 I'm delighted to welcome you to today's session in our series on the ethics of healthcare reform. So, this preview next Wednesday, David's song from the Department of Surgery will be speaking about the future of surgery under the ACA. It should be a great session. But today we have, especially my great pleasure to introduce Karen Kim, who is a professor of medicine in the sessions of gastroenterology here at the University of Chicago. As well as over the past three months ago, she has been a point to be the dean of faculty affairs, looking at the well-being of a variety of issues with faculty here in the biological sciences division. Karen is a long-standing student at the University of Chicago, where she was actually born here at the University of Chicago and grew up in Chicago, and really was introduced at a very early stage to the issues of immigrants and a diverse population. She's a Korean background, and her mother and her family's whole have been a barrier in the Korean community, and that sort of rubbed off on Karen, and she has really become both locally as well as nationally one of the leaders in a variety of issues of diversity, including Asian-American health as well as women's health. She currently is the president of the Asian Health Coalition of Illinois, as well as a Jewish tradition to the number of the national Asian-American health group also, and she still is completing her term now, she has a five-year term at the office of women's health at NIH, really sort of a prestigious position. Karen also directs the CUNY Engagement Disparities Corps within the University of Chicago's Comprehensive Cancer Center. And there's a variety of work that basically involves CUNY Hepatitis B here, colorectal cancer screening, community-based research, and it has two large center grants. One is the NIH grant, which is a partnership with the Chicago State University, looking to improve the education of both the Chicago State students as well as our students here at Christopher School of Medicine on a variety of public health human health issues. As well as a center grant from ARC, which is for healthcare research and quality, looking at trying to improve colorectal cancer screening in the Asian-American population. There's one more story about Karen that, you know, so the Asian-American population is very diverse, as Karen will tell you, and she's done a remarkable job of bringing together just about every one of the Asian-American ethnic populations within Chicago, and this is a really hard thing to do for a variety of reasons. So Karen has been masterful in the leadership of that effort. I would also message to you that Karen, sort of like her bio, but like on a personal level, she really is a tremendous leader, works with one of her students, was named to be a member of the Academy of Middle Educators, like Victor, and is a true leader of the culture competency in helping our students work together with diverse populations. So today, Karen will be speaking about the immigrants in the HCA. Ask this question. Thank you. Thanks, Marshall. So, again, thank you, Marshall. It's really a pleasure to be able to present today. I thought today I would start with a little bit about immigrants. What is the definition of immigrants? Who are immigrants? And how are they impacted by the Affordable Care Act? And then I want to talk a little bit about a subgroup that are limited to English proficient populations and that population's relationship to the Affordable Care Act. I'm going to end with a case study looking at the Asian-American population as sort of a model population that has both large number of immigrants as well as limited English proficient populations, and then to bring it really to home and talk about what we're doing on our own campus. So first of all, how do you become a U.S. citizen? And so there's four ways to become a U.S. citizen. You can be born in the United States, which is by far the majority. You can be born to a U.S. citizen parent, or your parent became a citizen before they turned 18. You are adopted by a U.S. citizen, or you are naturalized over time. If you're in the United States and you're not a citizen, then you're either an immigrant or a non-immigrant. And I'll talk first about non-immigrants. So when we think about non-immigrants, we're talking about people who are in the United States with no intention, at least when they come in, of staying here forever. And those tend to be students, those with temporary workers, visitors, or others who are in the U.S. temporarily when their visas only allow them to stay for a very limited amount of time. In terms of immigrants, there's two categories. So you are either a lawfully present resident, which I'm going to abbreviate as LPR, and those include people who have green cards, refugees and asylees, those individuals who may be escaping to the United States based on persecution, based on religion, race, political opinion, nationality, or groups. For people who are seeking asylum, those are people who are already in the United States, and they feel that going back to their home country will cause them harm, and they can apply to see if they can stay in the United States. Those groups are all lawfully present in the United States. And then we have a second category of immigrants that are called undocumented. We used to call these illegal aliens, which I find is a term that's very off-putting. And those can be people who have papers, were here legally, but then their papers expired, or those who entered the United States with a visa or a green card, and again, with a green card, without a green card. For those who have green cards under the lawfully present residents, those individuals need to renew every 10 years if they don't become a citizen. So there's two really big groups of immigrants. In terms of what is the magnitude of this population in the U.S.? That's from 2011 data. Overall, immigrants make up about 13% of the U.S. population, or 40 million who are foreign-born in the United States. Of those 40 million, about 15 million are naturalized U.S. citizens, so they have equal rights. About 13 million are these legally present residents. Over 50% of those are uninsured. And about 11 million are undocumented. What about immigrants in Illinois? There's about 1.7 immigrants in Illinois that makes up about 13% of our population, so about a little over 1 in 10. About half are naturalized citizens, and about almost a million are either legally present residents or undocumented. And about half a million of the immigrants in Illinois are uninsured, which makes up about 30% of those that are uninsured currently. About 48% or about 250,000 of those individuals will become eligible under the Affordable Care Act. So this is a very large population of immigrants that will be eligible. In terms of who are the immigrants, about 44% are Latino, about 11% Asian, and about 15% white, so people often from European countries. In terms of undocumented immigrants, this is a very, very large group that makes up about 4% of the U.S. population. 