact sheet that's been put out on effective communication. That link is here for your reference after the webinar.

Slide 18, the Americans with Disabilities Act titles II and III, title II covers state and local government services. This is state hospitals, county hospitals, public doctor offices that's receiving state or local funds. It is also -- yes.

It is private businesses, non-profit organizations that serve the public.

So this is -- most hospitals, doctor offices, small practice it's, it could be a dentist office, a nursing home, a psychological facility, even care that extends into the private home of someone but obviously that private care is being coordinated by a private business, private organization and stilets II and III is what we look to in the ADA in terms of providing accommodations for effective communication.

Slide 19, Affordable Care Act. It has a lot of the same information, a lot of the same language as the ADA but section 1557 specifically has this -- it is the third bullet point down, primary consideration which means that the public entity is encouraged to honor the choice of accommodation that the individual with the disability specifies with certain exceptions.

This is saying that the ACA is encouraging you to make contact with your deaf patient, ask them what they prefer. Do they prefer a sign language interpreter on site? Do they prefer VRI? Do they prefer captioning? Something else? Then do your best to meet that request. Sometimes, especially rural areas, an on site interpreter may not be readily available and so you have to use VRI or some other mode of communication, accommodation, and to be able to show your patient that, hey, we tried to find an on site interpreter and could not make this happen. That's what this primary consideration means.

Again, individual with a disability, the deaf person is going to be the expert on what is most effective for communication with them.

To make contact with them before the situation arises, and to know how best to interact with them. Slide 20, this is the Rehabilitation Act section 504. I'm going to mostly skip over it, it does have a lot of the same language as the ADA and ACA. Keep in mind the Rehabilitation Act covers federal entities. If a medical facility is receiving federal funds, so this includes Medicaid, then you are not only covered by the ADA but also by the Rehabilitation Act to provide accommodations for communication.

Slide 21. The ADA and providing accommodations does have some limitations. There are specifically two under the ADA, there is fundamental alterations, so if the provision of accommodation fundamentally alters the nature of the services being provided, then the entity is not required to provide that accommodation and undue burden. Fundamental alteration, we don't really see that in the context of providing communication accommodations. Undue burden, there's been some attempts to claim that providing sign language interpreting is too expensive, it is an undue burden on the business. We have not seen any case law uphold the claims. Undue burden is when providing whatever accommodation under the ADA is it exceeds the overall funds of the business, in simplified terms, it means by providing the accommodation your practice, your hospital, your facility will have to declare bankruptcy. You might see this more often with the idea of installing an elevator which could easily about a 20,000 dollar building alteration that could warrant a claim of undue burden. With sign language interpreting, it usually will cost a couple of hundred of dollars, there is some extreme cases but a couple of hundred dollars which will not stand up in court as undue burden. There was a lawsuit brought in 2008, Gerena versus Forgari, a physician refused to provide an interpreter because the hourly rate of the interpreter was higher than the hourly rate of the physician. Remember, with undue burden, it is the overall operating cost on the facility.

It is not one physician's hourly rate. The court found -- the court argued in favor of the defendant, of the deaf person and the physician and had to pay $400,000 and have a jury verdict in addition to $200,000 in punitive damages to the patient.

This was -- and then in the Silva versus Baptist hospital, they did -- the court did come out with a statement that said deaf patients are not entitled to an on site interpreter every time they ask for it. If effective communication within the circumstances is achievable with something less than an on site interpreter then the hospital is well within its ADA and rehab act rights to rely on other alternatives. We stress again, that the hospital ultimately gets to decide after consulting with the patient what auxiliary aid to provide, but whatever communication aid the hospital chooses to offer the hospital must ensure effective communication with the patient.

So for appointments like blood lab where you literally are walking in, sitting down, getting your blood drawn and you leave or other very simple, very quick appointments may not require an onsite interpreter. You really have to look at how much communication is happening, how long is the appointment, how complicated is the information, and if that warrants an accommodation to it to communication. Things like a lab draw might not warrant any accommodation at all, but if you have a lab draw that's in consultation then with an appointment, you may want to have the interpreter there and if they're had already there, then sure, they can go into the lab with the patient.

It really depends on what kind of communication is happening within the context.

Slide 22. Surcharges. As you can see, this is very simple concept. There is not a lot of information on this slide because the rehab act, ADA and ACA all prohibit providers from requiring a patient to assume any part of the cost of providing the exile area aid or services used as a accommodations to achieve effective communication. At in o time can you ask the patient to assist with the cost of covering the charges of the interpreter, of the CART provisions, also asking the interpreter -- asking the patient to bring their own interpreter, all of these kinds ever things are illegal under all three laws they're considered surcharges.

