Improving Documentation of Language Interpreter Use to Increase Compliance, Quality, and Safety

Abstract

Introduction:

The standard of care for language interpretation in healthcare encounters is well established and supported by civil rights law and hospital policy. However, the use of language interpreters for healthcare communication is inconsistent for families who use languages other than English. To promote interpreter use and improve compliance, a quality improvement team implemented a project to enhance documentation of interpreter use in clinical notes.

Methods:

The team developed a rule-based electronic health record tool to prompt documentation of interpreter use for the right patient at the right time. The team piloted and revised the tool in a primary care setting, and then implemented and disseminated it in a more complex inpatient pediatric hospital setting. The team measured compliance with documentation in hospital pediatric history and physical and discharge summary notes using statistical process control p-charts. Balancing measures included the authors’ time spent documenting interpreter use and perceived difficulty in documenting in the clinical notes.

Results:

On the hospital pediatrics service, the rate of compliant documentation in history and physical notes increased from 15% to 74% and was sustained for 14 months. Compliant documentation for discharge summary notes increased from 11% to 93% and sustained for 14 months.

Conclusions:

Electronic health record tools designed to document interpreter use can effectively prompt and monitor compliance through integrated and rule-based systems. Thus, they are essential for comprehensive quality improvement initiatives that encourage clinicians to use language interpreters and optimize communication, quality, and safety for children and families who use languages other than English.

INTRODUCTION

In the United States, 32% of children live in a home where at least 1 parent speaks a language other than English (LOE).¹ In 2023, Nationwide Children’s Hospital (NCH) had more than 1.7 million patient visits and 14,304 main campus hospital admissions,² and serves as the primary healthcare provider for children in Central Ohio. Of the admissions, 7,980 occurred in the hospital pediatrics service, and 519 indicated a need for language interpretation.

Children hospitalized who have caregivers who have low comfort with English have a greater risk for adverse events and longer lengths of stay.^3–5 Language interpretation via certified medical interpreters is the gold standard to ensure optimal communication among patients, caregivers, and healthcare staff.

Title VI of the Civil Rights Act of 1964 mandates that any program or activity receiving federal financial assistance must provide access to language interpreters for individuals who use an LOE.⁶ From August 11, 2000 to March 1, 2025, patients’ rights to language interpreters were further reinforced by Executive Order 13166, which required organizations receiving federal funding to improve access to services for individuals who use an LOE at no additional cost to those individuals.⁷

Institutional policy at NCH complies with these regulations by offering certified medical interpreter services at no cost to patients/guardians. The policy outlines that staff must use interpreters for any essential health-related communications and requires documentation of interpreter use in the patient’s electronic health record (EHR) whenever an interpreter assists with communications.

Although the standard of care for language interpretation is well established, healthcare staff do not always use certified medical interpreters for healthcare communication. Factors such as time constraints, the availability of interpreters, and family preferences influence clinicians’ decisions regarding the use of interpreters.^8–10 At NCH, leaders have worked to improve the overall environment and culture to encourage the use of language interpreters through increased access to video interpretation devices, staff training, the creation of a bilingual healthcare provider certification program, and the implementation of institutional policies regarding language interpretation provisions and requirements.

The team aimed to improve documentation of interpreter use in clinical encounters to measure adherence to policy and characterize healthcare provider interpretation use. They developed interventions based on the behavioral economics concept of nudges. Nudges are subtle, environmental factors that influence behavior in a desired direction.¹¹ In this project, inclusion of a prompt for documentation of interpreter use for the right patient at the right time signified the critical importance of interpreter use for clinical conversations and promoted accountability for healthcare providers to offer certified medical interpretation to patients and families.

The project goal was to create a documentation method that prompted clinical note authors to document interpretation only for patients and families who use an LOE for healthcare conversations to measure interpreter use and remind clinical providers to use certified medical interpretation. With the ultimate goal of implementing institution-wide changes, the team focused on the hospital’s pediatrics service. They chose this service due to an existing multidisciplinary quality improvement (QI) team, the complexity of hospital encounters with multiple notes and varying lengths of stay, and baseline data in the inpatient hospital environment that identified ample room for improvement.