60% are from Mexico, about 2% are from China and the Philippines. In Illinois, we have about a half million undocumented immigrants. So why is this important? I think it's important when we think about access to care in terms of will you be eligible under the Affordable Care Act. And so this graph shows three different populations. U.S. citizens, legal, permanent residents, and undocumented. So basically, if you are a citizen of the United States, you are subject to individual mandates under the Affordable Care Act. You are eligible for Medicaid, depending on your income level related to the federal poverty line. You have access to the health exchange, and you may be eligible for premium tax credits under the Affordable Care Act. Those are for people who are U.S. citizens. For those who are here legally, you are also subject to individual mandates, and you are eligible for Medicaid as long as you have been living in the United States for five years. You have access to the marketplace, and you may be eligible for tax credit. If you are undocumented, you are not subject to individual mandates. You are not eligible for Medicaid. You have no access to the marketplace, and you, of course, do not get any tax break. You are able, though, to use any emergency services, and you certainly are able to go to places like community health centers or federally qualified health centers that will be willing to see you. So this is a population that is really challenged under the Affordable Care Act. I'm going to switch over now and talk about another population that is very closely linked with being an immigrant, and that is the limited English proficient population. That is individuals who do not speak English as their primary language and have a limited ability to read, speak, write, or understand English. U.S. Census defines this as a person who speaks another language other than English at home and does not speak English well or not at all. So let's talk about how big this population is in the United States. More than 60 million individuals speak a language other than English at home. That's 21 percent of the U.S. population. And what the U.S. Census in their reporting, what they found was that of this 60 million, about 59 percent of those 60 million actually speak English very well. And so they would not be considered limited English proficient. However, about 25 million people fit under the category of limited English proficiency. I always know that there's somebody in clinic who has an inability to speak English so I can hear my resident screaming at them down the hall because certainly if they don't understand English, they must be deaf. And their tendency is to be screaming as if somehow that's going to make people understand. About 80 percent of limited English populations are foreign born. And when we think about the magnitude, one out of four people who will be entering the health exchange marketplace will be in this category. So I have to ask ourselves, will access be enough? Illinois has the fifth largest limited English proficient population. 2.6 million people speak a non-English language at home and about 1.2 million are limited English proficient. And there was studies that have been done in Chicago looking at this population to understand what are some of the barriers to access to care. This was a focus group done among limited English proficient immigrants in Chicago. And they found that 40 percent thought that the top barrier to access to care was not insurance, but was the inability to access care due to language. And this is a really huge overwhelming concern for this population. About 15 percent also had problems submitting necessary paperwork. So again, limited English proficient is not just about the ability to speak the English language, but it's about the ability to read it proficiently and write as well. And if you think again about the United States in 2009, this is us in Illinois, where a little bit under 10 percent of our population fits this category. And if you break it down a little bit further based on county and region, you can see that there are areas, this light purple area is at 9.7 to 23 percent limited English proficient, and this is less than 50 percent. And you can see in Illinois we have large pockets of individuals who are limited English proficient. If you look at the coastal regions, certainly in California, there are again huge numbers, 44 percent of California have limited English populations, but they have a very different robust infrastructure to address some of those needs because of the larger concentration of individuals that speak non-English languages. I would say that in Illinois within our safety net system we have one major safety net healthcare system and within that system there is one, currently one FQHC, Asian Human Services that is really geared towards seeing Asian populations and those are largely South Asians. There has been approval for one, a second FQHC to be open, Hamdar Center will open the second FQHC that really can address the language needs and health access needs of non-English speakers who are Asian American. There are numerous studies on active language on the healthcare encounter, certainly we know that those who don't speak English well are less satisfied with their healthcare have problems with accessing care have probably less utilization of the healthcare quality of care suffers costs go up and interventions also go up, unnecessary interventions. This is a study that was published by the Robert Wood Johnson Foundation and they asked in the course of the past year, how many times but decided not to visit a doctor because a doctor didn't speak Spanish or have an interpreter and you can see that one in five sought not to seek out care because of the inability to speak