In this episode, we discuss why you should pay attention to web accessibility for your practice, how to evaluate accessibility on your site, and what you can do to improve. We are joined by Vasu Tummala, a Senior Designer and Front End Developer here at P3 and our staff expert for all things related to web accessibility. Vasu shares his insights on how practices can make their websites more accessible for patients of all abilities.
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Michael: Welcome to the Paradigm Shift of Healthcare and thank you for listening. My name is Michael Roberts. I’m joined here today by Scott Zeitzer. Today we’re talking about why you should be paying attention to web accessibility for your practice. We’re going to look at how you can evaluate accessibility on your site and what you can do to improve. We’re joined by Vasu Tummala. He’s our senior designer and front end developer here at Health Connective and P3. We’re all one big company here. He’s our staff expert for all things related to web accessibility, no pressure Vasu. You’re going to share your practice, you’re going to share your insights today on how practices can make their websites more accessible for patients of all abilities. Thank you so much for joining us Vasu, we’re looking forward to the conversation today.
Vasu: My pleasure. Happy to be here.
Michael: All righty. Let’s talk about web accessibility means. This isn’t a topic that everybody’s familiar with. What does it mean? And then why is it important, especially for medical practices?
Vasu: Sure. I think it’s important just to start with, what is the web even? It is the greatest communication tool that the world has ever known. It reaches more people and is more important, and has a lower barrier of entry compared to anything that’s ever come before it. Whether we’re talking about stone tablets, the printing press, radio, television. Doesn’t matter, each one of those is built on the work of the past and has gotten cheaper and reached more people and has required that person to need fewer and fewer physical or socioeconomic abilities to access that media. The web is just the latest version and the current version of that. With that, you have a medium that can reach anyone regardless of what their hardware is, what their software is, what their language is, their location, physical abilities, network access. Doesn’t matter, they can get onto the web. Nothing’s been able to do that before in such a way.
With that, and the reason it can do that, is because just like all the previous mediums that have existed, it is more and more accessible in terms of the diversity of person that can interact with it. Regardless of your hearing ability, your vision, movement, sight, cognitive abilities, the web at its core was designed to reach all of those people. At its core, the web is supposed to be accessible and reach everyone. The only time that really doesn’t happen is when someone goes out of their way maybe, or isn’t really thinking about building that into the product that they’re creating. That could happen just because maybe they don’t know any better, or maybe it’s a time issue, or maybe it’s a cost issue. But accessibility just means being cognizant and being inclusive of who you’re trying to reach and building that in from the get go.
Scott: It’s a critically important thing, if you think about it, because everybody immediately thinks, oh, they can’t see or they can’t hear very well. It’s, no, there’s such a, you put it very well, there’s such a wide range of ways that a person might need some help, but they’re connected now, and then how do we ensure that? It’s something that I talk to a lot of my current customers, prospective customers, when we’re talking. I always say, Americans with Disabilities Act is going to be really important. Accessibility, Americans with Disabilities Act talks a lot about this. Everybody goes, [inaudible 00:04:00], yeah, whatever. [crosstalk 00:04:02]. “Hey, yeah, remember HIPAA?” They go, “uh-huh (affirmative).” I said, “Do you remember how that was going to be easy?” Of course, you keep everything private, no big deal, and how much time you spend with your lawyers making sure you’re HIPAA compliant, both online and in your own practice, in the brick and mortar world. I think the same thing’s going to happen with the Americans with Disabilities Act, which it’s a long winded thing, but what are the potential consequences of having a website that is not accessible?
Vasu: Yeah. When you define what a disability is, it usually breaks down into auditory, cognitive, neurological speech and visual or physical disabilities. When you put all those together, about 20% of the population at any given time has a disability, and will need the web to be accessible for them. The great thing about it is, when you make the web accessible, you also make it just easier to use and better to use for some without a disability. When you keep in mind stuff like font sizes and colors, you also make it easier to use for anyone with a partial disability or maybe someone that’s on a small screen, like a small phone or a smart watch. Something that you didn’t think about when you’re keeping in mind proper code, proper colors, proper font sizes, using the right heading, and the right navigation. It’s going to work somewhere where you didn’t anticipate it to work and where someone’s going to end up using it regardless of whether you were thinking about them or not.
