By Steven Clark
Is she checking her blood sugars?
¿Ella se está monitoreando los niveles de azúcar?
Does she do this before breakfast?
¿Ella se chequea el azúcar antes del desayuno?
Do you have any questions?
¿Tiene alguna pregunta?
It’s been a month since the patient’s last visit, and Harris Leitstein, a nurse practitioner who works with diabetes patients, is sitting in his office in the SBH ambulatory care clinic across the desk from an elderly woman and her home attendant. He’s asking basic questions about the woman’s condition and her self-management. Both women only know Spanish and Leitstein speaks only English so interpreting for them is a middle aged woman whose image appears on an iPad mounted atop a rolling cart.
Leitstein asks the home attendant about the patient’s lowest and highest A1C numbers, whether she’s been compliant with her weekly injection and if the woman’s daughter, who speaks English, will be available to talk to him sometime during the appointment. The translation works seamlessly to everyone’s satisfaction.
“It works really nicely,” says Leitstein. “It’s much more personal than the old system (which was conducted by phone). I like this much better.”
Voyce, the 24/7/365 on-demand interpretation system, is a play off the name of its founder, Andrew Royce. The system is now used widely at SBH, with more than 120 of the devices being quite literally rolled out this fall to outpatient and inpatient units throughout the hospital. St. Barnabas Hospital is the first hospital in the Bronx to use Voyce.
A touch of the screen connects patients and providers with an interpreter in threeway conversations that can stretch to as many as nine, should family members or others be brought in remotely. The hospital views this as essential should there be a return to the pandemic conditions of the spring when visitation was restricted.
Initial discussions between SBH language access coordinator Lynette Alvarado and Voyce started nearly a year ago, with arrival of the machines delayed by Covid-19. In addition to interpreting for patients in the hospital, Alvarado sees Voyce playing a key role in SBH’s growing telehealth program. Up until now, it’s been found that patients who don’t speak English are among the slowest adopters of telehealth.
The app provides interpretation in 235 languages and dialects, including less commonly heard ones like Mandinka and Marshallese. At St. Barnabas Hospital, about 85 percent of patients on a given day speak Spanish – about 20 percent of whom speak it exclusively, says Alvarado.
“It’s not just about translation but providing interpretation in cultural and sociological terms as well,” she says. “This means understanding the Bronx glossary that accounts for different meanings and expressions in more than 20 different dialects from Puerto Rican, to Mexican, to Dominican. In addition to this, we’re also providing services during a time of Covid-19 when both doctors and patients are wearing masks, covering their facial expressions.”
Dr. Mariana Kawalet, a first-year medicine resident at SBH who participated in the pilot study, left impressed by the system. A native of Jordan, who doesn’t speak Spanish, she has been using the app with a half dozen patients daily. “It’s been much better for patients to see an interpreter, not just a voice, and vice versa. This provides more [facial] cues,” she says.
Andrew Royce, who started Voyce in 2015 and moved it into the health care sector two years later, understands the importance of being sensitive to the different sides of the Spanish language. “As we train the Spanish interpreters, we teach them about the different dialects and so they are educated about the type of terminology they may encounter,” he says. “There is a big difference between Dominican Spanish and Spanish from Uruguay or Argentina or Chile. Our interpreters aren’t just people who come from, say, Mexico. They are people who have learned the art of interpretation. They know culture and dialect. Spanish is just one language, but languages like Arabic are similar. A good interpreter knows how to tailor their dialect. And, if the hospital at some point in the future would like us to break it down so there are specific dialects they request, we are amenable to that.”
Royce got the vision for his company while volunteering in Montreal at a time when thousands of Syrian refugees arrived in Canada. “I saw firsthand that there was a lack of access for these people,” says Royce. “Whether it is healthcare or judicial or educational, languages are the first wall, so to speak. That was our initial focus. Obviously, it’s hard to build a business on asylum seekers. In fact, many times we donated the services.
“I realized there was a big gap in healthcare for these kinds of services. A lot of patients who walk through the hallways of hospitals don’t get good [language] services or any services at all, or the doctors and nurses will use a patient’s family member or friend, maybe even a 10- or 11-year-old kid to interpret. I saw that as an area where we could scale and we saw the growth even back then in telemedicine, at a time when obviously telemedicine didn’t have the adoption rate or maturity that it has now.”
So, the company started with an assortment of pharmacies across the country, eventually expanding to over 9,000, including major chains. They then signed on several safety net hospitals in New York City and New Jersey and in the Midwest.
While interpretation services are hardly new, Royce points to several things that set his company apart. “Our mission is that the patient deserves fundamentally better care at hospitals. Whatever we can do physically or technologically to improve that, that is our mission.”
The simplicity of the technology and ease of use, he says, plays a major role. “If you grew up without technology, it’s very user-friendly. It’s almost like a walkie talkie. On the back end it’s super complex, way beyond my own understanding of technology. But on the front end for a user like you or me it’s very simple. This, along with the telehealth capabilities and ability to integrate into the electronic health records and into other telemedicine platforms, is key.”
A key area of differentiation, says Royce, is the caliber of his interpreters. “We have an extremely rigorous process for qualifying them,” he says. “We do continuous education and HIPAA testing once per year. Medical terminology testing. There are very, very high standards and, frankly, half the applicants fail our exam.”
Royce takes pride in the fact that his translators, the number of which he says are into the thousands, often appear on screen within a minute of being contacted. “If it’s a language like Tibetan, it may take up to five minutes. But we typically tell the user what the wait time will be. I had to wait 16 minutes the other day for a Uber. I didn’t want to wait, but at least I knew when they were coming.”
Another aspect that he considers beneficial is the mobility of his system. “At first I thought it was enough if you could just pull the app up on your phone,” he says. But I was a volunteer. If I were a doctor, and doing a delivery or an endoscopy, holding an iPhone doesn’t work. We saw the need for a sturdy, but slim mobile cart to keep the lines of communication open. It took us probably about a year to design the current modality. We realized you had to have a mobile device that can move quickly through the hospital. Frankly, sometimes the interpreter is on the phone while they are moving the cart.”
Royce says he’s heard stories where his device has directly impacted on the health or safety of a patient. “A hospital in Greenville, North Carolina that had just installed the device told us about a patient, a woman in the emergency room, who couldn’t speak or communicate, but was crying. Finally, someone said, ‘Grab the Voyce and get a sign language interpreter.’ They soon realized that she was deaf and knew sign language and through the interpreter found out that she was pregnant and going into labor. She was quickly rushed into labor and delivery and had her baby.”
As important, he says, is the ability to work with families and patients during the pandemic, something healthcare workers at SBH can certainly identify with. “This is when family members are having end-of-life conversations about loved ones who are alone in the hospital,” he says. “Understanding a provider in your own language offers some sense of dignity when you’re told that your husband or wife is passing away. At the very least, we can provide this during those tough and challenging moments.”