Video medical interpretation over 3G cellular networks: a feasibility study.
ABSTRACT To test the feasibility of using cell phone technology to provide video medical interpretation services at a distance.
Alternative cell phone services were researched and videoconferencing technologies were tried out to identify video products and telecommunication services needed to meet video medical interpretation requirements. The video and telecommunication technologies were tried out in a pharmacy setting and compared with use of the telephone.
Outcomes were similar to findings in previous research involving video medical interpretation with higher bandwidth and video quality. Patients appreciated the interpretation service no matter how it is provided, while health providers and interpreters preferred video.
It is possible to provide video medical interpretation services via cellular communication using lower bandwidth videoconferencing technology that provides sufficient quality, at least in pharmacy settings. However, a number of issues need to be addressed to ensure quality of service.
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ABSTRACT: We explored the feasibility and acceptability of the remote provision of a language interpretation service during general practice consultations. Three methods were used to provide an interpretation service: a physically present interpreter (PI), a remote interpreter accessed using an ISDN videoconferencing link at 128 kbit/s (VI) and a remote interpreter accessed by telephone (TI). Thirty-six non-English-speaking patients were invited to take part and 35 agreed to do so. Twenty-nine (83%) of the patients recruited were female. The age range of the participants was 24-51 years. Fourteen consultations took place with a physically present interpreter, 11 using videoconferencing and 10 using the telephone. Mean scores on the Patient Enablement Instrument were 5.2 for the PI group, 2.3 for the VI group and 5.1 for the TI group. Mean scores on the Medical Interview Satisfaction Scale were 5.3 for the PI group, 4.9 for the VI group and 5.3 for the TI group. The visual quality and sound quality of remote interpreting were satisfactory. Both videoconferencing and hands-free telephones can deliver an acceptable interpreting service in primary care.Journal of Telemedicine and Telecare 02/2003; 9(1):51-6. · 1.47 Impact Factor
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ABSTRACT: Twenty-one million Americans are limited in English proficiency (LEP), but little is known about the effect of medical interpreter services on health care quality. Asystematic literature review was conducted on the impact of interpreter services on quality of care. Five database searches yielded 2,640 citations and a final database of 36 articles, after applying exclusion criteria. Multiple studies document that quality of care is compromised when LEP patients need but do not get interpreters. LEP patients' quality of care is inferior, and more interpreter errors occur with untrained ad hoc interpreters. Inadequate interpreter services can have serious consequences for patients with mental disorders. Trained professional interpreters and bilingual health care providers positively affect LEP patients' satisfaction, quality of care, and outcomes. Evidence suggests that optimal communication, patient satisfaction, and outcomes and the fewest interpreter errors occur when LEP patients have access to trained professional interpreters or bilingual providers.Medical Care Research and Review 07/2005; 62(3):255-99. · 3.01 Impact Factor
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ABSTRACT: To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients. A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library. Any peer-reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care. In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers. Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.Health Services Research 05/2007; 42(2):727-54. · 2.29 Impact Factor
Video Medical Interpretation over 3G Cellular Networks: A Feasibility Study
Craig Locatis, Ph.D.,1Deborah Williamson, D.H.A., M.S.N., C.N.M.,2
James Sterrett, Pharm.D.,3Isabel Detzler, B.A.,4
and Michael Ackerman, Ph.D.1
1Office of High Performance Computing and Communications,
National Library of Medicine, Bethesda, Maryland.
2College of Nursing,3College of Pharmacy, and4Interpreter
Services, Medical University of South Carolina, Charleston,
Objective: To test the feasibility of using cell phone technology to
provide video medical interpretation services at a distance. Materials
and Methods: Alternative cell phone services were researched and
videoconferencing technologies were tried out to identify video
products and telecommunication services needed to meet video
medical interpretation requirements. The video and telecommuni-
cation technologies were tried out in a pharmacy setting and com-
pared with use of the telephone. Results: Outcomes were similar to
findings in previous research involving video medical interpretation
with higher bandwidth and video quality. Patients appreciated the
interpretation service no matter how it is provided, while health
providers and interpreters preferred video. Conclusion: It is possible
to provide video medical interpretation services via cellular com-
munication using lower bandwidth videoconferencing technology
that provides sufficient quality, at least in pharmacy settings.
