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People with disabilities represent the largest minority group in the United States and a priority population for health services research. Despite federal civil rights law, people with disabilities face inaccessible health care environments that fail to accommodate their disability. We present Michigan Medicine’s Disability and Accommodations Tab. This patient-facing questionnaire and shared data field in the electronic health record enables the collection and reporting of patient disability-related accommodations. The Disability Tab seeks to address provider- and clinic staff–reported barriers to providing accommodations and fosters an opportunity to redesign health care to meet the needs of people with disabilities.
People with disabilities represent a considerable proportion of the US population, with 27% of adults (in 2019) and 4% of children (in 2019) having a disability [
Federal civil rights laws in the United States—including Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, and Section 1557 of the Patient Protection and Affordable Care Act—delineate the responsibility of health care organizations to be accessible to people with disabilities. Despite these mandates, many health care environments remain inaccessible to people with disabilities [
To address barriers in communicating accommodations, the Centers for Medicare and Medicaid Services recommends collecting disability-related information at the point of care [
Michigan Medicine, the health care system owned and operated by the University of Michigan Medical School, is one of the largest health care systems in Michigan, serving over 2.7 million patient encounters per year at 3 hospitals and 40 outpatient clinics. Michigan Medicine has already developed strong commitments to improving the health of people with disabilities, including the establishment of model clinics, such as the Deaf Health Clinic in Family Medicine, and recognition and financial support for the Center for Disability Health and Wellness [
In 2019, Michigan Medicine’s faculty and staff (including CM and MMM), with the support of Michigan Medicine’s Disability Resource Group, met with MiChart Ambulatory Team (including HH) to create the Disability and Accommodations Tab (or “Disability Tab”). The Disability Tab is a shared data field based on a questionnaire (ie, SmartForm) within Michigan Medicine’s version of Epic, called MiChart, which collects discrete data from both the patient-facing portal (
Michigan Medicine is working to improve accessibility for patients with disabilities. This form is to identify accommodations that patients with disabilities may need when accessing Michigan Medicine clinics and hospitals. Completing this form does not guarantee that your Michigan Medicine clinic or facility has the accommodation available. If a specific accommodation is not available, Michigan Medicine is committed to working with you to find an effective alternative. Please directly inform you care team for any specific and urgent accessibility requests.
Initial disability classifications and accommodation options listed in the Disability Tab were created by subject matter experts at Michigan Medicine in collaboration with people with disabilities, disability advocacy groups and service centers, and care team staff who work routinely with people with disabilities. In June of 2021, the University of Michigan’s Center for Disability Health and Wellness established a work group to manage the development, pilot testing, and implementation of the Disability Tab. This group further refined the disability and accommodation options to meet federal, state, and local regulatory guidance, in addition to common accommodations for different disabilities (
Of note, the disability options listed on the Disability Tab differ from the Washington Group questions and the American Community Survey questions, as those specific questions measure only functional or activity limitations (eg, difficulty seeing and difficulty concentrating) [
Data from this questionnaire are displayed on patient’s Storyboard in MiChart (
The Disability Tab became active in the EHR and patient portal in October 2020. As of December 2021, however, the Disability Tab had not been promoted by Michigan Medicine nor had systematic data collection been incorporated into the clinic workflows due to the COVID-19 pandemic. In addition, no patient portal (MyChart or MyUofMHealth) reminder had prompted patients to complete the questionnaire. Despite this lack of promotion, as of December 13, 2021, almost 3000 patients (n=2941) had completed questionnaires (for reference, Michigan Medicine has over 240,000 active primary care patients). Among these patients, 1 in 4 (n=738, 25.1%) report mobility disabilities, followed by patients reporting mental health disabilities (n=441, 15%); patients who are deaf, hard of hearing, or deafblind (n=426, 14.5%); patients with cognitive disabilities (n=388, 13.2%); speech or other communication disabilities (n=209, 7.1%); blindness or low vision (n=185, 6.3%); and upper body or fine motor skill impairment (n=161, 5.5%).
