[Paper Review] Evaluation of accessibility of open-source EHRs for visually impaired users

Megha M Moncy, Manya Philips Pilli+3 more|PubMed|Nov 5, 2023

Digital Accessibility for Disabilities9 references4 citations

TL;DR

This study evaluates the accessibility of three open-source EHRs—OpenEMR, OpenMRS, and OSHERA VistA—for visually impaired users using screen readers (JAWS, NVDA, VoiceOver). It finds that while all systems offer partial accessibility, OpenMRS performs best, with OpenEMR and OSHERA VistA showing critical issues in keyboard navigation and screen reader compatibility, highlighting the need for improved accessibility in EHR design for inclusive healthcare.

ABSTRACT

This study investigates the accessibility of open-source electronic health record (EHR) systems for individuals who are visually impaired or blind. Ensuring the accessibility of EHRs to visually impaired users is critical for the diversity, equity, and inclusion of all users. The study used a combination of automated and manual accessibility testing with screen readers to evaluate the accessibility of three widely used open-source EHR systems. We used three popular screen readers - JAWS (Windows), NVDA (Windows), and Apple VoiceOver (OSX) to evaluate accessibility. The evaluation revealed that although each of the three EHR systems was partially accessible, there is room for improvement, particularly regarding keyboard navigation and screen reader compatibility. The study concludes with recommendations for making EHR systems more inclusive for all users and more accessible.

Motivation & Objective

• To assess the accessibility of widely used open-source EHR systems for visually impaired users.
• To identify barriers in user experience caused by poor screen reader compatibility and keyboard navigation.
• To evaluate the usability of EHRs through automated and manual testing with three major screen readers.
• To provide actionable recommendations for improving accessibility in EHR design for blind and low-vision users.
• To address the research gap in accessibility evaluations of open-source EHRs for visually impaired populations.

Proposed method

• Conducted automated and manual accessibility testing on three open-source EHRs: OpenEMR, OpenMRS, and OSHERA VistA.
• Utilized three industry-standard screen readers: JAWS (Windows), NVDA (Windows), and Apple VoiceOver (macOS).
• Performed task-based evaluations including login, patient search, medication ordering, and demographic editing.
• Assessed keyboard navigation, focus management, label visibility, color contrast, and screen reader audio feedback.
• Evaluated consistency of screen reader announcements across different interface elements and forms.
• Identified accessibility gaps through systematic observation and comparison across platforms and EHR systems.

Figure 1: Dashboard of OpenEMR

Experimental results

Research questions

• RQ1 How accessible are OpenEMR, OpenMRS, and OSHERA VistA to visually impaired users using standard screen readers?
• RQ2 What specific challenges do screen readers encounter when navigating the user interfaces of these EHRs?
• RQ3 Which EHR system demonstrates the most consistent keyboard navigation and screen reader compatibility?
• RQ4 What accessibility barriers—such as unlabeled controls, poor focus management, or inconsistent audio feedback—were identified in the evaluation?
• RQ5 How do the accessibility features of open-source EHRs compare to the needs of blind and low-vision users in clinical workflows?

Key findings

• OpenMRS demonstrated the highest level of accessibility among the three EHRs, with consistent screen reader support and functional keyboard navigation.
• OpenEMR exhibited significant accessibility issues, including failure of screen readers to announce incorrect login attempts and poor form navigation.
• OSHERA VistA had notable compatibility problems with Apple VoiceOver, particularly in form completion and focus management.
• All three EHRs required some mouse interaction despite being designed for keyboard use, undermining accessibility for visually impaired users.
• Screen readers occasionally failed to fully announce interface elements, leading to confusion and incomplete task completion.
• The study identified inconsistent labeling of controls and poor color contrast as recurring issues affecting usability for low-vision users.

Figure 2: Dashboard of OpenMRS