Why should the patient have to explain her needs and requirements over and over to every staff person and provider? Could an Accommodation alert on the EMR header plus a comment field accessible to all staff detailing the patient’s accommodation needs be the answer?
The case study
The female patient in her early 30’s was deaf from birth, had been using ASL lifelong. She did not verbalize. She lived alone and was socially isolated. She got through each day but was not strong on planning ahead for potential problems. This patient also had progressive vision loss. In the past year she could only read small chunks of text if material was enlarged and bolded, which her clinic did for her. She could no longer see well enough to follow sign language. She had been using Tactile sign language for about a year now at her family practice clinic visits. The staff knew her and always requested a Tactile interpreter. However, her language of record in the hospital EMR still showed as ASL. There was no accommodation FYI alert for this patient. (An FYI alert is a flag on the medical record header that links to a field describing the patient’s accommodation needs. It can be created by someone on the patient’s care team.)
The patient required exploratory surgery for abdominal pain. The Family Practice clinic referred her to the General Surgical clinic, which scheduled her for an exploratory laparotomy surgery and a likely two- to three-day inpatient stay. The hospital pre-admissions staff are responsible for arranging for language support for upcoming surgeries. They were unable to have the usual phone call with this patient because she did not have a videophone. The Pre-Admissions staff person saw that the language on the EMR header was ASL, so she made arrangements with an agency to book an ASL interpreter for surgery day. A letter was sent to the patient advising her of surgery arrival time.
The patient arrived two hours before surgery as directed. An ASL interpreter was there. The Surgeon, the pre-op nurse, and the anesthesiologist all needed to converse with the patient to review her condition, her procedure, her risks, and her consent for various contingencies. The patient was stressed because of the surgery. She could not see the ASL interpreter well enough to have the conversation. The ASL interpreter was not skilled in Tactile. The patient and the care team were frustrated and felt that they were not able to communicate, but they went ahead with the surgical procedure because they knew how difficult it was for the patient to make arrangements for care. The Recovery Room experience was just as poor, with a different interpreter who was not skilled in Tactile.
When the inpatient floor received the patient from Recovery they again requested an ASL interpreter because they had no EMR FYI alert about detailed accommodation needs to guide them. Hospital staff, who could not communicate with the patient, assumed that the patient had low language skills in general and simply could not make good use of the provided interpreter. As a result, the patient went through her entire inpatient stay with no effective communication. She was discharged home without understanding her self-care instructions or her meds. She was given normal format written discharge instructions, which she could not see.
This case is an example of the hospital being out of compliance with regulatory guidelines, in that the patient did not receive the accommodation she required for communication. An Accommodation Alert on the EMR header, connected to a text field with the comment below, could have ensured a properly supportive health care experience: “Patient fluent in ASL but now uses Tactile due to deteriorating vision. Needs very large bold font for written materials, keep brief.” And her language of record should have been updated by clinic staff when she started using Tactile.
Collaboration between the language access program manager, IT, and the owners of the EMR banner real estate is key to mitigating this risk. The task is to place explanatory text comments in the EMR, which are visible to all staff and providers, related to the specific accommodation needs of a patient.
Many patients have specific needs that should be clearly visible to all staff on the EMR banner, such as:
The patient is a hearing child with one deaf parent;
The patient is developmentally delayed and is non-verbal himself, but has an attendant who speaks Tagalog
The patient comes from a Spanish-speaking family and is Deaf herself, using ASL, when she comes for care she needs both ASL for herself and Spanish for her husband when he accompanies her
The patient is deafened late in life due to a brain tumor, does not use ASL, instead uses CART
The patient is hearing but needs accommodation to speak due to a tracheostomy, low vision/needs help filling in forms, etc.
Each EMR Electronic Medical Record program is configured differently. Most have some Registration Comment field in the header which can be used for critical information about patient accommodation needs. Yet most hospitals and clinic systems prevent staff from using these text fields out of fear that staff will enter inappropriate comments about the patients.
Instead of wasting these critical text fields, HC organizations can commit to managing them properly.
If space on the banner is fiercely competed for, create a flag that means ACCOMODATION ALERT. When the flag is turned on, any staff person can click on the alert and see the full text of the alert.
To assure appropriate content in the Alert text file, specific protocols are disseminated to staff related to the permissible types of content, phrasing, and validation and maintenance procedures. To audit the content for proper entries, a manager in Interpreter Services or Patient Access Services should review all entries in these text variables on a monthly basis so that confusing or inappropriate entries are corrected. Minimal effort would be required for this task as most patients do not require accommodation beyond straightforward interpretation.
Both patients and care teams are well served by making Accommodation Alerts visible in the EMR banner. The HC organization provides better care with this pro-active care alert and avoids liability for failure to provide necessary accommodation. The patient does not have to explain his or her needs to every staff person and provider.