Several health system wide initiatives have recognized the potential benefits of the Disability Tab to collect and display information about accommodation needs. One of these initiatives was the May 2022 rollout of MyChart Bedside, a tablet-based inpatient portal tool to improve the patient experience. The use of MyChart Bedside enables patients to complete the Disability Tab questionnaire during their inpatient stays directly from their MyChart Bedside tablets. These patient responses populate the Disability Tab field in the Storyboard for care team members to see. As of September 1, 2022, a total of 4732 patients have Disability Tab information in their medical records. Among these patients, mobility disabilities and wheelchair use were the most common (n=1134, 24%), followed by no disabilities (n=939, 19.8%); ‘other’ disabilities (n=800, 16.9%); hard of hearing, deafness, or deafblindness (n=793, 16.8%); mental health disabilities (n=676, 14.3%); cognitive disabilities (n=653, 13.8%); speech disabilities (n=356, 7.5%); blindness (n=330, 7%), upper body and fine motor skill impairment (n=256, 5.3%); other sensory disabilities (n=223, 4.7%); and respiratory disabilities (n=43, 0.9%).
Example of the Disability and Accommodations Tab questionnaire in the patient-facing portal. As the tool is specific to requesting disability-related accommodations, the requested accommodation is required after selecting a disability classification. © 2022 Epic Systems Corporation. The MyUofMHealth App is powered by MyChart® licensed from Epic Systems Corporation, © 1999-2022.
Disability and accommodation options in Michigan Medicine’s Disability and Accommodations Tab.
Disability classification | Available accommodation options |
Blind/low vision |
Audio descriptors Braille Provide documents in large print Screen readers Human guide Exceptions to the COVID-19 visitor policy Other, please specify |
Cognitive, intellectual, or developmental |
Assistance with completing surveys/patient intake Check for understanding Closed captioning during video visits I want to give people information in advance, before going to the clinic (see ‘other’) I have a support person, please involve them in my medical discussions Provide directions/follow-up in writing Use visuals or pictures to explain concepts Modifications to the COVID-19 mask policy Modifications to the COVID-19 visitor policy Need for reduced sensory input Other, please specify |
Hard of hearing, deaf, or deafblind |
Assistive listening devices ASLa interpreter Closed captioning during video visits Provider(s) and staff wear a clear mask Provide directions/follow-up in writing Quiet space for communication Real-time captioning Use written communication or information Modifications to the COVID-19 visitor policy Other, please specify |
Mental health |
Additional structure and assistance regulating emotions Clear protocols to help me prepare for care Need for reduced sensory input Provide directions/follow-up in writing Modifications to the COVID-19 mask policy Modifications to the COVID-19 visitor policy Other, please specify |
Mobility disability or wheelchair use |
Adjustable tables Assistance with transfers and walking Availability of transfer equipment (eg, a lift, a transfer board) Human assistance with transfers Larger exam rooms Wheelchair scales Modifications to the COVID-19 mask policy Modifications to the COVID-19 visitor policy Other, please specify |
Respiratory |
Modifications to the COVID-19 mask policy Need for oxygen tank Plug outlet for oxygen concentrator Other, please specify |
Speech/communication |
Closed captioning during video visits Confirm that I understand Give me additional time to speak Understanding prompts from the provider Whiteboards for communication Other, please specify |
Other sensory |
Fragrance-free environment Limit touch Placement in room early Other, please specify |
Upper body and fine motor skill impairment |
Assistance with clothing management Assistance with completing surveys/patient intake Assistance with transfers Modifications to the COVID-19 mask policy Modifications to the COVID-19 visitor policy Other, please specify |
Other (please specify) |
Other, please specify |
None | —b |
aASL: American Sign Language.
b—: Not applicable.
Example of the Disability and Accommodations Tab on the patient Storyboard in MiChart. © 2022 Epic Systems Corporation.