Slide 23, what kind of interpreter do you need? Most situations are going to need your standard sign language interpreter who is is just interpreting between a spoken language and the sign language. In cases where a patient is a deaf immigrant who does not use American sign language or may have cognitive disabilities, that are going to make it more difficult for them to understand, consent to a procedure, for example, you may want to bring in a certified deaf interpreter who is a deaf sign expert or native language model, native language user who works in conjunction with a hearing sign language interpreter.

They -- deaf people are just -- they have a more innate sense of how to get their message across to another deaf person that most hearing sign language interpreters as second language learners just don't have so as hearing interpreters, we also don't live as a deaf person day to day and don't have the same experience that might be required in these more complicated situations. Deafblind interpreter, not all hearing interpreters have experience working with deafblind people or deaf people with low vision. It is a slightly different skill. Not all hearing sign language interpreters want to necessarily do that work because it is a little bit more of a stress on the body, it takes more physical requirements I guess you could say. The interpreter, I'll have images in a moment but if you think of Helen Keller, that's the easiest picture I can paint, it is literally interpreting into someone's hand. Sometimes deafblind people may not have their hands on the interpreters hands but they'll have them more toward their forearm, an elbow so that they can track where the sign language is going, they can track where the limited vision that they have needs to be focused and there is variations on this. We won't get into it.

Just make sure that you have a sign language interpreter who knows how to provide this service if it is requested.

Other services like cued speech, it is not going to be seen mump, it is hard to find this type of interpreter, not many have that skill. An oral interpreter, don't see this very often anymore. We never really did, but it is becoming a thing of the past.

All right. Certified deaf interpreter, you may have seen certified deaf interpreters working on the news, especially if they -- they seem to be pictured especially the New York press conferences about the hurricanes, there was one -- I I this this picture that is it from the April outbreak a couple of years ago, the bottom right hand picture, Slide this by the way, bottom right hand picture, there is an image of a man speaking at the podium and to his right, there is another man using sign language and he is a deaf interpreter who is trying to get this very important information out to population who may not be able to read the captioning, who may need it in a more accessible way.

It is more of a simultaneous interpreting experience -- I'm sorry, more of a consecutive interpreting experience instead of simultaneous. It is going to take a little bit longer. When you have certified deaf interpreters, sometimes the communication that you have struggled with, perhaps if this one person for so long is just magical and everyone is able to understand and if you haven't had that experience yet, I hope you'll be able to some day.

Next slide. Slide 25.

Here are some images of deafblind interpreting and you will see in the top left image, this is more of that, you know, traditional Helen Keller style where deafblind person has their hands on top of interpreters hands and the interpreter is signing continuously with physical contact with that deaf person.

The middle image, bottom, this is more of the tracking style where you don't have the interpreter sitting directly in front of the deafblind person, they're off to the side, the deafblind person has one hand on the interpreters' hand or arm and is able to track sign language in that respect. Then to the right, you have a woman that's using a power chair and it looks like some kind of breathing with device and the interpreter is -- has -- you know, both hands and the patient's hands, I want to show this image though. When we talk about VRI, it is important to keep in mind that your patient and what kind of communication is needed, what kind of accommodations are going to be effective. In all three of these situations, I think that having an interpreter on a screen may not matter how big or small that screen is, it could be a problem for the -- these people to be able to use as a communication accommodation.

Back to interpreter qualifications. This is Slide 26. The three images that I have here, they're all pictures. Unfortunately from a recent situation where fake interpreters have been hired. You may think how does this happen? How does it happen so often? Didn't they know that that interpreter was not qualified for the job? Keep in mind, the em that hire sign language interpreters, they're typically not fluent in sign language, they don't necessarily ask for an interpreter's credentials, they take an interpreter at their word that I'm a sign language interpreter today and they go with it. So the top right, you have -- this is -- this was for the hurricanes in Florida, the guy in the yo low shirt is actually a life gathered and he apparently has a cousin who was deaf and o so he knows maybe 20 vocabulary signs boob advicely not in you have for a press conference on a national disaster. The middle evenly manage, similar situation. I had I it was they had caught a criminal. I don't remember what happened. The woman in black was her hand kind of doing jaw jaw hands to the side, was not credentialeled or qualified, and then the bottom image, it is Nelson Ma de la's funeral and this man a with his hands I guess up with the blue Laniard around his neck, you know sign language at all, you know South African sign language at all and was are providing basically ribberrish the whole time. It happens often, want to interest not every interpreter is qualified, make sure when you're hiring services, that you are either San Diego for credentials, checkingy you are state laws, do they need to be licensed, any experience in medical, et cetera.

If you have not checked your states' requirements, there is a website here on this slide, that you can access after the member yarr to figure out what your date requires and how to he can des the exactries, names, phone numbers, addresses, email adreadeds for the interpreters should you need their services.


