Breadth and Simplicity of Accessibility in Health IT – Part 3

The previous articles in this series, Disabilities and Accessibility in Health IT: The Need Is Constant and Automating Accessibility in Health IT, explored the current landscape in accommodating diverse patients and web site visitors in health care. This article explores some important areas I haven’t yet touched on, and ends with an appeal for better web sites for all.

Other ways to make technology more usable

Bonnie Kerker, Associate Professor at the Department of Population Health at the NYU Grossman School of Medicine, discussed the difficulties of lower-income communities trying to get access to online health care and other social services. Through a community-based initiative called Together Growing Strong (TGS), she and her colleagues have collected a lot of information through intensive partnerships with community representatives in Sunset Park in Brooklyn.

Residents of Sunset Park, most of whom immigrated from China and Latin America, are hard-working and have tight-knit communities, but face a lot of barriers to participation in U.S. society. Many don’t know English, many are undocumented, and many hold down multiple jobs but have few financial assets to fall back on in an emergency.

Telehealth, which suddenly became a necessity when the COVID-19 pandemic hit, simultaneously opened doors and erected more barriers. On the positive side, virtual visits allow more treatment for disabled patients and those who have transportation problems—patients, for instance, of Dr. Paulo Pina, a pediatrician at NYU’s Family Health Centers at NYU Langone, whom I also interviewed for this article.

Pina says that his health center will be piloting the use of a medical exam kit for children with special needs, allowing physical exams to be done during virtual visits.

On the negative side, telehealth runs into the classic barriers already mentioned: lack of Internet access, (Kerker points out that some patients live in the basement, given the extreme overcrowding in New York City), lack of access to computers, lack of English proficiency, and lack of technical knowledge. TGS has worked with a local tech company to provide technical assistance to the community, and has met with a wide range of influential people from the grassroots level to city councilors and state senators in an attempt to address these issues.

Technically, Family Health Centers made a change that hugely improved access for their low-income patients. Originally, virtual visits were available only through an app that patients had to download and configure—tasks that exceeded their technical capabilities. When the developers converted the app to a web site, these problems evaporated. The staff can send each patient a text message or email message with a link, and the patient merely has to click to join the virtual visit.

This story may have some general lessons for other developers. They often love to create Android and iOS apps because these can offer convenient features and a slick interface. But the downside might be too much for patients who have to configure and learn the app.

This article series already mentioned the importance of supporting multiple languages. A site can also offer multiple tiers of text, ranging from simple to sophisticated.

Wolters Kluwer, which I have profiled before, provides two tiers of patient education resources. I exchanged email with their Associate Director of Public Relations, André Machado Rebelo, about how the company creates these tiers.

The simpler documentation uses plain language principles such as active voice, conversational tone, short sentences and paragraphs, bulleted lists, and supplemental graphics accompanied by brief written descriptions. The more complex articles are offered to patients who want and can understand more details.

The documents are tested with people with various levels of health literacy, and their editorial team assesses the content using readability formulas such as Flesch-Kincaid. They aim for a fifth to sixth grade reading level in simpler Basics documents. Finally, they strive to use inclusive language in all their patient education content, mindful that readers vary in terms of age, ability, access to resources, cultural background, etc.

FDB (First Databank), a company that maintains data on medications, offers patient instructions in nearly 30 languages at a fifth-grade to eighth-grade reading level.

Brandon Cooper of Get Real Health points out that clinical data—such as test results—often appears in the patient’s healthcare portal before the clinician sees the data. The data is often loaded with medical jargon that the patient can’t understand or might find frightening. Therefore, some help for lay people, and even people who might have a cognitive impairment, would benefit many patients.

The WCAG recommendations reflect much of the wisdom cited so far. For instance, Success Criterion 3.1.3 asks for a way of “identifying specific definitions of words or phrases used in an unusual or restricted way, including idioms and jargon.” Success Criterion 3.1.5 tells sites to include a version of the text “that does not require reading ability more advanced than the lower secondary education level.”

Making accessibility simple

To sum up this series, I’ll offer my own suggestion to anyone designing an interface: Keep it simple. This principle is usually the best for people with disabilities, but also the best for everybody.

You can eliminate flashing ads and intrusive popups to accommodate people with epilepsy and attention problems. But doesn’t everybody hate those ads and popups anyway?

In general, you don’t need many images on each page. Google learned that principle early on. Images slow down page loads for people with limited Internet bandwidth. You’re better off all around if you don’t depend on images to attract attention and guide the reader’s navigation. If people are coming to a web site for an artistic experience, fine—go ahead and snazz it up with multimedia. But 99% of the time, people are visiting a site to get information or perform a task, and a cleaner, unambiguous site without a lot of froth is best.

I am continually frustrated by the hiding of navigational aids under icons. No one can figure out what most icons mean unless the meanings are already known. Many icons culturally biased, such as the common pentagonal house for the “home” page, or forward and back buttons that are based on conventions in cultures that use left-to-right languages. And whoever thought of hiding a site’s main menu under three horizontal lines—I hope that person is banned from speaking at UI/UX conferences.

As for language style, I’ve spent much of my career training authors to avoid unnecessary jargon and making too many assumptions about a reader’s knowledge. My articles are written above a fifth-grade level, admittedly, but I adjust my style to the expected audience.

Those are my opinions; I am betting that many web site visitors agree with them. But if you want to base your web site on other philosophies, just make sure you accommodate all the people who you are trying to serve. This series provides a starting point for your journey.

About the author

Andy Oram

Andy is a writer and editor in the computer field. His editorial projects have ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. A correspondent for Healthcare IT Today, Andy also writes often on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM (Brussels), DebConf, and LibrePlanet. Andy participates in the Association for Computing Machinery's policy organization, named USTPC, and is on the editorial board of the Linux Professional Institute.

   

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