By: Jacqueline A. Wynter, OTD, OTR/L
The Americans with Disabilities Act (ADA)
The Americans with Disabilities Act (ADA) is a federal civil rights law that makes it illegal to discriminate against people with disabilities (ADA.gov, n.d.). The ADA protections encompass state and local services including health care, social services, and transportation (ADA.gov, n.d.). Unfortunately, despite the intention of the ADA, people with disabilities continue to face discrimination in all settings including health care and social services access. The challenges occur when accessing both in-person and telehealth services.
People with disabilities use health services more than individuals without disabilities (Kennedy, Wood, Frieden, 2017). Despite having more of a demand for health information, they experience a lack of information when compared to people without disabilities and report difficulties accessing services (Kim, Yuan, Liebschutz, Cabra, Kazis, 2018; Kennedy, Wood, Frieden, 2017). Some of these difficulties relate to accessing timely basic medical care, difficulty obtaining specialty services, and lower rates of cancer screenings and treatment (Kennedy, Wood, Frieden, 2017). Other issues include inaccessible waiting rooms, bathrooms, and medical equipment (Valdez, Rogers, Claypool, Trieshmann, Frye, Wellbeloved-Stone, Kushalnagar , 2021). However, telehealth services can offer benefits for people with disabilities.
Telehealth is a general term that includes both telemedicine and telerehabilitation (Cason, 2012). Telemedicine uses technology to deliver health care services to improve access, quality, and cost (Kvedar, Coye, & Everett, 2014). Telemedicine describes direct clinical services while telehealth typically refers to a wide array of health-related services such as education, patient care, and remote monitoring (Schwamm, 2014). In this issue brief, the term telehealth will be used to discuss these medical services that use technology to address health care. For some people with disabilities, telehealth provides a way to access medical care without with the challenges of on-site and building inaccessibility issues. It also lowers transportation costs and increases access to specialists (Valdez et al., 2021). Other benefits include a lower cost of care and a decreased need for paid personal assistance services (Annaswamy, Guiterrez, Frieden, 2020).
While telehealth was used prior to the COVID-19 pandemic, COVID became a catalyst for its rapid expansion. Telehealth allowed providers to pivot between in-person visits to online care which reduced in-person contact and exposure to the COVID virus (Lawson, King, Rontal, 2022). However, as with in-person visits, telehealth has shown to have its own set of accessibility issues for people with disabilities.
Accessibility Issues to Telehealth
Poor access to telehealth services among people with disabilities can result in poor health outcomes, decreased quality of life, and increased health–related costs and inequity in accessing services (Gallegos-Rejas, Thomas, Kelly, Smith, 2022). Access to devices for telehealth services is an issue for people with disabilities. While 81% of people without disabilities own a desktop or laptop, only 62% of adults with disabilities have digital access (Perrin & Atske, 2021). There is a similar discrepancy in smartphone ownership, with 88% of adults without disabilities owning smartphones compared to only 72% of people with disabilities (Perrin & Atske, 2021). This disparity is even greater among older adults, with only 61% of adults over the age of 65 owning smartphones (Pew Research Center, 2021). Access to high-speed internet is also a barrier. An estimated 44% of people without disabilities report having access to high-speed internet as compared to only 26% of Americans with disabilities (Perrin & Atske, 2021). The broadband divide is even higher in low-income and rural communities due to a lack of infrastructure ( Annaswamy, Guiterrez, Frieden, 2020). Poor internet quality can result in poor video quality during a visit or frequent disconnections (Valdez et al., 2021).
User interface can be another factor limiting telehealth accessibility for people with disabilities. Individuals who may have intellectual disabilities, are deaf, hard of hearing, have low vision, or are blind and speech-disabled may have difficulty accessing video-based telehealth services (Valdez et al., 2021). This may be because telehealth platforms may not provide custom accessibility features (Annaswamy, Guiterrez, Frieden, 2020). For example, video conferencing programs may not allow an interpreter needed for someone who is deaf to join a telehealth appointment in a separate room (HHS, 2022). A person who is blind or has limited vision may find that they are unable to use screen reader software on the web-based platform to access their telehealth appointment (HHS, 2022). Additionally, individuals who have limited English may need instructions about how to set up a telehealth appointment in their preferred language (HHS, 2022). Yet another issue is that even when a person with a disability has access to a smartphone, the smartphone may not be optimized for use with the telehealth system, which can further limit the ability of low-income individuals to access services (Dixit, Van Sebille, Crawford, Ginex, Ortega, Chan, 2021).
Physical access may be another issue for people with disabilities in accessing telehealth services. The person with a disability may require a caregiver to set up their device, physically log them onto their appointment, and position and change the camera angle to interact with the healthcare provider (Lawson, King, Rontal, 2022). There may also be privacy concerns related to telehealth visits as individuals may have to share their space with others and disclose private and health information in a shared space (Lawson, King, Rontal, 2022).
