Blinded to Problems: How VA’s Electronic Record System Excludes Visually Impaired Patients

Sarah Sheffield, nurse practitioner in a Veterans Affairs Clinic in Eugene, Oregon, had a problem. His patients – mostly aged 70 and over – could not read computer screens. This is not an unusual problem for older people, which is why you might think OracleCernerthe developers of the agency’s new digital health record system would have anticipated this.

But they didn’t.

Federal law requires that government resources be accessible to patients with disabilities. But patients cannot easily enlarge the text. “They all learned how to get reading glasses and sturdy magnifying glasses,” said Sheffield, who retired in early October.

Difficulties are daily reminders of a harsh reality for patients in the VA system. More than one million patients are blind or partially sighted. They rely on software to access prescriptions or send messages to their doctors. But often the technology fails them. Either the screens do not allow users to zoom in on the text, or the screen reader software that translates text to speech is not compatible.

“None of the systems are accessible” to these patients, said Donald Overtongeneral manager of the Association of Blind Veterans.

Patients often struggle even to log on to websites or enter the basic information needed to register for hospital visits, Overton said: “We’re seeing our community stop trying, check and disengages. They become dependent on other individuals; they renounce independence.

Now the developing VA medical record system, already bloated by outsized costs, has been deferred until June 2023. So far, the project has threatened to exacerbate these problems.

While users in general have been impacted by numerous incidents of downtime, delays in care and missing information, barriers to access are particularly acute for blind and visually impaired users – whether whether patients or healthcare system workers. At least one Oregon-based employee has been offered help — an assistant to read and click buttons — to navigate the system.

More than 1,000 Section 508 complaints are in a backlog to be assessed or assigned to Oracle Cerner to address them, Veterans Affairs spokesperson Terrence Hayes confirmed. This section is part of the federal law guaranteeing people with disabilities access to government technology.

Hayes said the issues described by these complaints do not prevent employees and patients with disabilities from using the system. The complaints – 469 of which have been referred to Oracle Cerner for correction, he said – mean that user disabilities are making things more difficult, to the point of requiring mitigation measures.

The project is under new management with big promises. North Kansas City, Mo.-based developer Cerner, which originally landed the VA contract, was recently taken over by database tech giant Oracle, which plans to overhaul the software, the director of the Mike Sicilia company during a Senate hearing in September. “We intend to rewrite” the system, he said. “We haven’t found anything that can’t be resolved in a relatively short time.”

But it will happen under continued monitoring. Rep. Mark Takano (D-California), chairman of the House Veterans Affairs Committee, said his committee will continue to oversee the department’s compliance with accessibility standards. “Whether they work for VA or receive health care and benefits, veterans’ needs must be met by companies that want to work with VA,” he said.

Takano, as well as fellow Democrats Sens. Bob Casey of Pennsylvania and Jon Tester of Montana, sent a letter Oct. 7 to VA Secretary Denis McDonough noting significant gaps in agency systems and urging VA to engage with all disabled veterans, not just those who are blind.

VA was alerted early and often that Cerner’s software was causing problems for blind and visually impaired users, as evidenced by interviews and file review. As early as 2015, when the Department of Defense and VA were considering purchasing new systems, the National Federation of the Blind submitted letters to both departments and Cerner expressing concern that the product would be unusable for clinicians and the patients.

The alerts also came from inside VA. “We pointed out to Cerner that their system really relies on vision and that’s a major issue. The icons are really, really small. said Dr. Art Wallacea VA anesthesiologist who participated in one of the agency’s user groups to help with the eventual design of the system.

The Cerner system, he told the agency and KHN, is user-unfriendly. On the clinician’s side, multiple high-resolution monitors are needed to display a patient’s entire record, and AV facilities don’t always benefit from this wealth of equipment. “It would be very difficult to use for the visually impaired or normal people wearing bifocals,” he concluded.

Before the software was deployed, the system also failed a test with an employee working with a team at Oregon’s White City VA Medical Center dedicated to helping blind patients develop their skills and independence, said Carolyn Schwab, president of Local 1042 of the American Federation of Government Employees.

In testing, the system did not work with adaptive equipment, such as text-to-speech software, she said. Despite receiving these complaints about the system, VA and Cerner “implemented it anyway.” Recently, when an AFGE regional president asked VA why they were using the software — despite federal mandates — he got no response, Schwab said.

Some within the company also thought there would be difficulties. Two former Cerner employees said the standard medical record system was getting long in the teeth when VA signed a deal to buy and customize the product.

Because it was built on old code, the software was difficult to fix when problems were discovered, employees said. Moreover, according to employees, Cerner took a stubbornly incremental approach to correcting mistakes. If someone complained about a faulty button on a page full of other potholes, the company only fixed that button — not the whole page, employees said.

VA spokesperson Hayes denied the claims, saying the developer and the department were trying to address the issues holistically. Cerner did not respond to multiple requests for comment.

Accessibility errors are equally present in private and public sector medical record systems. Cerner fixed a bug with its Safari web browser rendering of its patient portal when the Massachusetts Institute of Technology student clinic threatened legal action, the former employees said. (“MIT Medical does not, as a general practice, discuss individual vendor contracts or services,” spokesman David Tytell said.)

Legal threats — with hospital systems and medical record systems regularly facing lawsuits – are the most obvious symptom of a lack of accessibility within the American healthcare system.

Deep inaccessibility plagues the booming telehealth industry. A recent survey of the American Federation for the Blind found that 57% of respondents had difficulty using vendors’ proprietary telehealth platforms. Some used FaceTime. Many said they couldn’t log in or couldn’t read information transmitted through chat sidebars.

Existing federal regulations could, in theory, be used to enforce higher accessibility standards for health technologies. The Department of Health and Human Services’ Office for Civil Rights issued guidance during the pandemic to make telehealth technologies easier to use for patients with disabilities. And other agencies might start relying on hospitals, because they receive funds from the government or from federal providers, to make sure their offerings work for these patients.

It might not happen. These regulations could prove ineffective, advocates warn. Although there are several laws in effect, proponents argue that enforcement and stricter regulations have not been put in place. “The concern of stakeholders is: are you going to slow this down any further?” said Joe NahraDirector of Government Relations at Powers Law, a Washington, DC law firm.

Integrating accessibility has always benefited all users. Voice assist technology was originally developed to help blind and visually impaired users before gaining popularity with gadgets like Siri and Alexa.

Disability advocates believe that providers often advance technology without considering the impact on the people who will depend on it. “In the rush to be first, they’ve put accessibility on the back burner,” said Eve Hilldisability rights attorney at Brown, Goldstein & Levy, a civil rights law firm.

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