Most healthcare providers and other business owners know that they must make their physical environment accessible for all members of the public, including those with disabilities, as required under Title III of the Americans with Disabilities Act (ADA). However, some may not be aware that accessibility also extends to the virtual environment; websites must also comply with accessibility requirements under the ADA.
Recently, MIEC has fielded a number of calls from concerned members regarding how they can comply with accessibility requirements for their websites. Many of these calls have come from the acupuncture community, although this issue exists for all types of healthcare providers who maintain a public website.
Furthermore, MIEC has seen a recent trend in claims against acupuncturists involving “surf-by” lawsuits, in which an individual who is not a patient files a lawsuit alleging that the provider’s website failed to meet accessibility requirements under Title III of the ADA.
“Surf-by” claims often start with a single individual who visits a large number of websites specifically for the purpose of evaluating compliance with accessibility requirements for those with disabilities- like having text-based alternatives to content like photographs or graphics, allowing full functionality using just a keyboard, etc. Businesses whose websites lack these features are named in lawsuits which, in California, can also permit the recovery of statutory damages under state law under the Unruh Civil Rights Act. Additionally, these claims can be very difficult to defend, and they often involve limitations in or a complete lack of coverage under malpractice insurance policies.
It is worth noting that a standalone website, if not associated with a physical place of business, may not be subject to ADA requirements. However, for physical businesses offering any website-based services (such as making an appointment online), courts have generally ruled that their websites must also meet public accommodation requirements under the ADA.
Unfortunately, there are few laws or specific regulatory standards that outline the requirements for website accessibility; the ADA was passed in 1990 and it did not address e-commerce, nor has it been updated to address website compliance. Interpretation of the ADA has expanded gradually to address website accessibility, but there has been no official change in the law- a proposal by the U.S. Department of Justice to establish website compliance standards was withdrawn in 2017, and has not been reissued.
In the absence of government standards, healthcare providers and other business owners should follow the private guidelines established by the Web Content Accessibility Guidelines (WCAG). These standards have often been referenced by courts in determining ADA compliance and remediation, and they provide the best guidelines for those attempting to achieve compliance in website accessibility.
The current standard is WCAG 2.1, available here. There are 3 different levels of WCAG compliance; level AA has generally been the accepted standard for compliance.
In summary, the WCAG standards address the following areas:
- Provide text alternatives for non-text content.
- Provide captions and other alternatives for multimedia.
- Create content that can be presented in different ways, including by assistive technologies, without losing meaning.
- Make it easier for users to see and hear content.
- Make all functionality available from a keyboard.
- Give users enough time to read and use content.
- Do not use content that causes seizures or physical reactions.
- Help users navigate and find content.
- Make it easier to use inputs other than keyboard.
- Make text readable and understandable.
- Make content appear and operate in predictable ways.
- Help users avoid and correct mistakes.
- Maximize compatibility with current and future user tools.
Some specific examples of WCAG compliance include:
Alternative Text for Images
- Images should include equivalent alternative text (alt text) in the markup/code.
- If alt text isn’t provided for images, the image information is inaccessible, for example, to people who cannot see and use a screen reader that reads aloud the information on a page, including the alt text for the visual image.
- When equivalent alt text is provided, the information is available to people who are blind, as well as to people who turn off images (for example, in areas with expensive or low bandwidth). It’s also available to technologies that cannot see images, such as search engines.
- Some people cannot use a mouse, including many older users with limited fine motor control. An accessible website does not rely on the mouse; it makes all functionality available from a keyboard. Then people with disabilities can use assistive technologies that mimic the keyboard, such as speech input.
Transcripts for Audio
- Just as images aren’t available to people who can’t see, audio files aren’t available to people who can’t hear. Providing a text transcript makes the audio information accessible to people who are deaf or hard of hearing, as well as to search engines and other technologies that can’t hear.
- It’s easy and relatively inexpensive for websites to provide transcripts. There are also transcription services that create text transcripts in HTML format.
Fortunately, healthcare providers have several options for determining whether their website meets the standards set by the WCAG. Auditing sites such as the one hosted by the Bureau of Internet Accessibility provide free compliance reports and links to resources.
Additionally, there are several options for achieving and maintaining compliance with current standards for website accessibility. Large practices with in-house IT support may choose to develop disability access features directly on their web platform; however, this would also necessitate constant monitoring, auditing and updating as standards change or new content is added.
For smaller practices and/or those with websites that are infrequently updated, there are several third-party vendors that offer software solutions. Please note that MIEC has not evaluated and cannot specifically recommend any vendor, but some of the available third-party solutions include:
For healthcare providers selecting a third-party vendor, it would be advisable to choose a vendor that offers a defense and indemnification provision that requires the vendor to defend any claims that arise from website accessibility issues, and to pay any damages that result. If a vendor does not offer any legal protection, ask them to add it to their contract.
It is worth noting that, for some practices, it might be more cost-effective to redesign a WCAG-compliant website than to address individual changes to move an existing website into compliance.
For more information, please contact MIEC’s Patient Safety & Risk Management team at firstname.lastname@example.org or (800) 227-4527.