to their doctor. This is looking at limited English proficient populations in cancer screening for pap smear mammography and colorectal cancer screening and you can see there is an enormous difference in utilization of cancer screening when you don't speak English. This is perhaps one of my favorite studies that kind of sums this up. This was a study that was looking at an emergency room in New York City they looked at 4,000 consecutive visits and they looked at whether you are a bilingual speaker you use an interpreter and if you didn't use an interpreter and what you can see here is that if you didn't use an interpreter and you were talking to somebody who didn't speak English and was twice as likely to do testing you were more likely to admit the patient because if you can't speak to them you can't figure out what's wrong you admit them. Actually you spent more money and you spent less time. So this is a real problem and this kind of sums up what happens when you're with individuals who don't speak your language. This is a study that we're publishing right now that looks at race and ethnicity concordance in terms of colorectal cancer screening looking at a race and ethnic concordance with a limited English Korean cohort and you can see that if you're a Caucasian and this is looking at fecal called blood testing return versus not return versus return and you can see that if you compare the Caucasian physician versus the Korean physician the Korean physician did much much better in terms of getting FOBT results returned. If you looked at language concordance this is a physician with an interpreter and this is a Korean speaking physician and again similar to others in the data you can see that there was by far a preference for people to be returning their FOBT cards by being prompted by somebody who either was Korean among the Korean cohort or spoke the language. So we know that there is not only quality of care issues but there is compliance issues and adherence issues that come along with being able to speak the same language. In terms of language requirements under the Affordable Care Act certainly even prior to the Affordable Care Act Title VI of the Civil Rights Act as well as Executive Order 13166 by President Clinton said that we could not discriminate on the basis of language, race, ethnicity, religion and so these have already been in place and for anybody who receives any federal funds it is required that we provide language access to those with limited English proficiency but under the Affordable Care Act there is also many many policies that have been put in place. There is non-discrimination requirement and culturally and linguistically appropriate requirements that all suggest that we need to provide language access for limited English proficient patients. But there are some thresholds so that threshold under the Affordable Care Act in 2012 the federal regulations adopted a threshold of 10% or more of the population living in the consumers county are literate only in the same non-English language for language services. And a 10% threshold leaves out millions of individuals to have access to care under the Affordable Care Act. And so there has been a lot of policy discussion about changing this threshold to because under this threshold only 23 states will have counties that have a representative sample of people that are 10% speaking the same language where ACA kicks in in terms of mandating translation and interpretation services. We drop it down to 5% or even 500 individuals which is what we're being for than all 50 states are going to be involved. So there's a problem and this problem can play out in many different ways. There's also minimal criteria for translation so interpretation is oral and translation is written and for limited English proficient eligible groups of 10% or 3,000 you must translate and provide all vital documents and documents available in multiple languages. So that is if 10% of your population or 3,000 individuals speak that language. If you have 5% or 1,000 you must translate vital documents but can offer oral translation of other documents and if you have groups of less than 100 you can provide written statements that oral translations of written materials are available. So these are kind of the rules. So again I ask ourselves is access enough and what I want to do is sort of switch over and talk specifically about one population that really has problems summarized by being both an immigrant having high numbers of limited English proficiency. So this is looking at the US population from 2000 to 2010 and what you can see is the fastest growing population is this one on the top which is Asian American followed closely by Hispanic. And so this is a population that is rapidly growing in the United States. If you look at the percentage change in language spoken at home between 2000 and 2011 you can see at the very top of the list again is other Asian languages. You can see there's Hindi here Gujarati, Chinese Vietnamese and here is Spanish. And you can see that this is there are some languages that have gone down Lao, Japanese, Polish, Yiddish, Greek. And I think that this is again a population that is rapidly rising and languages that are being spoken are often Asian languages. The other thing to think about is the portion of the population that is limited English proficient. So among all Spanish speakers about 46% are limited English proficient. That's not the same in many of the Southeast Asian languages. So among the Lao, the Vietnamese and Korean, many of these populations are actually greater than 55 to 60 some up to 70% of their entire population that's limited English proficient. So again you have a population that is in tremendous need of help and certainly because Asian population makes up about 5% of the US population there's really going to be very few large counties that are going to have that 10% threshold that we're looking for. So in Illinois there's about 505 about half a million Asian Americans in Illinois where the fifth largest state. Chicago is the sixth largest metropolitan city for Asian Americans. About 65% of all Asian Americans are foreign born. 80% speak another language at home. And compared to the rest of Illinois which is about 10% limited English proficient about 32% of Asian Americans one in three are limited English. The poverty rate for this group also varies by groups but in aggregate it's