Charles Lee, MD

Independent pharmacies comprise a shrinking 35% of all retail pharmacies, predominantly serving patients in smaller cities and towns with 50,000 or fewer residents.

 Just as the retail pharmacy industry has changed in recent decades, these smaller communities are 97% more racially and ethnically diverse than they were in 1980.

 These demographic changes have increased the diversity of languages spoken in rural and non-metropolitan areas, in addition to the growth of the number of residents.

With a larger population of limited English proficiency (LEP) residents, a few state legislatures have passed laws requiring pharmacies to print prescription labels in languages other than English when requested by the patient. The major potential benefits of such laws are clear: fewer patient medication-related errors and greater adherence to treatment plans due to better understanding of instructions. The latter of which is especially important considering patients with LEP tend to have a lower medication adherence rate than English proficient patients.

New York and California have had multi-lingual prescription label laws on the books for years. In 2020, Oregon enacted its law, SB 698, which requires pharmacies to print labels in 1 of 14 languages in addition to English at the patient’s request, which more than doubles California’s 5 required languages and New York’s 6. Oregon’s required languages include Spanish, Russian, Somali, Arabic, Chinese (Simplified), Vietnamese, Farsi, Korean, Romanian, Swahili, Burmese, Nepali, Amharic, and Pashto.

Multi-lingual prescription label laws still raise the question as to why 6 or 14 languages are in use considering there are more than 350 languages spoken in households across the United States?

Most pharmacies only need a few languages representing their local community, but those languages vary by location across the country and the less common languages represent a more difficult resource issue for many pharmacies. The capability to generate labels and patient education materials in a wider range of languages can cost-effectively attract and retain more patients to independent pharmacies, distinguishing them in their communities while increasing customer loyalty.

Existing Federal Rules for Language Access

While the labeling laws in New York, California, and Oregon are newer state laws, pharmacies in other states are also obligated to provide language services to LEP customers. Existing federal rules (EO 13166) already require meaningful access for persons with LEP based on enforcement of Title VI of the Civil Rights Act of 1964 “National Origin Discrimination Against Persons with Limited English Proficiency.” These rules are enforced by the Office of Civil Rights.

However, state labeling laws similar to Oregon’s add specificity for pharmacies, as determined by their state boards of pharmacy, as opposed to the broader federal requirements. Oregon’s law, for example, requires pharmacies to post signs informing patients with LEP that they are entitled to free, competent oral interpretation and translation services.

In many smaller communities, prescribers and pharmacists usually rely on available bilingual staff, oral interpretation services, such as telephone interpreters, or family members to educate patients, but often do not provide written translation instructions for their medications. Oral instructions are more easily forgotten or misremembered, leading to potential medication-related errors and patient harm.

A study of Hispanic parents with LEP and limited health literacy indicated that they were 

 to make mistakes dosing liquid medications for their children.

 Likewise, patients with LEP had lower medication-related self-efficacy scores than patients with greater English proficiency, which may put them at greater risk for medication errors and lower adherence.

Access to easy-to-understand printed dosing instructions and educational materials can reduce such medication errors while improving patient self-efficacy. However, providing such medication instructions in the language preferred by the patient or caregiver should not cause significant operational and financial burden or disruptive manual processes for pharmacies.

Independent pharmacies need a low-cost offering from their pharmacy management and dispensing system vendors that automatically generates multilingual labels and education within their established workflows. Such systems should store the customer’s preferred language, automatically generate labels on repeat visits, and offer an increasing number of supported languages in the future.

The capability to capture preferred language is important because patients and caregivers with LEP are often embarrassed or intimidated to request such assistance at each visit. A survey of LEP Spanish-speaking adults found that “fear of disclosing limited English skills” was a major barrier to accessing needed care, and their LEP has led to miscommunication about medication changes.

 In an ideal situation, the documentation of the preferred language should be transmitted with the prescription from the provider and automatically entered in the system.

