The Vision of Universal Access

The historical roots of the terms accessibility and usability (see glossary before for multiple definitions of each) are very different.  Accessibility, or the ability to access, is rooted in the human right of access to services and products.  Starting especially with the 1970s, it has evolved to thehaving a pillar in the laws and regulations that permeate many fields that include education, disability, since the 1970s, and has continued to evolve events such as passage of the Americas with Disabilities Act (ACT) of 1990.  Usability, or the ability to use, is rooted in traditions extracted from the field of ergonomics/human factors.  It has evolved dramatically in recent years, driven by practical challenges in designing interfaces that people with widely embrace, especially in areas such as mobile devices, computers and web browsing.

Many of the roots of universal access came from considerations of the built environment, especially as related to physical access to services by individuals with disabilities. In recent years this has expanded. In particular, one outcome of the rapid changes in telecommunications and information technologies has been our perspective on access to information and services. Expectations have changed. For instance, teachers often expect students (now called "learners") to have access to word processing and to the Internet, and young people now consider themselves to have an unalienable right to a cell phone, to email, and to instant messenging on the computer. The change is real, and is affecting the fabric of our civilization, including how governments view access. "Universal access" is both a principle and a process, and difficult to define precisely. Here we utilize, as a starting point, the following definition of Universal Access that would make sense in Module 2. The following is from Wikipedia (at least as of the beginning of March 2007, I had written most of it, and eventually need to expand it):

• Universal Access refers to the ability of all people to have equal opportunity and access to the functionality of a service or product from which they can benefit, regardless of their social class, ethnicity, background or physical disabilities. It is a vision, and is some cases a legal term, that spans many fields, including education, disability, telecommunications, and healthcare. It is tied strongly to the concept of human rights.

In many developed countries an intrastructure exists to help implement the vision. Examples include access to education at the grade school, high school and sometimes college level; disability-related laws such as the Americans With Disabilities Act of 1990 in the United States; univeral access policies and funding that support for telecommunications infrastructure to underserved rural and inner city areas such as high bandwidth lines to local government and healthcare buildings in small towns; and universal access to healthcare in some countries, especially in Europe, Canada and Japan.

Note that the term "universal access" has multiple meanings, depending on the context and the stakeholder group:

• To the Office for the Advancement of Telehealth, it ties to equitable access to educational and health services - especially as related to setting up infrastructure to help break down barriers of distanace for those in rural or impoverished communities.
• To standards bodies such as the International Telecommunications Union (ITU), "universal access" refers to technological communications access, where the focus is on the equipment rather than on the person using the technology. Similarly, to agencies such as the FCC, universal access refers to the technical reach and degree of competition for various forms of telecommunications access (e.g., radio, broadcast and cable TV, cell phones).
• To the rehabilitation community, univeral access refers to access of individuals to information and services, no matter what their disability. It also has some ties to the concepts of universal usability and universal design that we covered in Module 2, i.e. products that are usable by everyone to the maximum extent possible.
• To the U.S. Access Board, it is a legal responsibility: To develop (and periodically update) accessibility guidelines (e.g., see Part 1193). This mission was set by the Rehabilitation Act of 1973 (Section 502), with Section 508 of the same act requiring that electronic and information technology purchased by the Federal government be accessible to individuals with disabilities. But it didn't have "teeth" until the Rehabilitation Act Amendments of 1998 of Section 508a, motivated in part by the Americans With Disabilities Act of 1990, required the Access Board to publish standards that set forth a definition of electronic and information technology and the technical and functional performance criteria necessary for accessibility for such technology; these accessibility guidelines & standards became official in 2001, available in various formats and with technical assistance. Key Federa laws Mandating Accessibility (maintained by the U.S. Access Board):
  • Section 255 of Telecom Act of 1996 - All telecom products and services be accessible and usable by persons with disabilities to extent readily achievable
  • Section 508 of Rehab Act of 1973/1998 - accessibility requirements for federal departments and agencies that use electronic and information technology
• To the Wide World Web Consortium (W3C), the key body for web protocols (see also Module 2, Part 5), it related to web accessibillity. W3C has established the Web Accessibility Initiative that includes web content accessibility guidelines for web page design.

From our perspective, all of these are relevant, and synergistic. This shows the broad-based nature of the concept of access which includes barriers that can be encountered because of the physical interface, physical distance, or equity issues such as cost.

Thus while there are often tight ties between the terminology of Universal Access and Universal Design, the former is more a more general concept. Universal Design can be viewed as primarily a "direct access" approach to access that doesn;t usually depend on a use's assistive technology, and the Universal Design Performance Measures for Products are applicable. There are, however, ohters strategies.