However, a number of issues need to be addressed to ensure quality
Key words: pharmacy, technology, telecommunication, telemedicine
has improved the prospects of offering services by video. Bandwidth
improvements have extended to cell phone networks, making it
theoretically possible to increase accessibility to video medical in-
terpretation in areas that have been underserved.
Medical interpretation has been provided by trained interpreters or
on an ad hoc basis by friends, relatives, or anyone conveniently
available. The advantages of using trained interpreters have been
documented in three research reviews.1–3Trained interpreters out-
perform ad hoc ones and can raise the level of clinical carefor patients
with limited English proficiency (LEP) to that given with language
rofessional medical interpretation services have usually
been provided in-person or by phone. Protocols have been
developed enabling transmission of voice and video data
over computer networks and increasing Internet bandwidth
concordance.1Communication quality is rated higher with trained
interpreters and there are fewer errors that affect diagnosis and
treatment.2Ad hoc interpretation is more error prone because inter-
preters may not understand technical information health providers
give and may omit or distort it out of embarrassment. Moreover, pa-
tients may be less forthcoming because of lack of privacy and confi-
dentiality if interpretation is provided by friends or relatives. Use of
trained interpreters is associated with increased use of healthcare
services, higher preventative screening levels, improved compliance,
and greater patient satisfaction.1,2Consequently, providing profes-
sional language assistance services has become a standard for
healthcare organizations receiving federal funding.4
There are few studies of remote medical interpretation; one
systematic review identified only nine,3most involving the phone
and comparing remote simultaneous medical interpretation (RSMI)
to proximate consecutive medical interpretation (PCMI). In RSMI,
the interpreter is not physically present; the doctor and the patient
usually wear headsets and technology directs their speech to the
interpreter, not to each other. The interpreter’s speech is directed
back to the doctor and patient allowing interpretation while they
talk. In PCMI, the interpreter is usually physically present and re-
sponds after each person speaks, although PCMI also can be done
One of the two videoconferencing studies in the systematic re-
view found similar patient satisfaction with video, phone, and in-
person interpretation,5while the other found that interpreters
preferred face-to-face service most, but favored using video more
than the phone.6The results of the latter study were similar to an
earlier one of telephonic and in-person interpretation where in-
terpreterspreferredcontact in-person.7Bothvideostudiesthat were
reviewed had limitations. One used older Integrated Services Digital
Network (ISDN) technology at a bit rate of 128 kilobits per second
(Kbps) that was too low for full motion video, involved a single
provider and interpreter, had too few encounters for statistical
comparison, and only used data from patients.5The other had only
qualitative data6but its results were similar to a subsequent qual-
itative study where providers and interpreters preferred in-person
and then video interpretation to telephonic.8
conducted by some of the authors had results similar to the two prior
qualitative studies.9Patients, providers, and interpreters rated the
quality of 80 in-person, 80 telephonic, and 81 video encounters pro-
vided by the PCMI. Seven interpreters and 24 providers participated.
Ratings for in-person interpretation were significantly higher than
those for remote methods and the difference was due to providers and
interpreters who experiencedall threemethodsand were morecritical.
Patients only experienced the type of interpretation service provided
ª MARY ANN LIEBERT, INC. ? VOL. 17NO. 10 ? DECEMBER 2011
TELEMEDICINE and e-HEALTH 809
rating differences between remote methods, but interpreter ratings of
video encounters approached significance (p=0.08) and, in inter-
views, providers and interpreters overwhelmingly preferred video.
Most encounters involved postpartum consultations where providers
moved about the room and demonstrated procedures. Video was
valued because interpreters could see patient’s body language and
phones because their hands were free and preferred it to speaker
phones because it had superior microphone range.
H.323 standard definition videoconferencing appliances were
used in the previous study with a data rate of 384 Kbps, sufficient for
on carts that could be moved to different hospital rooms as needed
and had pan, tilt, and zoom (PTZ) cameras that could be controlled
remotely. Communication in the hospital was over its wireless net-
work,using802.11 routers,while that intheinterpretation officewas
over a wired network. It took time to set up equipment and it used up
space, even though communication was wireless and the carts were
not large. The question arose whether it would be possible to provide
the video service on laptops using cell phone transmission to provide
greater mobility and extend service accessibility.
