| Submitted By: Scott Stare
/ CMS Office of Minority Health
|
| Data Element Information |
| Rationale for Separate Consideration |
Preferred Language is a related data element to Interpreter Needed that is included in USCDI. Among an estimated 67.3 million people in the U.S. who speak a language other than English at home, 23 million individuals have limited English proficiency.1,2 Therefore, Preferred Language alone is not a sufficient indicator of English-language proficiency and thus is not an adequate proxy for identifying which patients among the non-English preference population need or prefer language services.
Collecting patients’ self-reported need for interpretation services, in tandem with Preferred Language, more accurately reflects language proficiency and subsequent language access service needs and preferences. Using the Interpreter Needed data element can assist health care organizations in providing more appropriate patient-centered care and eliminate guesswork or assumptions by health care teams regarding which patients need an interpreter, ultimately improving the patient experience. Without the Interpreter Needed data element, there is a significant barrier to important health data interoperability that may risk delaying and/or disrupting patient engagement.
1. Ziegler K, Camarota SA. 67.3 Million in the United States Spoke a Foreign Language at Home in 2018. Center for Immigration Studies. October 2019. Accessed May 19, 2023. Retrieved from https://cis.org/Report/673-Million-United-States-Spoke-Foreign-Language-Home-2018
2. Zong J, Batalova J. The Limited English Proficient Population in the United States in 2013. Migration Policy Institute. July 8, 2015. Accessed May 19, 2023. Retrieved from https://www.migrationpolicy.org/article/limited-english-proficient-population-united-states-2013 |
| Use Case Description(s) |
| Use Case Description |
Delivering Person-Centered Care:
Interpretation services improve patient comprehension of clinician discussions and patient care quality.1 Interpreter Needed data is routinely collected and used in both inpatient and outpatient hospital settings. Patients are typically asked by administrative staff whether they need an interpreter as part of the registration or scheduling process. Once the need for an interpreter is captured in the electronic health record (EHR), often as a structured field (e.g., check-box or dropdown menu), administrative staff or providers use this information to arrange for interpretation services to be available during the encounter. Collecting Interpreter Needed also facilitates services for patients with communication needs beyond spoken language, such as indication for an American Sign Language interpreter.
Referrals:
Exchanging data on a patients’ interpretation needs facilitates transfers of care and referrals to specialty care and social care organizations. Within health systems, a patient’s need for an interpreter is often exchanged as free text in an administrative or clinical note or through emails and phone calls. If the Interpreter Needed data element was included in the USCDI, the data element would be exchanged in a standardized, highly visible format, allowing specialists’ offices to arrange for interpretation services in advance of the patient’s appointment, creating efficiencies in workflows, ensuring patients can be seen during a scheduled visit, and providing patients with a more positive care experience. Exchanging this information may also decrease the likelihood patients are lost to follow-up care due to scheduling issues. Similar efficiencies can also be realized for referrals to social services organizations using care coordination platforms (e.g., Unite Us®) as well as transitions of care, such as patients moving to long-term care facilities.
Improve Outcomes of Care:
Individuals with low English proficiency (LEP) have been shown to receive worse care and have poorer health outcomes, including higher readmission rates.2-4 Communication with individuals with LEP is an important component of high-quality health care, which starts by understanding the population in need of language services. Unaddressed language barriers between a patient and their care team can negatively affect the ability to identify and address individual medical and non-medical care needs, to convey and understand clinical information, including discharge and follow-up instructions, all of which are necessary for providing high-quality care. Understanding the communication assistance needs of patients with LEP, including individuals who are deaf or hard of hearing, can address these language barriers and is critical for ensuring good outcomes.
