Electronic and Information Technology

Question 18: What are the challenges posed by the inaccessibility of EIT, including EIT kiosks, POS devices, and ITMs? Are there issues regarding other uses of EIT that the Department should consider adopting to ensure that EIT equipment is accessible?

The challenges posed by inaccessible EIT, including EIT kiosks, POS devices, and ITMs, vary depending on the type of technology, the intended purpose of the technology, the environment of use, and the type and severity of disability. Accessibility standards governing EIT need to be specific enough to provide consistency and performance-based enough to allow flexibility to accommodate emerging technology.

In general, the most common challenges posed by inaccessible EIT fall into 6 general categories:

  • Access to people with mobility disabilities, including people who use wheelchairs
  • Examples of barriers include:
    • reach ranges for controls
    • viewing angles of controls, displays or information
    • heights of writing surfaces
    • size, placement, slope and surface of path of travel and clear floor space
  • Access to people with vision disabilities
  • Examples of barriers include:
    • touch screen interfaces without audio and tactile input options
    • visual (on-screen or printed) information without audio, tactile, large print, or high contrast output options
    • video information without audible description
    • Biometric authorization, authentication, or identification mechanisms that depend on retina or iris
    • input mechanisms that time out
  • Access to people with manual dexterity disabilities
  • Examples of barriers include:
    • objects required for interaction (styli, credit card swipes, keypads, mobile devices) that are hard to retrieve, hold, position, manipulate, and stow
    • Keypads and buttons (physical or on-screen) that are small or require precision to operate or don’t work with prosthetic devices
    • Input mechanisms that time out
  • Access to people with hearing disabilities
  • Examples of barriers include:
    • audio or video information that is not captioned or otherwise available in visual format
    • audio information without volume control
    • hearing aid interference
  • Access to people with cognitive and learning disabilities
  • Examples of barriers include:
    • Content, authorization/authentication systems, and navigational controls that are complicated, lack simple cues, or use multiple media at the same time
  • Access to people with other physical disabilities
  • Examples of barriers include:
    • Interactive mechanisms (such as facial recognition or body scanning) that assume a particular "standard" appearance, size, or posture (sitting versus standing)

The effects of inaccessible EIT are not limited to consumers of goods, information and services. Inaccessible EIT also poses significant barriers to employment of people with disabilities. Unless accessibility is built in and assistive technology is readily available, individuals with disabilities will be forced even further out of the labor force.

As EIT becomes more prevalent, it replaces human staff (as, for example, automatic parking payment machines are replacing parking attendants), leaving people with disabilities without access to flexible, on-demand, individualized assistance.&nbsp Inaccessibility forces people with disabilities to give up their independence and, often, their private financial, health, or other personal information, to strangers in order to interact with machines. It is, therefore, imperative that EIT be as universally accessible, as consistent from device to device, as flexible/accommodating to the user, and as simple to understand as possible.

It is also important not to simply recognize and address the barriers that inaccessible EIT currently poses. The technology development cycle is much faster than the regulatory cycle, so it is important to be forward-looking to address, not only the EIT barriers currently on the table, but also those drawing board and beyond. The drivers for rapid adoption of these technologies include:

  • Staff savings
  • Increased customer satisfaction due to simpler, easier, and more entertaining transactions
  • Integration with customer relationship databases for improved loyalty and increased opportunities to sell to the customer

These drivers will only accelerate over time, regardless of the specific technologies in play at any given moment. Comprehensive and efficient accessibility regulation will demand comprehensive but clear definitions of the covered EIT, and clear functional requirements for them. However, such new regulatory detail must be accompanied by explicit Department confirmation of the ways in which long-standing ADA requirements already apply to EIT.

As specified in the “general categories” of barriers above, EIT accessibility is certainly affected by the inherent features of EIT devices themselves (e.g., size and positioning of keypads or other buttons on the device, nature of visual display screens, and presence of styli and card swipe features). However, EIT access is also affected by the way these devices interact with, and function in, the myriad different environments in which they are used. Indeed, such contextual factors can be among the most decisive factors in creating or mitigating access barriers for people with certain types of disabilities. This is particularly true as to smaller , more portable EIT devices, which are affixed but adjustable, and which are affected by positioning and orientation decisions made by covered entities.

