Digital accessibility challenges remain for telehealth

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.

While telehealth could be a boon for patients who struggle to get to in-person appointments, it shouldn't be looked at as the only solution.

There are times when in-person visits are needed, said Maria Town, CEO of the American Association of People with Disabilities. She wants to see telehealth flexibilities from the COVID emergency made permanent, but stressed telehealth investment shouldn't distract from efforts to make in-person care more accessible.

And in addition to expanding audio-only services, policies that bolster broadband infrastructure, telehealth reimbursement and easing state licensing restrictions could also prove helpful to ensuring access to telehealth services in the long term.

It's often a challenge for patients with intellectual and developmental disabilities to find specialists nearby who accept Medicaid, the program through which most patients with disabilities are insured, said Margaret Nygren, CEO of the American Association on Intellectual and Developmental Disabilities.

Increasing Medicaid payments for telehealth services could encourage more providers to offer such services, while relaxing licensing restrictions could make it easier for patients who don't have a specialist in their area to see a provider who's farther away—potentially in another state.

The Missouri Department of Mental Health's developmental disabilities division last April started offering residents who have a disability and are on a Medicaid waiver access to emergency medicine physicians via telehealth. It's through a contract with StationMD, a telehealth company that specifically treats patients with intellectual and developmental disabilities. Roughly 20% of encounters have been completed with only a phone call, such as when a patient needs to refill a medication or has a simple question.

If a physician needs a more in-depth examination or conversation with the patient, they'll transition to a video visit, but all encounters start with an audio-only phone call, explained Dr. Maulik Trivedi, StationMD's chief strategy officer. If a clinician determines the patient needs an in-person visit to address the issue, they'll coordinate with a local emergency department.

The Missouri department started its partnership with StationMD last year because of the COVID-19 pandemic, but is working to continue offering it, said Valerie Huhn, deputy director at the Missouri Department of Mental Health and director of the division of developmental disabilities. Patients don't pay anything to call the service, as the state pays $24 per-member per-month for the program.