about 12% which is higher than statewide numbers of about 9%. And the Midwest has some of the largest and most rapidly growing Asian American growth rate in the country. And I should point out that when we talk about Asian Americans we are really lumping a very, very non-homogeneous group. These are some of the bigger groups but again there's over 50 languages spoken within this population. In terms of census 2010 overall the Chicago population dropped by 5% in the 2010 census but if you look at Illinois, Cook County and Chicago 2000 versus 2010 the Asian American population alone you can see there was a 39% increase in Illinois 24% in Cook County and a 17% in Chicago. So these populations are really rapidly growing. If you think about the safety net system in Illinois and particularly in Chicago and you compare it to other states we have about again looking just at Asian Americans about half a million Asian Americans and about 16.2% of uninsured Asian Americans should have access to our safety net. Unfortunately our safety net sees only about 1.4% and HRSA recently reported that only 1 in 5 uninsured Asian Americans are receiving care at either community health centers or federally qualified health centers. And so we kind of wonder where the rest are going and under affordable care act one of the things through the marketplace and looking at medical homes as well as coordinated care many many physicians that treat these limited English populations are actually in single solo practices. And under affordable care act that has become very very difficult to practice given what you need to do in order to meet current guidelines and quality of care issues and so this is a population that is really becoming abandoned. In terms of the impact on affordable care act looking at insured pre and post ACA in Illinois looking at these different populations I just will tell you that post affordable care act we think that there will be about 75,000 Asian Americans in Illinois who will be entering the marketplace and what's interesting about this group compared to other racial ethnic groups although small in number compared to the Hispanic and African American population the Asian American population that will be entering under affordable care act will have the highest percentage that is 63% will be insured through the private marketplace compared to 50% among the African American and 56% among the Hispanic. So if you are a healthcare system you might think that this is a population that you want to accommodate. The problem is the healthcare system really has not has real challenges in terms of serving Asian Americans. Asian Americans stand out as being one of the least well served and they are least likely to feel that the providers understand them to be involved in medical decision making and to have confidence in their provider. This is a study from the Commonwealth Fund looking at the patient-physician interaction for Asians and this is looking at great confidence in the doctor among those, among total adults among English speaking Asians and among those who are non-English speakers and this is having confidence in your doctor this is being involved in decision making about healthcare and that spent enough time with the doctor and again you can see the trend is if you don't speak English and I would imagine this would be the same with any non-English speaking group. If you don't speak the language you're not going to have as much confidence or buy into the ability to care for your health. So I want to turn it over a little bit think about this place so obviously this is a CCD and this is the University of Chicago and think about what's happening on our own campus. So in terms of appealing to the leadership of this hospital to think about the need to provide equal access to care for Asian Americans this is looking at the density of Asians in Illinois now most Asian Americans live in one of four counties Cook County, Will County, DuPage County or Lake County and you can see in this map where you see the red reddish color, maroon color that represents where that area has greater than 50% Asian Americans so you can see that probably this doesn't show up as clear as I'd like but certainly in areas around Chicago that's definitely the case and other areas you can see that there is sort of a suburban migration of a lot of Asian Americans particularly to outside of Cook County and then also over into DuPage County and if you overlay this these areas that have high density of Asian Americans with some of our offside provider locations certainly this is our hospital University of Chicago but this is where we have many offsite centers in the same squares and so there is really really interesting potential opportunity to start recruiting these individuals for healthcare within our own healthcare system but we do have some barriers this is even bringing it closer home this is Bridgeport and this is actually Armour Square which is Chinatown, Bridgeport and then sort of areas around Chinatown and you can see that in Bridgeport which is really within sort of the south side of where we are focused on as a hospital Bridgeport has 34% Asian Americans and in fact the community in Bridgeport now has the Asian population surpassed the number of Hispanics in that community and Bridgeport is the second largest Asian population now in Chicago and this is a population that is really right next door so again I kind of remind us of the threshold for providing language and translational services under the Affordable Care Act so again I remind us that the rule is that 10% or more of non-English speaking individuals in a county the problem is they have to speak the same language that might be possible if you are a Spanish speaker but if you are an Asian speaker that could be very very challenging and this exempts limited English proficient access for almost every non-profit hospital within the confines of this definition and it doesn't apply to any of the hospitals in Chicago based on this definition versus what the Department of Health and Human Services require which is a translation of vital documents when a language group is 5% or 1,000 individuals and I would say that while race and ethnicity data is very very poorly captured at our hospital the data on Asian Americans we think may hover around 3% although I think that that's probably not very accurate so in some ways we have created what is a very