For example, there is a widespread retail industry practice of affixing POS devices beyond the practical reach range or view of many persons with disabilities (including persons who use wheelchairs, persons of short stature, or persons with manual dexterity impairments). Irrespective of any future regulatory or design standard specificity that might be brought to EIT issues, this practice reflects a two-fold misunderstanding of existing ADA obligations. First, retailers often rely on an improper reference to general reach range requirements, rather than referencing more appropriate existing technical requirements.[1] Second, retailers ignore the overarching full and equal access obligations that the ADA imposes on their POS decision-making.

It is true that former and current architectural design standards do not explicitly address many new forms of EIT, which were unavailable or unimagined in 1990 when the ADA was passed. However, the Department should underscore that even when there are no precisely relevant standards targeted at particular types of EIT (now or in the future), more general ADA analysis still applies. Among other things, this analysis can require identifying and complying with technical standards that govern analogous situations.

As to POS access, the proper analogy is not to reach range requirements. Reach range requirements comfortably govern a single, gross-motor-skills interaction with a basic operating mechanism — a transaction so elemental that it can be effectively accomplished by a person seated in a wheelchair who is engaging an operating mechanism that can be overhead and out of view.[2]

However, such requirements do not appropriately govern modern POS devices, which over the past two decades have evolved to permit or require increasingly nuanced interactions with customers. Modern POS transactions generally require customers to absorb and respond to information presented by the device (including specifying which of several possible credit or debit transactions is to be conducted, and authorizing or confirming various steps in the process); to input specific unique personal data (including confidential “PIN” information); and to execute a signature.

These kinds of interactive and fine-motor-skills tasks are much more appropriately analogized to the type of “manual work,” “light detailed work, such as writing” or “check writing” activities that are contemplated by the existing work surface and counter requirements of both the 1991 and the 2010 Standards. Notably, the height specifications for these requirements are significantly lower than the reach range height requirements.[3] Thus, to the extent that existing technical standards are referenced in determining POS positioning and orientation, the reference must be to counter and work space height requirements, with attention to the view angle considerations highlighted in existing Guidance.

Moreover, to the extent that existing standards are deemed inapplicable to current or future EIT devices (e.g., where no express or analogous requirements can be identified), other more general provisions of the ADA still apply, including policy modification, communication access and barrier removal obligations. Retailers thus have existing, ongoing obligations to reasonably modify their point-of-sale practices and protocols to ensure access for customers with disabilities; to provide auxiliary aids and services; to remove barriers where it is readily achievable; and to provide alternatives methods of access to pay points.

In addition to devoting more focused attention to specifically identified EIT access issues, the Department’s current regulatory process should confirm and clarify that covered entities have ongoing EIT access obligations to carefully choose and reference appropriate requirements of existing standards, and to meet general ADA full and equal access obligations.

Appendix A provides some examples of current and developing uses of EIT in various contexts.

19. What types of EIT would permit individuals with communication disabilities to most effectively communicate from an accessible hospital room, nursing home facility, guest or sleeping room? Should the Department regulate effective communication from such facilities? What are the costs associated with various types of EIT in such settings?

DREDF holds the opinion that federal law already mandates, and the Department already regulates, effective communication wherever required by people with various disabilities and in all contexts, including the use of EIT in medical facilities. Sections 36.303(b) (3), and part (3) of the Title II auxiliary aid and service definition in Section 35.104, already includes the “[a]cquisition or modification of equipment or devices” in the obligation of covered entities to provide auxiliary aids and services, and this language logically encompasses equipment or devices that feature accessible electronic and information technology. This interpretation was recently reinforced by the 2010 revisions to the Title II and III regulations, which added the phrase “accessible electronic and information technology” to the listed examples of auxiliary aids and services.[4]

Given the fundamental nature of effective communication in the health care context, DREDF recommends that the Department explicitly clarify that the incorporation of increasingly common EIT to enhance accessibility features in such existing communication devices as call buttons and telephones, and assuring accessibility in new EIT such as patient kiosks, is already required by the auxiliary aids and services requirements of Titles II and III. We also firmly hold that the undue burden/fundamental alteration standard that currently applies to the obligation of covered entities to provide effective communication should also apply to medical facilities across all types and sizes. EIT, whether housed in fixed or portable equipment, is another medium for communication but it is not another kind of barrier, and achieving EIT accessibility is no more inherently costly, time-consuming, or out of an entity’s control than achieving effective communication through a face-to-face interpreter or providing and receiving alternative formats such as Braille. Neither technological interfaces nor medical equipment design are inherently “structural” and permanent in the same way as architecture.