In addition to the patient’s preferred language on the label, pharmacies should offer simpler drug-specific information sheets, written at lower reading levels in the given language. Concise drug information sheets that incorporate the key basic information on proper use, adverse effects, and when they should contact their provider can reduce the overwhelming effect of the more comprehensive drug sheets currently used. A visual medication literacy aid, known as the Universal Medication Schedule (UMS), can improve adherence by helping patients schedule their medications at 4 times during the day—morning, noon, evening, and bedtime. This UMS format is being used by a growing number of retail pharmacies.

Additional safety features, such as visual illustration of syringes with proper dosing and pill images, can also prevent medication errors. Simple visual instructional elements combined with easy-to-understand text can boost understanding and benefit both LEP and low health literate English-speaking populations.

 Approximately 1 in 3 individuals in the United States are considered to be low health literate.

 The ability to provide such consumer-focused features and services demonstrates to patients that independent pharmacies are committed to being a central health care resource in each community.

In 2019, there were 21,683 independent community pharmacies, down from 22,478 in 2014. Likewise, the average prescription volume was 57,414 per store in 2019, declining more than 1000 prescriptions since 2018.

Sustaining independent pharmacies in large and small communities will require these businesses to change based on how the market evolves. If their communities are becoming diverse, they should not wait for a new law requiring them to print labels in the languages representing their community.

Rather, independent pharmacies should be proactive and modernize their operations in anticipation of these changes to offer superior pharmaceutical care in their communities compared to their competitors, encouraging patient satisfaction and loyalty. Alliances representing community pharmacies, such as the National Community Pharmacists Association, can leverage their collective voices to push vendors for more consumer-friendly features.

By translating labels and education materials, pharmacies can, more importantly, improve their patients’ understanding of their prescription, including dosing and regimen schedules.

Implementing such changes does not need to be difficult, which has been proven in a 2015 survey which looks at New York City pharmacies.

 Reliable translated content solutions that can be easily integrated with pharmacy management systems have emerged to make it easier and faster for independent pharmacies to not only comply with state and federal requirements but also to go beyond the law to better serve their patients and the community.

Charles Lee, MD, is senior director of Clinical Knowledge for 

, which publishes and maintains drug databases for healthcare professionals that are used by the majority of the nation’s hospitals, physician practices, pharmacies, payers, and other health care industry segments.

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https://ncpa.org/newsroom/news-releases/2020/10/19/ncpa-releases-2020-digest-report

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. Published April 15, 2019. Accessed June 28, 2021.

5. 80th Oregon Legislative Assembly—2019 Regular Session. Senate Bill 698. 

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Articles

How Multi-Lingual Labels and Education Can Help Independent Pharmacies Better Serve Patients

Low health literacy can be a major obstacle to the proper use of medications.

What percentage of patients walk out of your pharmacy not knowing how to use their medicine correctly? According to the Institute of Medicine, nearly half of US adults will have some difficulty understanding their medication instructions.

 These patients have low health literacy. With 4.3 billion prescriptions dispensed in the United States last year, this challenge has the potential to affect a substantial number of patients.

Health literacy is a personal skill that includes the ability to gather, understand, and act on appropriate health information. Patients with low health literacy have difficulty with one or more of these steps. Each step is important because an inability at any stage detrimentally affects subsequent steps. Health literacy is such an important skill that it is a stronger predictor of health than age, income, employment status, and race.

Why Is Health Literacy Important for Pharmacists to Consider?

Addressing health literacy is important because it offers a practical approach to improving patient adherence by directly impacting the patient’s ability to selfmanage their medications. Let us take a look at each of the 3 health literacy skills to see what we can do to overcome low health literacy:

—Many patients do not know where to go to find information about their medicines. The Internet has so much information&mdash;from both reputable and nonreputable sources&mdash;that many people quickly become overwhelmed. Therefore, once information is collected, patients often have a tough time sifting through credible information to find actionable content.