As an example, consider the plan of our RERC on Accessible Medical Instrumentation for developing universal interfaces (through Project D3, targeting emerging technologies) that help make medical products more universally accessible, thus increasing the number of individuals with timely access to such technologies. We employ two strategies that, at a basic level, target access through telecommunication technologies (D3.1) and access through multimodal interfaces (D3.2). Furthermore, the primary focus on fthe multimodal interface concept involves use of a new national standard (ANSI/INCITS 389-393) on a User Interface Socket/Universal Remote Console (UI-Socket/URC) that should soon become the international standard ISO 24752. In the terminology of this new standard, a "target" is a device or service that has some functionality that a user would want to access. The "URC" is the user's preferred device for interaction, with "modes" of interaction that can depend on the user's abilities and preferences. In essence, this is personalized design, which is a different strategy from universal design. The URC is a form of an assistive technology, and a protocol is used to separate the functionality (or content) to be accessed from the actual approach for access.

Thus, there are many approaches for achieving access to the functionality and benefit of a product or service. So far the focus has been on the physical interface, whihc includes direct-access approaches (e.g., universal design) and indirect-access approaches (e.g., personalized interface design). But other barriers include distance and cost, the former of which leads to considerations of roles of telecommunications technoogies, including videoconferencing. This is our next topic. Of note is that teleconferencing "events" are often called by the general term "tele-encounters," and indeed indeed perhaps the work "encounter" is better than "interface" in capturing the concept of access.

Vision of Telehealth as Tool for Improving Universal Access

From an engineering perspective, the key concept is to maximize access for individuals, irregardless of their location, abilities and socioeconomic status. This is essentially an optimization problem, and engineers like to use problem-solving tools to solve such problems. However, currently engineers are not trained to think in terms of universal access, despite the fact that there are laws that mandate enhanced access to information, services and products. Ideally, decisions related to access should be addressed at the front end of the product design and evaluation process.

From a healthcare "systems" perspective, the aim is to find the optimal solution that minimizes/maximizes key performance indices, subject to a set of system constraints. The healthcare "system infrastructure" can be viewed as providing a set of constraints on the viable set of alternative solutions. This include the practical barrier of distance. Telehealth relaxes some of the constraints imposed by the infrastructure, and thereby expands the solution space. In principle, the addition of such alternative tools should, if used wisely, only improve care. By breaking down the barrier of distance, telehealth tools add possibilities for more timely access to assessment information, support services, and treatment. For instance, telecommunications tools in the home can provide alternatives to the conventional model of outpatient and home visit services, that typically include the constraint of limited weekly encounters, each with a pre-specified amount of time.

With this conceptual framework, why isn’t telerehabilitation flourishing? Reasons include (Rosen, Winters and Lauderdale, 2002, Winters, 2002b):

• The reality that there is not one optimal protocol for telerehabilitation, with different problems requiring different technologies and procedures,
• Lack of outcomes research studies, both those comparing telehealth vs. conventional approaches, and comparing different forms of telehealth,
• Low penetration of electronic healthcare records (EHRs) and of standardized protocols in rehabilitation, which makes incorporation of telehealth tools more difficult,
• Pragmatic turf and financial concerns, especially in the allied health professions, and
• A lack of educational materials and training programs.

Hopefully this Module, by being available through the Internet, helps address this last barrier.

Access To/Through Telecommunications Technologies

• Legal Definition (Telecom Act of 1996): "the transmission, between or amoung points specified by the user, of information of the user's choosing, without change in the form or content of the information as sent and received."
• Section 255: ... a manufacturer of telecommunications or customer premises equipment, and providers of telemunications services, shall ensure that the equipment is designed, developed, and fabricated to be accessible to and usable by individuals with disabilities, if readily achievable. And if not readily achievable, the equipment or service should be compatible with existing peripheral devices or special customer premises equipment commonly used by individuals with disabilities to achieve access.
• "E&IT" = Electronic and Information Technologies
• RERC Telecom Access Distinctions: Time-sensitive (near-real-time, minimal delay) tele-conversation, tele-messaging, and emergency alerting/communication
  • Tele-conversation: two-way language-based conversation ("talking" and "listening")
  • Tele-messaging: back-and-forth message blocks
  • Emergency alerting (urgent notification) and communication (interactive)

