Federal law requires that medical interpreters be provided to limited English language patients at no cost, which often leaves the language services department as a cost center.


Effective communication between patients and healthcare providers is a critical component of quality healthcare. Without informed consent, the ability for providers to explain procedures to their patients and to build general mutual understanding and rapport quickly deteriorates, and patient outcomes can suffer. It is no surprise, then, that many healthcare organizations take communication challenges very seriously.

With more than 25.9 million Americans reporting that they speak English less than “very well,” which amounts to 9 percent of the overall U.S. population age 5 and over, communication challenges are more prevalent than ever. Carolinas Healthcare System (CHS), a not-for-profit health system with more than 900 care locations, has pioneered a communication strategy for treating limited English proficiency (LEP) patients, while saving the organization more than $1.5 million in annual interpreter expenses and maintaining high levels of patient satisfaction.

Treating LEP Patients

Historically, there were two main interpretation modalities used in healthcare settings: on-site interpretation and over-the-phone interpretation. There are pros and cons to each solution. Onsite interpretation is largely considered the industry ideal. Bringing an interpreter into the room with LEP patients allows for verbal and nonverbal communications to take place (in the form of body language and facial expressions). On-site interpreters can also make empathetic connections with patients, and often alleviate fears. Unfortunately, on-site interpreters are expensive. Some institutions, such as CHS, employ full-time staff interpreters in various languages, but there is no way to staff for every language. In those situations, healthcare facilities rely on agency interpreters—who often charge significant minimums, especially for after-hours work. Over-the-phone interpretation is much less expensive, but the quality of communication suffers without access to non-verbal communication cues.

Federal law requires that qualified medical interpreters be provided to LEP patients at no cost to the patients, which often renders hospital language services departments as cost centers. In 2015, CHS spent $3.3 million on contract interpreter expenses, accounting for more than half of their overall language services budget.

Mitigating Expenses

A new interpretation modality has been gaining traction in the past few years; video remote interpretation (VRI). VRI combines the benefits of on-site and over-the-phone interpretation in the following ways:

  • Immediacy
  • One device can reach interpreters who know hundreds of languages
  • Charges are by the minute, with no after-hours rates or session minimums
  • Benefit of non-verbal communication

CHS saw the potential for VRI early and deployed more than 400 devices in more than 100 locations between 2015 and 2016. In addition, the system set a new guideline stating that any time agency interpreters were needed (e.g., a Vietnamese man arriving at the emergency department after hours), health system staff were to use VRI as a first line of defense. If it worked well, staff could continue the call for the duration of the session.

To encourage staff to follow the new guideline, CHS leaders fostered an environment of excitement over the new technology through internal articles and interviews, leadership engagement, and multiple technology trainings to really drive the new processes home. In addition, they got location managers on board and provided hard stop dates for agency interpreter use.

Within one year, agency expenditures went from $3 million to $1.5 million.

Carolinas Healthcare System Reduces Language Interpretation Costs
Carolinas Healthcare System Reduces Language Interpretation Costs

While the $1.5 million in cost avoidance is the most notable result from CHS’s widespread use of VRI, it is just a portion of the results achieved from the transition. VRI was in limited use in 2015. Following CHS’ 400-device deployment, minute usage annually rose from 370,211 in 2015 to 915,466 in 2016, an increase of 247 percent. These results occurred without a decrease in staff or over-the-phone interpretation use, representing a significant unmet need for interpretive services.

The additional 545,255 minutes of VRI interpreting were used to serve patients who had previously gone without professional interpretive services, likely relying on ad hoc interpreters or untrained bilingual staff members. Today, CHS is engaging in more interpretation than ever before, and even with the increase in volume, CHS has seen a systemwide language access expense reduction of $203,360.

Carolinas Healthcare System Video Remote Interpreter Use, 2015-16
Carolinas Healthcare System Video Remote Interpreter Use 2015-16

In addition to the cost savings, CHS has anecdotal evidence that patient satisfaction has risen, especially among hearing impaired patients—a faction of the limited English proficiency population that has always struggled to gain access to interpretive services because over-the-phone interpretation is not possible for them.

For example, a deaf patient who regularly seeks care at CHS prefers VRI to on-site interpreters. Despite HIPAA regulations, deaf and hard-of-hearing communities are often small and tight-knit. These patients and their families may know local on-site interpreters personally. Even though HIPAA regulations protect them legally, knowing an interpreter personally can put deaf/hard-of-hearing patients in difficult situations as they find themselves torn between being forthcoming with healthcare providers and worrying that personal medical knowledge will be shared within their communities.

The immediacy and face-to-face connections possible with VRI were put to good use with a deaf psychiatric patient. She presented at a CHS behavioral health facility emergency department. The staff called for an on-site interpreter, but the patient was left without communication while she waited. A nearby tech noticed something amiss with the patient and grabbed a VRI device to communicate more quickly. Through VRI, hospital staff came to learn that their patient was suicidal. Treatment was initiated immediately, something that would not have been possible without access to an on-demand video interpreter.

Benefits for Patients and Hospitals

VRI has completely changed the way CHS communicates with LEP patients. With patient care a critical part of the decision to deploy VRI technology, the monetary savings were an unprecedented, but not unanticipated bonus. Through a dedication to new and innovative technology, CHS has been able to benefit both its patients and its institution.


Danilo Formolo is director of patient experience, Carolinas Healthcare System.

David Fetterolf is president, Stratus Video Language Services.

Publication Date: Friday, December 01, 2017