It would be anathema for a health care facility in the U.S. to have a main entrance that’s not physically accessible to all people. Yet many of their digital front doors block people with disabilities. They need to change that.
More than 30 years after the Americans with Disabilities Act was signed into law with the aim of removing obstacles to people who are blind, deaf, or have other physical or mental disabilities, the digital landscape continues to erect barriers to access. An investigation by Kaiser Health News in 2021 showed that nearly all of the Covid-19 vaccine registration websites reviewed weren’t accessible to people who are blind, a major violation of disability rights laws in the middle of a public health emergency.
Digital accessibility involves designing webpages to be inclusive of people who have visual, motor, auditory, speech, or cognitive disabilities. More than 61 million people in the United States — nearly 1 in 4 Americans — and more than 1 billion people worldwide have one of these disabilities, including 46% of people age 60 and older. With the number of Americans 65 and older projected to nearly double from 52 million in 2018 to 95 million by 2060, federal officials have already identified the accessibility of online health information as an urgent need.
An issue brief we wrote on behalf of the American Health Information Management Association (AHIMA) Foundation and Mathematica shines a new light on how difficult it can be for people with disabilities to navigate the health care system. Our research found that among 106 top hospitals in the U.S., most of their homepages — their digital front doors — are not accessible to users with disabilities and older users.
Using accessScan, a free audit tool for online web accessibility, we assessed whether the websites of these hospitals, all recognized as top hospitals by U.S. News and World Report in 2021-2022, complied with guidelines created by the World Wide Web Consortium, the internet’s primary international standards organization. Only 4.9% of homepages fully complied with the consortium’s most recent guidelines for web content accessibility. Nearly 80% were semi-compliant, meaning that their pages met some, but not all, of the accessibility requirements. However, even a semi-compliant webpage is likely to cause people with disabilities trouble navigating it, likely rendering it inaccessible to them.
The accessibility issues we saw were often the same from hospital to hospital. The most common problem was lack of color contrast — a strong contrast between the color of the text on a page and the color of the background is critical for readability. Many pages lacked alternative text, which is used by screen readers to describe what an image is meant to convey. Our analysis also surfaced a pattern of missing or inaccessible labels, which is important because buttons and search fields on websites need to be clearly labeled so they can be easily identified by assistive technology.
Some people with disabilities or injuries cannot use a mouse and need to be able to navigate a site using only the keyboard. Many hospital webpages lacked such keyboard accessibility, which wasn’t detected through the type of automated audit we conducted for our analysis.
Medical records are a vital part of health management. But as with hospitals’ homepages, millions of Americans face difficulty accessing their personal health information through patient portals. Individuals living with disabilities who are unable to successfully navigate their electronic health records are at a disadvantage in managing their health care. This includes the ability to send messages to health care providers, review test results, make appointments, and refill prescriptions. This may translate into less-than-optimal health for these individuals, who are already at higher risk for illness and injury.
As the digital age flourishes and technology becomes more advanced, health care websites and patient portals are becoming more intricate. Unfortunately, this means a steady decline in accessibility. In a recent survey conducted by the AHIMA Foundation and Knowbility, individuals who have low vision, mobility-related disabilities, are deaf or hard of hearing, or have a cognitive disability reported a daily struggle when trying to access information digitally.
The Websites and Software Applications Accessibility Act (S. 4998 and H.R.9021) was introduced into Congress by Sen. Tammy Duckworth (D-Ill.) to build on the Americans with Disabilities Act and address the current gaps in enforcing digital accessibility. Although this legislation represents a step toward improving the experience for all users of hospital websites, including those with disabilities, it will take time and effort to tackle the lack of awareness and ambiguity surrounding digital accessibility today.
We see five key steps hospitals can take to improve the accessibility of their websites:
Use a combination of automated and manual audits to inspect webpages for accessibility problems and produce a list of potential errors that warrant further investigation.
Hire and train full-time digital accessibility employees to ensure long-term improvement. Experts highly recommend naming a digital accessibility coordinator who is different from the hospital’s currently designated ADA coordinator and setting up an interdepartmental work group that includes decision-makers from within a wide range of departments: information technology; health information management; human resources; diversity, equity, and inclusion; procurement/vendor selection; and marketing and brand management.
Foster multi-sector collaboration with community advocacy groups, local centers for independent living, and ADA regional centers to ensure they are engaging and conducting user-based testing with older adults and individuals who have disabilities when developing solutions.
Collaborate within the hospital system across administration, management, and operations to address the root causes of website issues. For example, color contrast and other color errors on the hospital homepage might be an issue that falls under the hospital’s brand guidelines and is within the purview of marketing.
Provide education opportunities for hospitals and health care systems in the U.S. on the role of web accessibility in ADA compliance.
In a digital-first — and often digital-only — society, the broad diversity of users’ functional needs must be taken into consideration and health care facilities must keep both their physical and digital doors accessible to everyone.
Amanda Krupa is a director at AHIMA Foundation, where Jill B. Roark is a health communications consultant. Kirsten Barrett is a principal researcher at Mathematica.