Initially, COVID-19 was dubbed “the great equalizer” due to its transmissibility across borders and demographic groups. As the virus continued to spread, however, it became evident that the elderly, immunocompromised, and marginalized groups were disproportionately affected. Health care responses, including the expansion of telemedicine, fueled by the CARES Act, redefined access to care for many vulnerable groups. Telemedicine encompasses health care consults conducted by health care professionals via audio-visual technology with patients synchronously. Despite having the aim of expanding access to care, telemedicine has the propensity to exacerbate disparities for marginalized groups, including people with disabilities. Telemedicine can be convenient and effective for many populations but can simultaneously alienate people with physical impairments and disabilities, such as visual impairments (VI).
Visual impairment ranks among the top 10 leading causes of disability amongst US adults. The impacts of VI are not just exclusive to vision but also affect mental, oral, and physical health. Specifically, VI has been associated with a higher risk of depression and hip fractures, lower health-related quality of life, and worse oral hygiene. In 2017, an estimated 7.08 million people lived with visual acuity loss in the US. Of those with visual acuity loss, an estimated 1.08 million were living with blindness. As defined in the US, VI is best-corrected visual acuity of equal to or worse than 20/40 (logMAR of 0.3) in the better-seeing eye. Blindness, a subset of VI, is defined as best-corrected visual acuity equal to or worse than 20/200 (logMAR of 1.0).
The causes of VI can vary by race and ethnicity. Age-related macular degeneration accounts for 54 percent of all blindness among White Americans. Among African Americans, cataracts and glaucoma accounted for 60 percent of blindness. Glaucoma was the most common cause among Hispanic Americans, accounting for 28.6 percent of blindness. In adults ages 40 years and older, 3.22 million people had VI, while 1.02 million people were blind. These numbers are projected to double by 2050. With the increase in VI and blindness in the United States, it is crucial to reconsider the feasibility of telemedicine for this population. Current evidence suggests that persons experiencing blindness struggle navigating telemedicine portals due to the lack of accessibility customization. Although some telemedicine software programs offer assistance, most platforms are not created with an accessibility-based design, leaving some users without support. Furthermore, most telemedicine portals lack essential tools such as screen readers, magnification, and high-contrast software—all typical applications used by the visually impaired community. Design flaws that do not promote usability for disabled populations make some platforms relatively inaccessible for independent use.
Evidence suggests that telemedicine can offer numerous benefits, including quicker appointment dates, access to specialists, overcoming transportation-related challenges, and, in recent times, reduced COVID-19 exposure. In particular, transportation hurdles limit independence, as persons experiencing VI have to rely on others to get from place to place. Those who use public transportation face challenges such as lack of rural public transit, minimal travel options on weekends, excessive wait times between scheduled rides, and inaccessible information about schedules or changes—all of which become less of an impediment with virtual care options. Following the onset of the COVID-19 pandemic, transportation difficulties for people with VI grew exponentially, to include concerns about social distancing (inability to perceive if other passengers are wearing masks), rapidly rising rideshare prices, and barriers to accessing COVID-19 testing centers. The hurdles that VI patients experience in accessing health care make telemedicine an appropriate alternative for health care consults, as it overcomes transportation barriers and helps build independence.
Current Efforts To Address The Issue
Currently, there is no all-inclusive telemedicine software that permits independent use for persons with VI. The lack of accessibility tools prevents patients from freely scheduling appointments or navigating e-visit portals. Other commonly reported barriers include poor color contrast, lack of text alternatives for pictures, videos without captions, and mouse-only navigation. In a recent report published by the American Foundation for the Blind, 70 percent of those with VI attempted to use telehealth during the pandemic, with 57 percent reporting accessibility challenges with telehealth platforms.
Although policies are in place, there is still work to be done to create an accessible environment that is inclusive for all. For example, the 1990 Americans with Disabilities Act (ADA) obligates a nationwide mandate for providers to extend their services; however, there are no clear legal standards within the Web Content Accessibility Guidelines, WCAG 2.0, and WCAG 2.1. As a result, public facilities have flexibility in complying with the ADA’s general requirements. Only in March 2022, did the Department of Justice (DOJ) issue a long-overdue web accessibility guidance under the ADA. This guidance requires state and local governments, alongside public businesses, to make their websites inclusive and accommodating for people with disabilities. Prior to the 2022 guidance, essential tasks such as accessing bank accounts online or filing a police report online were not required to be disability accessible due to a lack of regulations clarifying the exact ADA obligations for the public businesses. Similarly, only recently in July 2022, did the DOJ alongside the Department of Health and Human Services issue guidance on nondiscrimination in telehealth to ensure accessibility to people with disabilities. How these guidance policies translate in clinical practice is yet to be seen.
