Patient-reported outcome measures (PROMs) have become an integral component of contemporary healthcare delivery, supporting clinical decision-making, performance improvement and value-based reimbursement. These tools capture symptoms, functional status and quality of life directly from patients, offering insights that are often unavailable through clinical assessment alone. However, their effectiveness depends on equitable access and meaningful participation.
Patients with a non-English preferred language (NEPL) face persistent barriers across the care continuum, including limited access to preventive services, lower satisfaction and increased risk of adverse outcomes. Language concordance between patients and health systems is therefore a prerequisite for patient-centred care. Digital health platforms promise scalability but can also reinforce inequities when language access is inadequate. Experience from a large integrated health system illustrates both the potential and the limitations of multilingual, electronic health record–integrated PROM collection, highlighting how technology design, workflow and organisational choices shape equitable access.
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Multilingual PROM Integration Within the Electronic Health Record
PROMs are designed to quantify aspects of health for which patients are the most reliable source of information, including symptoms, function and health-related quality of life. When embedded into routine care, they can improve efficiency, prioritise patient concerns and support shared decision-making. Within a large health system using a single electronic health record (EHR), PROMs were fully integrated into clinical workflows and administered either through a patient portal or on tablets in clinic settings. During the COVID-19 pandemic, reductions in in-person visits exposed disparities in PROM access, particularly for patients with a NEPL.
In response, all PROMs within the EHR were translated into six commonly spoken non-English languages: Spanish, Portuguese, Arabic, Russian, Haitian Creole and Chinese. The patient portal and associated patient-facing content were also translated into these languages and embedded within the EHR. This required substantial financial investment and technical redevelopment, as multilingual functionality was not a standard vendor feature. Patients were required to select a preferred language within the portal to access translated content, while in-clinic completion relied on staff selecting the appropriate language before providing a tablet. Interpreter services, staff training and patient education materials supported implementation.
Language concordance was defined as completion of a PROM in the patient’s preferred language as recorded in the EHR at the time of completion. Analysis focused on PROMs as the unit of assessment rather than individual patients, reflecting variation in the number of PROMs completed over time and across clinical contexts.
Patterns of Language Concordance Across Modes of Collection
Between the first quarter of 2022 and the third quarter of 2024, 2,657,469 completed PROMs were included for analysis. PROMs were most frequently completed in English, accounting for 97.2% of all responses, while Russian and Haitian Creole each represented 0.1%. Patients with English recorded as their preferred language completed PROMs in English 99.9% of the time, with only 0.1% completed in non-English versions, suggesting occasional documentation errors.
Among patients with a NEPL, language concordance increased steadily over time following implementation of multilingual PROMs. Despite this progress, most PROMs from NEPL patients continued to be completed in English. By the third quarter of 2024, language concordance reached 33.9% for PROMs completed through the patient portal and 58.1% for those completed on tablets in clinic. Concordance was consistently higher in the in-clinic setting than via the portal.
Improvements were driven primarily by patients with Spanish and Portuguese as their preferred languages. While gains were observed across languages, uptake varied, indicating differential engagement or accessibility. The higher concordance observed with in-clinic tablets suggests that direct support and facilitated workflows can partially mitigate digital and language barriers that persist in remote completion.
Technology, Workflow and Equity Constraints
Several limitations emerged during implementation, underscoring how digital design and workflow choices influence equitable access. Within the patient portal, access to translated PROMs depended on recognising a small icon used to select an alternative language. This icon was not intuitive and did not clearly signal the availability of multilingual content. As a result, patients could receive PROMs in English by default, even when a non-English preference was recorded elsewhere in the system.
In clinic settings, tablets did not provide clear instructions for patients to select their preferred language independently. Instead, workflows relied on front-desk staff to make this selection, creating a potential point of failure when recorded and actual language preferences differed. While bilingual staff could reduce this risk, such capacity is neither universal nor sustainable. Accurate documentation of language preference also depended heavily on registration processes, often conducted by telephone, where staff proficiency and patient empowerment varied.
Additional complexities related to proxy completion further affected data accuracy. Although interpreter services were available, the extent of interpreter involvement in PROM completion was not systematically tracked. Family members or caregivers may also have acted as proxies, raising concerns about whether true language concordance and patient voice were consistently achieved.
Resource constraints introduced further equity considerations. Translations were implemented pragmatically when validated versions were unavailable, using forward translation without full linguistic and cross-cultural validation. While this approach prioritised timely access, it acknowledged trade-offs between scientific rigour and urgent equity goals. Moreover, the high cost of restructuring the EHR limits generalisability. Health systems serving large NEPL populations may be least able to afford multilingual digital infrastructure, potentially exacerbating existing disparities.
Experience with multilingual PROM implementation demonstrates that translation alone is insufficient to ensure equitable participation. Although language concordance improved over time, substantial gaps persisted, particularly within patient portals. Technology design, workflow dependencies and proxy involvement all influenced outcomes, revealing structural barriers embedded within digital health ecosystems. The findings underscore that equitable patient-reported data require coordinated attention to EHR design, staff processes and organisational commitment. Addressing language barriers in PROMs may also signal broader challenges affecting all patient-facing digital tools. Achieving representative, patient-centred data therefore depends not only on multilingual content but on sustained efforts to align technology, workflow and equity objectives across the health system.
Source: JAMIA Open
Image Credit: iStock