E&IT Overview: New Interface Technologies, Trends

• Reading material: Chapter 16 (Vanderheiden & Zimmermann), pp. 159-164
• Display/Output Technologies
• Monitor displays: flat panel more common, dropping cost of large displays
• LCD touchscreen/paintable panels (low-cost, flexible, appearing everywhere)
• Heads-Up/Eyeglass displays (worn by user, projected virtual display)
• 3-D displays
• Virtual Reality technologies
  • immersive worlds and avatars (user can move in virtual world)
  • Virtual altered reality (move in unrealisitic environment)
  • Augmented reality (projection mapping to augment information or objects)
• Kinesthetic feedback devices (force feedback joysticks, mice)
• Speech output improvements:
  • quality of synthesized speech
  • automatic prononciation
  • low-cost chips (e.g., $10 text-to-speech)
  • incorporation of speech-capabile products into standard products
• Audio displays: added audio cues to info on screens
• Tactile displays (of lower resolution)
  • dynamic: vibrotactile, electro-tactile stimulation
  • Permanent physical: variable-height pinds, ferro-electric fluids, wax.
• Olfactory displays
• Novel Input (and Modality Translation) Technologies
  • Speech recognition
  • Lip reading
  • Gesture recognition
  • Pen-based: handwriting recognition & digital pens/ink
  • Special keyboards (one hand, small keyboards, glove which senses, etc.)
  • Direct brain control (e.g., for simple switches)
  • Biometrics (bio-identification)
• Changing Form of "Documents"
  • E-documents, e-books
  • World Wide Web
  • Style sheets - visual and aural
  • Visual to audio technologes
  • Scalable vector graphics
  • Interactive documents
  • Live documents
• Key Trends in IT
  • Computing Power
  • Semantic Web (structured for automated interpretation, enabling smarter web-based user agents)
  • Web and Network Services (may include new translation/assistance services)
  • Distributed Interfaces (e.g., distributed content)
  • Wirelessness/interconnectivity/interoperability
  • GPS (Global Positioning)
  • Ubiquitous/Pervasive Computing (access points everywhere)
  • Smart Spaces (context-aware environment)
  • Artificial Intelligent Agents
  • Visualization in Education (visual simulation/motivating technologies)

Components of Augmentative & Alternative Communication Technologies

• Reading material: Chapter 9 (Williams, Romich and Salomaa), pp. 76-81
• Method of representing language (pictures, alphalet, semantic icons)
• Method for making choices (pointing device)
• Output of AAC system (e.g., speech)

Glossary of Terms Related to Accessibility and Universal Access Concepts:

Ability
A basic trait of a person that the person brings to a new task.

Access Board
An independent Federal agency devoted to accessibility for people with disabilities. Created in 1973 (as the Architectural and Transportation Barriers Compliance Board, or ATBCB) to ensure access to federally funded facilities, the Access Board is now a leading source of information on accessible design. The Board develops and maintains design criteria for the built environment, transit vehicles, telecommunications equipment, and for electronic and information technology. It also provides technical assistance and training on these requirements and on accessible design and continues to enforce accessibility standards that cover federally funded facilities.

Accessibility

• Ability to access the intended use of a product or environment or service for which there is a possibility of benefit. 
• Usability of a product, service, environment or facility by people with the widest range of capabilities (ISO 9241-171, definition 3.2). 
• The degree to which an environment (physical, social, or attitudinal) makes appropriate accommodations to eliminate barriers or other impediments to equality of access to facilities, services, and the like, for persons with disabilities (Carmona)

Accessibility, Degrees of
There are degrees of ability to access a product or service, potentially both at the level of the individual and the level of the total population.  Proposed scales include degree of difficulty (up to impossible), and degree of handicap (up to fully handicapped).  The former is commonly used in accessibility guidelines, the latter is used in an ISO-IEC draft standard.

Accessibility Guidelines
Typically a sequence of stated guidelines and standards, each of which is followed by a list of checkpoints, with each checkpoint given a priority level  (e.g., “must” because otherwise some users will find use impossible; “should” because some will find use difficult; “may” because some will find use somewhat difficult). In this context, these guidelines are part of a formalized, consensus process coordinated by a standards body or an agency of the government.

Accessibility Metric
Measures or scores aimed at estimating the degree of accessibility of a product, typically as a collection of scores that represent accessibility for different general categories of activity limitation, impairment or disability. The metric typically takes into account both design features and anticipated task procedures. 

Accessibility Features
Design features that enhance the accessibility of a product or environment or service.

Accessible Design (legal perspective, United States)
The design of entities (products, environments, or services) that satisfy specific legal mandates, guidelines, or code requirements with the intent of providing accessibility to the entities for individuals with disabilities.