VRS interpreting, there are is vioxx RI and there is VRSor S, video relay service, easy to think about this, it is on the telephone, it is phone calls, live interpretation on a phone call. Hearing alchohol large titlesern dials a deaf person's phone number, that number is registered with the foxic CC as a video front. As a pearing person hears that, it is automatically routed through a sign language interpreter and that report person connects the call to a video phone and can hear you in the you are the.

Het site, can see and talking to you. You can see the person on the screen screen.It is live interpret prairie -- it is live interpretation on a phone call. I also work as a video relate service interpreter, I think it is very savvy for hospitals now away to do a lot of patient preop intake questions, medical history offer relay service, this is if you have the tame touts this video relay service, ' ment -- the paperwork with your patient, this is a savvy resource to utilize, it is free to you, it is free to the deaf person. So video relay service, keep in mind that it is a phone call though and must -- that two people on both ends must be in separate rooms, separate places, separate facilities, it is illegal to use VRT if both the hearing and deaf person are in the same room

You can't legally be using VRA and telephone call services as an abombor accommodation in a medical setting -- as an accommodation in a medical setting. The patient shows up, call me on the cellphone? That's illegal and you can be fined for this. Next slide, it is Slide 28.

Video remote interpreting. VRI, where VRS you cannot use it, VRI is meant to be used where both the hearing person and the deaf person are in the same room.

Today we're using it in this webinar and we're -- it is not the case.

I am Chicago, the have interpreters are in D.V. and that's another use of RVRI and it in medical situations is typically where the patient and the provider are sitting in the same panel together. The deaf person can see the interpreter on the screen. The interpreter, they may be sitting in a different state or the same. The screen is right in there with the patient and the provider typically can hear the interpreter as well. So you have simultaneous interpreting on the screen. You look at the screen, you have three setups here. The top one, the screen is on a mobile desk space that can be rolled through different rooms and the screen is quite large.

That I think is possibly the ideal of VRI setup, that it may not be accessible in every situation.

You have the middle image, VRI on a smaller screen, still on the mobile setup, and then on the bottom one, the provider is actually holding it looks like an I. pad with the interpreter on the screen. That's a problem to me because somebody has to be holding the VRI device the whole time. It can be in the absence of an on site interpreter the opportunity to utilize video communication technology, to obtain interpretation services. It is a Boone for everyone, especially if you live in a rural space where there are not a lot of sign language interpreters available, there are not -- maybe there is not a lot of services around in general so VRI is an answer to that.

Slide 29, so why should we use VRI. There are challenges to procuring on site interpreters. On site interpreters must be prearranged and take staff time to confirm. This he can take two to 7 business days in advance to secure an on site interpreter in some instances the agency or the provider had as to pay travel time to that interpreter, late notice fees, cancellation fees, evening and weekend differential, et cetera. There is an interpreter shortage generally ongoing nationwide especially rural areas, but I know that in Chicago we really struggle, we don't have enough interpreters to go around, it is not just rural areas. Sometimes no interpreter is available immediately at which further delays occur.

Slide 30 , getting setup, this is some of the equipment you would need to provide those VRI services.

Slide 31 #, the ADA has specific requirements for VRI to be used as an effective accommodation. These are that the realtime full motion video and audio over a dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers high-quality video images that does not produce lags, choppy, blurry or grainy images or irregular pauses in communication.

Think back to the last time you used Skype or face time or made a video call with someone of any kind. Was it perfect the entire time? Could you see your person perfectly? Were they choppy, blurry, et cetera? Typically the use of VRI, the quality of VRI, VRS, it is similar to that.

It is not as though VRI and VRS are -- they magically avoid all of the same problems that you might see in face time or Skype.

So keep that in mind if you're thinking of using VRI as an accommodation with your patients.

The ADI says that it also must be a sharply delineated image that's large enough to display the interpreters face, arm, hands and fingers and the face, the arms hands and fingers of the person using sign language regardless of his or her body position. Obviously you want to be able to see the interpreter. You don't want their face cutoff out of the screen.

Then also your patient, most doctor appointments, most patients are coming in being able to move around and reposition to be in the screen. What if your patient is in a full body cast and they're not able to move to accommodate and reposition themselves to be a part of the screen, what if they have CT and what if they -- you know, the list goes on and on, but it is not that the interpreter needs to be seen but the deaf person also needs to be able to be seen by the interpreter and sometimes that makes VRI not an effective acome occasion disagree. The interpreter has to have a clear understanding of the voluntary us, hear the provider, that's usually less of a problem but it still can be. Adequate staff training to ensure quick setup and appropriation of the VRI machine. That is often a problem. If hospitals have one VRI machine and that VRI machine gets moved from department to department, room to room, suddenly you need the VRI machine and nobody knows where it is or maybe it is kept in a closet and only one person in the entire hospital knows which closet it is kept in, it sounds funny, but it happens regularly. So these are all requirements for using effective -- using the VRI as an accommodation towards effective communication.