Michael: We need to be accessible in healthcare in every which way we can.
Vasu: Yeah. If you’re someone that works in healthcare, you are more than likely interacting with someone who has a disability, whether it’s permanent or temporary. It could be that they lost their glasses or they pulled a muscle. It could be something temporary like that. But if you are trying to say that we are an expert in this medical field and you’re not able to communicate with them or make allowances for them, then there is definitely some damage you’re doing to your brand and to your image around that.
Scott: There’s a win here on so many different levels when you make your site accessible. Michael, you bring it up, it may not be like, of course you don’t want to get fined, but the PR is terrible. But just making yourself available just from a pure sales perspective, from a pure branding perspective, that you mentioned, all of us it’s, you’re dead on with that. I guess the follow up would be, when you’re looking at your website, for everybody listening in, how do you evaluate the accessibility of a website?
Vasu: There are tools out there that can do what’s called automated testing. The most well-known one is from a group related with the web consortium that runs the web standards. This tool’s called WAVE. It can do an automated test and it can tell you if you have errors, if you have warnings, if you have any issues that crop up. Errors are the biggest issue. It’s the highest tier problems that you have. If you have errors, that’s something you need to address immediately. Warnings you need to get to shortly thereafter.
WAVE would be a good way if you have a practice and you just want to know. Run it through the tool, WAVE. Just do a Google search for WAVE accessibility and you’ll find the tool. It’s not going to give you a score, it’s just going to tell you the number of errors and the number of warnings. That’s where it comes into play. Then you need to figure out what to do with that, because it’s not a simple score that you can just say, “Oh, B is okay, I can live with that.” Once you have these numbers, unless you’re very familiar with developing website or code, then you need to seek out a professional to help you with that. These numbers and that you’re going to get are mostly for developers, and also sometimes the automated testing can be wrong for better or worse. Sometimes it’ll miss things that are areas that need to be improved and fixed, or sometimes it’ll give you a failing score in something that is just fine, it just doesn’t know how to test for it.
Once you use one of these tools to give you the quick answer, then you need to figure out, you need to find a partner to work with and have them go through your site and with a fine tooth comb and make improvements. That’s assuming you have a site that is pretty up to date and that you like, and that you want to keep. If not, then maybe it’s time to consider a newer design that is usually going to be more inclusive from the get go. It could even be cheaper just to have a whole new design made or move your content into a new design because it could have accessibility considered from the start.
Michael: Yeah. Sometimes trying to retrofit that stuff can turn into a real painful exercise.
Scott: Been down that pathway many times. I would say, just to add into that, everybody listening, just because you have a new site doesn’t mean it’s accessible. The developer didn’t take the time to focus on that and make sure that it working appropriately, that’s going to be an issue. Don’t assume that, oh, I’m on WordPress or, oh, I’m in Wix or Squarespace or whatever, that it’s magically accessible. Although all that I just threw out are fine platforms, but hey, you’ve got to still have it work correctly, check for it.
Vasu: Unfortunately in 2021, accessibility, even though it’s something that’s supposed to be core to the philosophy of the web, it’s still something that as you go to school for computer science or design, or you go to a bootcamp or you’re self-trained, you often don’t learn about accessibility. The vast majority of the web is still inaccessible, regardless of who’s making it and regardless of the cost or the size of the institution.
Scott: This is where if you go back to that ADA thing, where you go, guys, it’s coming.
Vasu: Yeah, it’s already here. These web guidelines are defined by something called the Web Content Accessibility Guidelines, is the standard. We’re at version 2.0 right now, and version 3.0 of these guidelines was just put into public review over the summer, this past summer, so those are coming. Within the last few years they got pulled into the Americans with Disabilities Act, I think it’s part of title three.
