One of my pet interests is health literacy and its far-reaching impact on quality and access to healthcare. The issues surrounding it can almost be insidious in nature. Despite this, health literacy is typically only given superficial coverage in traditional training programs.
Here in South Florida we have an especially diverse patient population with a higher than average percentage of those with limited English proficiency (LEP). It’s pretty intuitive, but LEP patients are (unfortunately) more likely to encounter barriers to health care and are associated with poorer outcomes than non-LEP patients.
In part to address this, there was actually an Executive Order mandating “meaningful access” be given to LEP persons for Federally-funded activities (what, you didn’t think ‘meaningful use/access’ was limited to EHRs and the like?). Consequently, hospitals, clinics, etc. began incorporating translators and other language access services (LAS) as SOP (at least on paper) due to their receipt of Federal funding/payments. However, a funny thing happened on the way to implementation in community pharmacies – much as those pharmacies and the healthcare professionals that staff them are treated differently than similar entities/professionals in our system of health care…this mandate has been treated more as a voluntary compliance issue. What, if any, impact has this had on reimbursement or outcomes? The jury is still out. However, as a first step to methodically examine this issue, we conducted a national survey of availability and use of LAS in community pharmacies; the initial results of which have recently been published in the Journal of the American Pharmacists Association (JAPhA).
Pharmacist responses to the survey ranged from descriptions of widely advertised and seamlessly integrated interpretation (verbal) and translation (written) LAS services to the (rarely observed) attitude of ‘if they’re in our country they should speak English’. Overall, we identified issues regarding awareness (e.g., about half of pharmacies with LAS capacities did not report making them known to patients), use of LAS (e.g., about 40% said they “never” used interpretation/translation tools), and workflow/time (e.g., a quarter of respondents said they simply lacked time to use LAS). Alternately, there were encouraging signs as pharmacies that did apprise patients of LAS availability used a variety of methods including in-store direct notification, signage, flyers, and targeted mailings. Additionally, more LAS products are becoming available such as Elsevier’s MEDcounselor Languages module, which advertises SIG translation and patient education materials in 14 languages. Another gem that area pharmacists have started using (albeit moreso in AmCare clinic settings) is the free MediBabble iPhone app. My understanding is that a future update will (ahem) include pharmacists in the introductions section.
Unfortunately, our article “Community pharmacists’ use of language-access services in the United States” is behind a subscription wall, but I would be happy to answer any questions that I can.
Disclosure: A couple years ago we received a grant from one of the quadrillion companies Elsevier operates for an unrelated research study. Inclusion of their product in this post is mostly due to timing (I just received an email about it), and should probably not be construed as a conflict of interest except for the most Mel Gibsonian of conspiracy theorists. Separately, this JAPhA LAS study was funded by a NSU President’s Grant. Going forward we are planning to study the LAS disconnect further, as well as possible solutions that may include tools such as automated LAS kiosks in pharmacies and online functionality as well as LAS availability notification via social media; funding source(s) TBD.
Source: Feichtl MM, Clauson KA, Alkhateeb FM, Jamass DS, Polen HH. Community pharmacists’ use of language-access services in the United States. J Am Pharm Assoc. 2011;51(3):368-72.
If you’re not familiar with the website for TED (Technology, Education, and Design) Talks, you are missing out on a great resource that also happens to be free. Suffice to say for now that the TED events are expensive ($6000), exclusive (fill out an application just to be eligible to pay the 6K), and according to attendees - well worth it. Fortunately, the Powers That Be at TED decided back in 2007 that if they were really about “Ideas Worth Spreading” then they probably should unshackle them. For anyone who has to teach or present, these talks represent a mini-master class in communicating in the one-to-many model. For those looking to see content experts, there are plenty of those. And for futurists, think-tank wannabes, and people sincerely looking to be inspired to create change – TED has those talks in spades as well.
I recently viewed a TED talk by data journalist David McCandless on The Beauty of Data Visualization. I decided to watch the video because we’ve been dabbling with data visualization for displaying some of our research findings. Employing data visualization techniques appears to be growing trend in informatics as one way to help process the unprecedented volume of data that can be accumulated in a relatively short time.
It turns out McCandless also wrote the book The Visual Miscellaneum: A Colorful Guide to the World’s Most Consequential Trivia, which a student had given to me earlier this year (Köszönöm!). The technique is akin to a visual version of performing a content analysis to find what themes emerge in qualitative research. In that way it can also act as its own information filter, detect patterns that are not readily apparent, give context to potentially misleading ‘facts’, and prompt further lines of inquiry. This book has a little more modern, pop-science feel than the more precise works by Tufte, but definitely prompted me to think about things a bit differently…and that is a pretty big value itself.
The TED video was quite good and had some clever bits such as the examination of military budgets by raw numbers versus as a percentage of GDP, followed by the number of soldiers by country and then per 100,000 people. It’s a little specialized, but if you’re interested in the topic – it is a treat.
There was a recent news item taken from an article in Pediatrics examining what happens when computerized language assistance services (LAS) are imperfect. It focused on the erroneous translation of prescription information from English to Spanish in pharmacies in New York and possible consequences. That was similar to an aspect of our LAS research we highlighted in an interview in The Oncology Pharmacist several months ago. We are examining related problems as well, including low- and high-tech solutions to varying issues with LAS (e.g. automated LAS kiosks, natural language processing, pictographs). In December 2009, we presented a poster of the results of a national survey of the use of language assistance services (sometimes called language access services) in community pharmacies. One of the major concerns in using LAS cited by pharmacists (52.1%) in our study was about mistakes made with translations (written) and interpretations (verbal). Their concerns appear to be at least somewhat justified based on the results of the Pediatric study. This is a contributing factor as to why almost half (49.8%) of pharmacists in our survey who have LAS fail to notify their patients of its availability.
One of the aspects of information quality that is still very much an imperfect science is readability. There are a handful of established tools to evaluate it, with the Flesch Kincaid Grade Level (FKGL) being the best known. The FKGL is simple and thus limited.
I first met Qing Zeng when I was giving a poster presentation during Mednet in Toronto in 2006 (Mednet later morphed into Medicine 2.0). We exchanged some ideas and our business cards, and that was it for awhile. We reconnected at AMIA and formally explored some research ideas. One area of potential collaboration revolved around a tool her group was developing called the Health Information Readability Analyzer (HIReA).
Fast forward to today. The paper resulting from that initial collaboration was just published in the Journal of Alternative and Complementary Therapies. In it, we used HIReA and FKGL to evaluate the readability of patient and professional leaflets. We focused on leaflets of dietary supplements (e.g. ginseng, fish oil, SAMe) used in a common (i.e. diabetes) and less prevalent (i.e. chronic fatigue syndrome) condition. The patient-targeted leaflets ended up being much more difficult to read than their desired level by both measures. Part of this may be due to the fact that the leaflets were not created specifically for consumers, they were just scaled down versions of leaflets originally tailored for clinicians and researchers. Hopefully our results will help provide some guidance as more patient-targeted health information is created, as well as serve as an introduction of HIReA in a broader forum.
Note: If anyone happens to get a glimmer of recognition from the name HIReA, this was also the tool later used to assess the readability of the top 50 prescribed drugs in Wikipedia presented at Medicine 2.0 in 2009 and later at other venues. Our JACM article goes in-depth about the HIReA tool and will likely address many of the questions people have had about it at the various presentations in conjunction with the Wikipedia study.