The primary goal guided the specific aim: to increase documentation of language interpreter use in history and physical (H&P) and discharge summary notes in hospital pediatrics from baseline to 80%, and to sustain this level for 1 year. Balancing measures included the time spent documenting interpreter usage and the perceived difficulty of documentation by clinical note authors (Fig. 1).

Fig. 1.

Key driver diagram. DC

METHODS

Context

NCH, a large, free-standing tertiary children’s hospital in Columbus, Ohio, with 551 registered beds, operates 14 ambulatory primary care clinics in the Central Ohio community. In-person, video, and telephone language interpretation by certified medical interpreters facilitates communication for care with children and families who use an LOE. Additionally, NCH uses Epic as its EHR (Epic Systems, Verona, WI), supported by a clinical informatics team that includes physicians and nursing informatics experts. Institutional policy regarding language interpretation at NCH requires documentation of conversations containing clinically relevant information to patients and caregivers who use an LOE for healthcare conversations.

The multidisciplinary team included physicians, informatics experts and builders, QI specialists, regulatory specialists, and a physician quality leader. They developed and implemented interventions using the Institute for Healthcare Improvement model.¹² Using behavioral economics and the 5 rights of clinical decision support as guiding principles, the team developed interventions to create flexible and nimble solutions that promote compliant documentation for the right patients at the right times within the EHR.¹³ The right patients are those who use an LOE for healthcare conversations themselves or have caregivers who do, and the right times are notes that reflect discussion of clinically relevant conversations with patients and families. Concurrently, the team developed a solution that enables the efficient assessment of documentation compliance, eliminating the need for regular manual chart audits.

To achieve the primary goal of increasing documentation of language interpreter use, the team developed and tested initial interventions in the primary care environment. Because primary care encounters are shorter (estimated 30–120 min) and involve fewer healthcare staff than inpatient admission encounters, testing the documentation interventions in the primary care environment first was more feasible. The team did not collaborate on a full QI project in the primary care setting. Baseline data were not available at the time of the pilot, as the former EHR tool was unable to generate reports. Only a limited manual chart review occurred to understand regulatory compliance. After testing initial interventions in the primary care environment, the team implemented these interventions in the inpatient hospital environment and studied encounters within the hospital pediatrics service.

Intervention

Primary Care Pilot

The team studied existing practices for documenting interpreter use. Practices and associated improvements included the following:

1. Assess the need for interpretation. During appointment scheduling or upon a patient’s arrival, the registration team enters and updates the information for a family’s language interpretation needs. Additionally, clinical staff may update interpreter needs during any encounter. The routine, repeated update is key as the need for language interpretation may change depending on the caregiver accompanying a patient to an encounter and the patients’ and families’ English language skills that develop over time.

2. Interpreter-use documentation. The existing documentation method used an “opt-in” approach, in which clinical note authors selected a primary historian(s) and “via interpreter” from an Epic SmartList, that is, a predefined list of choices used to customize documentation. To preserve existing “opt-in” documentation habits, the team implemented an “opt-out” approach to standardized note templates, using rule-based functionality. Only for patients marked “yes” for “needs interpreter” in the demographics section of the EHR would a documentation prompt appear (Fig. 2).

3. Closing encounters and signing notes. No reminders to document interpreter usage existed before this project. Therefore, alongside the rule-based Epic SmartTools, clinical providers received a reminder to document interpreter use before closing the encounter if they did not record interpretation use and the patient’s demographics in the EHR indicated a need for an interpreter.

Fig. 2.

EHR tool.

Pilot changes to the interpreter documentation in medical encounter notes and nursing rooming workflows went live in primary care only in December 2022. Dissemination to primary care staff occurred via email and existing staff meetings. A primary care physician and clinical informatics leader led dissemination efforts in the primary care environment and elicited feedback from staff.