A pharmacy setting was targeted for testing cellular video service
because pharmacies are numerous and geographically dispersed and
because of a survey conducted by some of the authors identified a
study showed that few pharmacies had Spanish-speaking pharma-
cists, that there were few mechanisms other than printing bilingual
labels for communicating medication information or verifying a
patient’s understanding, that most pharmacists felt they had limited
ability to counsel LEP patients, and that most pharmacies had access
to the Internet and to cell phone service.
Materials and Methods
Alternative technologies were identified and initially
tested at the pharmacy and interpretation office sites and
then tried out with patients. The initial evaluation in-
volved determining cell phone service and bandwidth
requires a certain level of cell phone service. Older G2
service is insufficient because, although G2 cell towers
provide digital transmission, average data rates can be as
low as 56 Kbps and peak rates are about 150 Kbps. While
G3 services can transfer data at rates accommodating
Web access and related Internet services such as one-way
video streaming (Webcasts) and videoconferencing, the
bandwidth problem is compounded because different cell
phone carriers employ different underlying technologies
with varying transfer rates depending on the version. The
fastest versions may not be deployed in all areas carriers
serve and available bandwidth can still fluctuate de-
pending on how traffic is routed. Some may route voice
and data over the same cell tower antenna while others
may divide the spectrum amongst different antennas to distribute
load. These 3G bandwidth issues, which had to be addressed in the
feasibility study, have persisted with the introduction of 4G tech-
nologies increasing transfer rates by another order of magnitude.
Video tests were done using code division multiple access (CDMA)
cell technology. Evolution Data Optimized (EV-DO) Rev A was de-
termined to be the appropriate version because EV-DO Rev A has
downlink rates of 600 to 1,400 Kbps with burst up to 3.1 megabits per
Mbps. Prior to Rev A, CDMA service provided downlink transfer rates
extreme asymmetrical transfer rates were suitable for one-way video
streaming and movies on demand, but more symmetrical bandwidth
is needed for bidirectional videoconferencing. Importantly, the EV-
the Charleston, South Carolina, region where the study was con-
ducted. The carrier’s Web site, aimed at consumers, only referred to
the availability of ‘‘mobile broadband,’’ however, and additional in-
quiries had to be made to determine the exact technology.
The video and audio available on most cell phones at the time had
inadequate quality and the phones were cumbersome to control. Po-
sitioning the cell phone to frame both the pharmacists and patient and
hold it in a stable position would be difficult and panning, tilting, and
zooming the cameras remotely was not possible. Consequently, Per-
ipheral Component Interconnect (PCI) or Universal Serial Bus (USB)
cell modems connected to laptops for Internet access via cell networks
were used instead (Fig. 1). Varied cameras and videoconferencing
software could be installed to provide video interpretation services.
H.323 standard videoconferencing software was tested initially but its
data rate of 384 Kbps for full motion video and even lower rates (e.g.,
128 Kbps) proved unworkable, with unacceptable latency and jitter
evenwhentestedonCDMAbydifferent carriers.VSeewas selectedfor
videoconferencing because its data rates, while variable, could go as
Fig. 1. Laptop with Peripheral Component Interconnect (PCI) cell phone modem
at interpretation office.
LOCATIS ET AL.
810 TELEMEDICINE and e-HEALTH
control of PTZ cameras, it provided secure Federal Information Pro-
(AES)-encrypted video transmission, and its video looked superior to
other low-bandwidth products. The VSee default video window size
was 240·320 pixels, but could be expanded.
The pharmacy at the Harvest Free Clinic in the city of North
Charleston, South Carolina, agreed to participate. Although lo-
cated in a concrete building originally used for ordinance re-
search in World War II at a somewhat remote shipyard, the
pharmacy occupied an area where glass windows and doors were
installed. Its cell signal was good and preliminary tests were
successful, as were those at the interpretation office at the
Medical University of South Carolina (MUSC). Almost a year
passed after the study received funding and Institutional Review
Board (IRB) approval. A laptop with a Sony standard definition
D-70 PTZ camera was installed in the pharmacy while one with a
Logitec HD 9000 camera was placed in the interpretation office.