The other thing, this has nothing to do with the ADI but in terms of your practice. Think about the cost. A lot of people want to use VRI because they think it is going to save them on cost. The interpreting services.

VRI, they charge by the minute.

So as an example, if you are being charged $2.50 per minute, for 20 minutes of VRI, that will cost you 50 bucks whereas you have to pay usually a two-hour minimum with an interpreter that you may only use for 20 it minutes and then, you know, you're paying a lot more for under utilized services.

However, VRI in this example, you only have to use it for 45 minutes before you have already started to pay for more -- pay more for VRI than 45 minutes with an interpreter, it was as two-hour minimum. Something to keep in mind.

You may or may not actually be skirting the cost of interpreting services by utilizing VRI.

Slide 33. The pros of CVRI, potentially quicker way in an emergency response situation. If a person runs into the emergency room, they need effective communication, you have the VRI machine there, you can pull it out, hopefully you get an interpreter on the screen right away and you're ready to go. That's an ideal situation.

Entities and areas with limited access to qualified on site interpreters, they have alternative options. It reduces the propensity for non-compliance in the a, DA, ACA and rehab act to achieve effective communication. It is something that I can give patients immediately and not refusing to provide any kind of accommodation. VRI offers it interpreting offices in night and weekend hours when on site interpreters may be harder to secure. Increased anonymity for deaf patients, you have access to interpreters out side of the local community, the deaf community is small, the interpreting community is also very small, everyone tends to know everyone.

Maybe you get a deaf patient that doesn't want their local interpreters because they don't want the local interpreters to know all of their personal health information. Understandable.

Then VRI is billed per minute, which in some instances could be more economical, depending on the need.

Slide 34.

The cons of VRI. Video picture quality is rarely optimal. This is a number one complaint of use of VRI from deaf people. Staff training on how to use the equipment and service is regularly lacking. Lack of positioning versatility. The screens a used are unreasonably small, there was a case a couple of years ago where the provider was trying to have a deaf person use VRI on, you know, an iPhone and so the screen was about 2 inches by 3 inches and this is supposed to be an effective accommodation. That didn't work so well.

Deaf patients want a familiar interpreter. Sometimes you have the opposite. You want the deaf person whose familiar with that interpreter, who knows their skill, who trusts them. With VRI you have an inconsistency with interpreter, when you have an on site interpreter, you typically have the flexibility of requesting the same interpreter for ongoing visits with a patient that allows for continuity of care. This interpreter already knows what's been going on they know what kind of communication works best with this patient. Versus VRI, if you use VRI for let's say an emergency room. A patient comes in the emergency room, you pull it up. You will get one interpreter for the first 20 minutes and then you turn the VRI off because the doctor is not coming back for a while and the deaf person -- there is nothing going on. Then the doctor comes back, you know, an hour and a half later and you need it again.

When you turn it back on, when you connect to another interpreter, it is not necessarily the same interpreter, you lose that continuity of care.

VRI does not serve deafblind, deaf and low vision patients. There is also sometimes with VRI a potentially long wait for an available interpreter. The interpreters are sitting in either a call center, sometimes in a remote location but they're still dealing with an incoming queue of calls. Sometimes there are not enough VRI interpreters to go around, you may be on hold for a long time waiting for a VRI interpreter. You cannot have VRI equipment anywhere near an MRI machine. An interpreter cannot handle the fuel communication of all the people in the room. Sometimes, depending on the situation as an interpreter in the room, I might become -- a traffic conductor, where if I need a few extra moments to expand a concept for this deaf person to make sure that communication is happening, I can easily control the situation and ask the doctor can you hold on a moment, and vice versa. If you're on the VRI machine, you have less ability as an interpreter to control the flow of traffic which can be a problem sometimes.

Less optimal than visual conditions for the interpreters, you see the -- sometimes the lighting in patient rooms, doctor offices, it is not great. You end up with an image that the -- the image on the interpreter's screen of the deaf person that the interpreter cannot see them. If you cannot see your deaf patient, you can't interpret for them. You have less control of credentialal requirements with VRI.

You don't always have the ability to know if this interpreter that you're getting on a VRI screen, are they nationally certified, how much experience do they have with the specific medical situation that you're dealing with. Again, it is billed per minute which can quickly add up, and then sometimes the equipment can break, which is also a common complaint of the community, the equipment is broken, nobody knows until the patient shows up and then suddenly you don't have that accommodation available.