Pharmacists can make this process easier for patients by guiding them to reputable resources. One such resource is MedLine Plus from the National Library of Medicine. If a patient does not have Internet access, consider giving him or her a printout of pertinent information. A good rule of thumb is that half of all people forget what you tell them once they walk out the door, so giving them printed information is always a good decision.

—Approximately 1 in 8 patients has some vision loss.

 If patients have difficulty reading, it is hard for them to understand instructions. As our population becomes older, vision loss is becoming increasingly prevalent. Ask if your patients wish to receive information in larger font sizes or if they need help reading the material. Check to see if you can print larger font sizes on bottles and in handouts.

Another 30 million Americans have limited English proficiency. If patients cannot read the English instructions, this is an obvious barrier to understanding them and a safety concern. There are a few vendors who now offer multilanguage medication instructions for patients. Avoid giving just the dense, English-only medication instruction sheets that have been dispensed with medicines in the past, hoping that your patients can somehow figure out what they mean.

Another approach to improving understanding is a visual one. There is growing support for the Universal Medication Schedule (UMS), which graphically represents 4 daily dosing times with the amount of medicine to be taken at each time. Some pharmacy management systems can now print UMS images on container labels and handouts.

—As mentioned in other articles in this issue, medication adherence is multifaceted and can be affected by many issues such as financial resources, access to transportation to the pharmacy, etc. One of the nice benefits of the health literacy approach is that we can improve patients’ self-management skills and increase their awareness of the importance of each medicine. Including periodic reviews with patients, such as a medication therapy management session, can reinforce proper adherence behavior and identify other barriers to adherence.

There are measurement tools to score a patient’s health literacy levels, such as the Rapid Estimate of Adult Literacy in Medicine. These tools, however, are generally used only for research purposes and are impractical for daily use.

How Do You Target Low Health Literacy Patients?

The point of this approach is that you do not need to target any particular groups. This approach benefits everyone, and low health literacy patients the most.

As you can see, understanding is the cornerstone of patient adherence. Remember that half of your patients likely face obstacles to their ability to understand their instructions. Accommodating low healthy literacy provides a practical method for improving health outcomes for all your patients.

Dr. Charles Lee is founder and president of Polyglot Systems, Inc (Morrisville, NC), which he founded in 2001 with a mission to develop practical, affordable, multilanguage technology solutions to improve health care access and reduce disparities for underserved and limited English proficient patient populations. He is an internal medicine physician, an adjunct assistant professor at the UNC Eshelman School of Pharmacy, and a member of the FDA’s Risk Communication Advisory Committee.

Health Literacy: A Prescription to End Confusion

. Washington, DC: National Academies Press; April 2004.

		Report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. 

		American Foundation for the Blind website. 2013. www.afb.org.

Patient Understanding: The Cornerstone of Medication Adherence

Patients and caregivers are seeking smartphone health apps that are adaptable to their needs.

Mobile health technology holds great promise to improve our health care system, especially to engage consumers. In 2012, 46% of all US adults owned a smart phone. In 2013, smart phone ownership had risen to 56% and 85% of all adults over age 18 had access to the Internet.

 Yet there appears to be a continuing disconnect between apps created by developers and apps that effectively engage consumers.

A recent review of Google Play and Apple AppStore found more than 200 mobile health care applications that were co-branded with health care organizations and targeted for patient engagement.

 Yet many health apps have failed to have an impact. There are apps that provide access to health records, allow appointment scheduling, prescription refills, and medication reminders—features that are often driven by what health care organizations believe patients need. However, according to data from the Pew Internet & American Life Project, the number of Americans using technology to track their health or fitness didn’t change between 2010 and early 2013.

 Even Google Health failed to find the right approach to engage consumers and discontinued its service in early 2012.