The need for an interpreter, along with preferred language, are included as standardized patient assessment data elements for four Post-Acute Care (PAC) Quality Reporting Programs: Long-Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs).5-8 Prior to adopting these questionnaire items, PAC considered recommendations from the HHS Data Standard for Primary Language and the National Academies of Sciences, Engineering, and Medicine (NASEM) 2009 report to use a two-part question assessing spoken language, but PAC finalized the two items used today (i.e., collecting Preferred Language and Interpreter Needed) since they are not limited to only ‘spoken’ language.9
Sources:
1. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-754. doi:10.1111/j.1475-6773.2006.00629.x
2. Karliner, L. S., Kim, S. E., Meltzer, D. O., & Auerbach, A. D. (2010). Influence of language barriers on outcomes of hospital care for general medicine inpatients. Journal of Hospital Medicine, 5(5), 276–282. https://doi.org/10.1002/jhm.658
3. Kim, E. J., Kim, T., Paasche-Orlow, M. K., Rose, A. J., & Hanchate, A. D. (2017). Disparities in hypertension associated with limited English proficiency. Journal of General Internal Medicine, 32(6), 632–639. https://doi.org/10.1007/s11606-017-3999-9
4. National Academies of Sciences, Engineering, and Medicine. (2016). Accounting for social risk factors in Medicare payment: Identifying social risk factors. Washington, DC: The National Academies Press.
5. Centers for Medicare & Medicaid Services. LTCH CARE Data Set & LTCH QRP Manual. October 01, 2022. Accessed September 12, 2023. Retrieved from: https://www.cms.gov/medicare/quality/long-term-care-hospital/ltch-care-data-set-ltch-qrp-manual
6. Centers for Medicare & Medicaid Services. IRF-PAI. October 01, 2022. Accessed September 12, 2023. Retrieved from: https://www.cms.gov/medicare/payment/prospective-payment-systems/inpatient-rehabilitation/pai
7. Centers for Medicare & Medicaid Services. Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual. October 01, 2022. Accessed September 12, 2023. Retrieved from: https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual
8. Centers for Medicare & Medicaid Services. OASIS User Manuals. December 14, 2022. Accessed September 12, 2023. Retrieved from: https://www.cms.gov/medicare/quality/home-health/oasis-user-manuals
9. RTI International, RAND Corporation. Final Specifications for SNF QRP Quality Measures and Standardized Patient Assessment Data Elements (SPADEs). July 2019. Accessed September 08, 2023. Retrieved from: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/final-specifications-for-snf-qrp-quality-measures-and-spades.pdf |
| Estimate the breadth of applicability of the use case(s) for this data element
|
(Level 2)
Literature suggests that interpretation services represent both a growing and unmet need in the U.S. health care system.1 Furthermore, interpretation needs are increasing among safety net providers, such as the 1,4002 community health centers (CHCs) that provide primary care to some of the most vulnerable populations.3 The Health Resources & Services Administration requires CHCs to report the number of patients “best served in another language” as part of Uniform Data System.4 Additionally, nearly 30,000 PAC providers5 among LTCHs, IRFs, SNFs, and HHAs collect Interpreter Needed data and report quarterly to CMS through the Internet Quality Improvement and Evaluation System (iQIES).
We anticipate that Interpreter Needed data would be commonly used in these settings, as well as in the 407 health systems5 currently operating in the U.S. Approximately 96% of non-federal acute care hospitals and 78% of office-based physicians utilize certified EHRs,6 indicating that electronic capture of Interpreter Needed can be ubiquitous. As such, we anticipate that a significant proportion of the roughly 945,952 physicians7 currently working nationally would capture, access, and exchange Interpreter Needed data.
Sources:
1. Taira BR, Kim K, Mody N. Hospital and Health System-Level Interventions to Improve Care for Limited English Proficiency Patients: A Systematic Review. Jt Comm J Qual Patient Saf. 2019;45(6):446-458. Doi:10.1016/j.jcjq.2019.02.005
2. Bureau of Primary Health Care. Health Center Program: Impact and Growth. Health Resources and Services Administration. Reviewed August 2022. Accessed July 11, 2023. Retrieved from https://bphc.hrsa.gov/about-health-centers/health-center-program-impact-growth#:~:text=HRSA%20funds%20nearly%201%2C400%20health,more%20than%2030%20million%20people.
