Department of Justice
Nondiscrimination on the Basis of Disability by State and Local
Governments and Places of Public Accommodation;
Equipment and Furniture

MODEL COMMENTS:
Medical Equipment Questions

 

Introduction and Overarching Issues

DREDF strongly agrees with the Department's understanding that "[t]he provision of accessible equipment and furniture has always been required by the ADA and the Department's implementing regulations under the program accessibility, reasonable modification, auxiliary aids and services, and barrier removal requirements."[1] Regardless of when the Department issues medical equipment and furniture accessibility and scoping standards, and how the Department sets the timeline for the triggering of those standards, Title II and Title III entities are already obligated to provide full and equal access to healthcare services for people with disabilities, up to the point at which an entity qualifies for a relevant defense under the ADA.  The passage of the Patient Protection and Affordable Care Act, and the enactment of Section 510 of the Rehabilitation Act of 1973, merely results in the placement of a more precise and standardized regulatory overlay on a general access obligation that has always existed given the degree to which American medical diagnoses, treatment and education heavily incorporate standardized equipment and new technologies.

At the same time, we recognize that equipment and furniture occupies a somewhat unique position among the universe of things for which the Access Board has typically provided detailed technical standards.  As physical objects, equipment and furniture have proportions and characteristics that can be more or less accessible for people with various disabilities.  Covered entities can be required to purchase equipment that has certain accessibility characteristics.  The actual accessibility of equipment and furniture in practice, however, is highly interdependent on both the structural dimensions of the buildings and rooms in which they are housed, and the entity-specific policies, practices, and procedures (or lack thereof) that govern the item's use.

For example, a medical exam table must have such inherent features as a certain minimum height, height-adjustability, sufficient cushioning, and retractable padded side arms to be accessible.  A particular exam table may have these characteristics and still not be fully accessible unless it is placed in an exam room where enough clear floor space is consistently maintained to give a wheelchair user sufficient maneuvering room to enact independent transfers where possible, and permit the use of portable or track lifts.  Furthermore, an accessible table in an adequately sized room will still not be practically accessible from the point of view of a person with a disability unless he or she knows that such a room is available and requests it, the provider has reliable scheduling policies and procedures in place for offering and booking the room and any other necessary equipment, and office staff are adequately trained in the use of the table and the provision of lift and staff transfer assistance.

In fine, medical equipment and furniture exists in the context of physical structures, but is demanded, tested, procured, operated, stored, moved, and scheduled for use in large part through a medical facility's policies, practices, and procedures. This intersection of architectural, equipment design, and policy elements means that the Department's accessibility requirements for medical equipment and furniture must address all three of these elements. There is also a further element raised by the inaccessible technical interfaces and patient displays commonly used in medical equipment. Covered entities are under an existing obligation to provide auxiliary aids and services where necessary to ensure effective communication with people with disabilities, and this obligation includes a duty to acquire or modify equipment or devices.[2] The medical equipment and furniture regulations must touch on all these elements, and the Department must ensure that it does not dilute existing standards applicable to any one of these elements.

With regard to policies, practices, and procedures, the Department should expressly clarify two points.  First, health care entities of all sizes remain responsible for providing policy modifications to the point of fundamentally altering the nature of the activities and services offered as contemplated in Title II (28 CFR 35.130(b)(7)), or to the point of a fundamental alteration in the nature of the business as contemplated in Title III (28 CFR 36.302(a)).  Second, a covered entity's obligation to engage in policy modification does not end merely because the entity fulfills its equipment design obligations.  For example, a dentist's purchase of an accessible dental chair may fulfill her obligations with regard to accessible equipment, but if one of her patient's has a condition that means he cannot independently transfer to the chair regardless of its accessible features, the dentist is still obligated to provide such policy modifications as assisting the patient to transfer, or examining the patient in his own wheelchair, up to the point where the modification would constitute a fundamental alteration of the dentist's business.  The provider's policy modification obligations are distinct and remain regardless of the provider either meeting his accessible equipment obligations or having a defense to those obligations.

With regard to accessibility standards for equipment and furniture, the "Legal Foundation" section of the E&F ANPRM uses the example of a height-adjustable exam table to illustrate Title II and Title III's application to equipment and furniture, and strongly suggests that the Department will use an "existing facilities standard" for medical equipment and furniture.  That is, Title II entities will be required to provide accessible medical equipment so that health care services are "readily accessible . . .when viewed in its entirety" (28 CFR 35.150(a)), and Title III entities will be required to engage in "readily achievable" equipment design barrier removal (28 CFR 36.304).  It follows that Title II entities will have a fundamental alteration or undue burden defense to their obligation to acquire an accessible item of medical equipment, while Title III entitles will have only a readily achievable standard to meet for the same piece of equipment (an examining table is the example used by the Department in both contexts).

Since accessible medical equipment and furniture is so closely linked to broader health care access, it makes some sense to treat equipment and furniture standards as a component of "program access" under Title II.  This approach also encourages the kind of flexible innovation and creativity that can be so valuable in considering how to obtain needed diagnostic and treatment results when confronting equipment that does not yet meet accessibility standards.  However, the close relationship between architectural elements and accessible equipment design does not mean the two things are the same.  The Department must clarify that policy modification and the removal of equipment design barriers can be prioritized over architectural modification.  Unlike architectural changes such as the structural alteration of existing facilities or the construction of new facilities under "program access," equipment design barriers should not be addressed as a "last resort."

In the case of Title III, it is unclear why a covered entity's obligation to have accessible medical equipment and furniture is equated with that entity's obligation to remove barriers in existing facilities.  A careful balancing of urgent accessibility needs and the legitimate concerns of covered entities lie behind the development of the existing facility standard, and that balance does not necessarily apply wholesale to the unique situation of medical equipment and furniture.  The de minimus readily achievable standard for Title III entities exists because Congress recognized that architectural barrier removal can be burdensome and expensive.  This scenario may not hold true, or apply to the same degree, in equipment and furniture replacement and modification. 

For example, an individual medical practice located in an existing facility may have only two examination rooms, each of which lacks sufficient clear floor space for the operation of a portable floor lift.  Architectural barrier removal in this case, entailing the removal of walls or undertaking an addition or an expensive, time-consuming retrofit of the ceiling infrastructure for a ceiling track lift, may not be "readily achievable."  As a result, that provider need not purchase a portable floor or ceiling track lift.  This analysis does not, however, naturally lead to the conclusion that the acquisition of any and all items of accessible equipment should fall within the less demanding standard of what is "readily achievable."  The purchase and use of a free-standing overhead lift in one of the exam rooms could avoid the need for structural change, and yet comprise an action that, while it may or may not be "easily accomplishable and able to be carried out without much difficulty or expense" (see 28 CFR 36.304), is still not unduly burdensome on the covered entity. 