In addition, we urge the Department to take the position that the provision of effective communication through whatever medium can never be a “fundamental alteration” of medical services. As already noted, effective communication, and the informed consent that depends upon it, is legally, ethically, and practically fundamental to the provision of effective medical care. A covered entity may successfully establish that the use of EIT to provide effective communication in a particular factual situation is an undue burden and therefore not required, but the use of EIT to enhance accessibility in devices intended to provide communication cannot in itself fundamentally alter the medical care or communication service being provided.

Below are specific examples of EIT that have emerged in the medical context which could benefit from the Department’s release of clear technical and scoping requirements. The examples are not intended to be exhaustive. Please also note that the examples below are not necessarily distinguishing between devices that enhance communication directed toward a person with a disability from a provider and communication from a person with a disability, as communication ultimately is a two-way street. An individual patient or family member/companion, who has vision, hearing, or speech impairments, or difficulty grasping complex concepts, must receive effective communications from medical providers to respond and communicate in return.

Manual Call and Television Remote Controls

Nurse call buttons and television controls in accessible hospital rooms and other medical facilities require modification for those with limited or no speech or movement. Televisions in hospital rooms are not simply used for entertainment, but provide important information regarding the hospital’s operating procedures and layout, as well as recovery and health maintenance videos. Requests for assistance and television remotes could be controlled through such alternative techniques such as sip/puff devices, pillow buttons, and adapted switches. Adaptive large-button switches can be operated with a closed fist, and the large, soft, and smooth surface of a pillow switch makes it suitable for head or check activation.

Please also note that setting standards for these items still requires staff training and policies and procedures regarding EIT items. For example, nurse stations should take particular note when ever a patient has no or limited speech and indicate this next to the patient’s call light.

Electronic Patient or Visitor Kiosks

Please see Appendix A to Question 20.

Audible Information Formats

One option for providing typically written information for people (inpatient or outpatient) who need information in audio formats is the use of an outbound messaging system or interactive voice response system to communicate with patients in languages and formats they can understand. A variety of these products are available. Some examples and their web sites are listed below:

These different products have different features, but all of them enable individuals to gain access to orally delivered information over the phone. They allow callers to obtain data in a relatively anonymous way that also complies with the Health Information and Patient Privacy Act. Patients are given a pass code to access information such as: test results, care instructions, and appointment reminders through their phones. The provider or a designated staff member, sometimes with the assistance of an interpreter, dictates relevant information into the application via a microphone (many models conveniently use a computer’s USB port for the microphone connection).

In addition, some products:

  • Allow patients to choose to receive messages by text, e-mail, land line or cell phone, pager or fax;
  • Allow patients to confirm their appointment using a 2-way text message or e-mail;
  • Call patients with a generic message informing them that a test result or other information has been dictated into the patient’s private voicemail box. When patients receive this message, they can call a toll-free number, input a pass code, and then listen to the message;
  • Send reminders when messages are not retrieved;
  • Send e-mail and voice messages to remind patients when they have not come in for tests that the healthcare provider has ordered.

Captioning on Public Televisions

All televisions in public areas should have the closed captioning activated. Since televisions in public areas (and likely patient rooms) in medical facilities are unlikely to date from before 1993,[5] this requirement will not even involve the replacement or acquisition of equipment or furniture, but is purely a policies and procedures issue that should be accomplished through staff training and public and staff instructional signage on the sets. All televisions in patient rooms should also have captions available, including the facility and educational health care information made available through the set.

Assistive Listening Devices

Assistive listening devices should be considered for use with patients who have hearing loss and who would benefit from being able to personally amplify the volume of a discussion. This technology helps protect the confidentiality of staff conversations with patients. As with all the EIT technologies, qualified professionals should train staff on the availability and use of assistive listening devices, and the public must be notified of equipment’s availability.

Videophones

This technology enables high quality interpreter services to be available in emergency contexts, and in locations or situations where qualified American Sign Language (ASL) interpreters are in short supply. Massachusetts General in Boston is an example of one facility that uses this technology for those very reasons, thereby providing patients with a variety of interpreting methods that are appropriate to different individual situations and patient preferences. The potential kinds of interpreting services available include:

  • Portable videophones – enable inpatients to gain access to ASL interpretation from their bedsides;
  • Permanently installed public videophones in locations that are accessible 24 hours a day, providing patients and family members/companions with access to ASL services;
  • Interpreter Phone on a Pole (IPOP) – This is a mobile unit that allows patients in almost any department or off-site clinic in a scattered-site medical facility to receive immediate interpretation services in a wide variety of languages, including ASL;
  • Video Medical Interpreting (VMI) Network – enables facilities, particularly widely scattered or rural hospitals or practices, to cooperatively participate and fund videophone services where a single facility may not have the resources to provide twenty-four hour in-person ASL translation.

