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November 2013

ONC Challenge Spotlights EHR Access
By Lindsey Getz
For The Record
Vol. 25 No. 15 P. 8

The project sought to provide greater opportunity for people with disabilities.

As more medical facilities adopt EHRs, it’s important that they consider the issue of accessibility for all users. Despite nearly one in five Americans having a disability, most EHRs do not take into account these individuals’ needs.

To address this problem and generate possible solutions, the Office of the National Coordinator for Health Information Technology (ONC) recently challenged developers to create and test an application that makes it easy for disabled consumers to access and interact with health data stored in EHRs. The resulting solutions shed light on the future of EHR design and how these systems may evolve to become compliant with section 508 of the Rehabilitation Act.

Greater Accessibility
It could be argued that disabled individuals utilize the health care system more often than the able bodied. Nevertheless, this population is not being properly addressed when it comes to HIT advances. “Health information technology and EHRs hold great promise in improving the health outcomes and coordination of care for people with disabilities,” says Rosaly Correa-de-Araujo, MD, MSc, PhD, a senior scientific advisor to the director of the division of geriatrics and clinical gerontology at the National Institute on Aging. “However, the accessibility and usability of HIT is a matter of serious concern to people of diverse disabilities, including those who have vision, hearing, intellectual, manual dexterity, mental health, developmental, and other types of disabilities.”

The problem’s influence goes beyond the patient. “This concern extends to [the patients’] families, health professionals, researchers, administrative [staff], and other staff delivering or involved in health care administration and who also might have a disability or become disabled while on the job,” Correa-de-Araujo says. “Similarly, students with disabilities in training to become health care professionals need to have accessibility and usability in the tools they use as part of their trainings. Having an accessible EHR contributes to improving access to information care, the quality of health services, and ultimately enhancing the quality of life for people with disabilities.”

The ONC challenged developers to create a module or an application that would make it easier for the disabled population to access and interact with EHR data. The contest required that the application be easy to use and simple to install as well as capable of identifying and linking to relevant local or online communities and organizations, being downloaded from one or more EHR systems, and leveraging and extending the eHealth Exchange’s (formerly the Nationwide Health Information Network Exchange) standards and services.

Pinaxis, a small innovation development shop that ultimately captured top honors, formulated a unique strategy for addressing the EHR accessibility conundrum. “We approached the solution in terms of greater accessibility for everybody, including both the able bodied and the disabled,” says Jared Schwartz, information architect and lead strategist for Pinaxis. “In general, many of the user experiences are poor, and systems need greater accessibility as a whole.”

During the course of its research, Schwartz’s team identified fragmentation as a major hurdle. To overcome this challenge, Pinaxis developed Apollo, a patient-focused, 508-compliant design module that would connect the gaps. The resulting patient portal is designed to work with any provider’s EHR, says Schwartz, who adds that practices typically are reluctant to discard a system that’s been paid for and that staff members have been trained to use.

“Health IT professionals will recognize Apollo as a universally tethered PHR that can interact with multiple EHRs,” he says. “We approached the problem as accessibility in general because we don’t feel the market was driven in a way that practices would be highly enticed to change to a brand new model just because it was 508 compliant. Our solution says, ‘Keep your EHR, you’re already paying for it and using it.’ Instead of a complete switch they can just hook it up to Apollo and offer a better user experience to the patient. To me, if you’re going to invest in innovation, you want a big-picture idea.”

Other Solutions
In addition to Pinaxis’ winning entry, two runners-up impressed the judges. RegisterPatient offers a patient portal and PHR via the Web that includes an accessibility application developed for people who are vision impaired. The other runner-up, Remedy Systems, is a mobile virtual health record designed to be a clinical viewer.

Nir Pengas, vice president of research and development for Remedy Partners (creator of Remedy Systems), says the company was intrigued by the challenge to make its system accessible to the disabled. “The importance of making EHRs more accessible in the context of our product is to provide a more robust solution for our end users, some of whom are dealing with vision disabilities,” he says. “Our goal was to provide the best user experience possible for the vision impaired with as minimal of an impact on our development effort. We wanted to be able to provide this feature and have it easily available for those who need it without the need to switch between context and confuse the users who do not.”

The concept of adding nonobtrusive features proved successful. “For physicians who have low vision, for instance, voiceOver makes navigation and data consumption easy without making any changes to the product,” Pengas says. “Most EHRs are granular and detailed. The ability to know what is under your finger and figure out what the user can do and to have the data read out loud are both powerful features.”

Becoming Compliant
As practices move forward with EHR implementations, accessibility for the disabled will be a critical factor when it comes to not only usability but also privacy and security. “When the design, development, fabrication, and deployment of EHR systems are not mindful of the accessibility and usability needs of the largest number of users, interoperability across systems and the potential for user interfaces that create dependence on others, such as for users with vision disabilities, may ensue,” Correa-de-Araujo says. “Since interoperability is an essential factor to these standards, incorporating them in HIT, including EHR, is very important as are standards for security, privacy, confidentiality, transport, and exchange.”

 — Lindsey Getz is a freelance writer based in Royersford, Pennsylvania.


Guidelines to Consider
The following standards address the issue of making EHR systems accessible to the disabled:

• Web Content Accessibility Guidelines of the W3C Web Accessibility Initiative for website accessibility

• Section 508 standards were developed by the US Access Board through a process involving representatives from industry, government, the general public, the international community, and other areas. Federal agencies are required to follow section 508 standards to comply with the Rehabilitation Act. Furthermore, the 508 standards may be used by nonfederal entities to demonstrate a commitment to making technology accessible and usable for people with disabilities. These well-known guidelines and standards have been in use for more than a decade.

• Standards for telecommunications service providers and equipment in section 255 of the Communications Act. Rules found at 49 CFR Part 6, “Access to Telecommunications Service, Telecommunications Equipment and Customer Premises Equipment by Persons With Disabilities,” provide extensive requirements on how to design and develop for disability accessibility and usability. Similarly, rules found at 49 CFR Part 7, “Access to Voicemail and Interactive Menu Services and Equipment by People With Disabilities,” provide extensive operational requirements to ensure such interfaces work for people with disabilities.

— LG