perfect storm for health disparities among this Asian American population we have a disproportionate burden of limited English proficiency we're a very small but very rapidly growing population in many ways within the healthcare system we're not recognized as a minority I mean it's interesting we make up 3% of the population we're a third of what we're maybe less than half of the African American and Hispanic population but because we don't fall under the underrepresented in medicine category Asian Americans are often completely left out we have numerous subgroups and so being able to address the healthcare needs of many many subgroups would be really cost prohibitive and finally there's often a lack of interest or priority setting in addressing the healthcare needs of these populations so let's think about our own faculty this is data from famous which is the double AMC has a database of all faculty at the University of Chicago apparently I guess when I when I started here I must have filled it out although I don't remember so I'm not sure what I would answer but it's a very very comprehensive database and what we looked at was the race ethnicity and language of individuals within this database among our 900 or so faculty and based on famous we have about 21% Asian American and that makes sense because about 1 in 5 graduating medical students now are Asian American we have about 0.6 or 5 who fit in the category of Hispanic which is incredibly low however when you look at those who see patients about 60 faculty that see patients reported that they speak an Asian language and those Asian languages that are spoken are here on the side and as you can see there's really a large number but despite only having 5 that reported being Hispanic and famous we have 70 individuals who speak Spanish on faculty many of them are also speaking these languages and so I think the idea is that when you have a healthcare system and you're thinking about limited English proficiency the capacity to speak a Spanish language in the hospital is far greater than our capacity to speak an Asian language which is a real problem for individuals who come in I just met with a faculty a few weeks ago who said that a patient flew in from Japan to come enter a cancer clinical trial and in her ability to try to navigate the system was really not able to understand eligibility criteria for that trial so she flew in she rented an apartment she came to her first visit and found out that she was ineligible and he says that she sat in his office for about an hour and cried telling him how horrible this was that she would actually go somewhere else that actually could speak the language so I mean I think it's a missed opportunity if we don't have an ability to interact with patients this is again similar to faculty if you look at this is the language spoken by several classes ago the Pritzker School of Medicine and this large piece of the pie is Spanish so even among our students we have a really large capacity to speak Spanish that's not the same necessarily for Asian languages so who knows what this is okay what is it so this is so how many let me just see how many physicians how many people in the room are physicians who see patients raise your hand for a second okay and how many people have seen this before so it's interesting so this is Marty which is this is sorry Marshall I was thinking about you last night let's try and pull this together so this is my accessible okay I had memorized this so many times so let's see my accessible let's see no what is it it's an interpreter so it's my accessible real-time trusted interpreter that's what it is Marty my accessible real-time trusted interpreter so at least in the CCD this is a computer screen that sits on sort of a cart and when you have somebody that's coming in for a procedure for instance this is where we use it a lot in GI that need to be consented you can dial up and you get actually a real person coming on screen and you just talk to each other it's actually wonderful and I think it would be wonderful if it was also available throughout the rest of the hospital and I actually don't know what the cost is but it's it's wonderful I think one of the big barriers for things like Marty and for other ability to work with limited English proficient populations is as you may know who pays for that I mean that comes out of the hospital pocket so we have to pay for interpretation and translational services this is not something right now that we are allowed to build to insurances and I think that this is something that we really need to advocate for if we want to be able to reach out to all populations so this is Marty and I think this is really very helpful but again it needs to be disseminated across the hospital to reach and I see Mr. Joel Jackson here sitting he's going to be leading our cultural competency program so hopefully you'll get to know Marty really well over the coming years okay alright good so I'm going to and by thinking about some potential solutions you know I think that culturally and linguistically appropriate services are incredibly important that is not only that we provide language access but that we are important and I think that there is a big push under the leadership of Brenda Battle and the diversity and Melissa Gilliam under diversity and inclusion to really try to think about in a very thoughtful strategic way how we are going to make this happen there certainly needs to be a tremendous amount of education and awareness about these issues and I think this education cannot stop just at the walls of our hospital you know I think that there needs to be a whole dialogue around community and public health infrastructures because I think that we don't do a good enough job as well intentioned as we are if we don't involve the community now one of the things that the Asian Health Coalition which Marshall said I am the president of this organization nonprofit called the Asian Health Coalition and one of the things that the coalition was able to do is become an in-person counselor for the Affordable Care Act the state had put together eight million dollars to be able to talk to communities that reach and access communities that might not be able to enroll in Affordable Care Act due to language or cultural barriers and the Asian Health Coalition was the organization that was chosen to work with both the South Asian and the Lao community