Many of the above uses of technology were pioneered, and continue to be primarily considered, in a Limited English Proficiency (LEP) context. ASL services can be readily incorporated into an existing LEP system, or even serve as an impetus to refining and improving LEP translation within or among medical facilities since a dial-up language line is not an option for ASL interpretation. The Department’s clear regulatory direction on videophone scoping and quality in medical facilities will help elevate the profile of all translation needs and highlight the critical importance of staff training wherever translation is required. All medical facilities and offices should be required to include notification of the availability of ASL interpreters in existing language interpretation service signage. The Department should also clarify that the availability of the above technology in medical facilities does not obviate the facility’s obligation to provide in-person interpretation to ensure effective communication where required by the nature, length, and complexity of the communication, and consultation with individual patient (or family member/companion) concerning their preferences and needs.[6]

Question 20: What are appropriate scoping criteria for the availability of accessible EIT and triggering events for the replacement or refurbishing of EIT devices, including kiosks, ITMs and ATMs, to ensure accessibility?

Answer to Question 20:

Appropriate scoping criteria and triggering events for accessible EIT must provide the greatest possible access to goods, services, and information offered by Title II and III entities through the technology, while recognizing relevant ADA defenses that have provided adequate protection to covered entities for the past twenty years.

Hundreds of thousands of inaccessible kiosks and other EIT currently dot both the public sector and commercial landscape. EIT provides programs, services and information in the health, education, financial, retail, transportation, entertainment and government sectors. There is no escaping the fact that each day, more and more machines are doing what people used to do. In November 2010, for example, AARP reported that twenty-two states have emergency rooms equipped with (completely inaccessible) machines that dispense prescription medication. (For additional details about varying types of kiosks currently available, see http://lflegal.com/2010/07/self-service/ and response to Question 18.)

Robust and stringent scoping and triggering event requirements, as well as mandated technical and performance standards and clear definitions, are necessary so people with disabilities do not fall further and further behind in the 21st century technology environment. The following principles will ensure that people with disabilities are able as quickly as possible to access the myriad services, programs and information now provided by covered entities through EIT, including kiosks, ITMs and ATMs.

Definition of EIT, kiosks, ITMs and ATMs

The Department should ensure that its new regulations for EIT include a forward-looking definition that will embrace the myriad types of electronic and information technology currently being used, and that will be used, by Title II and III entities to provide programs, services and information covered by the ADA.

The Department should include accessibility requirements for the information and interface aspects of a variety of equipment, not only for equipment that is primarily for the purpose of information input and output. Thus, for example, digital thermostats in hotel rooms, digital interfaces on exercise equipment, communication elements of medical equipment, and other equipment for which information, communication, and interaction are important functions, should be required to be accessible. Such information and interfaces should be required to comply with the performance and technical standards of Section 508.

Technical and Performance Standards for EIT

The new regulations should reference the Section 508 technical standards. Industry, people with disabilities, and the public at large need a consistent standard for accessible EIT development, and applying the technical standards of Section 508 to EIT used by Title II and III entities to provide programs, services and information will provide that. (This is different than the new web standards, where Commenters recommend that WCAG 2.0 AA, and not Section 508, serve as the technical standard. Unlike web accessibility, there is no internationally sanctioned direct set of robust and flexible technical standards for EIT that the Department should point to).

The Department’s new rule should recognize that detailed technical standards already exist in Section 707 of the 2010 Standards for Accessible Design for Talking ATMs and Fare Machines. Developed as a result of a multi-year rigorous rule making process, the Talking ATM technical standards should not be tampered with (although we do recommend below a change to the Talking ATM scoping provision in Section 220 of the Standards.) The Department’s new rules should not re-create the wheel of Talking ATM standards.

In addition to adopting Section 508 standards, the Department should adopt a generalized performance standard for EIT, such as the following: "EIT shall be accessible to and usable by persons with disabilities so that persons with disabilities may access, perform or acquire the same programs, services and information that the covered entity offers to people without disabilities by means of EIT with a substantially equivalent ease of use."

