Industry Voices—Truly inclusive EHR design is within reach

One in 4 adults in the U.S. has a temporary or permanent disability, including visual, auditory, cognitive and mobility impairments—a number that will climb as the population ages. Nearly half (46%) of Americans aged 75 and older report having a disability compared to just 24% of those 65 to 74 and 12% of those 35 to 46.

The prevalence of disability is why the health IT developer community must prioritize electronic health record (EHR) designs that advance disability inclusion across healthcare, allowing patients, providers and other healthcare workers requiring accommodation to fully and effectively participate in both the provision and receipt of healthcare.

What disability exclusion looks like

Technology has been the solution to so many daily challenges that it can be difficult to view it as anything but helpful. Often, however, the features that make technology user-friendly for most can block some healthcare professionals with disabilities from performing their core responsibilities.

Spending a day observing EHR users lays bare the accessibility issues with health IT tools for users with specific disabilities:

  • Drop-down menus make it difficult for someone whose severe rheumatoid arthritis or hand injury affects their ability to use a mouse for electronic charting.
  • Using color alone, like red for critical alerts and blue or green for notifications, may not have the desired effect on someone with a color vision deficiency, which could in turn create patient safety issues.
  • Patients with low vision struggle to message providers without an option to zoom in on text.
  • Drag and drop design elements are challenging for those with hand injuries or other issues that make gripping or maneuvering a mouse problematic.

In some cases, design or coding choices can hinder the accessibility solution. A clinician with low vision shared a story with the EHR Association User Experience Workgroup about how she was stopped in her tracks during a patient exam by an unlabeled button on an EHR screen. The missing label caused her screen reader to just repeat the word “button,” forcing her to stop what she was doing until a colleague could help—a disruption that could have been avoided by properly labeling the button with the required input. 

The clinician was frustrated at both the disruption to her care process and the need to rely on a colleague to successfully perform such a basic task because of a missing label.

Understanding the disability spectrum

Challenges to inclusive design often stem from viewing disability as a binary status. However, disabilities vary widely in severity and permanency, with symptoms existing on a spectrum.

For instance, blindness can mean low vision rather than total vision loss. Similarly, a wheelchair user may have some ability to stand or walk. Temporary disabilities can result from injuries or illness, while conditions like multiple sclerosis, Parkinson's and diabetes can cause fluctuations between “abled” and “disabled.”

Thus, disability should be defined as:

  • Temporary, affecting an individual for a short time. These are typically illnesses or injuries that keep someone from fully participating in routine activities until they recover.
  • Permanent, affecting the individual for life. This could be an illness or injury from which there is no recovery, or it could be present from birth. 
  • Episodic, permanent conditions (e.g., diabetes and multiple sclerosis) for which there are no cures and severity changes from one day to the next. People with episodic disabilities like vertigo, migraines and some forms of mental illness experience random periods of fluctuating good health and ill health.
  • Situational, affected by someone’s environment or circumstances (e.g., difficulty hearing information in noisy or crowded rooms).
  • Dynamic, randomly shifting in severity or fluctuating over time (e.g., a flair-up of a chronic illness or pain).

Basing accessibility designs on a binary definition of disability can lead to EHR features that make technology user-friendly for some healthcare professionals with disabilities but create obstacles for others.

A better approach

The better approach to accessible EHRs is to consider all the challenges design elements create for individuals with a range of issues and then build functionality that allows for multiple options. For example, keystrokes, mouse clicks and voice commands can all be used to achieve the same outcome regardless of the type or severity of dexterity issues.

Design elements can also leverage the multitude of assistive technologies already available—such as subtitles and/or transcripts on video content to assist those with hearing impairments—and adjust them to meet specific disability needs. For example, ensuring touch targets are sized large enough in mobile applications to be easily activated by users with low vision or dexterity limitations.

Inclusion benefits all

By moving away from a binary definition of disability and taking time to observe how users access and interact with health IT in the real world, we can identify design elements that overcome obstacles at any point along the disability spectrum.

When that understanding is incorporated into the design and tested by people with a range of disability types to ensure efficacy, it brings us closer to truly inclusive EHRs and other health IT—which benefits all.

Tammy Coutts is the lead software designer for user experience and usability at EHR vendor MEDITECH as well as the vice chair of the EHR Association's User Experience Workgroup.

Also contributing to this piece were fellow workgroup members Libby Eddings, senior inclusion and accessibility user experience designer at Oracle Health; Mike Shonty, lead software designer at MEDITECH; and Jennifer Sagerian, manager of user experience and design system as well as accessibility program lead at MEDITECH.