and so this is one of the brochures that announced one of the informational sessions this is in Hindi talking about the Affordable Care Act and I think this partnership has been incredibly important because I think that without the ability to go out into the community to teach them about the Affordable Care Act you'll have access that will not be accessed and so I think this is important and this is an example of what some of the training that took place in the coalition this is a navigator training in Chicago this is a Bhutanese refugee enrolling in Rogers Park and this is one of the Laotian monks signing up in Kane County and you really need to reach beyond our walls to make sure that we can bring individuals in the other thing I think that's important is sort of the pipeline and I've been thinking a lot about this pipeline I think that probably anybody who knows me at any meeting that I go to when we talk about minority issues I'm always raising my hand and saying well what about Asian Americans I'm like the militant Asian American but I think that this pipeline is incredibly important to address this population and so I always tell Asian students I think that Asian students often medical students often feel left out of the diversity dialogue conversation they feel often that they're not really at the table they don't fit really into the white category they're not an underrepresented minority their data often is reflected of the Caucasian population but they have many many other barriers and so I think that this is something that we really need to support this pipeline to be much better under affordable care act and with electronic medical records is that we really need to have accurate data and accurate surveillance I mean I know even on collecting data on race ethnicity and language I mean we really need to do a more robust job in being able to have that information available not only for patient care and quality of care but for research as well because I think that drives a lot of the data that allows us to understand that there's differences in populations and finally I think that we really need to spend a lot of energy around policy and advocacy and that is particularly if you think specifically about limited English populations I think we really need to push to adopt this 5% or 500 LEP threshold for vital documents I mean it is unconscionable that you have patients come to us and they can't get care because they can't speak or read English so I had a patient the students have probably seen this where I have the picture with my thumb with a big old piece of poop on it and that is a picture that always reminds me what happened with the patient who we saw in the GI procedure on four separate times he brought a ride in to get screen for colon cancer he brought his instructions in every single time he was a Spanish speaker the instructions were completely only in English he came every single time to his appointment with a ride he turned back because of poor prep he had a poor prep because he never took the prep because he never was able to understand those instructions I mean that should just not happen and we need to have a system that identifies and labels all limited English proficient populations so when they come in we can avoid this from happening again I think we really need to also increase access to interpreter services so I think Marty is wonderful I think that as we try to make our hospital system confident it would be very important to think about barriers to sort of organizational barriers to culturally competent care it's usually not because anybody is trying to exclude somebody it's just that sometimes it is what it is so in the primary care clinic and this may be different now I know that we can often use language lines to talk to patients that is that there's somebody on one end of the line your patient is on it so a three-way call and you're on there is the most personal way to talk but at least that there opens up a line of communication and I don't know if this is still the case I mean Marshall and Deb you could probably tell me but in primary care clinic there are no phones in clinic in the clinic rooms is that still the case so you can imagine that if you have a patient that doesn't speak there's phones in the hall so if you needed to use a language line in primary care clinic Joel you should change this you're going to have to stand in the hall and Emilio is here too to talk about the international program so I mean I think that the responsibility is to make our organization capable of delivering culturally competent care and I also think we probably need periodic language needs assessment checks so we can make sure that we are delivering quality of care and in a way that that is user friendly so I don't know how many of you saw Claire Pomeroy's grand rounds a few weeks ago on the slide and I thought when I looked at the slides before she presented I had no idea what this meant but somehow the slide has really resonated with me this is the difference between equality and equity and these are kids trying to look at the baseball game and equality is when everyone gets the same stool you can see that these guys can't see and equity is when you might have to give somebody an extra building block in order to have a fair chance of seeing and I think that this is really I remember Emily was talking to me once and said this is an ethics conference but where are the ethical questions so I guess this is my ethical question is that for this very small population that is obviously in need of health services how do we go from equality to equity to make sure that we create the health care system that allows equitable distribution of health care and I think that's our challenge, thank you that's a really good question I know that a lot of the sort of documents you can get into many different languages in Epic and so when you do your discharge planning you can you know if it's constipation you can do it in Spanish you can do it in English you can do it in English you can do it in English you can do it in English you can do it in English you can do it in English if it's constipation you can do it in Spanish you can do it in English you can do it in several languages but in terms of actually can we take our plan and in real time get it translated I don't think it has that capacity although I think that the language capacity in Epic is probably much