Accessible Design (general)
Accessible design strives to maximize accessibility and minimize barriers that prevent individuals from participating in the use of a product. There are two basic design strategies for enhancing access: direct access (direct adaptations to designs that significantly improve their accessibility) and assistive access (interfaces that enable an add-on assistive technology to provide the user with full access).

Accessible Product or Environment or Service
A product or environment or service is accessible if the intended use or benefit can be realized effectively by people with disabilities.

Activity (ICF)
Execution of a task or action by an individual.

Activity
The process of doing something, representing the functional result of human performance.  Activities often can be broken down into smaller tasks.

Activities of Daily Living (National Center for Health Statistics)
Activities of daily living are activities related to personal care and include bathing or showering, dressing, getting in or out of bed or a chair, using the toilet, and eating. In the National Health Interview Survey respondents were asked about needing the help of another person with personal care needs because of a physical, mental, or emotional problem. Persons are considered to have an ADL limitation if any causal condition is chronic.

Activity Limitations (International Classification of Function, Disability and Health, ICF)
Difficulties an individual may have in executing activities.

Alternate/Alternative Formats (legal, Section 508)
Alternate formats include, but are not limited to, Braille, large print, disks, audio formats and electronic formats.

Alternate/Alternative Methods (legal, Section 508)
Different means of providing information, including product documentation, to people with disabilities. Alternate methods may include, but are not limited to, voice, fax, relay service, TTY, Internet posting, captioning, text-to-speech synthesis, and audio description.

Assistive Technology (legal, Section 508)

• Any item, piece of equipment, or system, whether acquired commercially, modified, or customized, that is commonly used to increase, maintain, or improve functional capabilities of individuals with disabilities. (lega, Section 508)
• An extrinsic enabler that is the basis by which human performance is improved in the presence of disability. 
• A means of reducing handicap.

Assistive Technology Service (legal, United States)
Any service that directly assists an individual with a disability in the selection, acquisition or use of an assistive technology device.

Auxiliary Aides and Services (June Isaacson Kailes)
These may include:  Qualified interpreters, qualified readers, note takers, computer-aided transcription, 1:1 facilitators (for people with learning and understanding disabilities), telephone handset amplifiers, assistive listening systems, telephones compatible with hearing aids, open and closed captioning, e–mail or other electronic communications; use of telecommunications devices [TTYs] for enrollees who are deaf, hard-of-hearing or have speech disabilities, video text displays, and other effective methods of making aurally delivered materials available to individuals with hearing impairments; audio recordings, Braille materials, large print materials, and other effective methods of making visually delivered materials available to individuals with visual disabilities.

Communication Access 
Providing content in methods that are understandable and usable by people with: reduced or no ability to speak, see, and/or hear and limitations in learning and understanding.

Cross-disability access 
Accessibility across groups of people with different disabilities.

Design for All (European Institute for Design and Disability, EIDD)
Intervention in environments, products and services with the aim that everybody, including future generations, and without regard to age, capabilities or cultural origin, can enjoy participating in our societies. To achieve this broad goal, we must follow two basic principles: facilitate the use of products and services [and] ensure that users take part in the product design and evaluation processes.

Electronic and Information Technology (legal, U.S. Access Board, Section 508)
Includes information technology and any equipment or interconnected system or subsystem of equipment, that is used in the creation, conversion, or duplication of data or information. The term electronic and information technology includes, but is not limited to, telecommunications products (such as telephones), information kiosks and transaction machines, World Wide Web sites, multimedia, and office equipment such as copiers and fax machines. The term does not include any equipment that contains embedded information technology that is used as an integral part of the product, but the principal function of which is not the acquisition, storage, manipulation, management, movement, control, display, switching, interchange, transmission, or reception of data or information.

IADL (Instrumental activities of daily living Centers for Disease Control and Prevention, CDC)
Activities related to independent living and include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone.

Inclusive Design (Royal Society for the Encouragement of Arts, Manuafactures and commerce, RSA, UK)
Inclusive design is a process whereby designers, manufacturers and service providers ensure that their products and environments address the widest possible audience, irrespective of age or ability. It aims to include the needs of people who are currently excluded or marginalised [sic] by mainstream design practices and links directly to the concept of an inclusive society.

Information Technology (legal, U.S. Access Board, Section 508)
Any equipment or interconnected system or subsystem of equipment, that is used in the automatic acquisition, storage, manipulation, management, movement, control, display, switching, interchange, transmission, or reception of data or information. The term information technology includes computers, ancillary equipment, software, firmware and similar procedures, services (including support services), and related resources.