This two-pronged regulatory construct (general performance and technical specifications) is currently used in the Department’s new construction regulations. Section 36.401(a) of the DOJ’s Title III regulations defines discrimination as including a failure to design and construct facilities that are "readily accessible to and usable by individuals with disabilities" and Section 36.406 requires that new construction " shall comply" with the technical standards set forth in the Standards for Accessible Design.

Scoping and Trigger events: New and Altered EIT

100% of new and altered EIT, including kiosks, ITMs, and ATMs owned, leased or operated by covered entities that provide services, programs and information to the public should meet accessibility standards. "New" in this context should be defined as technology installed on or after the effective date of the new regulations. "Altered" should include technology installed prior to the effective date and refurbished or modified in any way thereafter, including any significant software modification or upgrade. The Department’s well-established "maximum extent feasible" protection for covered entities should apply to alterations of EIT.

A 100% requirement for new and altered EIT makes sense from the perspective of people with disabilities, the general public, and the covered entity. Significantly, the cost of accessibility at the time of new purchase or alteration is minimal, often involving only inexpensive hardware and a nominal software license fee, a fee that can at times be applied to multiple devices or even enterprise-wide without a per-device cost.

Moreover, it is unfair to make a person with a disability wander around seeking a small percentage of accessible devices among many. This is especially so for people with visual impairments who cannot see the accessible device, or signage designed to identify the accessible device. Braille or large print signage, tactile markings, or other (non-audio) identifiers cannot be located until the person with a visual impairment is at the device, searching for the identification.

The general public is also inconvenienced by anything short of full accessibility. In the grocery store check out context, for example, a blind shopper who has stood in line only to discover an inaccessible point of sale device will delay other customers in that line. If the blind customer is directed to then move to the front of a second line with an accessible device, not only is the customer embarrassed and inconvenienced, but another line of shoppers is made to wait. Universal, accessible design is possible in the world of technology: the Department of Justice should insist upon it.

100% accessibility also benefits covered entities, which typically want a uniform approach to technology for infrastructure management, customer service, and staff training purposes. Indeed, even though current regulations require only one Talking ATM per location, many financial institutions have converted every ATM to a Talking ATM to avoid inconsistent brand identity and to provide full service to all customers at all locations. Bank of America announced in 2010, for example, that all 18,000 of its ATMs were Talking ATMs. See http://lflegal.com/2010/03/bank-of-america-atms/. All major ATM manufacturers are now able to ship Talking ATMs as easily as they can deliver inaccessible machines. Indeed, more than five years ago Triton, an ATM manufacturer that sells ATMs across the pricing spectrum, including low cost devices, announced publicly that all its ATMs would ship with audio capabilities. (The Department should modify Section 220.1 of the 2010 Standards for Accessible Design and eliminate the "one per location’ scoping for automatic teller machines or self-service fare vending, collection, or adjustment machines. These machines should be subject to the same 100% rule as other types of new EIT.)

Scoping and Triggering Events: Existing EIT

To ensure the greatest access possible to the hundreds of thousands of inaccessible kiosks and other EIT currently owned, leased or operated by Title II and III entities and deployed across the country, the Department’s new regulations should clarify that accessibility upgrades to existing EIT are considered auxiliary aids and services under 28 C.F.R. 36.303 and 28 C.F.R. 35.104

Such a classification fits easily within the Department’s existing Title II and III regulatory construct. The 2010 revisions to Sections 36.303(b)(1) and (2) and to the definition of auxiliary aids and services in Section 35.104, for example, added the phrase "accessible electronic and information technology" to the list of examples of auxiliary aids and services in all these sections. And, by leaving untouched the language of Section 36.303(b) (4), and part (4) of the Title II auxiliary aid and service definition in Section 35.104, the Department reaffirmed that auxiliary aids and services also include "[a]cquisition or modification of equipment or devices."

In the new regulations specifically addressing kiosks, ITMs and other types of EIT, the Department should clarify that adding accessibility features to these devices is already required by the auxiliary aids and services requirements of Titles II and III.

As auxiliary aids and services, the obligation to add accessibility features to kiosks that were installed prior to the effective date of the new regulations would be subject to the "undue burden" defense for Title III entities, and the "undue financial or administrative burden" defense for Title II entities. See 28 C.F.R. 36.104 (Title III) and 28 C.F.R. 35.150(a)(3) (title II). The Department should clarify that adding accessibility features to existing kiosks would never require a fundamental alteration of the kiosk or EIT.