Digital literacy can play a significant role in people with disabilities accessing telehealth services. Digital literacy involves the ability to access and understand health information as part of one’s health care (Sieck, Rastetter, McAlearney, 2021). Older adults have lower digital adoption than other groups (Perrin & Atske, 2021). Individuals with cognitive impairment and intellectual disabilities may also need assistance navigating telehealth services (Lawson, King, Rontal, 2022). A lack of health literacy can reduce access to telehealth and result in health inequities for people with disabilities.
Recommendations to Address Telehealth Accessibility
Telehealth will continue to be used to address the growing healthcare needs among the US population. It is imperative that these accessibility issues be addressed to reduce health disparities among people with disabilities. To address the discrepancy between people with disabilities not having devices to access telehealth services, organizations can provide or loan individuals devices that allow them to access telehealth services. As of 2021, the Federal Communications Commission was offering grants to health care systems that could be used to provide their patients with internet services and devices (Sieck, Rastetter, McAlearney, 2021). To address privacy concerns, nonprofit organizations, religious organizations, and public schools could provide private spaces for individuals. This could also include designating private areas in shelters for unhoused individuals to have their telehealth visits (Anaya, Mota, Hernandez, Osorio, Bautista, 2022).
Digital literacy screening tools can help identify the needs of people with disabilities. Digital literacy training can also be offered at community centers, libraries, and places of worship to address those needs (Sieck, Rastetter, McAlearney, 2021). Additionally, health care organizations should provide training and technical support to patients to ensure they are able to access telehealth platforms (Dixit, Van Sebille, Crawford, Ginex, Ortega, Chan, 2021).
Organizations that receive federal funds should follow recommendations for user-friendly digital health tools, such as Health Literacy Online, by the Office of Disease Prevention and Health Promotion. (Anaya, Mota, Hernandez, Osorio, Bautista, 2022). Web accessibility standards need to be improved and enforced on telehealth platforms (Annaswamy, Guiterrez, Frieden, 2020). Software developers need to redesign both app and web-based technology to address the needs of people with disabilities that make the user experience easier and more functional (Valdez et al, 2021). Telehealth access can also be improved through: (a) voice-activated commands; (b) simpler designs; (c ) engaging informal caregivers; (d) improving compatibility with assistive devices used by people with disabilities; (e) making user interfaces that streamline navigation; (f) compliance with WCAG-AAA guidelines; (g ) the consistent implementation of standards and plug-ins to allow sign language or closed captioning on the screen simultaneously while services are provided; (f) solutions to reduce the cognitive and physical load of access; (g) the ability to receive all communications in plain language; and (h) the ability to allow multiple users on the same account (Dixit et al, 2021; Valdez et al., 2021).
Health care organizations should also provide training to their health care providers about accommodating people with disabilities to address access issues. Organizations can also provide staff trainings that address equity issues (Gallegos-Rejas et al., 2022). Additionally, health care organizations can offer patients incentives to encourage developing service models and patient collaboration that meet the needs and expectations of people with disabilities (Gallegos-Rejas et al., 2022).
Although the Department of Justice has offered guidance that the internet is a place of public accommodation, the ADA does not provide standards for accessibility or instructions for making websites accessible (Annaswamy, Guiterrez, Frieden, 2020). The lack of regulations under the ADA that specifically address web accessibility, technical standards, and compliance timeline implementations has resulted in a gap in interpretation between businesses, advocates, and courts (Annaswamy, Guiterrez, Frieden, 2020). There is a need to organize regulations under the ADA with regulations being issued under Section 504 of the Rehabilitation Act of 1973 and Section 1557 of the Affordable Care Act (Annaswamy, Guiterrez, Frieden, 2020). Technology companies that design and distribute telehealth products should be subject to these laws by considering their businesses and products health care and not technological organizations and products (Annaswamy, Guiterrez, Frieden, 2020).
The use of telehealth services has increased significantly since the COVID-19 pandemic. While telehealth offers many benefits for people with disabilities, including lower transportation costs, a lower cost of care, and a decreased need for paid personal assistance, inequity in accessing service may widen the health care gap. Issues affecting people with disabilities in accessing telehealth include having the devices and bandwidth to access telehealth services, the need for physical assistance by a caregiver to log into telehealth platforms, and digital literacy issues among people with disabilities. However, health care organizations can address this by loaning devices to patients and providing them with training and technical support. Making technology companies that design and distribute telehealth products accountable to nondiscrimination laws, considering their businesses and products health care and not technological organizations and products, and improving web accessibility standards can also help improve access to telehealth services and decrease the inequity gap among people with disabilities.
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These materials do not constitute legal advice and should not be relied upon in any individual case. Please consult an attorney licensed in your state for legal advice and/or representation. These materials were prepared in partnership with the Southeast ADA Center to highlight developments relevant to the impact on health care access and the Americans with Disabilities Act (ADA). These materials are based on information in effect at the time of publication. Federal and state disability rights law can change at any time. In addition, state and local laws and regulations may provide different or additional protections. Materials are intended solely as informal guidance, and are neither a determination of your legal rights nor responsibilities under the ADA or other federal, state, and local laws, nor binding on any agency with enforcement responsibility under the ADA. The accuracy of any information contained herein is not warranted. Any links to external websites are provided as a courtesy and are not intended to nor do they constitute an endorsement of the linked materials.