more robust than we might use yeah so that's a good question so should we refer individuals back to an area that has language capacity so you know there used to be a very large Chinese hospital in Chinatown which closed and I think that it's probably I think in terms of thinking about access to healthcare I think that we need to be ready as a healthcare system to provide access for all populations regardless of if they speak English and we need to be able to provide for them at our own hospital so you know I think there are many individual practices solo practitioners or very small group practitioners among many of the Asian communities but I think they're also struggling under Affordable Care Act to make sure that their technology is up to speed and that their quality of care is well documented and so many of those solo practitioners have either joined forces, have joined hospitals or have closed and so I think that what we're seeing is that with you know millions of individuals immigrant and limited English proficient populations coming into the exchange and marketplace and having access to Affordable Care I think we are going to have to be ready for a much more diverse patient population and I think it's our responsibility to do you know I think that's a good point I think that there's probably I don't think every healthcare system can have addressed every sort of language I mean I think there's 6,000 languages I think there are areas within our surrounding hospital that have you know there's large Chinese community that may speak Mandarin Cantonese, many other dialects of Chinese and then there's large Hispanic communities as well and I think that we have we've done better with in-house Spanish interpreters but I do think that we could target potentially target one or two sort of populations and make sure that we have resources available for those populations and then everyone else would need something like Mardi but I know at hospitals that are some hospitals have exactly what you're describing sort of that in the when you call you can get many different language options we just have not really done that very well Thanks for talking to me can you clarify or kind of talk about that a little more Yeah so that study looked at compliance or adherence with handing in colon cancer screening if you were doctor with a Korean speaking Korean versus a non Korean speaking doctor with an interpreter and without a doubt the presence of a Korean speaking physician at least in this small group motivated individuals to be screened more so than those with an interpreter and I think studies have shown that interpreter is better than no interpreter but having a native speaker is always the best and I think that's kind of what that study shows So I wanted to talk about the case from the Japanese visitor because we do have a good system for international patients they all need to be flagged and sent to the international office and we coordinate and we have our own interpreters to make sure something like this doesn't happen so my guess is that case probably someone got an appointment without going through the international office and that's how the system broke in terms of domestic patients we have a bigger challenge because it's a much bigger community and there's a bigger chance that they will show up without being properly flagged but there's several initiatives going on to improve these systems currently interpreting services falls under social services in the hospital so they're outside international and we're trying to get better coordinated now Yeah and I think this international program is under Amelia Williams leadership is going to really grow beautifully and I think in terms of when we see patients I think that his group is really the, should be the point of contact for all these individuals so they don't slip through the crack I would definitely agree Sorry we have two more over here I like very much your picture of raising those who are short but do we really have to bring the one who is taller bring them down and shorten their spine So I think that's the yeah I don't think so Yeah Yeah I was pediatrician volunteer in one public hospital here in Chicago and I want to ask what is the level the educational level of the interpreter because I want to ask a brief comment I listen one case in the clinical history where the patient was with one the interpreter and the interpreter were translating what he believed but was not the real issue that the patient has and was very very it's a big problem and the interpreter was not much primary level of education in South America Yeah so I think that you bring up a really good point right now we don't have a uniform certification process for interpreters and I think that's sometimes you and probably many of us who've worked with interpreters sometimes you have people who are really great and professional and seem to have a very high level of competence and at times like that so I had a similar experience I worked with somebody who spoke a Chinese language and she asked the interpreter to leave because she felt like her English was better than the interpreter's English and so that's a problem and it's a problem from a medical legal standpoint and a documentation standpoint and as healthcare providers we have the right to ask for interpretive services if we feel that we cannot communicate effectively with our patients and a lot of times our patients will say oh no I don't need it because I can speak well enough and then as you're getting into sort of the intricacies of going over a health plan you realize that actually the language maybe actually capacity may be much more limited so that's a good point yeah yeah and that's so the problem she said was that the interpreter was probably undereducated or maybe not very well qualified and if you don't speak the language you are really helpless and dependent on your interpreter right to be able to say the right thing so that's a problem thanks that was really great do you think that this wouldn't be a solution for everybody but speaking to people from other cultures it's not just interpretation I think maybe it would be helpful for all of us to be a little bit better educated of how these cultures actually work and maybe that's why interpreter doesn't add as much because we don't have the background to understand where the patients are coming from and it took me a while to I use my fellows