3. Regenstein M, Park YH, Krips M. The Use of Interpreters in Health Centers: A Mixed-Methods Analysis. Journal of Health Care for the Poor and Underserved. 2023; 34(1), 224-245. doi:10.1353/hpu.2023.0015
4. Bureau of Primary Health Care. Uniform Data System 2022 Manual: Health Center Reporting requirements. Health Resources and Services Administration. 2022. Accessed May 17, 2023. Retrieved from https://bphc.hrsa.gov/sites/default/files/bphc/data-reporting/2022-uds-manual.pdf
5. Elizabeth PH, Beth C. CMS and ONC: Enabling Data Interoperability Across the Continuum [Conference session]. HIMSS Global Conference & Exhibition, Orlando, Florida. February 11-15, 2019. Accessed September 08.2023. Retrieved from https://365.himss.org/sites/himss365/files/365/handouts/552692753/handout-101.pdf?_ga=2.175135138.1075935813.1551912875-931449337.1548954117&_gac=1.124679544.1548954118.Cj0KCQiA1sriBRD-ARIsABYdwwGtnvjAVVBIypUBVCOoBvIjyyXaNl21y2Zw82lp3segejOLVHMy2XIaAh3eEALw_wcB
6. American Hospital Association. Fast Facts: U.S. Health Systems. 2023. Accessed July 11, 2023. Retrieved from https://www.aha.org/system/files/media/file/2023/04/Fast-Facts-US-Health-Systems-Infographic-2023.pdf.
7. Office of the National Coordinator for Health Information Technology. National Trends in Hospital and Physician Adoption of Electronic Health Records. 2021. Accessed August 25, 2023. Retrieved from https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records
8. Association of American Medical Colleges. Active Physicians by Age and Specialty, 2021. Accessed July 11, 2023. Retrieved from https://www.aamc.org/data-reports/workforce/data/active-physicians-age-specialty-2021 |
| Use Case Description |
Public health reporting:
Among the 3,000 state, local, tribal, and territorial public health departments1 operating nationally, the standardized collection and exchange of the Interpreter Needed data element has the potential to benefit public health reporting, such as disease surveillance. For example, some mandated public health reporting triggers contact tracing, and information on individuals’ interpretation needs could support public health officials in providing interpretation services to facilitate the contract tracing processes.
Health care administration:
Interpreter Needed data could assist health care organizations in improving their provision of interpretation services. By collecting data on how many patients require interpretation services, as well as the languages commonly requested, providers can more accurately assess and tailor the services required to adequately serve their patient population, e.g. provide in-person interpretation services for the most commonly requested languages, and offer telephonic/virtual interpretation services for less commonly requested languages. Interpreter Needed data can also facilitate efforts to meet the standard for communication and language assistance as defined in the National Culturally and Linguistically Appropriate Services (CLAS).2 Finally, inclusion of the measure to Create and Implement a Language Access Plan that adheres to the CLAS standards in value-based payment programs, such as the Merit-based Incentive Payment System,3 signals potential for inclusion in future quality measures related to language access.
Health equity research:
Collecting Interpreter Needed data could facilitate health equity research, including clinical and translational research and comparative clinical effectiveness research. Preferred Language is often used as a proxy for Interpreter Needed, even though these are not interchangeable concepts. As such, much of the EHR-derived research on English proficiency-related disparities in care are based on Preferred Language. Access to more accurate data on interpretation needs could assist researchers in more granularly identifying important health disparities among patients with non-English language preference, and longitudinally track disparities over time.
Alignment with federal reporting requirements:
Inclusion of the Interpreter Needed data element in the USCDI could help to align existing data collection requirements with other federal efforts, potentially streamlining data reporting processes for health care organizations. For example, including Interpreter Needed in the USCDI would align with HRSA’s Uniform Data System reporting requirements, which may be helpful to reduce burden for CHCs that are already reporting the number of patients “best served in another language.”4 Additionally, CMS receives Preferred Language and Interpreter Needed data collected through PAC assessments among LTCHs, IRFs, SNFs, and HHAs.5 Including Interpreter Needed in the USCDI may also align with data collection efforts of non-health care agencies, like the U.S. Department of Housing and Urban Development (HUD).6
Sources:
1. The Commonwealth Fund Commission on a National Public Health System. Meeting America’s Public Health Challenge: Recommendations for Building a National Public Health System That Addresses Ongoing and Future Health Crises, Advances Equity, and Earns Trust. June 2022. Accessed July 11, 2023. Retrieved from: https://www.commonwealthfund.org/sites/default/files/2022-06/TCF-002%20National%20Public%20Heath%20System%20Report-r4-final.pdf