Additionally, depending on the nature of the access issue, EIT may also be subject to other existing policy modification or barrier removal obligations (see additional discussion in response to Question 18).

Conclusion

The Department is playing "catch-up" when it comes to ensuring the accessibility of kiosks, ITMs, and other types of EIT. It is, therefore, particularly imperative that new regulations be strong and unambiguous. The Department’s rulemaking on this important issue must move the country forward in its promise of full equality for people with disabilities.

The Department’s rules should mandate that any ITM, kiosk or other EIT installed or altered (upgraded or refurbished) after the effective date be accessible to people with disabilities. The Department should also clarify that accessibility features for existing kiosks, ITMs and other are already part of the definition of "auxiliary aids and services" subject to the well established "undue burden" / "undue financial and administrative burden" defenses. Similarly, existing policy modification or barrier removal obligations may also apply to EIT.

Only this type of scoping will fulfill the ADA mandate that a person with a disability must not be "segregated" or "treated differently" and must have an "opportunity to participate" that is "equal to that afforded to other individuals." 42 U.S.C. 12182(b)(2)(A)(iii); 28 C.F.R. 36.202(b).

If there is any doubt that swift decisive action by the Department is needed now, it can be found in the following text from a press release issued in September, 2010 by Instymeds, a company that makes prescription – dispensing kiosks for public use – kiosks that do not have accessibility features:

Johnson Drug at ARMC, located in Amery Regional Medical Center, today announced it has begun offering InstyMeds, a fully automated ATM-style machine that dispenses prescription medications directly to patients immediately following their doctor visit. The system, the first of its kind, offers a safe, convenient way for patients to receive their prescription medications on-site.

"This new system allows patients to get their urgent care and emergency prescriptions filled after clinic hours, when local pharmacies are closed. They can now have those prescriptions filled at the medical center" says Julie Hanlon-Johnson, managing pharmacist. "InstyMeds helps them get back on the road to recovery as soon as possible.

The InstyMeds system automates the entire process from the prescriber issuing the prescription, to the patient obtaining their medications, and payment collection. The patient can obtain their medications and be on their way in about the same time it takes them to use their bank ATM.

http://www.instymeds.com/index.php?page=press. It is very likely that such dispensers will soon be available in drug stores and allow customers (who can use the machines) to fill prescriptions at hours when the pharmacy in the drug store is not open. People with disabilities should be able to obtain needed drugs during the same hours as everyone else.

In its initial Standards for Accessible Design, adopted almost twenty years ago, the Department recognized that bank ATMs had to be "independently usable by and accessible to" persons with disabilities. The 2010 Standards clarified what it means to be independently usable by prescribing detailed accessibility requirements. Also in 2010, the Department’s revised its ADA regulations to specifically recognize that Title II and III entities are required to provide accessible electronic and information technology.

The Department must now continue this progress and make sure that people with disabilities can also use all the EIT that is now so integral to the provision of Title II and III programs, services and information.

APPENDIX A

Health Care. Electronic kiosks and other EIT are developing into a central tool in the provision of health care services, including for patient self-service check-in and check-out, self-service medical testing and monitoring, medication dispensing, and making medical records, test results, and recommendations available to patients.

  • In May, 2010, Fujitsu announced it would be conducting a symposium entitled "Self-Service Healthcare: Migrate Over 50 percent of Patients to Kiosks" http://bit.ly/dre52J. According to NCR MediKiosk White Paper entitled Putting the Patient in Control: Employing Technology Solutions to Empower Patients: "self-service kiosks provide an additional channel for insurers to support healthy practices and preventative care by recommending specific tests or procedures to patients with chronic disease management at the point of service. For example, at check-in, patients with diabetes may receive a message from health insurers or health plans encouraging them to discuss the importance of testing for hemoglobin A1c with their physician." http://www.ncr.com/documents/putting_the_patient_in_control.pdf.
  • In-store self-service medical monitors are also likely to increase, going beyond simple blood pressure cuffs and heart rate monitors to full biometrics (weight, body fat, glucose, blood oxygen) with internet connectivity, flat screen displays of medication and disease management information, and the ability to save personal health records (see http://www.lifeclinic.com/synergy.aspx).
  • EIT will also be used by pharmacies and other health care providers to dispense medications. The "The InstyMed kiosk" is a "fully automated prescription dispensing system" that is 100% touchscreen and 100% inaccessible. See http://www.instymeds.com/, a site that includes a 3 minute video of the self-service kiosk.