Feedback Incorporated into Interventions

Generally, staff in the primary care clinics adapted quickly to the changes in interpreter documentation. Staff provided feedback after the initial dissemination period (December 2022 to June 2023) (Table 1).

Table 1.

Pilot Feedback and Associated Changes

Feedback	Issue	Changes Made
The prompt for documenting interpreter usage is not triggering for some patients	In some cases, caregivers may not have disclosed that an interpreter was needed for medical care, and the prompt for interpreter documentation is not populating into notes	Provided education so that the provider can also add the prompt into the note using an Epic SmartPhrase even if the demographics do not indicate a need for interpretation
Cannot change answers on the list if it is incorrectly documented that an interpreter was used	The rules on the list were pulling in the language used for interpreter documentation. Still, once these additional data were populated, the providers could not reselect a different option on the list. They would have to erase their original selection and manually reenter the list	The initial draft of the Epic SmartTools included an automatically populated language field. Once the language field was removed, the list was reselectable, and providers could easily change their documentation
Using the original historian list, which includes documentation for interpreter use, does not count as documentation	Interpreter use for the provider is documented in 2 locations: in the original historian list in the notes, and in the new list that was populated. The lists created extra work for the providers	Educated providers that documentation of interpreter use via the new prompt is preferable to the original historian list because it more specifically documents interpreter use
If trainee notes are not correctly documenting interpreter use, it is difficult for the attending physician to attest to and correct them	If the trainee notes are not documenting interpreter use, correcting the notes with the SmartList that is not reselectable was difficult, and the attending would want to document their interpreter use	Provided education that the provider add the documentation prompt into the note using a “dot phrase” even if the list is not already populated. The initial build included the patient’s preferred language, which prevented the field from being reselectable. After removing the automatically populated language field, the list became reselectable, and providers could easily change their documentation
It is challenging to close charts when interpreter usage is undocumented, resulting in delays in encounter chart closure	Some providers did not understand how to fulfill the necessary interpreter usage recommendation to close the chart, resulting in several charts not getting closed promptly	Education was provided on using the new interpreter list in notes. If unable to document interpreter use, one can still close the chart because this recommendation is not a hard stop

Description of Final EHR Build

The team decided that the documentation tool should be distinct from the historian/informant SmartList documentation to prompt documentation of interpreter use for an encounter. They created a separate prompt for the medical provider to indicate the use of an interpreter for the encounter, and rule-based logic displayed this prompt only for patients marked as needing an interpreter in their patient demographics. The team combined the historian/informant documentation and the rule-based interpreter-use prompt into a single Epic SmartPhrase (ie, “dot phrase”): “historianinterpreternch.”

Creating this single “dot phrase,” that is, a keyboard shortcut that inserts a block of text into a clinical note, at the system level allows for any future changes to historian and interpreter documentation to be made in a single location to update all system and user templates that use the “dot phrase.” Furthermore, the team created the tool for universal use, allowing it to be included in clinical note templates across ambulatory, emergency, and inpatient environments. The historian/informant list and the interpreter use prompt are data-enabled, allowing the system to capture provider responses as discrete data.

Additionally, the team created an identical SmartList without rule-based functionality. The team named this phrase “interpreterused.” They created this tool for situations in which an interpreter was used. Still, the note’s author was either unable to update the interpreter need in the demographics section of the EHR or updating the demographics was inappropriate. For instance, a visiting grandparent (not a primary caregiver) was present at the bedside and required interpretation, but the parents (absent from the bedside) used English for healthcare conversations.

Dissemination

The team inserted the “dot phrase” for historian and rule-based interpreter documentation into all primary care note templates in July 2023, followed by the inpatient hospital pediatrics H&P, daily progress note, and discharge summary templates. The use of documentation tools by interpreters was also supported, as were telephone and in-person encounters.