Furthermore, the readily achievable standard was designed to inherently strengthen over time as existing facilities were either altered or eventually overtaken by new construction, which are subject to the stronger "undue burden/fundamental alteration" standard and the "readily accessible to and usable by" standard, respectively.  If medical equipment accessibility standards are to be tied to a readily achievable standard, then at the very least, that standard should also incorporate "triggering events" that would elevate the performance standard from "readily achievable" to undue burden/fundamental alteration.  Facility alterations that update or retrofit provider offices, or the voluntary purchase of new equipment such as replacing old exam tables, or a move to a newly built facility, should trigger a switch from the "existing facilities" standard to the more demanding alteration or new construction standards.  There is no reason to "freeze" medical equipment and furniture standards in existing construction standards. Ultimately the goal is to have fully accessible medical equipment and furniture in every health care facility so that people with disabilities and aging Americans can have the same access to medical services that is available to people without disabilities.  This goal is intrinsically more achievable because equipment and furniture is easier to change than foundations and walls. 

Returning to the above example of the Title III entity with two examination rooms, if the medical office were to freely undertake a renovation or addition, or decide to upgrade its current exam tables, these actions should automatically require the acquisition of accessible equipment and furniture unless doing so would constitute an undue burden or a fundamental alteration.  Furthermore, even if the purchase of lifts or exam tables is found to be an undue burden or a fundamental alteration, the medical office is still under an obligation to undertake reasonable modifications of policies, practices and procedures such as maintaining staff training on transfer assistance and having such ancillary equipment as sliding boards and sheets available. 

One other consideration for establishing higher accessibility standards for Title III entities is consistency.  From the patient's point of view, the need for accessible equipment remains the same whether the entity providing healthcare services is a county clinic/hospital or a private hospital or doctor's office, but treating the acquisition of accessible medical equipment and furniture as if it is part of program accessibility for Title II entities, but akin to the removal of architectural  barriers from an existing facility for Title III entities, results in the potential for the highly inconsistent availability of accessible equipment.  Furthermore, if the US Department of Health and Human Services and other relevant federal entities choose to adopt medical equipment and furniture regulatory standards enacted under Section 510 of the Rehabilitation Act and those enacted by the Department under the ADA, as could easily be the case down the road, those departments are more likely to require a standard analogous to standards enacted under Title II rather than the public accommodations standards of Title III.  The reach of federal funds through the Medicare and Medicaid programs, however, would potentially mean that the same health care entities that were originally subject to a lesser standard as a Title III ADA entity would be subject to a more demanding standard as a federally funded entity under Section 504.  Public policy should  minimize disincentives for providers joining Medicare and Medicaid programs, especially in light of the program expansions contemplated under the Affordable Care Act.  Application of the higher standard from the beginning would help minimize the future impact of medical equipment and furniture standards under federally funded and/or federally conducted Rehabilitation act regulations.

It is also important to provide standards that are consistent with the technical and functional standards of Section 508, for the information and communication elements of medical equipment. As our recommendations below indicate, all medical equipment that provides patient-facing information and communication features should be required to comply with communication accessibility standards, such as redundant audio, visual and tactile alert signals and patient-provider communication capacity during exams (e.g., to indicate when patient should hold breath or regulate breathing for radiological diagnostic equipment), accessible means to communicate with nurses and other staff from a hospital bed, and accessible infusion pump controls and alarms.

The need for consistency and greater certainty therefore argue for regulating medical equipment and furniture more broadly under Title III's general non-discrimination mandate at least in a manner analogous to Title II's program accessibility requirement, rather than attempting to force medical equipment and furniture under an ill-fitting Title II "architectural barrier removal in existing facilities" analysis.

Both barrier removal and policy modification are rooted in the same requirement for full and equal access.  If medical equipment and furniture is to be used to provide thorough examinations, accurate diagnosis, and effective treatment for people without disabilities, then that equipment and furniture must be made accessible to people with disabilities who are otherwise receiving medical care that is less effective and/or timely.  The balance of risk to people with disabilities and the burden on covered entities calls for the effective, swift removal of equipment design barriers beyond that which would be achieved through the simple application of existing facility barrier removal standards.

1. The Department is considering adopting the Access Board's standards for medical diagnostic equipment.  What other types of medical equipment and furniture should the department include in its proposed regulation?  What modifications to other types of medical equipment and furniture, including equipment and furniture used for treatment or other non-diagnostic purposes, such as hospital beds, should be included in the Department's proposed regulations?

Introduction

We understand that the Access Board is developing regulatory standards for medical diagnostic equipment that the Department will consider adopting.  We strongly recommend that examination tables and chairs of all types, and the lifts used to provide lift/transfer assistance on to those tables and chairs, be considered "medical diagnostic equipment" by the Access Board and also included in the Department's proposed regulations.  From the patient's point of view, each category of item performs a distinct and necessary function to enable an individual with a disability to receive an effective examination in various contexts. 

Furthermore, our experience is that tables and chairs in medical, dental, and ophthalmology/optometry settings are frequently used for successive or simultaneous diagnostic and treatment purposes, and even medical procedures are not necessarily easy to neatly characterize as diagnostic or treatment.  Other types of equipment such as gurneys, lifts, and bathroom commodes are commonly used for both diagnosis and treatment since out/in-patient examinations and care both frequently require transfers and specimen collection.  Ultimately, it makes little sense for providers or the department to parse out the degree to which a particular item of furniture or equipment is used for diagnosis or treatment.  The Department's regulations should simply apply broadly to medical equipment and furniture, regardless of whether the item is used for diagnosis or treatment procedures, and scoping requirements should ensure that facilities and offices have accessible tables, chairs, and other equipment available for both diagnostic and treatment purposes.  There may be some specialized items with built in chairs that are used almost exclusively in a treatment context, but fromthe patient's point of view there is little point to establishing accessibility standards for diagnostic purposes, but no standards for the equipment that is actually used to treat a newly-diagnosed medical condition.

Given the difficulties of equipment categorization described above, we are including comments under this question on items that we clearly consider "diagnostic" and that do not specifically fit in any other E&F ANPRM question.  We support the Department providing regulatory requirements on accessibility for all of the medical furniture and equipment described below, even if some of the items are primarily associated with treatment.[3]

              Examination Tables and Chairs

Specific types of this category of equipment are discussed in greater detail in the answer to Question #2 immediately below.