Vasu: And something like, I want to say almost 10 years ago, there were maybe 2,700 cases that were filed, like legal cases around this. In 2019 it was 11,000 cases.
Scott: Yeah. A lot of lawyers are hopping online, taking a look, trying to find those sites that aren’t appropriate. For some of them it’s just a way to earn a buck. I get it. For some it’s, they may have a disability as well, they want to ensure that things are getting fixed at an appropriate pace, shall we say?
Vasu: Yeah. It shouldn’t just come down to legal ramifications. I know we talked about-
Scott: I agree.
Vasu: The brand impact before. Since the internet is the best way to reach out to people, especially those that might not be able to get to you because of a disability, it can also be a competitive advantage. If your website is more accessible than your competitor or another practice, or even just another online information source that you may be competing with to get real information out there, having something accessible means more people can use it. It also makes it more trustworthy. It means the code is better. Oftentimes that means that your search ranking is going to be higher because of it. You get the benefit of both building trust and reputation, and it’s almost a bonus that you then become legally compliant as well.
Michael: If you also combine that with one of the big factors of healthcare right now, which is that last mile delivery, and this is true of a lot of different types of logistics, so many people struggle with now, how do we bring this to a rural area? How do we take this to be able to accommodate people in all of these different spaces? These are the kinds of considerations that help you get there. It’s not going to solve everything, but this is definitely a key component in being able to make that work. We’re talking a lot about how it helps. What are some of the issues that you’ve seen, Vasu, and some of the things that we’ve encountered just as a team around accessibility, whether it’s something for the medical practice or even for medical companies that we’ve worked with?
Vasu: Sure. I guess, the good news, if you can call that, is the issues that I’ve seen on medical practices, they’re the same you see anywhere on the web, whether it’s a news site or a media site, or blog or even social media. They usually break down into errors in presentation that could happen, and they’re almost never malicious. It’s not like someone is on purpose trying to make something inaccessible or is on purpose leaving information out. They just maybe they don’t know, or maybe they’re short on time or they don’t have the budget to address it. But usually there are five or six main items, with the biggest one being what we call alternative text for images.
When you have images on a site, they break down into two big groups. You could have images that are just for presentation, so it could be like a stock image or maybe a photo of a location or something like that. That maybe it offers some value to the person reading it, like saying that this is an image of Central Park, for example, can help-
Vasu: Set the tone or set the mood for what you’re trying to convey. But if you leave that out, if someone has poor sight or no sight, or is using an assisted device like a screen reader, if you don’t say what that image is in the code, then there’s no way for that image to be presented to that user. Again, we’re talking about upwards of maybe 20% of your visitor base that might not be able to figure out what that image is or even know that it’s there. The other bucket would be images that are really important to the documents. That could be a chart for example, or a figure. If you’re only conveying data in the form of a chart, how would someone with poor vision or no vision going to know what you’re saying? They’re not.
In the code base, we have ways of putting in supplemental textual information about, first off, whether an image is vital to what you’re conveying or whether it’s just for presentation, you can ignore it. It is vital or whether it’s information you’re conveying or it’s setting the mood. We can put in alternative text, what needs to be said to the user so that they don’t miss out as well.
Overwhelmingly, that is the biggest item that is missing from websites when it comes to accessibility. You often run across this in a CMS, where maybe you just upload an image and the CMS doesn’t know what to put in there for the alt text. Some social platforms will use AI to figure out what the image is about and they’ll put in something in there, like Facebook, Instagram, they’ll do this. But for something like a CMS, it doesn’t really have a good way of using any of that so you need to put it in yourself. If you don’t know to do that, then what’s going to end up getting read out to the user is just the file name of the image, and that’s not very helpful.
Michael: For sure.
Scott: Let me interject, CMS, content management system. You get back to this point, you’re trying to make, and this is a major portion of the accessibility part. When you’re putting that alternative text in, that’s your opportunity to reach out to those people, that 20%. Don’t just say, I don’t know, I’ll be silly. Ambulatory surgical center. It’s like we have a brand new ambulatory surgical center. Might be a little bit better to say than simply the term ambulatory surgical center. It’s nice, but take advantage of the fact that you can put in some info.