Twenty-six patients, two pharmacists, five interpreters, and one
nurse participated. The nurse was bilingual, consented patients, and
assisted with the technology. Half of the consultations were done by
phone and half by videoconference. Patients were asked to comment
on the interpretation service after each consultation. The pharma-
cists, interpreters, and the nurse were interviewed at the end of the 3-
month tryout period. The same interview protocol was used (Fig. 2),
but only the interpreters answered the question about how the laptop
theonly participantswhousedH.323inthepriorstudy. Althoughthe
pilot study involved providing Spanish interpretation, follow-up
tests weredoneto judge thesuitability of thevideo forsignlanguage.
There were two types of outcomes: technical ones associated with
implementing the technology and people ones concerning their
perceptions of the technology and its use. The pilot implementation
varied from the preliminary test in several significant respects. First,
the videoconferencing equipment had to be moved to a room toward
the interior of the building away from the windows in the pharmacy
lobby because of privacy. The room’s concrete pillars and walls
blocked cell phone communicationand arepeater amplifyingthe cell
signal had to be installed. Connectivity proved to be more of a
problem at the MUSC interpretation office. Cell service was consid-
erably worse than when initially tested and a wired network was used
Patients’ perceptions were like those in the previous hospital clinic
study. They were exposed to only one method and were pleased to
have the service. The eight participating providers and interpreters
were exposed to both methods and were more critical, as in the
earlier study. When they were asked about encounter quality, five
indicated that in-person interpretation was superior, two did not
mention in-person but only the superiority of video to phone, and
one felt that all methods impacted encounter quality the same. When
they were asked to directly compare the two remote methods, six felt
that video was better and two felt that they were about the same.
None indicated phone superiority. Provider and interpreter responses
to the question about rank ordering interpretation methods were
more definitive. Everyone’s first preference was for in-person in-
terpretation, seven indicated video as their second preference, and
only one indicated the phone. The ability to see what was happening
and to have more personable communication were the most cited
reasons. The pharmacy was a new venue for the interpreters who had
to become familiar with a host of medications. Interestingly, both
pharmacists indicated that the video helped them detect when an
interpreter might be having a problem with the information
Six of theeight providers andinterpretersfeltthatthe smallervideo
window provided sufficient quality for interpretation in pharmacy
settings. One pharmacistfeltthatthe video window sizewas too small,
possibly because of not knowing how to increase the default setting,
and one interpreter preferred the full size, full screen H.323 video used
in the previous study. However, the five interpreters who used the full
screen videoconferencing appliance and the sub-full screen laptop
were equally divided, when asked to compare the two video technol-
ogies. Two felt that the H.323 appliance was better because of image
quality, two felt that the laptop software was better because of its ease
of use, and one felt that they were the same. Everyone mentioned
technical problems, albeit different ones. Some mentioned connection
problems while others mentioned difficulties hearing or
seeing (lighting). Medication names and how to com-
considered essential for interpreters to control their
view, proved unessential because the pharmacist and
that the video quality was suitable for sign language.
Participants were pleased with video. When asked
to comment generally about the study, several men-
tioned they were impressed that videoconferencing
could work on cellular networks and that there were
few problems or ones easy to troubleshoot once the
1. Tell what you think of the research study and technology implementation. What
went well and not so well?
2. How do you think the quality of the patient-provider encounter compares be-
tween in-person, video, and phone interpretation?
3. How do the two remote technologies compare – video versus the phone?
4. If you could provide interpretation services in-person, by video, or by phone,
which would you use first, second, and third? Why?
5. Have you done video medical interpretation before? If so, how does the video
used in this study compare to what you used previously?
6. Do you think the video technology used in this study was sufficient for providing
interpretation services? Why or why not?
Fig. 2. Interview protocol.