              Accessible Scales

Correct weight measurement is critical for a variety of medical purposes, including tracking obesity, determining the risk of such medical conditions as cancer, high blood pressure, and depression, and determining correct prescription medication or anesthesia dosages.  Ongoing monitoring of weight is also a vital component of health maintenance during pregnancy or while treating diabetes, cardiovascular disease, and other chronic conditions.  Standard medical weight scales require a patient to stand on a small platform while a provider finds and notes the patient's weight and height.  Wheelchair users and other individuals who are unable to use standard weight scales because of activity limitations or mobility or balance issues have had providers ignore their need for accurate weight measurement, or have been given the humiliating "choice" to be weighed in an inappropriate setting such as on a laundry scale.  Accessible weight scales that do not require a patient to have the independent capacity to stand, balance, and/or transfer on to a platform are now available in a wide variety of models and styles, and there is simply no justification for any facility or provider's failure to take accurate weight measures for all patients with disabilities.  Accessible scales are available that are integrated into other medical equipment (e.g., a patient lift, a hospital bed), or that allow a wheelchair user to independently access a surface for weight measurement on a stationary stand-alone device that is either wall-mounted (folding or non-folding) or on an in-ground platform.  Portable platform scales are also available in folding and non-folding models.

People who have difficulty independently standing on a platform scale can also be accurately weighed through an independent or assisted transfer to a bed scale, or to a wheelchair which is then weighed on a platform scale.  In the case of an assisted transfer, trained transfer assistance and lifts must be available.  Facilities should also offer such ancillary devices as step-stools with rails, adjacent grab bars, and walker-type devices to aid patients with disabilities in getting on and off a step-up scale, and to increase a patient's stability and safety while being weighed.

An accessible weight scale should have the following features:

As with all accessible medical equipment, provider staff must be trained in the availability, operation, and adaptable features of the available accessible weight scales, as well as in the availability of transfer equipment and transfer/lift assistance when needed by individuals who need to be weighed.  Staff also cannot assume that a wheelchair user knows the weight of his or her wheelchair, and must provide transfer options to people if their wheelchairs need to be weighed separately.

              Radiological Diagnostic Equipment

Computerized Tomography (CT), Magnetic Resonance Imaging (MRI), x-ray, and mammography are important diagnostic tools that are commonly used to screen for numerous medical conditions.  These technologies must be equally available to people with disabilities.  Unfortunately, most of these technologies are designed so that individuals must assume a single specific posture, such as lying prone or independently standing upright, often for a considerable length of time.  People who have balance, posture, endurance, muscle weakness or fatigue, and/or spasticity issues may be unable to use these technologies as designed without experiencing considerable or extreme discomfort that makes it impossible to either use the machine or achieve high quality images.

Each type of equipment interacts with the body in a somewhat different way, so each type of equipment will benefit from having specific technical recommendations.  However, a number of general accessibility features can also be incorporated into all radiology diagnostic equipment as follows:

Radiological Diagnostic machines are among the most expensive pieces of equipment purchased by medical facilities.  Covered entities may incur significant capital outlay switching from an inaccessible machine to one that provides better access.  At the same time, the Department should keep in mind that many medical facilities and centers replace their radiological diagnostic equipment relatively frequently due to the rapid pace of technological and functional advancements in this equipment.  The establishment of regulatory standards on accessibility in radiological diagnostic equipment will help put accessibility considerations on the agenda of research and design teams in the first place by increasing demand, and this in turn will broaden the choice and availability of universally designed, top quality and innovative devices for purchase by medical facilities and providers.

In this context, it is useful to note developments such as the CXDI series of digital X-ray devices developed by Canon.  Each machine is completely portable and can be carried by hand like a laptop computer or even an I-Pad, and the series comprises variable surface sizes for taking digital x-rays of different body areas that can then be viewed on a computer screen soon after the imaging process is complete.[3]  Other digital X-ray devices may be more traditionally mounted in a medical facility, but their design provides flexible positioning options.  For example, Ziehm Imaging's Exposcope x-ray devices are mounted on a C-arm bracket so that the imaging equipment can be rotated 45 degrees around a patient.  While the development and advancement of such innovations may not be primarily driven by accessibility needs, the devices help meet at least some accessibility concerns.  Rather than have accessibility needs addressed in a haphazard and serendipitous fashion, such that a new innovation may meet the needs of people with mobility impairments but fail to address the needs of people with visual impairments or spasticity, the Department should establish overall accessibility parameters for radiological diagnostic equipment in general, in addition to setting more device-specific technical requirements.

               Commodes and Shower Transfer/Benches

Drop-arm commode chairs enable individuals with mobility disabilities, independently or with some assistance, to use a toilet safely and with increased comfort.  Portable shower benches perform the same function for shower use.  Commodes and shower/transfer benches should include the following accessibility features:

One model of commode will not serve the needs of all patients, and currently there is no one model available on the market that combines all of the above features.  However, there are models of commodes and shower/transfer benches that have at least some of the above features, and establishing the above as minimum accessibility standards will encourage the development and manufacture of more fully accessible products.

              Continuous Railing Systems

A well-designed, continuous network of grab bars placed along clinic and hospital hallways and walls, and in patient rooms along the pathway from bed to toilet to shower, is effective for many patients in providing stability and reducing falls.  This standard would, for example, benefit infusion patients who need to use the restroom frequently due to increased hydration, but also experience fatigue and decreased energy due to the treatment.

              Complementary and Alternative Medicine (CAM) Equipment and Furniture

Alternative and traditional medical treatments, such as acupuncture, chiropractic therapy, and massage, are gaining increased recognition from health plans and insurance companies as the medical establishment moves toward treating the "whole person."  "Alternative and Complementary Medicine Departments" are now seen on most major medical campuses.  These departments treat patients through a variety of modalities, combining standard Western treatment such as radiation and surgery with traditional and alternative therapies.  Based on the clinical treatment needs of patients, tables in these departments are typically manufactured and distributed by chiropractic or massage/retreat type manufacturers. If used in a "clinical" or standard medical facility or treatment context, these tables and chairs must be held to the same standards as the standard medical examination and treatments tables and chairs.  That is, they must be height adjustable to a minimum 17 to19 inches, provide sufficient surface width and height to safely accommodate transfers and positioning of any individual with balance or movement control issues, and be useable with ancillary equipment such as supportive straps, cushions or rails.  One simple way to provide ample width is to design tables that can be "locked together" side-by-side in a stable way to provide a safe and comfortably broad surface.