Slide 35. This is more feedback from the deaf community, this is more feedback on VRI from the deaf community directly of why they prefer not too use VRI as opposed to an on site interpreter. Video quality is regularly picks lated, jerky, trailing, blurry, the limitations make it ineffective as an accommodation, not being able to move it around, lighting issue. Staff do not know how to use the equipment or how to find the equipment, the equipment is broken, medical providers are not transparent about using it when they say the deaf patient will call the doctor's office beforehand saying I want to confirm that an interpreter will be there and the provider says, yes. An interpreter will be provided. They get there and the interpreter is actually on the VRI machine and not an on site interpreter. This feels like a slightly manipulative tactic and it is a great way to burn a bridge with a patient real quick. Often there is still a wait involved to get an interpreter on VRI. Slide 36.

Again, bringing up the images of deafblind interpreting. In and out with information that you have on VRI, it is easy to see that a VRI machine would not be accessible to these patients, would not be effective.

Slide 37. The images on the right, they're fairly common for any kind of video phone image.

This trailing, blurring, bizarre color ration, this happens often.

This is -- what happens in this case that was settled, U.S.A. versus doctors hospital at renaissance, deaf parents of a 4 month old receiving cancer treatment were repeatedly denied effective communication through an on site interpreter, the hospital tried to use VRI multiple times but the machine often did not work or the staff couldn't find the equipment.

The full settlement agreement, the link if you're interested in reading it is provided in this PowerPoint.

On to Slide 38, Sutherland versus Bethesda, I have an image of this here, it is basically what ended up happening. In the situation. Sandra was # 0, hospitalized for two weeks after a heart attack. The hospital insisted on using VRI during her stay and never provided her with an on site interpreter. What's ironic about this case, about 10 years prior, that very same hospital had been disciplined by the Department of Justice for not providing accommodations at all. Now they're providing an accommodation, but they're providing one that is ineffective. The VRI regularly malfunctioned and during the stay she underwent a procedure before which the doctor was out and the VRI machine, it wasn't effective, it resorted to gesturing his communication which, of course, brings all kinds of concerns about consent and any kind of paperwork that would need to be processed p obviously she was not pleased and ended up with a complication after the procedure and she ended up in the ICU where a nurse when she -- when she woke up, woke up from a short coma, the nurse provided her only written information about the medication that she was being given. Again, obviously, ineffective communication, and a very stressful experience regarding healthcare for this women. Her case was seen in addition to others that were brought against Bethesda but this was the worst of the cases. If you're interested in that case, I can get you the settlement citation.

One last one, Silva versus Baptist hospital in Miami, in 2017Silva along with others brought in the suit, but particularly these patients visited two hospitals that were under the same parent company and were denied interpreters, the hospital chose to rely on a problematic VRE set up and family and friends when that failed.

The 11th circuit court said that -- oh, the hospital tried to say that they were not -- the parent company, excuse me, the parent company tried to say that they should not be sued because they are just the owning company, they were not providing be direct service but the 11th circuit court said it doesn't matter if you're not providing direct service if you are the company responsible for this organization then you are liable.

Also in this case, I think it is on slide -- a slide coming up.

The hospital also tried to argue that nothing bad happened to these patients on these occasions where effective communication was not garnered and therefore they should not be held liable and the 11th circuit court said that the outcome of the situation does not glee gate the responsibility of providing effective communication or providing accommodations. It is kind of the idea of there is a law saying everybody hases to wear seatbelts, it doesn't matter if you get in an accident or not, you still have to wear the seatbelt.

Slide 40. So this is a use of VRI, I call it a Cinderella story, this is the best example of best practices, equitable service, et cetera. This story is from Sutter health systems, they wanted to start using VRI. There was already a -- the deaf communication is not crazy about using VRI, they don't love it usually. I don't know if this one in Fremont is set up nearly across the street from the school for the deaf which is a -- obviously a central location for a lot of deaf community activity.

A prominent deaf community member got wind of Sutter health system wanting to use VRI and sent a video around social media saying that Sutter was going to force all deaf people to use VRI from now on, there wouldn't be anymore options for on site interpreters, the deaf community responded accordingly with complaints and in response, Sutter actually arranged a community forum with the local deaf community and specifically solicited the deaf community for feedback and concerns why are they feeling this way, what was going on, what could Sutter do to meet them, to meet the demands and the result was that Sutter established a community-based deaf-led, deaf culture and VRI training program that any department in the hospital if they want to begin using VRI, the department must complete this training led by a local deaf community member that they bring in to the hospital. The department has to complete the training and then only then will they gain access to the use of the machines of VRI and they also have a -- they maintain a policy that on site interpreters must remain the respected accommodation option for deaf patients or possible.