But there is a bright side to this story. Patients and caregivers really do want to use their mobile devices more to connect with their health care providers. But they want the developers to listen to their needs—not develop tools that annoy them with constant reminders (encouraging many to shut it off or remove the app completely) or only focus on things they would do just once a year (they forget how to use the app or can’t remember the password). So, if we are really interested in engaging patients&mdash;not just to check off a box to say “we have mobile technology”&mdash;we should start by better understanding the patient and listening to their needs. Here are 4 things to keep in mind:

—The technology should be personal and adapt to the needs of each patient. All people are the not the same and technology shouldn’t treat them as if they were.

 Healthy peoples’ needs are very different from patients with multiple chronic illnesses. We need to understand how patients vary based on their conditions. Identify repetitious tasks that lend themselves to time-saving technology.

 Accommodate elderly and visually-impaired patients by enabling larger display fonts or content in alternate audiovisual media formats.

 One of every 3 adults in the US has low health literacy, which is defined as the ability to 1) gather, 2) understand, and 3) act on appropriate health information. Because those with low health literacy are at the highest risk for preventable negative health outcomes, they are the ones who can most benefit from technology support. We can’t expect patients to become engaged if they can’t find or understand health information.

 Similarly, about 8% of adults have difficulty with the English language and really struggle understanding and navigating the health care system. They represent one of the most vulnerable populations and are at high risk for medication errors. And language doesn’t mean just Spanish. There are many other languages spoken in the United States.

So, one of the first goals for app developers should be to build tools that can adapt to the needs of each individual patient. In order to do this, we need to be better listeners and not assume that we know better than our patients about what they need. And don’t give in to the temptation to focus on the more highly educated, early adopters of technology— they may be easy targets but they don’t represent the patients who can benefit the most.

—Consumers should want to use the technology routinely. The challenge for developers here is finding the right balance of motivation and encouragement without annoying them with constant reminders. Again, find out what’s important for each patient or caregiver. Is it communication? Quality of life? Difficulty remembering? Repetitive tasks? Remote caring? Patents and caregivers (caregivers are usually very motivated and one of the earliest adopters of technology) should want to use the features frequently. Tasks that are performed once or twice a year are not engaging and the burden of relearning how to perform infrequent tasks makes them inconvenient for most users. Forgotten user IDs and passwords are common barriers to use in these cases.

—Keep the app design simple, clean, relevant, and obvious. Remove unnecessary clutter by adapting the content to each user. Access to features and information should be quick and obvious, not buried several layers down. Test your interface with people off the street and just observe what they do. See where they get stuck. Keep repeating until your design becomes obvious. An attractive, clean design will encourage users to come back and promote your tool to others.

—This is the part that most developers forget&mdash;the reward. Does the app make users feel good or provide an incentive for being engaged? Apps should also appreciate the effort of users for using it. For example, if users are able to access their personal health record, does the system recognize and encourage their input to keep the records updated? Or does it cause frustration because it is uneditable, even if they find errors? Examples of some other types of rewards include convenience (appointment scheduling), cost saving (discount on services), time saving (wait time monitoring), tracking (lab updates of relatives by caregivers, peak flow readings), and remote communication (access to nurses for questions).

Consider these 4 issues during your app development, and you’ll soon be on a solid foundation to create active and informed customers.

Charles Lee, MD, is the founder and president of Polyglot Systems, Inc. He received his Doctor of Medicine degree from Northeastern Ohio Universities College of Medicine and is board certified in internal medicine. He was a National Library of Medicine Fellow at the Duke/ University of North Carolina medical informatics program.

		Smith A. Smartphone ownership 2013 [published online June 5, 2013]. Pew Internet and American Life Project. http://pewinternet.org/Reports/2013/Smartphone-Ownership-2013/Findings.aspx.

		Conn J. More than 200 available apps co-branded with healthcare organizations [published online September 19, 2013

. www.modernhealthcare.com/article/20130919/BLOG/309199996#.

		Fox S, Duggan M. Tracking for health [published online January 28, 2013]. Pew Internet and American Life Project. www.pewinternet.org/Reports/2013/Tracking-for-Health.aspx.