Examples of accessible CAM equipment currently available in the market include:

  1. Earthlite – Ellora Massage Table:  Height adjustable from 17 to 36 inches above the floor to the top-of-cushion.  The table is available in widths of 25 inches, 27 inches and 30 inches and has a 650 pound weight capacity.
  2. ProLuxe Valencia Massage and Spa Tables:  Height adjustable from 18-34 inches above the floor to the top-of-cushion with a 550 pound weight capacity.

              Hospital Bassinets, Cribs, and Incubation Units

Hospital bassinets, cribs and incubation units in the newborn nursery, Newborn Intensive Care Unit, and/or in-patient children's wards must be accessible to enable a mother with disabilities (or a provider with disabilities) to gain access to a newborn for various purposes such as breastfeeding, bonding, comfort, and caregiving.  Usually there is no knee clearance allowing a wheelchair user approach closely enough to pick up or hold a child with both hands, and crib gates/doors cannot be let down without difficulty and considerable upper body strength.  There are cribs available on the market that provide parents or caregivers with the ability to gain access to most of a crib's interior.  Research and development is needed to incorporate the following needed accessibility features in bassinets, cribs and incubation units for the medical market:

Example of Accessible home crib:

  1. Fine Round Cribs:  this crib is round, offering 360° visibility of a child within, and features removable leg extensions that can be used to elevate a crib, providing knee clearance so that a wheelchair used can approach the crib closely.  There are double doors in the front of the crib that allow for access to 80% of the crib.  See
    http://www.abledata.com/abledata.cfm?pageid=113582&orgid=184974.

2. The Access Board is expected to promulgate design standards for medical and dental diagnostic tables and chairs.  Are there tables or chairs used for medical, dental, ophthalmology or optometry treatments, which are not typically used for diagnostic purposes, that would pose unique accessibility challenges?  What modified features would make these tables or chairs accessible?  What features would enhance patient stability and facilitate correct positioning?

Any discussion of accessibility standards for tables and chairs, whether used for examination or treatment purposes, must include consideration of how a room's size and space interact with the use of medical equipment within.  The finest and most accessible tables and chairs will quickly become inaccessible if placed in rooms that do not allow wheelchair users to maneuver or place themselves correctly in preparation for a transfer, and where employees do not know how the equipment operates.  Many examination rooms are crowded with furniture such as large desks and bookshelves that cannot be moved easily or quickly, and could be replaced with lighter, smaller or differently fixed items that serve the same function.  Clear usable space within examination, treatment and procedure rooms can be further maximized through a variety of portable, relatively inexpensive storage options.

Given the close relationship between examination and treatment purposes and procedures, already discussed in the introduction to Question #1 above, the following comments concern accessibility features and modifications needed in medical, dental, ophthalmology or optometry chairs and tables regardless of whether they are primarily associated with examination or treatment.

              Examination Tables

Exam tables are widely used for examinations, procedures and treatment in primary care as well as many specialty areas such as Obstetrics and Gynecology, Physical Therapy, Oncology, Podiatry, Dermatology, and Urology.  Thorough and proper examination cannot take place unless a patient is positioned safely, comfortably, and correctly, and providers are also able to adjust the table sufficiently to allow for visual and physical access to a patient as required.  The exam table is the equipment portal for so many additional procedures as well as specialty referrals.  When this primary step is inaccessible and performed badly as a result, patients with disabilities receive incomplete exams and delayed diagnoses, and experience increased reluctance to seek regular health maintenance and needed medical examinations.

Exam tables require the following features to be accessible:

Numerous sources, including the Institute of Medicine and the Surgeon-General, have noted the reality of the aging U.S. population and the resulting increased propensity for acquiring a disability or disabilities.  American health care is unprepared for this in many ways, including such basic infrastructure as accessible medical equipment.  Accessible, power-adjusted exam tables and readily available lift/transfer assistance equipment and training benefit not only patients with chronic or newly-acquired disabilities, but also aging providers through reducing the potential for workplace strain and injury and consequent lost productivity.

Exam tables with numerous accessibility features have become more common and less expensive in the market over the past few years.  Well-known companies that produce accessible tables include Brewer Company, Midmark, Hausmann, and Keitzer.

              Mammography Chairs

While it is often best for a person to continue to use her own wheelchair for a mammography scan, the ability to do so depends on whether the wheelchair arm is removable.  If not, then the person needs to transfer to an accessible mammography chair with the following features:

An accessible mammography procedure also requires the following features, which strictly speaking, are not technical requirements for the "mammography chair" itself, but for the diagnostic mammography equipment and its connection with the chair:

              Ophthalmology and Optometry Chairs and Tables

Early detection and treatment of eye and vision disorders are essential to minimizing vision loss and maintaining the functional abilities of people with and without disabilities.  However, the close relationship between vision impairment and some pre-existing conditions such as spinal-cord injury, and between vision loss and aging, which in itself raises increased potential for developing a disability,[4] makes regular vision care particularly essential for people with disabilities and older Americans.  More than two-thirds of adults who have vision impairments are over age 65, and the leading causes of vision impairment in the United States are age-related, including cataract, glaucoma, macular degeneration, and diabetic retinopathy.  In addition, a 2005 study estimates that for the first time in history, one of every 100 older citizens of the United States is aging with a long-term disability such as spinal cord injury, cerebral palsy, multiple sclerosis, post-polio, or intellectual or developmental disabilities.[5]One example of the correlation between a pre-existing condition and vision loss is that as many as 20 percent of persons living with the effects of a spinal cord injury have adult-onset diabetes (as compared to 7.8 percent of the non-ambulatory impaired general population that has diabetes) and an even larger percentage may have diabetes, but are asymptomatic.[6]

80 percent of the sensory information relayed to the brain is visual in origin.[7]  For those individuals accustomed to unimpaired or easily correctable vision, vision loss can have a significant and detrimental impact on the quality of life and on the capacity for self-care.  Early diagnosis and timely treatment have been shown to prevent vision loss in more than 90 percent of patients, and clinical practice guidelines recommend an annual dilated eye examination for all people with diabetes, including those with ambulatory impairments.[8]  At the same time, people with ambulatory impairments and balance and muscle-control issues, including many seniors, face numerous access issues when seeking the periodic comprehensive ocular examinations that are critical to their preventative health care.  As is true in so many areas of health care, those persons most in need of preventative care and maintenance are the same individuals most at risk of not receiving that care.  Common access issues faced by people with ambulatory impairments include:

As a result of the above physical and attitudinal barriers, people with disabilities who cannot independently transfer from their wheelchairs onto the examination chair and cannot access refractive equipment, receive no examination or a less comprehensive, manual eye examination.

