Blind in trouble: How VA’s electronic records system turns off the visually impaired

Sarah Sheffield, a nurse practitioner at the Veterans Affairs Clinic in Eugene, Oregon, had a problem. His patients — mostly in their 70s and older — can’t read computer screens. That’s not an uncommon problem for older people, which is why you might think Oracle Cerner, the developer of the agency’s new digital health record system, anticipated it.

But they didn’t.

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

The difficulties are a daily reminder of a grim reality for patients in the VA system. More than a million patients are blind or have low vision. They rely on software to access prescriptions or send messages to their doctors. But often technology fails them. Either the screens do not allow users to zoom in on text, or the screen-reader software that translates text to speech is not compatible.

“Neither system is accessible to these patients,” said Donald Overton, executive director of the Blinded Veterans Association.

Patients also often struggle to log into websites or enter the basic information needed to check in for hospital visits, Overton said: “We see our community try, check out and stop. They become dependent on the other person; They give up freedom.”

Now, developing the VA medical records system, already bloated by massive costs, has been delayed until June 2023. So far, the project has threatened to exacerbate those problems.

While users in general have been affected by numerous incidents of downtime, delayed care and missing information, barriers to access are particularly acute for blind and low vision users – whether patients or staff within the health system. At least one Oregon-based employee has been assigned support — an assistant assigned to read and click buttons to navigate the system.

More than 1,000 Section 508 complaints remain in a backlog for evaluation, or have been assigned to Oracle Cerner for resolution, Veterans Affairs spokesman Terrence Hayes confirmed. This section is part of federal law that guarantees access to government technology for people with disabilities.

Hayes said the problems described by these complaints do not prevent employees and patients with disabilities from using the system. The complaints — 469 of which Oracle Cerner has been assigned to fix, he said — mean users’ inefficiencies make it harder, until mitigation is needed.

The project is under new management with big promises. North Kansas City, Missouri-based developer Cerner, which originally landed the VA contract, was recently acquired by database technology giant Oracle, which plans to overhaul the software, company executive Mike Sicilia said during a September Senate hearing. “We want to rewrite” the system, he said. “We haven’t found anything that can’t be solved in relatively short order.”

But this will happen under constant scrutiny. Rep. Mark Takano (D-Calif), chairman of the House Veterans Affairs Committee, said his panel will continue to oversee the department’s compliance with accessibility standards. “Whether they work for the VA or receive health care and benefits, the needs of veterans must be addressed by the organizations that want to work with the VA,” he said.

Takano, fellow Pennsylvania Democrat Sens. Bob Casey and John Tester of Montana sent a letter to VA Secretary Dennis McDonough on Oct. 7 citing significant gaps in the agency’s system and urging the VA to engage with all disabled veterans, not just them. who are blind

The VA was warned early and often that Cerner’s software created problems for blind- and low-vision users, a review of interviews and records shows. In early 2015, while the Defense Department and VA were exploring purchasing the new systems, the National Federation of the Blind submitted letters to both the department and Cerner, expressing concern that the product would be unusable for physicians and patients.

Alerts also came from inside the VA. “We pointed out to Cerner that their system is really dependent on vision and that’s a big problem. The icons are really, really small,” said Dr. Art Wallace, a VA anesthesiologist who participated in a user group at the agency to provide input for the final design of the system.

The Cerner system, he told the agency and KHN, is user-unfriendly. On the clinician side, multiple high-resolution monitors are needed to display a patient’s complete record, and VA facilities don’t always enjoy the wealth of that equipment. “It would be very difficult for people with visual impairments, or ordinary people wearing bifocals, to use it,” he concluded.

Carolyn Schwab, president of the American Federation of Government Employees Locals, said before the software was launched, the system failed tests by an employee working with a team dedicated to helping blind patients develop skills and independence at the White City VA Medical Center in Oregon. 1042.

In tests, the system didn’t work with adaptive equipment like text-to-speech software, he said. After receiving these complaints about the system, the VA and Cerner “implemented it anyway.” Recently, when a regional AFGE president asked the VA why they used the software — despite the federal mandate — he got no response, Schwab said.

Some in the company thought there would be a fight. Two former Cerner employees said the standard medical record system was getting long in the tooth when the VA signed a contract to purchase and customize the product.

Because it was built on outdated code, the software was difficult to patch when problems were discovered, employees said. What’s more, according to employees, Cerner took a strongly incremental approach to fixing errors. If someone complains about a faulty button on a page full of other holes, the company will only fix that button — not the entire page, the staff said.

VA spokeswoman Hayes denied the claims, saying developers and the department work to resolve the issues as a whole. Cerner did not respond to multiple requests for comment.

Accessibility flaws are present in private sector medical record systems as universally. A student clinic at the Massachusetts Institute of Technology threatened legal action when Cerner’s Safari web browser developed a bug with its patient portal rendering, former employees said. (“MIT Medical, as a general practice, does not negotiate individual vendor contracts or services,” said spokesman David Title.)

Legal threats — hospital systems and medical record systems routinely face lawsuits — are the most obvious signs of a lack of accessibility within the US health care system.

Deep inaccessibility plagues the growing telehealth sector. A recent survey by the American Federation for the Blind found that 57% of respondents struggled to use provider-owned telehealth platforms. Some have resorted to FaceTime. Many reported that they could not log in or read information sent through chat sidebars.

Existing federal regulations could, in theory, be used to enforce higher standards of accessibility in health technology. The Department of Health and the Human Services Office for Civil Rights issued guidelines to make it easier for patients with disabilities to use telehealth technology during the pandemic. And other organizations may begin to lean on hospitals, because they are recipients of government dollars or federal vendors, to make sure their offerings work for such patients.

It may not be. These regulations could prove toothless, advocates warn. Although there are several laws on the books, advocates argue that enforcement and stricter regulations have not been forthcoming. “The concern of stakeholders is: Are you going to walk it slowly again?” said Joe Nahra, director of government relations at the Washington, D.C., law firm Powers Law

Creating accessibility has historically benefited all users. Voice assistance technology was originally developed to help blind and low-vision users before gaining widespread popularity with gadgets like Siri and Alexa.

Disability advocates believe that vendors often advance technology without properly considering the impact on the people who will rely on the technology. “In the rush to be first, they put accessibility on the back burner,” says Eve Hill, a disability rights attorney with Brown, Goldstein & Levy, a civil rights law firm.

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