Retail, Entertainment, and Services. EIT is fast moving beyond one-way information provision and simple vending. See http://www.slideshare.net/PSFK/psfk-presents-future-of-retail-report; http://www.kiosk.com/market/orderentry-kiosk-experience.php.

  • POS devices now require consumer input and self-checkout systems are becoming prevalent. Issues include placement, reach range, display placement/angle, visual and audio output, accessible input mechanisms.
  • Restaurants may move away from printed menus to electronic displays and devices, as well as multi-media displays while waiting.
  • Movie and entertainment ticketing kiosks are becoming commonplace and are being used for more and more types of experiences (e.g., ski lift tickets). http://kis-kisoks.com/custom9.html; http://www.kiosk.com/case-studies/ticketmaster.php; http://www.kiosk.com/case-studies/vail.php.
  • EIT vending machines now offer everything from electronics to makeup with touchscreen input, self-checkout, and self-service. See http://www.zoomsystems.com/zoomshops/zs_index.html. Potential barriers include inaccessible touchscreens, product displays, payment methods and pickup mechanisms.
  • Kiosks are also being used for photo development, http://www.frankmayer.com/portfolio/interactive_kiosk_solutions/sony_snap_lab.php, financial services and bill payment, http://www.kiosk.com/market/financial-kiosk-experience.php, gaming, http://www.kiosk.com/market/gaming-kiosk-experience.php, and credit applications, http://www.frankmayer.com/portfolio/interactive_kiosk_solutions/john_deere_kiosk.php.
  • EIT in retail is beginning to provide on-demand and just-in-time product information, such as detailed turn-by-turn/step-by-step directions to find products and services within a mall or store; on-demand product details (contents, instructions, manufacturing (e.g. "green"). Potential barriers include accessible format delivery of information and compatibility with assistive technology.
  • Retailers and brands are able to offer just-in-time discounts, coupons, loyalty rewards and other incentives delivered via kiosks, on-the-shelf dispensers, or other EIT devices. Barriers include reach ranges and visual-only formats.
  • Stores and hotels are providing customers with "concierge" devices to look up products (e.g., an electronic grocery list organized by aisle, with directions and the ability to check off items; an electronic tablet pre-loaded with local tourist and restaurant information, see http://www.timesonline.co.uk/tol/travel/business/article7111644.ece). Barriers may include accessibility for people with manual disabilities, accessible input and output options.
  • Stores are developing in-store networking systems to allow buyers to consult with their friends who are not in the store (via text, photos, and video). Barriers may include physical and communication inaccessibility for people with mobility, vision, and hearing disabilities.
  • Stores are developing in-store EIT feedback mechanisms to seek consumer input and respond in real time. Barriers may include physical and communication inaccessibility for people with mobility, vision, and hearing disabilities.
  • Stores are developing systems to make recommendations to consumers based on past and current purchase history. Barriers may include inaccessible communication mechanisms.
  • Stores are developing body scanning and facial recognition systems to recommend products based on size, age, gender, and other factors. This includes “virtual try-on” and “virtual fitting room” technology, which enables customers to interact with digital representations of clothing. See, http://www.internetretailer.com/2010/10/12/macys-offers-virtual-fitting-room-its-nyc-flagship-store
  • Barriers may include physical accessibility of the technology as well as the technology’s assumptions about body size, facial and physical appearance, and posture.
  • Body scanning systems are also replacing requirements to present identification to enter some “members only” public accommodations. For example, in August 2010 the 24 Fitness health club chain debuted a “Cardless Check-In,” which relies on an index finger scan. http://www.24hourfitness.com/health_clubs/cardless_checkin/. This technology is not accessible to patrons who do not have index fingers, or who are unable to create fingerprints. Positioning and reach range issues may also affect access.
  • Stores are offering EIT that allows customizing or previewing product effects (view a paint color on a photograph of your walls, see what a hair cut or color will look like on you). This technology may not be accessible to people with vision disabilities.
  • Stores are developing virtual display cases and holographic ads, which may pose barriers to people with vision and hearing disabilities.

Education. Colleges, universities, and secondary schools across the country are using self-service EIT for a variety of educational and administrative interactions with students, parents, and visitors.