Full and equal access to vision care services for people with disabilities requires ophthalmology and optometry treatment chairs, ophthalmology and optometry equipment stands, ophthalmology and optometry equipment tables, and dental examination chairs to have the following features:

Considerable accessible ophthalmology and optometry equipment is currently available on the market, as well as equipment such as chair glide systems, mobile equipment stands, accessible screening tables, etc. to facilitate transfers to, and/or modify, existing inaccessible ophthalmology and optometry equipment.

              Dental Chairs

The need for routine dental care, including preventative care and maintenance, oral surgery, and orthodonture, and the equipment access problems that people with disabilities face when seeking that care, are generally analogous to the situation outlined immediately above for ophthalmology and optometry care and chairs.  However, patients most frequently receive dental care while seated in a chair that providers set at various angles of recline as required for specific procedures rather than in an upright position, as is commonly required in ophthalmology/optometry practice.  As a result, dental chairs and equipment need the following distinct features to be accessible to people with disabilities:

              Birthing Chairs

A number of maternity wards and birthing centers offer the use of birthing chairs or couches in vaginal delivery rather than a hospital bed. These chairs require the same basic accessibility features noted for ophthalmology and dental chairs above. Namely, they must be:

              Infusion Recliners

Infusion recliners are chairs widely used, for example, by patients who are receiving Chemotherapy, donating blood, and being cared for in day surgery recovery areas.  Sometimes patients must use reclining infusion chairs for up to twelve hours at a time, and may be weak both before and after treatment. This makes transferring into a standard reclining chair difficult, and sometimes impossible, without the assistance of multiple staff members, for whom the patient may have to wait a considerable time.  While some of the infusion incliners currently on the market have a swing-away side for easier lateral transfers by wheelchair users, none of the chairs can be lowered to an accessible height (19 inches or less), or have an easy to-use leg lifting mechanism.  Infusion chairs would require at least the following features to be accessible:

3 (a).   What types of lifts are the safest, most efficient, and most cost effective lifts for transferring PWD in different medical or dental settings?

Battery-operated mechanical lifts are available in a variety of models. Moveable floor lifts and moveable and fixed ceiling lifts are in common use. Moveable floor lifts employ either electronic or hydraulic lifting mechanisms. Ceiling lifts require either installed overhead ceiling tracks or free-standing frames, which can be moved to serve specific needs, but which are not strictly portable. Some ceiling lifts themselves are portable, that is, they can be detached from the track, moved from room to room, and used wherever overhead track or free-standing frames are available. Certain overhead lifts are permanently installed on a specific length of track and cannot be moved from that track. These typically include an automatic charging device that activates when the lift "docks" with the device, thus ensuring that the batteries are regularly recharged.

Weight limits for floor lifts, and portable and fixed ceiling lifts are an important consideration and vary widely. Depending on cost, weight limits for floor lifts can range from 450 to 1000. Weight ranges for portable ceiling lifts can range from around 250 to 550 pounds. Permanently installed ceiling lifts afford weight ranges up to about 800 pounds, while at least one manufacturer offers such a lift with a weight capacity of 1100 pounds.

Portable ceiling lifts used with ceiling-mounted tracks require minimal space to operate effectively and either can be left in place or stored easily in a closet or drawer when not in use.  However, portable ceiling lifts cannot be used unless installed track or free-standing frames are available.  Free-standing frames can be moved to accommodate various needs, but much less easily than floor lifts, which offer the convenience and efficiency of potentially providing lift assistance in a variety of physical spaces.

Floor lifts can be moved from room to room and generally are less expensive than the combined cost of a ceiling lift and either track installation or a free-standing frame. However, they have the distinct disadvantage of being cumbersome to maneuver in small spaces such as physician or dental office examination rooms.

They require significant clear floor space when they are being used to transfer a person with a disability from a wheelchair either to an examination table or chair, or to diagnostic equipment such as a radiology table or MRI machine. For example, clear floor space is required for the lift to be positioned so a wheelchair user can be lifted from the chair and moved into proximity to the exam table or other diagnostic equipment. Space is also required under such equipment and devices in order to accommodate the "legs" of the lift, or so that access to the table or device can be accomplished from an orientation that ensures that the person can be lowered on to the surface safely and in the correct position. Such clear floor space often is either not available or is inadequate, especially in medical, dental and ophthalmology/optometry offices.

Storage of a floor lift also presents challenges in medical offices where space is at a premium. Thus, while the portable lift has specific advantages, its effectiveness must be evaluated in relation to the setting in which it will be used.

However, not every building, especially existing construction, has the infrastructure needed to support the installation of ceiling tracks. The potential structural retrofitting that may be required to enable the installation of ceiling tracks, or the additional room needed for the effective use of portable lifts, may involve considerable costs for some entities. 

A portable ceiling lift and free-standing lift track affords an intermediate solution that does not require retrofitting and may address the need for clear floor space in many settings. Moreover, the free-standing lift track can be moved if required.

Either floor or track lifts can provide safe and efficient transfer and lift assistance provided that the following features of use are incorporated:

One-time costs associated with any of these solutions must be seen in light of the costs of (i) lesser quality and delayed health care borne by persons with disabilities who do not receive needed lift and transfer assistance, (ii) the injuries and lost time suffered by both patients with disabilities and provider staff when non-mechanical transfer assistance is provided unsafely or by untrained staff, or in situations where lift options other than mechanical lifts are not available (e.g., for bariatric patients),[9] and (iii) the personal litigation risks posed by both (i) and (ii).  Employers at large and society must also bear the costs when the family members or friends of a person with disabilities are forced to take time off from employment because a provider unlawfully requires a patient with disabilities to provide her own lift assistants.

One of the most cost-effective ways to implement a requirement for lifts in hospitals and other health care facilities is to mandate the installation of the physical infrastructure and architectural elements needed for ceiling and floor lifts (e.g. ceiling infrastructure, adequate floor space in locations where lifts are likely to be used, storage) in all new hospital and health care facility construction, additions, or alterations that commence one year or more after the promulgation of final regulations on lifts.  This requirement should apply at a minimum to all the accessible rooms that are required for the facility by the ADA Standards for Accessible Design, as well as for all Emergency Departments.  As the Justice Department has frequently noted, it is less expensive to build in accessibility in the first place than to engage in retrofitting an existing structure after the fact.  Covered entities would also have the benefit of a clear mandate that would enable them to plan for the purchase and use of accessible equipment ahead of time.

3 (b). Should the use of lifts or staff to lift patients be considered a substitute for providing independent access to medical equipment?