They also have a policy of maintenance to make sure that there's somebody that's checking the VRI equipment regularly to make sure that it is working.

Since then, there has been a great relationship between Sutter health systems and the deaf community, everyone seems very satisfied, VRI is used there for deaf patients who accept it and it is also not the only option. That to me is above and beyond what a medical facility could do for their deaf community, deaf population.

Slide 41, again, best practice, just be transparent with the patients. If you are trying to use VRI be upfront with them, don't leave them assuming that you're getting an on site interpreter and have them show up and big surprise, there is no on site interpreter and it is actually a machine. You can use VRI as a stop gap for communication needs until an on site interpreter can arrive.

Train your people before they're allowed access to it. Require semi frequent refresher trainings. Designate an employee two four to test the equipment every so often, maybe once a month but especially before the services will be needed for an appointment. Supplement communication with visual aids and going back to that idea of posters, videos that you can pull up in an appointment with your deaf person. Slide 42, so again with the visual resources I can't stress it enough, if you can show a deaf person what's going on instead of just tell them, this is very helpful, the idea of a picture is worth,000 words. The idea that literacy is not optimal in some cases so just like hearing patients who are not literate in English, how would you approach care in these situations?

Get with the interpreter, avoid saying tell him, tell her, let them know, just speak in first person, that's considered most respectful to the deaf person. Do not ever gamble with talking in front of the deaf person and then telling the interpreter don't interpret that. As interpreters, we're ethically there to interpret all communication that happens. I had a doctor one time talking to other providers in the situation, but right next to the deaf person in vicinity talking about the fact that this woman was pregnant and she didn't know and then the woman, of course, reacts and the doctor is upset with me because I have been interpreting this whole time.

You wouldn't speak like that in front of a hearing patient. Why would you assume that you can do it in front of a deaf patient? It is kind of disrespectful.

Be careful you don't hand the patient paperwork to the interpreter. This happens more often than you think. As an interpreter, I have no business seeing the deaf person's personal paperwork. Again, use the clients as resources, use the patients as resources. They know best how to communicate most effectively and then also this is the best practice thing for pediatric inclusion and language modeling. So you might have a 6-year-old patient, a 5-year-old deaf patient with hearing parents. The parents are making the medical decisions but just because the parents are the ones making the decisions, should you not provide an interpreter and exclude that young, deaf patient. How much would you interact with your pediatric patients, how much would you talk to them? Just because they're deaf, that doesn't change, think about providing that accommodation for effective communication. We're running overtime a little bit in terms of running into our question and answer time. That finishes up my slides.

I will take questions now.

Robin Jones

Thank you very much.

It was a good discussion around these particular issues.

At this time we would welcome you to submit your questions for us. Direct your question to the presenter today and we'll see if we have any questions for anyone on the telephone before we start.


I would like to remind everyone to ask a question, press 4 and number one on the phone key pad. Again, that's star, then the number 1 # and then telephone key pad. We'll pause for a moment.

Robin Jones

We have some questions submitted on the webinar platform. Go ahead and start with those. What if the interpreter was not requested by the patient prior to the lab appointment, are they required to pay?

Shannon Montinho

No. If a deaf person shows up with their own interpreter, that's not been prearranged or no contract was signed by the hospital or practice, no. You're not responsible to retroactively pay that interpreter.

Robin Jones

What's best practice, to reschedule and address the communication needs at that time?

Shannon Montinho

It depends on the nature of the visit.

If it is just a lab draw, I don't personally necessarily see that, the need for rescheduling a lab draw. If it is a more in-depth appointment involving more complicated interaction, diagnosis, discussion of treatment plan, then I would say rescheduling sounds reasonable.

If they prefer to use their own interpreter, they can. Even if that interpreter is a family member in some circumstances they can. Sometimes it gets a little tricky with state laws regarding who can legally function as an interpreter. So long as that interpreter that they have brought personally is an adult this can be -- it is in most cases -- it is illegal, strongly discouraged from using children as interpreters. There are a couple of case laws that I can get to you later if you email me regarding instances where children were used as interpreters and it was -- it resulted in some negative results and the hospitals were later sued for using children as interpreters.

As long as that person is an adult, then it is possible. Yes, they could be used as an interpreter depending on the nature of the visit.

Robin Jones

Good. Thank you.

Robin Jones

I have another question.

Let's go back to the phone.

The questions on the phone --


Yes. I have a question. It comes from the --

Robin Jones

Go ahead.

Robin Jones

Check, make sure that your mute is not on, your line is active. Go ahead.


Is this my line? I'm not sure.

Robin Jones

Yes. It is. Go ahead.


My question is, I know of people who for example in OB/GYN setting or having a vaginal exam have been told that they have to use VRI and they didn't feel comfortable because of being on the screen undressed. They were still told that they had to use VRI. Can you address that?