P3 Pro Tip
Hey, this is Michael with your P3 Pro Tip.
Many practices have tried social media networks at one time or another, but many end up with a broadcast approach. Meaning that they just post their messages without ever engaging with any of the comments or otherwise interacting with their audience. This isn’t a very effective way of marketing your practice or building an audience on social media. Practices that are successful on social media take the time to review the interactions of their posts and respond when needed. It’s not necessary to reply to every single comment you get, but at a minimum you should be answering any questions that are posted on your comment threads. Letting those questions go unanswered is a clear sign that your practice isn’t really paying attention to social profiles and any audience you may have built up could quickly disengage. If your practice is going to do social media, make sure you do it the right way by dedicating enough time to review and respond to comments in a timely manner.
Michael: You’re listening to the Paradigm Shift of Healthcare, and this is Michael Roberts, Scott Zeitzer, and Vasu Tummala. Today we’re talking about web accessibility, how it actually plays out on your website. We’re looking into some of the top issues that we run across right now. And so we’re talking about alternative text for images. It’s also something that, again, this is a huge component of just getting basic search engine optimization correct. Paying attention on both sides of this equation are definitely going to be a benefit. What other types of issues do we run on into, or do we cover everything with alt texts yet?
Vasu: No, that was just one of five or six items that are common. But just to finish up on that one, you can even, if you have a headshot of someone, you can describe that headshot to someone. If someone has no vision at all, it might be beneficial to them to know what that person looks like or what their age is and you might want to interact with someone that is maybe your own ethnicity if you’re an immigrant that might make you feel more comfortable.
Vasu: Describing that in the alt text for someone’s headshot could be extremely comforting and informative to someone and give them more trust in their position and in the practice.
Michael: Yeah. I’ve never written one that way so that’s interesting to hear.
Vasu: Sure. Yeah. Just speaking, personally my mother likes going to physicians that are also Indian, she just feels more comfortable with them.
Vasu: That could be something that goes into an alt description for someone and would make them feel more comfortable. Besides that and that being the prevalent one, other things we see are, insufficient color contrast. That’s going to be the difference in color between the foreground colors, that’s usually text, and the background color. Some kind of maybe like the background color of the website, background color of an image background, background color of just some box or shape on the site. If there isn’t enough of a difference between those two colors, someone just won’t be able to see it, or they’re going to have a really hard time, they’re going to struggle with being able to read it. If someone has a hard time reading your site, they’re not going to put more effort into reading it, they’re just going to go somewhere else.
Scott: They’re just going to get annoyed and leave. You’re right.
Vasu: They’re going to get annoyed and leave, go find some other site that they can read. Oftentimes if you have great vision or even pretty good vision, you might not know that something is low contrast and you need to use some tool to calculate that difference. Oftentimes these colors are chosen just for aesthetic reasons, people like how they look and they aren’t really giving thought into how that might impact someone. Aesthetics and personal feelings can often have an accessibility impact. If you ever find yourself thinking, I like how this looks, and that’s the only reason you can really think about why you might want to go a certain way with some branding colors or how something looks, I would say take a few minutes and think about whether you’re willing to compromise on that. Whether those colors are accessible, and what the ramification would be if someone couldn’t read your site just because you felt like, purple’s my favorite color so I’m going to put that on the site, and now someone can’t read it. That’s going to be a problem.
Aesthetics just sometimes aren’t worth it, or at least they’re not worth not compromised. We also see lots of issues in heading structure, so using the right code to define what’s the most important heading on the page, the second most important thing on the page, the third most important, et cetera. If you think of a web page as an out with bullet points, that sometimes that format just doesn’t get used, and because of that, both Google or a screen reader doesn’t know how to categorize the information and present it to someone who is having trouble reading or accessing the page. The more you can use proper heading structure and help ease the user in and hold their hand and guide them through what is most important, the better. That’s often just missed. Someone might use bold text when they really should be using a level two header. They might end up looking the same on the page even though they’re different at the code level, but assist someone using an assisted device, it could be all the difference between knowing what’s important and what’s not important.
