Curbside Consult with Dr. Jayne 10/14/24

As a longstanding supporter of virtual health care, an article published this week in JAMA caught my attention. It addresses the issue of disability rights and accessibility in virtual healthcare.

I’ve been involved in discussions of accessibility in health tech for more than two decades, watching features evolve from those that are requested by software customers as “enhancements” for young EHR products to those that are mandated by federal certification requirements. Some of these are fairly straightforward, such as ensuring appropriate contrast for text, ensuring that color is not used as the sole indicator of something being an alert or concerning value, and compatibility with screen reader technology. Others are a bit more nuanced and generate discussion, but those conversations taper off when people realize they aren’t going to get around a certification requirement.

At one point in my career, I was working entirely in the realm of certified EHR technology and began to take these things for granted. Only when I moved into consulting and working with technology startups did I realize how some vendors lacked an understanding of basic usability principles, let alone accessibility standards. I can’t count the number of conversations I’ve been in where I’ve had to explain that the requirements are linked to specific health conditions, such as red-green colorblindness or macular degeneration, and that health tech companies should probably try to do the right thing regardless of whether they have a regulated product or solution. I understand that adding features adds to development costs, but often it costs the same to develop a product that’s compliant as it does to ignore the needs of end users. Font and color / contrast are good examples of this.

There are reasons other than documented health conditions to develop in certain ways, one being the needs of an aging workforce. Now that I’m past a certain age, I would wholeheartedly support efforts to help early-career solution developers understand the various physical changes that come with age. They may not be enough to qualify as a “diagnosis,” but for many of us, the likelihood that we can get meaningful work done on a 13-inch laptop versus a 24-inch monitor is low. I’m more sensitive to bad ergonomic configurations than I was 20 years ago, that’s for sure. For me, some of these factors are merely an inconvenience, but for patients and clinicians who have additional needs, these factors serve as barriers to the giving and receiving of quality care.

The JAMA article notes that this summer brought new federal regulations that cover the accessibility of websites and mobile apps for state-run and federally funded health programs, including Medicare, Medicaid, and public hospitals. However, it notes that “disabilities are diverse” and the lack of one-size-fits-all solutions means that many resources are simply inaccessible. It goes on to specifically explore the inaccessible nature of many virtual health solutions, including “incompatibility with screen-reading software, a lack of captioning, and interfaces that are difficult to navigate.”

I recently tried to explore a virtual health solution using my phone, but couldn’t even request an appointment because the calendar interface that was selected by the developers prevents you from keying in your date of birth. Instead, you were supposed to scroll back month by month to your date of birth, which in the case of some people in my household, would have required 600 swipes. How’s that for welcoming people over 50 to the platform? Frankly even if I were much more youthful, I wouldn’t want to use such a horrible user interface.

The accessibility requirements extend to entities that accept Medicare, Medicaid, or other government funds, including small independent care providers. Those types of entities have three years to meet the requirements, where larger organizations have two years to do so. Third-party solution providers will need to gear up to meet the needs of their clients on the appropriate timeline, since failure of an organization to comply violates the law. I’ll be interested to see how quickly technology providers begin promoting themselves as “WCAG compliant” since it’s version 2.1 of the Web Content Accessibility Guidelines that are required in the new regulations. Bonus points to the first exhibitor I see at HLTH that promotes this designation.

I’ll admit that I don’t know the details of compliance since it’s not an area that I’m working in. But in thinking of all the third-party or homegrown chatbot and patient portal solutions that are out there, I’m betting that consultants are at the ready to assist as organizations work to assess where they stand. I’m also wondering whether this might push some smaller practices to begin to assess the pros and cons of opting out of Medicare (which many are already considering) versus having to replace technology solutions. I have a number of colleagues who have transitioned their practices to Direct Primary Care models where they don’t interact with public funding at all, and if people are on the fence about that change, I bet something like this might just be the thing that pushes them over.

Although I do love me some good Federal Register reading, I’m not exactly feeling it tonight. I’m hoping readers who are experts in this area might consider pointing me to some summary resources, or even send me their comments to share in a future post.

I would also be curious to know whether the patients who these regulations are intended to help think that the regulations are adequate or if more needs to be done to improve accessibility on a faster timetable. I’m also curious whether any part of these regulations address the diverse needs of healthcare providers or whether they’re entirely patient-centric.

If you’re with a third party that is addressing these requirements or is already compliant, I would enjoy hearing how the process worked for you and what the relative effort was like. It’s important for all of us to understand the work that goes into healthcare IT to make it work for everyone who uses healthcare services.

What’s your take on accessibility in virtual care? Leave a comment or email me.

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