Shannon Montinho

Sure. Thank you for the question.

I would be curious as to number one, the reasons why they're told they have to use VRI. Language like that, I would hesitate to take it at its word.

In terms of not wanting to possibly be on screen, unclothed, et cetera, in those kinds of situations is absolutely reasonable. There is an option if the patient desires to turn the VRI off in certain situations. Same as you might ask a live interpreter for any kind of invasive exam to just step out of the room for a moment and then they can be right back. It depends on the preference of the deaf person, what they choose. I would start at the beginning of why they're being told that they must use VRI and then no other accommodation is considered.


What they were told is that the hospital has a contract and that's the equal access that they're providing.

Robin Jones

Basically they're saying it was their only option.



Shannon Montinho


So just because a hospital has a contract with VRI service doesn't mean that that then becomes the only option. They obviously are still very capable of hiring an on site interpreter. Again, if that's the situation obviously it is hard to stop in the middle of everything and talk about interpreter stuff.

There is always an option to turn the VRI machine off for that part of the exam that is -- where a patient may be exposed.

There is also hopefully the ability to move the VRI machine so that in using your example the machine would be closer to the patients face, the camera would only be facing the patients' face and not getting a full image of the full room in questionable angles, et cetera.


They were really concerned about being filmed and somebody having that document basically.

Shannon Montinho

VRI calls are not recorded. There wouldn't be a document after the fact.

Again, I can -- I would want to revisit the idea of we have a contract, therefore it is the only option.

What are gee going to do if a deaf, blind person shows up and they say this is the only accommodation we have because we have a contract. It is not effective. They have to figure out something else. If they can figure out something else for that deaf-blind person, why can't they figure that out for a deaf patient in this kind ever situation.


Absolutely. Thank you.

Shannon Montinho

You're welcome.

Robin Jones

Someone is asking about Hippa and what interpreter can and cannot --

Shannon Montinho

Interpreters, they adhere to a strict code of ethics that has basically the exact same confidentiality, it is not more can have confidentiality regarding patient information. In fact, sometimes I know that providers can be so concerned about confidentiality and Hippa, they don't want to disclose information to an interpreter in the context of an appointment or something like that. It actually hinders an interpreter's ability to do the job to facilitate communication, that's all -- we're not collecting any kind ever documentation about it, have a very strict ethical confidentiality restrictions and our license could be in jeopardy if we vie light those. In regards to that, there should be no problem with an interpreter being there for the knity, gritty details.

Robin Jones

If they choose to use a family number to interpret what risks regarding confidentiality are on the hospital staff tore providing information to a family member.

Shannon Montinho

I would start with the patient, are they comfortable using that family member, is the family member an adult, if a child, I would say confidentiality doesn't even come into play, that's a big no. No. If the family member is an adult and the patient agrees to use the family member, then I would say treat it as any patient that walks in with a family member. Do you sensor any information for that hearing patient or do you allow the family member into that intimate setting?

If the patient has any qualm was using the family member as an interpreter, then obviously I would respect that and keep in mind that family members because they're not trained interpreterses a lot of the time because they also sometimes struggle with fluency, they're not going to be your best bet for proving that you're complying with these federal requirements of providing effective -- of achieving effective communication. You know, you can use that family member but then if you are taken to court or sat in front of a panel of judges saying, you know, did you do your best to find a qualified interpreter as in the ADA, you're going to be able -- want to be be able to back that up.

Robin Jones

A couple are asking about -- one was what is the particular standard rate for interpreting and the other, do you have an idea of what is the cost for a basic setup of a VRI?

Shannon Montinho

I do not know the average cost.

Again, mine was -- my example that I did, it was just an example, and it was actually from a colleague of mine who had done a presentation a few years ago. The cost may have changed in that time.

I would suggest just calling a company that provides VRI and ask for consultation, ask for their rates. They would best be able to advise you on what getting set up would look like financially and logistically.

Robin Jones

What about do we know anything about the cost of the setup at all, have you had experience with that?

Shannon Montinho

I have not. I don't know if -- I mean, regarding the equipment needed, you'll need a camera, speakers, I don't know if your hospital may have some of that already or if it has to be special VRI equipment provided to you by the company. Again, I would call the VRI company and get that squared away with them.

Robin Jones

Great. Thank you.

The question here, they have heard of situations where hospitals who use VRI also had a none certified signer going temporarily when the VRI -- do you feel that's illegal also?

Shannon Montinho

It depends on what state you're in. So in the State of Illinois that would not be legal because of our state laws regarding who can function as an interpreter in medical settings.