Scott: Yeah. That’s a critical thing to bring up, and an automated error checker may not see it as just text and you just made it particular style of text, but that’s something that I know our team, and you’re a big part of that, spends a lot of time making sure that structure is appropriate so that it does work well. Michael, if I’m not mistaken, doesn’t it help with Google searches as well when you structure that type of stuff better?
Michael: It’s fine because, Vasu, as you’re talking to all these, I’ve not been guilty because I’ve not been able to let myself do it, but I definitely see marketers be very guilty of this behavior. I’ll just jump in here and change this thing around real quick. Wouldn’t it be nice if I could have this size of header instead of that? Yeah. But it does really confuse the importance level of everything. You’re sending mixed signals to screen readers, to Google, to all these different systems, and the more consistent you can be. But you actually have to work with your design team to get that right. Sometimes I am very guilty of, hey, I’ll just get this done this time and then I’ll go ask the designer next time. It makes a big-
Scott: I will not mention name of the company, but I’ll never forget. We were doing a very complex web application for a company. We had all the colors laid out and it was from a contrast perspective as well as a look, but we wanted to make sure that it was extremely usable. The person came in and said, “I think we’re just going to change it to blue and yellow.” Everybody stopped for a second. It was a very high level person. I guess I had the nerve to say, “Okay, why?” The answer was, “My daughter likes that.” Okay. That’s great. I’m sure if you’re a Los Angeles Rams fan, that’s good too. I know, Vasu, you have no idea. It’s a football team.That’s…okay. All right. You got that one.
It is important to look at it. If you take that time to do these things, as Michael’s saying, yes, you’re helping people, you’re doing the right thing, but you’re also getting the customer to actually interact with you and hopefully use you. In a practice, it would be a potential patient or a current patient to actually utilize the site for critical information. We’ve got alt text, we’ve got-
Vasu: Color contrasts [crosstalk 00:21:13]. Yeah, we got heading structures. Links need to be written really well with some consideration. For example, if you were to write a link that just said, “Click here.” Click here to do what? Click here for what reason? If your link isn’t really well written out, where it’s obvious what you are linking to or worse, if your link is maybe just an image, like a icon of a telephone that takes you to a contact form, you need to be putting in… Similar to all text, there is other alternative texts that you need to put into that link saying maybe what the purpose is, if it’s not obvious already. Now, the best way to do that is to write the copy so that it always makes sense. But if you are unable to do that, or maybe for an aesthetic purpose you can’t, then alternative text to really fully describe what that link is, is really going to help someone who can’t see what the screen says, be able to navigate around the site.
Another area we see a lot of issues, are with forms. For example, contact forms or patient forms, if those aren’t laid out properly with labels that fully define what each field is for and without controls that are properly set up to navigate through the form, a person with a visual disability or motor disability, all they might hear from their computer is that they have empty field after empty field to fill out and they’ll have no idea what’s supposed to go in there.
Scott: Yeah. We’ve all filled out forms where we’re shaking our head, and how many times we’ve left. When you make these forms that are poorly designed, and again, if you’ve got some disability or it’s just that, I’m out.
Vasu: Yeah, if you sprained your wrist, you might not be able to fill out that form in the office. Your only way to do it is through the web. If you also have poor eyesight, that’s a double whammy, and now what are you supposed to do?
Michael: We’ve covered a lot of issues that we do see as we’re getting towards the end of the show here. There are some different widgets that are out there and there’s one called UserWay. That’s something we’ve certainly seen before. What are your thoughts on something like that? It seems like it’s better than nothing.