Labeling (ANSI/AAMI HE74:2001)
(1) Act of describing the nature or contents of some device with respect to the name of the product,the manufacturer, the amount present, indications and instructions for use, or warnings associated with its use; (2) act of identifying display or control elements of a system with text or pictorial designators (modified from Stramler,1993)

Labeling (U.S. Food and Drug Administration)
“… All labels and written, printed, or graphic matter: (1) on the device or any of its containers, or (2) accompanying the device …” (in Section 201(m) of the Food, Drugs, and Cosmetics Act, 21 CFR Part 801, Labeling)

Multimodal
Multiple sensory and/or motor modes for an interface channel (e.g., between text and speech), such that more than one modality is available to access content or operate a product, and support for transformations among them.  Multimodal interfaces are often necessary for a product or service to be accessible.

Operator (IEC 60601-1)
Person handling a device for the purposes for which the device was intended.

Operable Controls
A component of a product that requires physical contact for usual operation. Operable controls include, but are not limited to, mechanically operated controls, input and output trays, card slots, keyboards, or keypads.

Reasonable Accommodation
A modification or adjustment to a job, the work environment, or the way things usually are done that enables a qualified individual with a disability to enjoy an equal employment or access opportunity. Reasonable accommodation is a key nondiscrimination requirement of the ADA.

Risk Analysis (ANSI/AAMI HE74:2001)
Structured review of a system to identify undesirable events that can occur because of that system’s use (including maintenance, etc.) and estimation of the likelihood and potential severity of those events. This term is often used synonymously with the term hazard analysis.

Self Contained, Closed Products (legal, Section 508)
Products that generally have embedded software and are commonly designed in such a fashion that a user cannot easily attach or install assistive technology. These products include, but are not limited to, information kiosks and information transaction machines, copiers, printers, calculators, fax machines, and other similar types of products.

Telecommunications
The transmission, between or among points specified by the user, of information of the user's choosing, without change in the form or content of the information as sent and received.

Transgenerational Design (James J. Pirkl)
The practice of making products and environments compatible with those physical and sensory impairments associated with human aging and which limit major activities of daily living.

Undue Burden (legal, Section 508)
Undue burden means significant difficulty or expense. In determining whether an action would result in an undue burden, an agency shall consider all agency resources available to the program or component for which the product is being developed, procured, maintained, or used.

Universal Access
Ability of all persons to fully access the intended use of a product or service for which there is potential benefit.   Universal access is rarely fully achievable, and barriers include the dimensions of interface design, distance and cost.

Universal Design (synonyms)
Inclusive design. Lifespan design. Transgenerational design. Design for All (Europe). Barrier-free design (old term).

Universal Design (Center for Universal Design, North Carolina State University)
The design of products and environments to be usable by all people, to the greatest extent possible, without adaptation or specialized design.

Universal Design (Council of Europe Committee of Ministers, 2001)
Universal design is a strategy, which aims to make the design and composition of different environments and products accessible and understandable to as well as usable by everyone, to the greatest extent in the most independent and natural manner possible, without the need for adaptation or specialized design solutions.

Universal Design/Usability (Gregg C. Vanderheiden)
Process of designing products so that they are usable by the widest range of people operating in the widest range of situations as is commercially practical.

Usability

• Ability to use.
• The extent to which a product can be used by specified users to achieve specified goals in an effective and efficient manner, to the satisfaction of these users.
• Extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use. (ISO 9241-11, definition 3.1

Usability testing (CDC)
Usability testing includes a range of test and evaluation methods that include automated evaluations, inspection evaluations, operational evaluations and human performance testing. In a typical performance test, users perform a variety of tasks with a prototype (or an operational system) while observers note what each user does and says while performance data are recorded. One of
the main purposes of usability testing is to identify issues that keep users from meeting the usability goals.

Use Error (ANSI/AAMI HE74:2001)
Act or omission of an act that results in a different outcome than that intended by the manufacturer or expected by the user, which may result from a mismatch between user, man-machine interface, task, and/or environment.

User Profile (ANSI/AAMI HE74:2001)
Summary of the mental, physical, and demographic traits of the end-user population as well as any special characteristics such as occupational skills and job requirements that may have a bearing on design decisions.

Web Accessibility (WAI, W3C)
Web accessibility means that people with disabilities can use the Web. More specifically, Web accessibility means that people with disabilities can perceive, understand, navigate, and interact with the Web, and that they can contribute to the Web. Web accessibility also benefits others, including older people with changing abilities due to aging.

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