  • Self-service kiosks are being used by colleges and universities "for automated registration, financial aid information, course catalogs, directories, way finding, academic & athletic event calendars, student ID validation, and more." See http://www.kiosk.com/market/government-kiosk-experience.php.
  • School and other libraries are implementing self-service EIT check-out systems. See http://www.cen-tec.com/.
  • Schools at all levels are also using "clickers," wireless personal response systems allowing students to answer questions and display those answers so the entire class can see. These remotes allow professors to take attendance, do polls, provide instant quizzes, and receive feedback. See "More Professors Give Out Hand-Held Devices to Monitor Students and Engage Them," New York Times (Nov. 15, 2010) http://www.nytimes.com/2010/11/16/education/16clickers.html.
  • High Schools are also turning to self-service machines to provide information to, and gather information from students. Ector County Texas issued a press release in February, 2010 announcing its purchase of 25 devices to "disseminate and collect a wide range of educational content – including administrative announcements, interactive graphics, sign-ins, and informational video to students, teachers, and parents." A requirement for the chosen kiosks was the "need to be able to stand alone – exposed and unattended." If these devices are not accessible, students, teachers and parents with disabilities are simply excluded from important school services. See press release at http://www.seepoint.com/company-press-release-article.asp?PressReleaseID=85

Transportation. Airline and train kiosks, which allow passengers to check-in, get boarding passes, select seats and perform other functions quickly, privately and independently, have been proliferating since first introduced in the United States ten years ago. See http://bit.ly/9gdxjA, a 2000 article about the "new technology". Unfortunately, despite clear non-discrimination mandates, these devices are largely inaccessible, even though the industry itself has recognized the need for access. (See IBM whitepaper, "The Need for Accessible Self-Service Travel Kiosks, at http://www-03.ibm.com/able/news/selfservkiosk.html. Information about IBM’s accessible self-service travel kiosks is available at http://www-01.ibm.com/software/ucd/gallery/kiosks_research.html. These terminals that started out as a convenience on the side have rapidly become the main, and sometimes the only approach for checking in.

Government Services. Examples of EIT used by state and local governments to provide services and information to the public can be found at http://www.kiosk.com/market/government-kiosk-experience.php. Automated government services include

[1]To date most retailers have referenced the 54 inch unobstructed side reach range requirement contained in Section 4.2.6 of the original ADAAG, which the Department is now identifying as the “1991 Standards.” There is also a new, lower 48 inch unobstructed side reach range requirement set out in Section 308 of the 2004 ADAAG, which the Department is now identifying as the “2010 Standards.”

[2] Significantly, to the extent that that visual interaction with an operating mechanism is contemplated, Guidance accompanying the 1991 Standards emphasizes that placement of operative features should “[c]onsider that the standard eye level range of an adult seated in a wheelchair is from 43 to 51 inches from the floor.” See ADAAG Manual: a guide to the Americans with Disabilities Act Accessibility Guidelines at 135 (Check-Out Aisles [7.3]). This same Guidance acknowledges that there are “aspects of design not specifically covered in ADAAG, such as the standard eye level range (43 – 51 inches) and the design and height of elements viewed up close or from above (e.g., certain information screens and display cases.).” Id. at 12 (Space Allowances and Reach Ranges [4.2]).

[3] As to the 1991 Standards, see Section 4.32.4 (accessible tables or counters; height requirement from 28 inches to 34 inches); Section 7.2 (sales and service counters; height requirement 36 inches); and Section 7.3 (check-out aisles; height requirement 38 inches). As to the 2010 Standards, see Section 902.3 (work surfaces; height requirements from 28 inches to 34 inches); Section 904.3 (check writing surfaces; height requirements from 28 inches to 36 inches); and Sections 904.1 and 904.3.2 (check out aisles and sales and service counters; height requirement 38 inches).

[4] See 28 C.F.R. 36.303(b)(1) and (2) and the definition of auxiliary aids and services in Section 35.104 for example, as amended by DOJ’s revised ADA Title II and Title III regulations, published Sept. 15, 2010, and taking effect March 15, 2011

[5] The Television Decoder Circuitry Act of 1990 required all new television sets 13 inches or larger manufactured for sale in the U.S. to contain caption-decoding technology by July 1, 1993.

[6] See 28 C.F.R. 35.160(b)(2) and 36.303(c)(1)(ii), as amended by DOJ’s revised ADA Title II and Title III regulations, published Sept. 15, 2010, and taking effect March 15, 2011.