Modifications to the SmartForm used for the Disability Tab requires substantial time for revising the code and testing for quality assurance before revisions are ‘live’ in the EHR. Further, ‘retiring’ disability or accommodation categories can lead to missing data if not properly coded. For this reason, we have implemented a Change Review Board process to review requested changes (eg, adding an accommodation field) with respect to the financial, reporting, and human resource impacts. The Disability Tab Change Review Board solicits regulatory feedback from both the Americans with Disabilities Act Coordinator and Patient Civil Rights Coordinator, and other interested parties (eg, the Office of Patient Experience).
With the implementation of the Disability Tab in MyChart Bedside (in May 2022), we recognized the need for a ‘mark as reviewed’ function on the questionnaire. This is particularly important when patient disability-related accommodation needs change due to onset or progression of disability. To address this need, we developed a button on the SmartForm that records the last user and the date or time the questionnaire was reviewed.
To identify opportunities to integrate disability data collection within the workflow in outpatient clinics, the Disability Tab started being actively used (eg, patients’ disability-related needs being documented by the care team on the Disability Tab) at the Dexter Health Center, operated by Michigan Medicine’s Department of Family Medicine, in March 2022. At Dexter Health Center, patients are asked to complete a paper version of the Disability Tab questionnaire, which then gets added to the electronic Disability Tab by clerical or medical assistants. Once entered, this information becomes available across all clinical encounters across Michigan Medicine Health Systems. Staff at this clinic are using the Disability Tab to prepare accommodations in advance of future clinic appointments. To understand modifications to their workflow and acceptability among care team staff, we are collecting data in an ongoing quality improvement study. Results of this study, focused on operation workflow of the Disability Tab (for collecting information and providing accommodations), will be disseminated at a later date.
With the widespread lack of centralized disability services in health care systems, health care providers and clinic staff are often responsible for determining and providing disability accommodation needs [
The Disability Tab provides an opportunity to specifically address provider and clinic staff barriers in providing accommodations to people with disabilities. Patients can report their specific disabilities and accommodation needs by filling out the questionnaire within the patient portal or being prompted by care team staff at the point of care; this information appears for health care providers and clinic staff in the Storyboard, as part of the patient’s demographic information. Moreover, this tool provides the opportunity to identify and articulate the role of caregivers as well as any alterations related to patient autonomy, addressing barriers often experienced by patients who have cognitive, intellectual, or developmental disabilities.
By design, the Disability Tab reports disability-related accommodation needs information systemwide, making this available to all care team members across all clinical encounters, not just the patients’ primary care providers, or hidden within free-text clinical notes, as is common in health care [
The Disability Tab is still relatively early in the implementation phase and there are several opportunities for future work, particularly to respond to potential limitations. First, the Disability Tab questionnaire uses disability categories that are not standardized to the American Community Survey or Washington Group disability items. Therefore, information from the Disability Tab will not facilitate population health comparisons. Although this may be a limitation, we determined early in the Disability Tab’s development that the goal of this tool was to facilitate accommodation access, not solely collect disability prevalence information [
Given the early stage of implementation, there are several outstanding questions. one question is whether the presence of disability identity impacts the process of care. For example, during the initial impact of the COVID-19 pandemic, there was considerable discussion of rationing (ie, declining) care to people with disabilities [
In its infancy, the Disability Tab demonstrates the opportunity to leverage EHR systems and health informatics to systematically collect disability-related accommodation needs to improve the quality of care delivered to people with disabilities and improve accessibility to health care environments. We encourage other health care systems to adopt similar approaches to address the health care needs of people with disabilities.
electronic health record
The authors would like to thank the Michigan Medicine Disability Resource Group for their support and advice on early conceptualizations of the Disability and Accommodations Tab.
HH, TGJ, MMM, and MAM were supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), part of the Administration on Community Living (ACL), under award 90DPHF0011-01-00. Additional support for this project has been provided by the Center for Disability Health and Wellness, funded by Michigan Medicine. The contents of this paper do not necessarily represent the policy of NIDILRR, ACL, or Human and Health Services (HHS).
All authors contributed equally.
None declared.