The use of lifts or staff to lift patients should not be considered a blanket substitute for providing independent access to medical equipment.  Many individuals with disabilities are capable of effecting their own transfers to such equipment as exam tables, and are most comfortable and prefer doing so, provided that the equipment in question is adjustable in height to an appropriate minimum height of 17-19 inches.  The fact that an entity has purchased and has lifts available should never excuse health care entities from purchasing adjustable-height examination or accessible diagnostic equipment, or act to discourage equipment manufacturers from designing independently accessible medical equipment.  For example, a wheelchair user can receive some examinations of equal quality, such as a mammography or an ophthalmology exam, while remaining in her chair and may strongly prefer to do so.  However, this option does not exist if the examination equipment is attached in a fixed position to an existing examination chair so that a transfer must take place.  A health care entity should not be excused from ensuring independent access by providing examination equipment that can be separated from examination chairs only because the entity has a lift and/or staff provides lifting assistance. (The entity will continue to have its usual defenses under Title II and III for not providing independently accessible equipment.)

Moreover, some individuals with disabilities experience pain, spasms, or other discomfort when being transferred with a lift. Positioning a lift sling for someone who is seated can cause unnecessary pain or discomfort, or be more difficult than providing assistance with other transfer equipment when performed correctly by trained and experienced staff.  Both mechanical and human lifts can, in turn, be far inferior to independent access to equipment wherever possible.  Medical staff must respect the person's own preference and knowledge about his or her transfer needs and capacity to gain independent access to specific medical equipment.

In individual cases and at particular times, when a person's disability, weight, state of health, personal preferences, and or a combination of these factors point toward the need for transfer or lift assistance, or when the person explicitly requests it, independent access may not be needed.  Otherwise, the use of lifts, just as with the use of human assistance and lift teams, should supplement and not supplant the provision of individually accessible medical equipment.  

4 (a). If a hospital or medical provider uses staff to lift patients onto and off of medical equipment and furniture, should it be excused from the requirement to have lifts in any or all situations?

The use of staff to assist in patient lifts and transfers is acceptable in the following limited and unusual situations and only with the patient's or legal guardian's agreement:

Aside from such rare situations, the availability of manual lifting assistance should not be used as an excuse for not having mechanical lifts and height-adjustable medical equipment, because manual lifting alone carries too many inherent health and safety risks.  Moreover, some individuals, such as persons with certain conditions such as neuromuscular impairments can sustain injuries from poorly executed staff lifting assistance.  Even correctly executed assistance from well–trained staff can place uneven stress on the patient's skin and body at the points of contact.  Anxiety about badly executed transfers and resulting pain and injury can cause people with disabilities to avoid seeking needed health care and disease prevention services.  People with disabilities can also be forced to wait until the one or two staff members who are trained and capable of providing lift assistance become available.  On the other hand, people with disabilities cannot be expected to endure improper lift and transfer assistance from untrained staff who are immediately available.  Either way, an individual who is often already partially undressed and may be experiencing ill health can suffer greater health risk and humiliation when forced to be dependent upon a "staff assistance/lift only" policy.

Finally, if staff lifting is commonly recognized as an acceptable substitute for the use of mechanical lifts, staff will also be subject to employer expectations concerning strength and lift capacity.  This can make it difficult for a staff member with lifting capacity limitations to receive needed accommodations.  The availability of mechanical lifts will enable employees with limitations to perform lifts with far less risk of injury. 

Very narrowly interpreting the instances where human lift and transfer assistance are acceptable options for achieving access is entirely in keeping with how the U.S. Department of Health and Human Services (HHS) an the Department have historically viewed carrying.  The U.S. Department of Health, Education and Welfare's[10] Section 504 Policy Interpretation No. 4, 43 Fed. Reg. 36035 (August 14, 1978) categorically stated:

Carrying is an unacceptable method for achieving program accessibility for mobility impaired persons except in two cases.  First, when program accessibility can be achieved only through structural changes, carrying may serve as an expedient until construction is completed.  Second, carrying will be permitted in manifestly exceptional cases if carriers are formally instructed on the safest and least humiliating means of carrying and the service is provided in a reliable manner.

The Department of Justice explicitly referred to and incorporated the above interpretation in its Section-By-Section Analysis to ADA Title II Regulations, 28 C.F.R. § 35.150(b)(b), 56 Fed. Reg. 35709, stating that "carrying an individual with a disability is considered an ineffective and therefore an unacceptable method for achieving program accessibility."  While these directives were originally made in the specific context of carrying when ramps were not available as a means of independent entry into a building, the fundamental idea that disability rights prioritizes independent access to activities, programs and services applies equally to the health care and equipment context.

4 (b). What types of training programs are available to provide information to medical staff on lifting and transferring patients with disabilities?

Yearly lifting and transferring competency training and refresher training for health care workers is critical. Many nurse education programs touch on lift and transfer assistance, though there is a need for such information to be more formally organized, presented, and institutionalized, with nursing students and new nurses given the opportunity to actually execute and practice transfer techniques with experienced nurses.  The California Nursing Association offers transfer training classes and some hospitals provide regular competency training regarding lifting. Commercial, off-the-shelf training products are also available,[11] although most such training focuses on methods to avoid worker injury and do not focus on the needs and perspective of individuals who require lifting assistance.  The implementation of lift team systems specifically trained to use the variety of equipment available is very helpful in large medical centers.

Considerable research and training has been done on the subject of "safe patient handling" from the viewpoint of minimizing the risk of injury for health care workers such as nurses and personal assistants.  Both the U.S. Department of Veterans Affairs[12] and the U.S. Occupational Health and Safety Administration (OSHA)[13] have developed good guidelines on safe patient handling in different contexts.  Safe patient handling standards and guidelines on topics ranging from mechanical lift use and storage and the room clearances needed for lift operation to proper equipment disinfection provide a good foundation for lift and transfer training, but for ADA purposes, such training must be supplemented by information on the person with a disability's right to barrier removal and policy modification, the prioritization of independent access and integrated means of accommodation, and disability culture. 

4 (c). What are particular situations, if any, where lifting by staff should not be allowed?

Lifting perhaps does not constitute a medical procedure in and of itself, but it remains physical contact in the health care context that requires patient consent.  If a person with disabilities refuses an offer of lift or transfer assistance, staff cannot force or override the person's wishes.  Respect for the individual patient's dignity and choice requires honoring the accessibility preferences of the consumer, and recognizing that competent people with disabilities know the transfer/lift assistance that will work best for them.  We recommend that the Department not provide a finite list of circumstances where staff lifting should not be allowed, or detailed criteria under which providers cannot provide lifts, but instead endorse an approach that mandates providing a range of transfer/lift options to people with disabilities, including adjustable diagnostic equipment, mechanical lifts, and policies and procedures for providing a trained, safe-lifting team.[14]  The Department should also emphasize that the individual's choice of transfer/lift assistance should be honored except for rare circumstances, for example, where a bariatric patient expresses a strong desire for staff assistance/transfers that would place both the patient and staff members at risk of injury.  In the event that a person with a disability's expressed lift preference cannot be safely accommodated, the entity must have a policy and practice of documenting the circumstances and reasons for the refusal, and the record will be made available for the Department and public's inspection upon request.