CELLULAR VIDEO MEDICAL INTERPRETATION
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TELEMEDICINE and e-HEALTH 811
cell signal was amplified at the pharmacy. The cell phone connec-
tivity problem at the interpretation office was unexpected, given the
university’s more central location, but was attributable to higher
been anticipated, even though the carrier separates spectrum, given
the high degree of cellular device usage among students, faculty, and
The discontinued use of the PTZ camera was unforeseen, but one
provider and one interpreter felt that not only the camera but also
the video itself may not be as essential in pharmacy settings. There
was little movement, unlike the previous postpartum study where
providers demonstrated aspects of baby care. In retrospect, the
initial pharmacy videoconferencing platform was over engineered,
adding complexity and costs. The use of built-in cell phone cam-
eras maybe possible in the future, given the generally fixed posi-
tioning of subjects at pharmacy sites and improvements in cell
phone camera quality, although initially positioning and stabiliz-
ing phones remains a problem. Laptop and tablet computer dis-
plays make it easier for participants to see the signals they send
and receive and to reposition the computer and its camera ap-
Insufficient time and exposure were also identified as a problem
in working with the technology and pharmacy content. The study
lasted only 3 months and the interpretation service was only
provided one morning per week at the time the clinic scheduled
non-English–speaking patients. It was assumed that interpretation
services in one context (a hospital ward) could transfer to another
(a pharmacy), but medication names and dosage requirements were
problems. Issues arose over whether the name should be pronounced
as it would in English or Spanish. Interpreters were provided a list of
more common medications, but inevitably there were prescriptions
not on the list. The use of VSee’s chat feature to type the name for
the interpreter to see was considered but it was not used, and sub-
sequent test showed that the name of the medication on the pre-
scription was generally large enough that it could be read when held
to the camera, although other information was not. Several inter-
preters mentioned needing a copy of the prescription prior to con-
sultation. Having electronic medical records systems interpreters
could access would alleviate the problem. Interpreters would have
become more knowledgeable and comfortable with medication ter-
minology over time. Follow-up tests using sign language showed
that the video was large and smooth enough.
The use of 3G cellular networks can potentially increase accessi-
bility to video medical interpretation services. The pilot feasibility
study proved that it was possible to do video medical interpretation
with adequate image quality for language and sign language inter-
pretation over cell phone networks, at least in pharmacy settings, but
only under certain conditions.
.Appropriate 3G network connectivity must be available. Only
3G (or 4G) networks have sufficient bandwidth and only the
more recent ones allocate enough uplink bandwidth to ac-
commodate bidirectional video.
. Efficient video CoDecs should be employed that can economi-
cally use available bandwidth while providing sufficient qual-
ity. While the latest cell technology has adequate bandwidth, it
is lower than what can practically be realized with landlines
and more susceptible to network congestion and other factors
affecting network performance.
.Tests need to be done in the exact locations where video con-
ferencing will occur, since cell phone signals are susceptible to
interference by building materials and the volume of traffic at
the cell towers serving a site.
. Use of cell signal repeater antennas should be considered when
signals are weak or variable. If a site already has good existing
network capability by landlines, there is no need to use cellular
wireless. If it does not and signals are weak, modest investments
can be made in amplifying equipment.
. Performance must be continually monitored. Cell towers hav-
ing sufficient bandwidth may become congested if use of
cellular services increases. This is not only a function of more
individual users but of the number of devices becoming cel-
.Use of peripherals (e.g., PTZ cameras) or complimentary
technology (e.g., chat) should be weighed in relation to the
activities occurring and content provided at the remote
healthcare site. Some may prove necessary while others may
not, and some can add complexity and costs. Built-in com-
puter (and possibly cell phone) cameras may suffice for some
.Policies for dealing with special terminology need to be es-
tablished, depending on the healthcare service being provided.
For pharmacies, they include providing prescriptions to inter-
preters in advance or using chat technology or video to display
product names as well as determining how names will be pro-
nounced (in English, Spanish, or both).
No competing financial interests exist.
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clinical care for patients with limited English proficiency? A systematic review
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6. Paras M, Leyva O, Berthold T, Otake R. Videoconferencing medical
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Address correspondence to:
Craig Locatis, Ph.D.
Office of High Performance Computing and Communications
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20854
Received: April 27, 2011
Revised: May 20, 2011
Accepted: May 23, 2011
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