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Simplifying High Volume Document Accessibility Challenges in Healthcare

Accessibility in Healthcare

This paper outlines one of the most vexing digital accessibility challenges facing health insurers today. Healthcare organizations are challenged to make the myriad of member-facing documents compliant with Section 508 and ACA anti-discrimination rules, improve access and avoid fines — in a timely manner while not blowing out internal budgets.

The Problem

The Section 508 ICT Refresh was effective January 1, 2018 and, for the first time, documents and PDF files were specifically included in the scope of the mandate. Section 508 of the Rehabilitation Act applies specifically to U.S. Federal entities and programs and in healthcare this translates to Medicare and TriCare health plans, therefore, many major U.S. health companies are impacted. Additionally, the Affordable Care Act also contains an anti-discrimination mandate, known as Section 1557, that also lists digital accessibility as a must-have for health plans operating under the ACA. The good news is that all major mandates now point to a single guideline as the goal post for document accessibility: WCAG or the Web Content Accessibility Guidelines, now on version 2.1.

Furthermore, the number of federal lawsuits under the ADA for website access have been skyrocketing, with 2018’s number of suits reaching over 10,000. This litigation and the regulatory landscape for making website content and key documents accessible has prompted action at major healthcare companies across the U.S.

The challenges of making health-related documents accessible are varied, but break down into these main categories:

  • Time to market. Traditional manual approaches are by nature slow, and result in slower service levels for people with disabilities, which could be construed as discrimination
  • Wide variability of document types and complexity. The sheer volume and complexity preclude a one-size-fits all solution to the problem, causing many companies to default to completely manual solutions which exhibit the slow service levels and high costs mentioned above
  • Lack of in-house expertise with document tagging strategies
  • Decentralized content authorship, lack of consistent approaches to accessibility and major training challenges
  • PHI considerations may exist if outside assistance is being used


There are three main approaches that are being deployed, and CrawfordTech provides best-of-breed solutions for all three. Each approach comes with tradeoffs relative to the above challenges:

Manual remediation

This process involves securely transferring un-tagged, inaccessible files to a provider at a secure data center (HITRUST, SOC2) that manually tags the files using Adobe Acrobat Pro or other tools and sends back fully tagged, WCAG-compliant files. This process generates compliant files, but is somewhat slow and expensive. Turnaround time is measured in days and costs are quoted usually between $5 and $10 per page for most documents, and usually a lot more for fillable forms. Sometimes manual remediation is done in-house by the health insurance company but this requires deep document tagging expertise and working knowledge of WCAG.

  • Virtually any document type can be addressed by manual remediation, however, page quantity, turnaround time expectations and costs are factors to consider

Automated Tagging

For some static documents, the process of applying artificial intelligence, algorithms and parameters to a program that tags the files in a semi-automated way provides some relief to the high cost and time delays of tagging files manually or the expense and delay of using a service provider. This results in mostly-tagged files that should then have tags for images and complex tables added manually and the documents tested for proper compliance.

  • Documents that best fit an auto-tagging approach include public facing documents such as annual reports, brochures, white papers and manuals.

Full Automation

The CrawfordTech Accessibility Express solution has been deployed at several large health insurance companies to completely automate the tagging and delivery of accessible files to members through existing portals. The process involves setting up template applications that predict the structure of incoming documents and in real-time, tags those files and delivers the files to requesting applications. This process works in both a batch and dynamic mode.

  • Good candidate documents for Accessibility Express include ANOC’s, EOB’s, Drug Lists & Formularies, EOC’s, Letters and Health Statements.

Figure 1: Sample, Dynamic Document Accessibility Process Flow

Best Approach

It is normal for a healthcare payer to have document types which fit all three of the above methodologies. Rather than try to fit a single solution into solving all of the problems, we are seeing many organizations employing a mix of the above solutions to achieve the best cost and ideal turnaround needs of different document types. For example, manual remediation is often the best approach for certain types of documents like plan brochures whereas Full Automation techniques should be used for handling personalized high-volume documents such as EOBs. The ideal solution is to work with a vendor that can provide best-of-breed solutions for all of your document types.

Business Case

The trend is for health companies to address as many documents as possible with Full Automation techniques due to the ability for automation to lower costs across a large volume of documents. The ROI for an automation solution is usually compelling when compared to ongoing manual remediation. The costs of software, professional services and internal resource costs usually are less than one year’s manual remediation expenses. Thereafter, only incremental services, internal costs and software maintenance are required.

Following are charts describing the high-level business case, one for a health company with medium volume spending around $500,000 per year on manual remediation, the second for a company with high volumes spending around $2M per year on manual remediation:

Figure 2: Automated vs. Manual Document Accessibility (Medium Volume)

Figure 3: Automated vs. Manual Document Accessibility (High Volume)

How to Engage

It’s very important to perform a detailed assessment so that optimal solutions can be deployed. Following are some of the key questions to be addressed:

  • What are all of the systems used to generate and store the documents to be made accessible?
  • What portals and web infrastructure are currently being used to present member-facing documents?
  • What are the current volumes and accessible formats being requested regularly?
  • Which documents will fit best in batch vs. dynamic models?
  • How many documents are on company websites which need to be made accessible?

Possible Leverage Point

Some of CrawfordTech’s Enterprise Output Management software may already be in use in your organization. If so, there may be the ability to simply add on accessible output formats such as accessible PDF or accessible HTML 5 to that platform, somewhat lowering costs and making procurement more streamlined. More discussion with the enterprise infrastructure teams may be required.

Getting Started

If you are planning to put accessible document solutions in place, you would normally take the following steps to get started:

  1. Identify vendors who provide the software and/or services you are contemplating
  2. Arrange general briefing and demonstrations with the vendors
  3. Arrange an assessment with at least one of the vendors
  4. Design the ideal solution architecture for your organization
  5. Get costs for the solution(s) you need
  6. Start your procurement process

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