2. U.S. Department of Health and Human Services Office of Minority Health. National Culturally and Linguistically Appropriate Services Standards. 2023. Accessed August 25, 2023. Retrieved from: https://thinkculturalhealth.hhs.gov/clas/standards
3. U.S. Centers for Medicare & Medicaid Services Quality Payment Program. Traditional MIPS: Explore Measures & Activities. 2023. Accessed August 28, 2023. Retrieved from: https://qpp.cms.gov/mips/explore-measures?tab=improvementActivities&py=2023
4. Bureau of Primary Health Care. Uniform Data System 2022 Manual: Health Center Reporting requirements. Health Resources and Services Administration. 2022. Accessed May 17, 2023. Retrieved from https://bphc.hrsa.gov/sites/default/files/bphc/data-reporting/2022-uds-manual.pdf
5. Centers for Medicare & Medicaid Services. CMS Data Element Library. Accessed September 08, 2023. Retrieved from: https://del.cms.gov/DELWeb/pubHome
6. US Department of Housing and Urban Development. Language Access Plan. Accessed May 19, 2023. Retrieved from: https://www.hud.gov/sites/dfiles/FHEO/documents/HUD_Language_Access_Plan.pdf |
| Estimate the breadth of applicability of the use case(s) for this data element
|
(Level 2)
Delivering person-centered care and managing referrals:
Hospital systems, ambulatory care providers, medical specialists, CHCs, and social services organizations that serve patients with non-English language preference (representing roughly 945,952 active physicians).1
Public health reporting:
Roughly 3,000 state, local, tribal, and territorial public health departments conducting mandatory contract tracing.2
Federal reporting requirements:
Any federal agency currently collecting information on language services, including the Agency for Healthcare Research and Quality (AHRQ), CMS, HRSA, and HUD.
Health equity research:
Academic, government, and private industry stakeholders interested in conducting health equity research related to patients with non-English language preference.
Sources:
1. Association of American Medical Colleges. Active Physicians by Age and Specialty, 2021. Accessed July 11, 2023. Retrieved from https://www.aamc.org/data-reports/workforce/data/active-physicians-age-specialty-2021
2. The Commonwealth Fund Commission on a National Public Health System. Meeting America’s Public Health Challenge: Recommendations for Building a National Public Health System That Addresses Ongoing and Future Health Crises, Advances Equity, and Earns Trust. June 2022. Accessed July 11, 2023. Retrieved from: https://www.commonwealthfund.org/sites/default/files/2022-06/TCF-002%20National%20Public%20Heath%20System%20Report-r4-final.pdf |
| ONC Priority |
- Mitigate health and health care inequities and disparities
- Address the needs of underserved communities
- Address public health interoperability needs of reporting, investigation, and emergency response
|
| Maturity of Use and Technical Specifications for Data Element |
| Applicable Standard(s) |
LOINC code 54588-9 corresponds to Interpreter Needed. SNOMED CT code 315593009 also corresponds to Interpreter Needed.
https://loinc.org/54588-9 and https://browser.ihtsdotools.org/?perspective=full&conceptId1=315593009&edition=MAIN/SNOMEDCT-US/2023-03-01&release=&languages=en
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| Additional Specifications |
The FHIR data exchange standard provides an extension to the FHIR Patient Resource— Interpreter Required—that would allow standard exchange of this data element: http://hl7.org/fhir/extensions/StructureDefinition-patient-interpreterRequired.html |
| Current Use |
(Level 2) Captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer |
| Extent of exchange
|
(Level 2) Between more than two production EHRs or other HIT modules using available interoperability standards |
| Supporting Artifacts |
Representatives from two top EHR developers that hold the majority of the market share for U.S. hospitals and 70% of hospital beds1 noted during key informant discussions that their respective EHRs offer clients a field for capturing structured Interpreter Needed data as part of their standard health IT products (i.e., EHR) and have done so for several years. Furthermore, representatives from both EHR developers indicated the vast majority of their clients (e.g., approximately 95%) routinely collect and use this data, typically as a required field (i.e., a field requiring a response to complete the form) in the demographics form.
A majority of the health systems interviewed also described regularly collecting Interpreter Needed data and documenting this information in the EHR using structured data fields. Those interviewed represented a variety of health care stakeholders including large academic medical centers, Federally Qualified Health Centers, integrated delivery systems, and acute care.