Given the successful implementation in primary care and inpatient hospital pediatrics settings, the project team and NCH leadership disseminated notifications widely within the institution via email messages, presentations at leadership meetings, and partnerships with allied health champions to encourage institution-wide adoption of the documentation tool. Project team leaders led dissemination presentations for Division Directors, the EHR Advisory Board, and Clinical Quality and Staff Leadership. Presentations provided information encouraging specialty representatives to update their respective templates and to encourage providers to update any personal templates. Team members from this QI project also met with clinical champions in social work, clinical nutrition, clinical pharmacy, and nursing to incorporate interpretation documentation into their clinical note templates and workflow. Efforts to integrate the new documentation into all institution-wide templates are ongoing.

Study of the Intervention

Since the historian list and interpreter-use prompts are data-enabled and capture discrete data, the team can monitor interpreter-use documentation compliance through EHR queries. Given the low preproject compliance and the QI project’s aim, the team focused its measurement efforts on the inpatient environment.

Measures

The team used documentation of language interpretation compliance in hospital pediatrics H&P and discharge summary notes as outcome measures. Each patient admission encounter typically has 1 H&P and 1 discharge summary, which involve essential clinical conversations with the medical team. The progress note type is used for various notes, ranging from daily progress notes to medical event notes, which may or may not include clinical conversations, making data reports more difficult to interpret.

Balancing measures included the perceived added time and cognitive burden associated with documenting interpreter use. Staff used Epic SmartTools consistently once they acclimated to the changes in the interpreter use documentation. The team gathered feedback via email from hospital pediatric attending physicians and resident physicians working in hospital pediatrics services through informal interviews.

Analysis

The team used statistical process control p-charts to display the monthly percentage of H&P and discharge summary notes that successfully documented interpreter use. For the analysis, the team defined a centerline shift in data as 8 consecutive data points above baseline.^13,14 They collected primary data from the EHR and created p-charts to detect special cause variation. Additionally, the team measured and analyzed interpreter use via video interpretation invoice data, displayed in a u’-chart (Fig. 3). The team created and analyzed all control charts with QI Macros (KnowWare International, Inc., Denver, CO).¹⁵

Fig. 3.

Video interpreter use for hospital pediatrics units.

Ethical Considerations

As part of the NCH institutional review board guidelines, QI projects designed primarily to enhance the quality of services or processes are exempt from formal institutional review board review. The Associate Chief Quality Officer in the Center for Clinical Excellence at NCH approved this QI project, received regular updates regarding the project’s progress, and participated in the development and implementation of the project’s interventions.

RESULTS

The period from July 2022 to July 2023 constituted the initial baseline for the p-charts created from hospital pediatrics data. The planning stages for creating and piloting the EHR tools, as illustrated in the key driver diagram, did not lead to a centerline shift. However, disseminating the final tool, as illustrated in the key driver diagram, did result in changes. The analysis included 2,343 admissions to the hospital pediatrics department between July 2022 and September 2024. The baseline average for the successful documentation of interpreter use in H&P notes was 15%, and for discharge summary notes, it was 11%. In August 2023, both charts exhibited a centerline shift. The new averages were 74% (Fig. 4) and 93% (Fig. 5) for H&P and discharge summary notes, respectively. Additionally, video interpretation devices, the primary language interpretation modality in hospital pediatrics units, increased from 2.75 to 3.40 uses per 10 patient days during the intervention period (Fig. 3). These centerline shifts sustained for 14 months.

Fig. 4.

Documentation of interpreter use in H&P notes.

Fig. 5.

Documentation of interpreter use in discharge summary notes.

Balancing measures results included that staff reported that the new documentation added minimal time or cognitive burden to their existing workflows. They noted that using the new documentation method was easy and expressed satisfaction with the rule-based functioning of the EHR tool.

DISCUSSION

Summary

In this QI project, the team aimed to increase documentation of interpreter use for H&P and discharge summary notes for children hospitalized in the hospital pediatrics service while minimizing the time and cognitive load burdens on healthcare providers. The project increased the percentage of compliant documentation for H&P notes from 15% to 74% and sustained this improvement for 14 months (Fig. 4). Even more significantly, successful compliance documentation for discharge summary notes increased from 11% to 93% and sustained for 14 months (Fig. 5). The increased success of discharge summary notes may be related to a restriction in the EHR that guides users to only 1 discharge summary note template for hospital pediatrics. In contrast, users can create their own H&P note templates, which may or may not include the tool for this project.