Efforts have also been made in Congress. The Disability Access to Transportation Act sought to promote access to care for persons with VI and disabilities through funding, improvements, and accessibility data. The act, however, failed to become law in the 117th Congress. Shortly after, in November 2021, the Infrastructure Investment and Jobs Act passed in Congress, providing $1.2 trillion in changes to transportation programs, including the renovations of public transit to ADA standards. This act includes $65 billion to expand broadband infrastructure and internet access. Additionally, the budget earmarks nearly $3 billion toward the promotion of digital literacy skills through digital equity and inclusion effects to connect unserved and underserved households, such as those with disabilities. While this is not specific to persons with VI, this guidance serves as a significant first step in improving access to care for all persons with disabilities.
Recommendations For Practice
At the design level, telemedicine design considerations should ensure compatibility with common external assistive technology devices—such as laptops, smartphones, tablets, and eSight, Food and Drug Administration-approved electronic glasses proven to enhance vision. Design considerations should include the use of high-contrast software as persons with VI are better able to detect high-contrast text and images than low-contrast text. Design should also incorporate accessibility features comparable to those offered by applications/software that provide voice over and image identification for persons with VI. Others have also mentioned the need for telemedicine features that can facilitate multiple users to join a telemedicine encounter if more than one type of assistance is required, such as a qualified sign language interpreter, specialist, or family member. Platforms such as T-Base and Switchboard are pioneers in “making websites and healthcare materials accessible to persons with low vision,” and providing telemedicine interfaces for persons with low vision; however, additional funding allocation to improve adoption in outpatient clinics is needed to ensure access.
Health care workers can also play a role in closing the telemedicine equity gap. Health care employers can require staffwide telehealth courses as part of annual training requirements. This training can include modules on telehealth for persons with disabilities with content that prepares staff members on caring for persons with disabilities in a virtual setting.
At the provider level, improved telemedicine access can also be achieved by modifying protocols and offering additional assistance to patients during different stages of the virtual visit. Before a confirmed medical appointment, clinic administrative staff can provide pre-visit device and connectivity testing to reduce technological barriers. Importantly, the pre-appointment consult should address patients’ unique technology needs, troubleshoot common technology issues that could occur during the interview, and specify contact information for technical support. Such consultation should incorporate appropriate formats such as braille, audio recordings, and digital formats, as needed. An organized text transcription in real time is beneficial, as it gives persons with VI an option to zoom into said text/images as they would any other document presented on their respective devices. During this process, administrative staff should engage patient companions and educate them on using the telemedicine platform. Printed material should also be available for family members and patient companions. Following the appointment, clinic staff can conduct surveys on patient experiences to gain insight into the appointment process. Patient feedback can be used as part of a continuous quality improvement process which in turn promotes patient-centered care.
Translating these recommendations into clinical practice requires funding to: increase telehealth accessibility for individuals with VI, support clinical transformation and technology support, and ensure continuous quality improvement to improve the telehealth experience for persons across the visual spectrum.
The COVID-19 pandemic has prompted a long-awaited technological solution in health care—the expansion of telemedicine to supplement existing health care services. As this technology spreads, future web-based platforms must account for an inclusive audience to provide sufficient care with the help of available assistive technology. The Department of Justice’s new TeleHealth and web accessibility guidance policies are significant initial steps, which should be supplemented by the creation of future guidance that promotes the advancement of inclusive resources as they are available. Health care professional associations can play meaningful roles in establishing best practices to supplement these DOJ guidance policies.
In times of major crises, people with disabilities are often overlooked. While telemedicine during the COVID-19 pandemic shows how disaster responses can fail to account for the needs of people with disabilities, it also serves as an opportunity to learn how to better respond to future disasters. Being disability-inclusive in planning can ensure that the VI population is not left behind in future disaster responses. The time for a change in accessibility standards during the present digital age is now.