Approach

The following sources of information and techniques were used to gather the information about barriers:

• Literature review
• Review of litigation
• Press review
• Ombudsman reports
• Disability advocacy organizations
• Research, reviews and summative reports
• Interviews with key organizations of people with disabilities
• Interviews with disability studies organizations
• Interviews with organizations for people with disabilities

Potential Barriers by Functional Requirements

The following operational requirements may present barriers.

Device Manipulation Barriers

Fine Motor Control

• writing (e.g. form-filling, signatures, stylus, “mouse signatures” etc.)
• physical manipulatives (e.g. swipe cards, etc.)
• devices with small controls (e.g. keypads, keyboards)
• devices requiring accurate pointing or gestures (e.g. mouse, touch screens, flat membrane keyboards)
• devices employing tactile feedback

Gross Motor Control

• devices that are easily damaged
• devices that are sharp or otherwise dangerous
• requirement to communicate in-person (as opposed to by phone or online)
• web sites or software lacking keyboard accessibility
• time constraints on use of communication

Effort & Reach

• excessive force
• reach (e.g. touchscreens)
• sustained effort (e.g. stylus)
• use of both arms simultaneously
• operating two parts simultaneously
• tight grasping
• pinching
• twisting of the wrist
• quick repetition (e.g. mouse clicks)
• device controls out of sight/reach from sitting position (e.g. kiosk)

Communication Barriers

Speech

• as primary communication mode (e.g. language, spoken, gestural)
• voice recognition (e.g. software, phone systems)
• voice identification
• barriers to lip reading (e.g. camera position, speaking quickly, masks)

Modality

Information conveyed through visual means:

• print documents and other text (e.g. forms, publications, books)
• graphics (e.g. images showing placement of blood pressure cuff)
• videos
• visual feedback/indicators/alarms
• dynamic communication devices (e.g. touch screens, soft controls such as buttons depend on mode)
• web sites or software (lacking keyboard accessibility, semantic markup for visual layout or other supports)
• colour-coding or colour indicators

Information conveyed through sounds:

• auditory feedback
• indicators/alarms
• lack of volume control

Cognitive Load

• complex or unnecessary information
• lack of attention cues
• lengthy phone menus
• expectation of continuous concentration (e.g. more than 15 mins)
• lack of memory cues and supports (e.g. instructions)
• expectation to retain and recall information

Processing

• complex or inconsistent text (e.g. forms, signs, etc.)
• text-intensive information displays
• time constraints on use or communication
• complex or unnecessary use of numbers or math
• time-telling, calendar use
• lack of word prediction or spell-checking support

Other Barriers

Physical Barriers

• biometric identification
• devices sensing body parts (e.g. capacitive or infrared controls)
• devices designed for a specific hand
• iris or other eye identification

Equipment Barriers

• not operable with AT
• older equipment (e.g. due to constraints on technology refresh funding) may not meet system requirements

Attitudinal Barriers

• when no other barrier exists, an individual who is older, has a disability or is in some other way perceived as vulnerable, may still be prevented from performing an action by a person in authority with an inappropriate attitude

Privacy & Security

• privacy threats (e.g. remote setting limits privacy, audio output overheard)
• information and data security (e.g. network security)

Scenarios

The following are scenarios where patients are required to perform certain functions in order to engage in virtual healthcare appointment booking and attending.

• Using a software platform to register and book an appointment
• Prepare for an appointment
• Attending the virtual visit and dealing with any technical issues
• Any asynchronous interactions such as chat or sharing of documents

Another application of virtual healthcare is the use of remote patient monitoring. The following are example scenarios where patients are required to perform a functions in order to engage in this aspect of virtual healthcare:

• Enrolling in the program
• Setting up the equipment and service
• Scheduling coaching or training
• Submitting records or data
• Completing health surveys
• Dealing with alerts, and clinician interventions

In all these scenarios, whether it is booking an appointment or setting up a health monitoring device, a number of functional barriers can arise that will affect an individual's ability to complete the activity. For example, if the instructions for setting up a device uses small text that isn't legible to the user, the user will experience a barrier in participating in this aspect of healthcare.

For additional detail on these example scenarios, refer to this document: Scenarios virtual care.pdf.

Barriers Identified by Subject Matter Experts

The following are barriers and requirements identified by subject matter experts. This is not intended to be an exhaustive list of all concerns - only those that were mentioned in conversations.

Access

• Access to a computer or device capable of performing virtual visit functions ^{1 4}
  
  • Functions include screen sharing and remote screen control ¹
• Internet access may not be optimal due to context (hardware, geography, service, infrastructure) ^{1 2 3 4}
• Access to services may not be convenient ²
• Access may depend on access to email or phone ²
• Bias, discrimination ³
• Transportation / Unable to reach place of primary care ³
• Hours of operation / pandemic shutdown ³
• Limited services offered to demographic ³

Effort and Reach

• Change camera position ^{1 4}
• Ability to properly face the microphone or screen for assessment / consultation ^{1 4}

Logistics

• Remote helper is needed to assist in visits ^{1 3 4}
• May be hard to book appointments if sharing an account ¹
• Multiple forms need to be completed and returned ^{1 4}
• Inability to follow-up with patients, build relationships, and get feedback ^{2 3}
• Consultations take longer online than in-person ¹
• Scheduling may cause barrier. Ad-hoc visits may be more convenient. ³
• Patients, clients, or family members need to be organized and recall appointment details (passwords, date/time etc.) ⁴

Understandability and comprehension

• Digital literacy / Is the person comfortable using the software? ^{1 2 3}
• Registration process can be confusing with multiple steps which can cause barriers ^{2 3}
• Language preferred vs. what is offered ^{2 4}
• Audio quality which can be impacted by microphone quality and type (i.e. speaker phone), and network quality. ^{1 4}
• Health literacy ³

Personal and Privacy

• Is the person comfortable sitting for X minutes? ¹
• Is the person okay with digital privacy concerns? ¹
• Lack of private space ^{1 4}
• Finding a virtual meeting platform that is private and / or complies with regulations (i.e. PHIPA)^{1 3}
• Not all clients have IDs or comfortable providing identity information ³

Value Proposition

• Uncertain benefit of online consultations vs. in-person. ^{2 3 4}
• Healthcare is a low priority ³

Trust

• Trust in software ^{2 3}
• Trust / familiarity with doctors and practitioners ^{2 3 4}
• Importance of predictable schedule ³
• Discomfort / distrust in clinical setting ³

Assessment / consultation limitations

• some procedures can't be done online and requires in-person ⁴

1 Accessibility Occupational Therapist

2 Maritime Doctor

3 Nurse Practitioner

4 Speech Language Pathologist

Existing Papers and Research

• Alberta Health Services identifying gaps and barriers with virtual healthcare visits vs. in-person consultations.