Although the increase in documentation compliance indicates that, before the intervention, many encounters in which providers used interpreters for communication were likely not accurately documented, the team also noted that video interpretation devices, the primary language interpretation modality in hospital pediatrics units (Fig. 3), increased from 2.75 to 3.40 uses per 10 patient days. This increase may indicate that implementing an interpreter documentation prompt may influence provider behavior to use interpreter services for more healthcare conversations. Although the rise in video interpreter use is modest compared with the documentation improvements, there is promise that clinical documentation prompts may contribute to comprehensive QI environmental and culture change, which may improve the quality and safety of care.

Interpretation

This QI project aimed to enhance compliance with documenting interpreter use in clinical encounter notes by implementing interventions based on environmental changes, using behavioral economics principles,¹⁶ thereby providing “nudges” toward desired behavior change. The current project provided “nudges” by switching from an “opt-in” documentation method to an “opt-out” method, such that providers were prompted to document interpreter use through a specific request. Additionally, this prompt highlights the vital role of interpreter use for clinical providers.

Previous studies have demonstrated that behavioral economics guide decisions to change healthcare provider behavior^17,18 and that teams use behavioral economics techniques when implementing EHR changes.^19,20 Other studies have shown increases in language interpreter use and documentation through the implementation of educational initiatives, increased access to interpreter devices, and EHR changes in pediatric emergency departments and primary care settings.^21–24 This QI project is unique in that it occurred in the pediatric inpatient environment and described the use of behavioral economics principles and clinical decision support.

The team used environmental interventions using EHR tools, as changes focused on the healthcare environment are often more successful and sustainable than educational interventions alone.^19,20,25,26 The 5 rights of clinical decision support were used as a guide in the following manner.¹³ Right information: the intervention provided healthcare providers with a menu of compliant documentation choices within the EHR tool. Right person: the intervention focused on the healthcare provider to ensure the actual person using the interpreter was also documented in the clinical note. Right format: the team embedded the EHR tool in note templates used by healthcare providers to complete clinical documentation. Right channel: the intervention specifically focused on the healthcare provider’s view in the EHR. Right time: the intervention included a behavioral economics “nudge,” specifically when documentation of interpreter use should occur in the healthcare provider workflow.

Future areas of QI efforts may include further analysis of responses within the EHR tool, specifically when healthcare providers document that they did not use a language interpreter, and comparing response groups to hospital outcomes such as length of stay, adverse events, and patient/family satisfaction. Further QI efforts focused on the efficient dissemination and implementation of effective EHR tools across institutions in both inpatient and outpatient environments will also benefit future projects.

Limitations

Current abilities to extract data from the EHR are limited in measuring outcomes across all types of notes, including those documenting clinical conversations, such as daily progress notes written by all healthcare staff. Additionally, because NCH currently does not restrict note template creation within the EHR, the dissemination and implementation of the EHR tool for interpretation documentation depend on the willingness of template creators to incorporate the EHR tool into their templates. Furthermore, this EHR enables the collection of discrete data elements, allowing for the monitoring of documentation compliance outcomes. Institutions that use other EHR systems may have different capabilities, which can reduce the generalizability of the project. Additionally, although valuable, documentation of interpreter use is an imperfect proxy of true interpreter use by clinicians.

In conclusion, proper documentation of interpreter use is essential for compliance and QI initiatives that enhance communication among healthcare providers, children, and families who use an LOE for healthcare. Employing EHR tools in note templates effectively changes staff behavior to use interpreters and document interpreter use without increasing documentation time or cognitive load burden. This project highlights the vital role that language interpretation plays in health communication, quality, and safety.

ACKNOWLEDGMENTS

The authors thank Manjusri Nguyen, Dane Snyder, and Jennifer Harris for their contributions to leadership, EHR tool development, and pilot dissemination.