and everybody else that I can to tap into to know if we have a visitor from Saudi Arabia I'm not going to shake their hand or actually make an attempt to that which I normally wouldn't think about because that's not my cultural background but maybe that is the gap that would lift the translator's help to a little bit better than where they are compared to native speakers I think that's a good point and actually trained medical interpreters are also supposed to do cultural brokering so if you do some kind of cultural faux pas which happens all the time no matter how competent you are they can tell you what's going on and I think if there is some cultural piece that is perhaps interfering with communication or enhancing communication actually real trained medical interpreters are supposed to help you with that so not only navigate the language but also navigate sort of some of the cultural norms that you may be violating in your interaction but and this access thing is a real big problem which we usually are able to get interpreters in clinic and so I find once you beyond that if you can admit a patient especially taken to the operating room it is a magnitude worse having them in the hospital have to deal with on a day to day basis and I just wonder if that's going to be at some point your push to try to fix that as well because it's one thing just in the clinic it's a bigger problem although smaller numbers when a patient is in hospital that's a huge problem I know I'm standing here talking about this but if I'm rounding and there's somebody who doesn't speak English well I might just go in there and sort of look at them and walk out because it's not the system is not easy for us to be able to sort of use language language lines necessarily especially in the rooms we don't have two way language lines so it's you know you're handing back and forth I think that's something that we have to think very carefully about how to address those issues because I think when I cover on the inpatient service I see a lot of actually on the liver service a lot of Spanish speaking patients and I feel like we don't have the capacity unless somebody on my team is fluent and unless there's somebody else there who can help us through that process so I do think that as we're trying to create a culturally competent system those are systems of things that we need to think about I have a question for you Karen you raised this issue of a culturally competent organization and the title of your talk is Beyond Access and clearly language is an important part but in your vision a culturally competent organization looks like when we look at the best practice hospitals in this area what's different or what does it look like so that's a great question I think that an example of a really great so first of all I think you need to make sure that you have training from at all levels in terms of cultural competency training and I think that's the very beginning of what needs to be done and I know that leadership now is really trying to bring people in like Joel to think very strategically about cultural competency training and that's not just physicians but nursing staff and other providers I think that the other thing that in terms of thinking specifically about the Asian population I think that so I think that kind of training would be important I think having access 24 hours a day to language access is incredibly important whether those are in-house interpreters or whether that is access to language lines or if we have a ton of Mardis, I mean if you had two Mardis on every floor I mean those are actually very very easy to use and you can get almost any language available and you get a real person so I mean that would be very very important I think the other thing is from top down thinking about leadership from top down we need to have make sure that our staff and the people that work in this hospital are kind of reflective of the communities that we serve and I think that kind of diversity in not only students but faculty and staff are incredibly important and I think that there needs to be you know very much from top town buy-in of constant education around the need for additional training and resources to make sure that we could provide both language and understand sort of cultural variations among groups without making assumptions I think that there needs to be a tremendous amount of training on unconscious bias because I think for many of you that have followed any of the work that was done around disparities and reported in the Institute of Medicine, unconscious bias often we want to do the right thing and we have no idea that we are actually either making comments that are disparaging or racist or that can be misinterpreted so I think that we need to sort of know ourselves as well. If you give an example of a hospital somewhere like a community hospital like Mercy they already have a huge, since they are located right next to Armour Square their sort of idea of cultural competency is they bring patients in kind of what you were talking about sort of thinking about structuring resources for one particular population they have on their day that they see their breast clinic for Chinese women they have every single person in that clinic speaks the Chinese language from the nurses, from the front end staff to the doctors now that's not practical right so that's not practical but what we can do is just make sure that we have not only providers that are that are trained but we have language resources and written resources as well the other thing I would caution people who do procedures is that if you do a consent and somebody who doesn't speak English well and something goes wrong you're very liable for a negative outcome and so what Amelia said is that our social work I think under social services our interpreters fall under social services but I think that it would be very unwise to consent somebody for a procedure without having documentation that an interpreter was present for a non-English speaker and what they do is if you know that you're doing that they will bring, they will consent and then they will put on the consent form a sticker and a date and time saying that they were present and they were there during the consent process and I really encourage people who are doing procedures to think carefully about using that resource and going forward let's give a big hand for Carrie thank you