Neva Fairchild has lived with low vision for most of her life. She regularly uses the internet with a screen reader, a type of assistive technology that converts text on a computer screen into spoken words—but couldn't get past a frustrating, incompatible telehealth application when she tried to set up her first virtual-care visit during the COVID-19 pandemic.
The application wasn't compatible with the screen reader she uses, so she ended up doing the visit with her specialist via FaceTime. That normally wouldn't be allowed, but is possible due to HIPAA enforcement discretion during the public health emergency.
Since then, Fairchild has completed two more telehealth visits, each of which used different video applications. While she was able to complete them with the designated applications, she said it was stressful.
"It was a lot to overcome," said Fairchild, a national aging and vision loss specialist at the American Foundation for the Blind. It's not just joining a video meeting, but also setting up a new user name and password while navigating an unfamiliar interface.
And once she's joined the video visit, she's not always sure whether she is fully in the frame or if the camera is pointed in the right direction.
"I wish there was just a telephone component," Fairchild said.
A growing chorus of healthcare groups are calling for just that, as the industry grapples with how to ensure the move toward virtual care doesn't leave out vulnerable patient populations. And their efforts are paying off in Congress, where bipartisan legislation has been introduced in both the House and Senate that would let Medicare Advantage enrollees use audio-only telehealth for some diagnoses and would require Advantage plans to reimburse for audio-only visits at the same level as in-person visits during the COVID-19 emergency. The House bill also extends to PACE enrollees.
"Audio-only is part of a (suite) of tools—audio, video, text, sensors," said Dr. Connie Hwang, chief medical officer and director of clinical innovation at the Alliance of Community Health Plans, one of 11 groups that signed a letter supporting the Senate bill earlier this year.
It can be difficult for patients with some disabilities to interact with video platforms, particularly if the software isn't set up in a way that's compatible with assistive technologies or, for those with hearing loss, if there aren't transcriptions or captions available. Telehealth platforms are also usually set up for one-on-one visits, so it can be difficult to include a caregiver or interpreter.
And disability has been linked with poverty, so some patients may not have access to high-quality video devices or live in areas with high-speed internet access.
"Many of the telehealth technologies are not necessarily most amenable for the needs of people with disabilities," said Brooke Ellison, an associate professor of health and rehabilitation sciences at Stony Brook University's School of Health Technology and Management.
According to an American Foundation for the Blind survey of blind and low-vision adults, 21% of respondents who reported using telehealth during the pandemic said the telehealth platform was not accessible. That could be because of buttons or graphics on the screen that aren't appropriately formatted, so a screen reader will just read aloud "button," rather than explaining what selecting that button does.
There's also the question of usability, which goes beyond technical accessibility.
"If I have to do 13 different things to do something you do with one mouse-click as a sighted person, it might be accessible—but is it really usable?" said L. Penny Rosenblum, director of research at the American Foundation for the Blind. She urged Congress to set up incentives or requirements for hospitals to do such usability testing before rolling out telehealth services.