In New York, that might be an option because they don't have any state laws. I know that in Washington DC, while they may not have any state laws regarding that kind of thing, they have such a high standard and small community of users that that may not be acceptable and you may get in hot water quickly.

Just depending on your state.

Your state law in terms of what's legal. Now again, I would caution is this person that's uncertified, are they qualified? Just because you're not certified doesn't necessarily mean that you're not qualified.

You know, what makes them credentialed or what makes them sitting for this situation. If they're not able to provide that communication effectively, then, yeah, I would say just hold on until you can get the VRI working again or until you can get a qualified certified interpreter.

Robin Jones

Another question you have, do you have any suggestions of who a patient should ask for when they're trying to get effective communication access at a hospital? In the past, there used to be patients or advocates, that person, the ifings didn't seem to be around anymore and the current healthcare system, do you have any suggestions?

Shannon Montinho

That is a great question. Unfortunately, there is no good answer.

Every hospital has it set up differently. Sometimes you will see services sometimes it is patient advocacy that the patient advocate office, sometimes patient relations and sometimes depending on o how the hospital has billing set up, each department is responsible for procuring their own services. It gets really complicated. If you have access to a social worker, sometimes they know who to get in touch with within the hospital and then some hospitals will have an ADA coordinatedder so you may want to check if the hospital has that.

Really, it does take a little bit of leg work on the part of the patient sometimes to justifying out who to talk to and how to get to that correct person.

Robin Jones

Someone here said they're a male interpreter and they have interpreted OB and child birth for individuals who were deaf and feel that the doctor was always good about something if it was private asking him to leave the room.

They were just providing that little insight there from their own personal experience with a previous question.

We're at the bottom of the hour, I don't want to leave them up, anyone else on the telephone that had questions. Anyone in the queue?


A question comes from a line. Go ahead and ask your question.


Hello. We had a situation in our hospital where a patient who was not deaf had a family member who was deaf and the family member was asking for an interpreter for himself. The patient -- he was not a patient. I thought the appropriate thing was to get the interpreter as soon as possible, it was an emergency department situation, I Figure if the patient herself collapsed or faints or anything, the decision maker then becomes that family member that was with the patient but they were telling the patient, no, you know, you're not the patient. We'll get you the video machine. The patient family member had visual issues and couldn't use the video machine. I wonder for all of the situations where patients come to clinics, for example, that are not deaf and they bring their family member, what will be the appropriate thing, should we get interpreters in our organization or do we only provide video interpreters where there is last-minute situations while an interpreter gets here or when, you know, there is situations like the lag situation or we know people are okay with the video machine, if not we'll get an interpreter regardless and we try to learn about our patient ahead of time.

Shannon Montinho


This is a very common question.

Does the right to accommodation, effective communication extend to companions, to family and friends who show up with patients?

The answer is yes. In most situations -- and again, like you said, if something happens with the patient, then that family member, next of kin, whoever is there, will become a resource for you as to how to proceed.

Also in cases where maybe a mother is hearing but the father is deaf and they are scheduled for a Lamaz class, you know, technically the mother is the patient, but the father is going to be a part of that care as well and also has the rights to effective communication. In a lot of cases, hearing patient, the care team, the family members, the deaf family members may be the ones responsible for caring for them after post op, whatever it may be, and in cases where maybe a parent is aging, deaf child is becoming their caregiver, those rights extend to family members, the patient is hearing, family members, they are protected, in terms of having the right to an accommodation and the instinct is right, they ever a right to an interpreter, when they get -- they have a right to an accommodation and you have to find out what accommodation is effective. Just because they're not the patient doesn't mean they're stuck with whatever accommodation is most convenient or is left over.

They are companion, they have a right to an effective communication, they have a right to an accommodation and that accommodation needs to be accessible to them.


Thank you.

Robin Jones

The real sum is that whoever they're communicating with that did not have a disability, you're communicating with them and the same holds true for the person, you know, who had a disability. If you're communicating with their family members or friends or if they're the person with the disability or the family member is, you can think of it, take the disability out of it, we normally communicate with this person. Then you make sure that's effective.

We're at the bottom of the hour. I thank you, everyone, who participated in today's session.

I hope that you found this useful to you. We'll send out an email at the conclusion of the, we'll send out the evaluation and we appreciate your feedback, and how to obtain the recording of the session once it is available and ready to be posted. Thank you for your participation, the contact information for Shannon is on the screen and in your handout materials and if you would like, feel free to do so. if you have questions, just going back to follow-up to the session, make sure you have contact with your regional ADA center by calling 800-949-4232 or to find a center that serves your area, go to

Again, thank you very much. To closeout the session, hang up the telephone, if you're on the webinar platform, closeout to your browser or use the file exit option in the upper left-hand corner of the screen.

Thank you very much. Have a great day.