HRSA’s UDS requires CHCs to report the number of patients best served in a language other than English, and specifically references “patients who were served in a second language by a bilingual provider and those who may have brought their own interpreter.”2
CMS requires collection of both Preferred Language and Interpreter Needed in standardized patient assessments for four PAC Quality Reporting Programs: LTCH, IRF, SNF, and HHA facilities.3 These facilities transmit data to CMS on a quarterly basis using LOINC-coded data fields A1110A (what is your preferred language?) and A1110B (need for interpreter). SNF and LTCH facilities have been collecting Interpreter Needed information for more than five years.3
The Joint Commission and AHRQ have also encouraged the capture of patient language access needs as structured EHR data.4,5
It is likely that the Interpreter Needed data element is exchanged to some extent among health care organizations due to reporting requirements by CMS PAC assessments. PAC settings have been collecting interpreter need information for several years, and many of them are members of larger health systems with interoperable EHRs or are members of health information exchanges. Furthermore, representatives from multiple EHR developers stated that, given the existing LOINC standard, the Interpreter Needed data element could be implemented with minimal time burden and complexity.
Sources:
1. Holmgren AJ, Apathy NC. Trends in US Hospital Electronic Health Record Vendor Market Concentration, 2012-2021 [published online ahead of print, 2022 Nov 8]. J Gen Intern Med. 2022;10.1007/s11606-022-07917-3. doi:10.1007/s11606-022-07917-3
2. Bureau of Primary Health Care. Uniform Data System 2022 Manual: Health Center Reporting requirements. Health Resources and Services Administration. 2022. Accessed May 17, 2023. Retrieved from https://bphc.hrsa.gov/sites/default/files/bphc/data-reporting/2022-uds-manual.pdf
3. Centers for Medicare & Medicaid Services. CMS Data Element Library. Accessed September 08, 2023. Retrieved from: https://del.cms.gov/DELWeb/pubHome
4. Medical Record - Preferred Language. The Joint Commission. Accessed May 17, 2023. Retrieved from https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/record-of-care-treatment-and-services-rc/000001373/
5. Defining Language Need and Categories for Collection. Agency for Healthcare Research and Quality. Updated May 2018. Accessed May 17, 2023. Retrieved from https://www.ahrq.gov/research/findings/final-reports/iomracereport/reldata4.html
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| Potential Challenges |
| Restrictions on Standardization (e.g. proprietary code) |
None identified. |
| Restrictions on Use (e.g. licensing, user fees) |
None identified. |
| Privacy and Security Concerns |
None identified. |
| Estimate of Overall Burden |
Stakeholders noted that health care organizations that currently collect Interpreter Needed data using a non-standardized field may be inconvenienced by a new requirement to map the data element to terminology standards. For the small number of health care organizations and providers that are not currently collecting Interpreter Needed data, adding this assessment to administrative workflows may slightly increase patient and staff time burden, for a brief period of implementation. |
| Other Implementation Challenges |
None identified. |
ONC Evaluation Details
Each submitted Data Element has been evaluated based on the following criteria. The overall Level classification is a composite of the maturity based on these individual criteria. This information can be used to identify areas that require additional work to raise the overall classification level and consideration for inclusion in future versions of USCDI
|
Criterion #1
Maturity - Current Standards |
Level 2
- Data element is represented by a terminology standard or SDO-balloted technical specification or implementation guide.
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Criterion #2
Maturity - Current Use
|
Level 2
- Data element is captured, stored, or accessed in multiple production EHRs or other HIT modules from more than one developer.
|
Criterion #3
Maturity - Current Exchange |
Level 2
- Data element is electronically exchanged between more than two production EHRs or other HIT modules of different developers using available interoperability standards.
|
Criterion #4
Use Case(s) - Breadth of Applicability |
Level 2
- Use cases apply to most care settings or specialties.
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Submitted by nedragarrett_CDC on
CDC's Comment for draft USCDI v5
In support of this data element. The need for interpreters underscores the critical role of communication especially in diverse societies where language barriers can impede access to care, affect the quality of services received, and impact health outcomes.
Moreover, language barriers can hinder the accurate collection of health data across different communities. Implementing an "Interpreter Needed" data element would ensure public health research and surveys are designed with language needs in mind, resulting in data that are both more inclusive and representative. Interpreters enable public health workers to accurately collect information during case investigations, provide guidance on quarantine measures, and understand the movement and interactions of individuals to control the spread of diseases. Additionally, in the context of emergency preparedness and response, comprehensible communication is essential. Identifying populations that require interpreter services enhances the efficiency and effectiveness of emergency communication and support, ensuring critical information reaches everyone in need.