5 (a). What features, such as low bed heights, can best enhance the accessibility of hospital beds and gurneys?

Low bed heights are crucial for people with disabilities using hospital beds.  Many people who use such mobility devices as canes and walkers, or who have frail joints or bones resulting from such conditions as osteoporosis or as a side effect of various medications or treatments, still prefer and are capable of getting in and out of bed largely independently, but cannot risk leaping up or jumping down from a bed that cannot be lowered or adjusted in height.  This is also true for people of small stature, and for wheelchair users who employ a pivot transfer or use a sliding board.  For those people who do need an assisted transfer, adjustable bed height will also facilitate transfers and lift assistance.  Since the bed is adjustable, its ability to be lowered to within 15 inches from the ground to the top of the cushion will not impede the bed's ability to serve taller individuals as well, with or without disabilities.  Key accessibility features needed for hospital beds include:

Gurneys are frequently used for diagnostic and other medical procedures and should be included in the Access Board's promulgation of design standards setting forth minimum technical criteria for accessible medical diagnostic equipment used in, or in conjunction with, provider offices, clinics, emergency rooms, hospitals, and other medical settings.  For example, gurneys are typically used for ultrasound, electrocardiogram, catheter, and gastro-intestinal procedures, as well as for transferring patients within a medical facility or campus.  Many hospitals and clinics prefer the use of gurneys because (i) patients can remain in one position and still be moved easily by staff for multiple procedures and/or tests, (ii) patients can receive tests and treatment and then recover on the same surface with less lifting/transfer assistance by staff and resulting strain on the patient, and (iii) fluids that can spill to the floor during clinical procedures and tests require ease and quickness of equipment movement for cleaning and sterility purposes.  Since gurneys commonly are used for diagnostic procedures, the Department should mandate essentially the same accessibility features as needed in beds, with the following explicit additional requirements to clarify that a patient typically may use a gurney for less time than a hospital bed, but use for any length of time requires the following minimum features:

The incorporation of accessibility features in gurneys used exclusively for surgical procedures or in hospital emergency rooms may appear to be unnecessary since staff members almost always perform transfers in those contexts.  However, adjustable height features are still very useful during staff transfers.  In addition, an individual with a disability can be required to spend an unexpected and considerable amount of time on a gurney while in the ER or after being prepared for surgery.  Those individuals who are at risk of pressure sores and/or who require position and stability support while lying prone, as well as larger individuals or persons with balance issues, should be able to rest as comfortably and securely as possible whether they are undergoing a scheduled examination procedure or awaiting an emergency consultation or surgery.

5 (b). Are these features available in products that are currently available?

These features are available in products that are currently available, though they may not yet be collectively available in a single product.  Hospital beds are commonly available that go to 15 inches from the floor to the top of the mattress.  There are now hospital beds available that go even lower than the recommendation made here.  See for example http://www.phc-online.com/Full_Electric_s/14514.htm (last visited December 24, 2010).  Hospital beds are also available in semi-electric models, where the head and foot position is controlled by an electric hand control and a manual crank sets the bed height, and full-electric models, which have an additional motor that controls the bed height with an electronic hand control.

Gurneys commonly available on the market have tended to have a higher minimum height than hospital beds, and the move toward a thicker cushion of 5 to 6 inches, while welcome because it preserves patient skin integrity and comfort, has raised additional concerns since the cushion can increase the minimum adjustable height for transfer purposes.  A typical minimum gurney height on the market is 20.5 inches from floor to platform (excluding the cushion).  However, gurneys that lower beyond this point do exist.  For example, Stryker's Power-PRO XT is an emergency services gurney that goes to a minimum height of 14 inches, is adjustable in length, and has a weight capacity of 700 pounds.[15]   This particular model is intended for use in emergency responder vehicles rather than in an ER or clinical context, but this and other similar models could be modified for such use (e.g., provided with wheel locks and additional ancillary positioning and support equipment) given the desirability of its other accessibility features.

6 (a). What technologies are currently available to increase the accessibility of infusion pumps?

Infusion pumps are used to distribute nutrients or such medications as hormones, pain relievers, or antibiotics through fluids that are delivered in controlled dosages as low as 0.1 mL/hour throughout the day.  The infusion of fluids can occur through intravenous, subcutaneous, or epidural methods.  The pumps commonly will be characterized as either large volume, associated with nutrient delivery, or small volume, associated with medications.  Both large and small volume pumps can be designated as stationary or portable within a clinical setting.  Ambulatory pumps designed for outpatient use tend to be more compact and are completely portable.

Infusion pumps can be programmed by patients, but in many cases the units are pre-programmed by a clinician.  However, the programming often consists of merely setting a ceiling level of medication beyond which a patient cannot deliver higher dosages, so that the patient remains responsible for the pump's delivery of correct dosages and for monitoring those dosages.  Patients must therefore have the capacity to accurately input, monitor, and potentially correct an infusion pump's dosing rates and volumes, even in pre-programmed systems, as over- and under-infusion can lead to serious problems for the patient.  Regulations require that infusion pumps have alarms associated with errors in input or problems in delivery, but the alarms tend to be only auditory, with some also providing error indications through visual output on the display screen.  Common problems that can occur with infusion pumps include data entry errors due to such problems as a misplaced decimal point, errors relating to volume or rate of flow that can arise from leaks or kinks in delivery tubing, and incorrect input of infusion begin and end times.[16] 

Ambulatory infusion pumps enable an individual to administer needed nutrients or medications in the comfort, convenience, and privacy of one's own home.  This option must therefore be equally available to people with disabilities, which requires mandating the following features for effective and safe use by individuals with visual and motor control impairments:

Some newer infusion pumps can be controlled through a PDA or personal computer.  This would be a useful option for inputting and monitoring infusion pumps if a person with a disability already uses an accessible PDA or personal computer, though the infusion pump itself should still have the capacity for providing multi-sensory alerts.

6 (b). What types of infusion pumps are partially or fully operated by patients in the normal course of treatment?

See answer to 6 (a).