Vasu: Yeah. Better than nothing is definitely how I would describe it. That could be really important actually. But once you use that WAVE tool that I was talking about earlier, if you notice that you do have errors and warnings, especially errors, those are the biggest tier of problem. It might take you a little while to find a development partner or for them to address the issues or for that redesign that you’ve been putting off. Using UserWay as a stop gap solution is a pretty good way to go because it at least gets you somewhere. It can tackle items like font size, the color contrast we were talking about. It has its own built-in screen reader, which can be beneficial, although maybe not. I’ll get to that in a second.
But even just those couple items, in increasing the font size, increasing the contrast, that alone can clear up a lot of errors and warnings and at least get you by during… It maybe takes a few days, maybe it takes several weeks or even a few months to get a new website developed from scratch. Having that in place is something that can protect you somewhat legally, and it can also help your site become a little bit more inclusive while that’s being done. But there are several things it can’t to do. It can’t rewrite the heading structure that we were talking about. It has no way of knowing what the images are, so it has no way of writing alt text. It doesn’t really know the context of a link, so, again, if you don’t have your link text written properly, it doesn’t have a way of providing that alternate link text. It also has no way of figuring out how a form that’s been improperly… What the labels are supposed to be for that.
It’ll tackle a couple things, maybe one or two items out of the five or six, but certainly not all of them. It might give you some legal protection, but even last year there were still 250 cases of someone getting sued and they were using UserWay. It helps, but it’s not a full shield. There’s also a performance implication. Since you are adding code to your site to try and add accessibility as a bolt-on item, it is going to slow down your website and a slower website is going to be less fun for everyone, less usable for everyone. It will impact your Google search score. Better than nothing can help in the interim, but it’s definitely not a solution.
Michael: Yeah. That makes a lot of sense. As we’re looking at what practices should be doing, really, the first step is, go check your score. What was the name of the tool again, that they should be looking at?
Vasu: WAVE. W-A-V-E. you’ll just put in your address, and unfortunately, it’s not going to give you a score like an a or B, it’s just going to tell you how many errors, how many warnings you have and if there any other issues. From that, you can then talk to a development partner and figure out what to do from there.
Michael: Sure. You’ve got, first step is, just go take a look, use the WAVE tool, get a sense of how many errors you got. And then you may be looking at a full new site. You may be looking at some easy fixes that your developer can make for you and get fixed for you. There’s definitely a pathway forward here. It’s definitely something that’s not overly complicated to get started.
Michael: Just get an understanding of what your checkup looks like in terms of just being healthy as a practice.
Vasu: First step is to run that tool, and then the second step is just a decision. If your site’s 10 years old and you think you have a pretty decent budget, I would go for a new site. Not only will you tackle all the inclusivity and the accessibility aspect, you’re also going to get a branding refresh. That always looks modern and professional, and like you’re an active practice or company.
Scott: Yeah, and I think one of the things, if anybody takes anything away from this conversation, if you’re managing a practice, running a practice, are the practice, when you pick your partner, have this conversation. If they have no idea what you’re talking about, don’t know about these tools, don’t really get accessibility, find another developer, they’re out there. It’s not like we’re the only shop that knows how to do this. There’s quite a few out there that do, and I think it’s a critical part of the win, so to speak.
Vasu: Yeah. There’s a good chance that just looking at statistics, there’s a good chance your site is probably not going to be a hundred percent compliant. Most of the web is not. Also because of that, means most of the partners out there that you might have heard about or worked with in the past might not be the right fit for getting you to that next level.
Michael: Absolutely. As we’re talking through this too, I can’t stress enough, search engine optimization, just good copywriting, good processes around leading your patient to what they need. All of these things go hand in hand. There’s a lot of overlap between just good overall marketing and good accessibility. Vasu, thank you so much for coming. Everybody-
Vasu: Yeah, my pleasure.
Michael: A great week. Do take a look. Just check that WAVE tool. See where you’re at with your site and have a great week everybody. Thanks so much.
Scott: Our pleasure.
Announcer: Thanks again for tuning to the Paradigm Shift of Healthcare. This program is brought to you by Health Connective, custom marketing solutions for med tech and pharma. Subscribe on Apple podcasts, Google Play, or anywhere you listen to podcasts.