7 (a). What are the greatest difficulties facing individuals with disabilities in accessing rehabilitative and exercise equipment and furniture in a therapeutic setting?

People with various disabilities face similar barriers to using rehabilitative and exercise equipment and furniture, regardless of the setting.  In a therapeutic setting, individuals exercise to regain or maintain range of motion and strength after experiencing a primary or secondary impairment or injury.  However, the main categories of activity offered in rehabilitation include stretching/flexibility exercises, strength training, and cardiovascular endurance training, which are the same main exercise activities offered in a non-therapeutic gym or fitness center.

Unfortunately, even in therapeutic settings these activities are usually offered on or through equipment that assumes users have a body type within "average" height and weight ranges, and such physical capacities as the use of the legs, the capacity to grip, unimpaired vision, and fine motor control.  One product survey of cardiopulmonary equipment "found a lack of accessories and options that would better assist users with impairments. Removable seats, access to weights, ergonomic pins, cuffs, supports and safety devices have all been identified as desirable features for universal equipment, yet most of the products found have been targeted for the younger, unimpaired population."[17]

There is a difference in operations between therapeutic settings and non-therapeutic settings.  Exercise in a rehabilitation context is usually more closely supervised, and providers either control the machine settings and/or provide ready assistance with adjusting machine settings and transfers.  However, while the goal of rehabilitation is usually recovery from a specific injury or health event such as a stroke, maintaining functional recovery inevitably requires the ongoing use of exercise equipment as part of one's lifestyle.  The therapeutic setting is the ideal place and time for individuals to gain access to barrier-free exercise equipment and to learn how to use such equipment as independently as possible in anticipation of a return to the community.  Some of the main access barriers interfering with the goal of independent access to rehabilitation equipment are:

7 (b). What equipment and furniture most effectively permits accessibility for different types of rehabilitative needs?

Many rehabilitation and exercise machines could be made more accessible and easier to use for people with disabilities and seniors with newly acquired health conditions through low cost adaptations such as the ones described below.[18] 

Additional design modifications such as control consoles that feature raised lettering, single-handed adjustment levers, weight machines that have lower starting weights and smaller incremental gains, and recumbent cardio machines with hand and feet components that can move together or separately also enhance accessibility for different rehabilitation needs.  Such design modifications are also critical to accessible exercise equipment in non-therapeutic settings and is described in greater detail in the comment on Exercise Equipment, in the section on "Universal Design: Accessible Exercise Equipment is Available" in the answer to Question #12.

7 (c). Can different types of equipment meet different access needs of, for example, people with low-vision who need access to visual displays on equipment?

Universally designed exercise equipment, developed and manufactured by such innovative forums as the Inclusive Fitness Initiative (IFI) in England, is commercially available and combines multiple features that assist people with low-vision and/or limited manual dexterity or mobility.  All IFI certified machines include such features as slower starting speeds on cardiovascular equipment and lower starting weights and weight increments for weight machines that would be particularly helpful in a rehabilitative context.

Further, all accessible exercise equipment must meet the Section 508 technical standards, which will guarantee access to on-screen information through audio output and tactile controls. This will make the exercise equipment accessible to people who are blind or have vision impairments.

Please see the comment on Exercise Equipment, in the section on "Universal Design: Accessible Exercise Equipment is Available" in the answer to Question #12.

7 (d). Are there differences between exercise equipment in therapeutic settings and exercise equipment in non-therapeutic settings (e.g., gym or fitness center)?

As noted above, accessibility barriers and solutions are essentially the same for exercise equipment in therapeutic and non-therapeutic settings.  However, there are possibly other needed aspects in rehabilitation equipment that may result in a particular machine not being entirely interchangeable from one context to the other.  Cardiovascular and strength-training equipment that is designed specifically for therapeutic use generally has smaller incremental weight and resistance increases than comparable machines built for recreational fitness.  For example, a weight machine in the rehabilitation context should have weights that increase in increments as low as 1.25 pounds.  This is a desirable feature for people who are methodically rebuilding strength after an injury or a newly-acquired health condition.  However, the need for lower increments may limit the machine's total weight capacity, thereby limiting the machine's use in a non-therapeutic context for consumers with and without disabilities who are seeking a heavier work-out.  Machines that combine the potential for very small weight or resistance increments and the full cumulative weight or resistance total desired in a general fitness market may either be difficult or less cost-effective to design and manufacture.

In sum, the lower total weight and resistance ranges possible in equipment that is especially designed for rehabilitation purposes reduces the risks of re-injury or strain for therapeutic users, but may make the machine less appropriate for the general fitness consumer.  Facilities such as Veterans' Administration hospitals who can serve veterans with and without mobility or vision disabilities, seeking therapeutic and non-therapeutic activity, often have a mix of both recreational and specialized rehabilitation equipment in light of the slightly different consumer needs fulfilled by each category of equipment.  Notably, this difference has no impact on the common need for accessibility features and maximum independent access in both specially rehabilitative and general exercise equipment.

7 (e). What exercise equipment or machines are available to meet the needs of individuals with mobility impairments?

For particular models and types of accessible and universally designed strength and cardiovascular training equipment, please see the comments on Exercise Equipment, in the section on "Universal Design: Accessible Exercise Equipment is Available" in the answer to Question #12.  Endorphin Rehabilitation and Fitness Solutions, at http://www.endorphin.net/ (last visited December 29, 2010), provides one example of accessible specialty exercise equipment for rehabilitative and therapeutic settings.  The company produces cardiovascular and strength training machines with such features as rotating and removable seats, independent upper and lower limb workouts, height-adjustability on upper body cycle machines, and wall-mounted weights which will work for a wheelchair user.  Endorphin has supplied some general fitness facilities such as YMCAs, but their exercise equipment has mainly been purchased by distributors for long term care facilities, hospitals, clinics, and rehabilitation centers.

8. What types of ancillary equipment are most effective in different types of medical or dental examination or treatment settings?

Many people with disabilities have difficulty assuming, and maintaining for any length of time, positions commonly required for various examination and treatment procedures (e.g., lying prone).  Individuals who at risk of experiencing pain, loss of balance, and/or spasticity with transfers benefit from both procedural flexibility and an innovative willingness to accommodate on the part of health care providers and technicians, and the provision and informed use of adaptive ancillary equipment.  Some of the most useful and common examples of such ancillary equipment include:

Examples include the UMF Patient Assist Armrest, which rotates 360 degrees and can be locked into place, though one problem with this armrest is that it cannot be fully recessed and therefore interferes with a wheelchair user's lateral transfer even when the armrest is folded down.  Another example is Articulating Knee Crutches, which provide stability and control to patients who cannot hold their legs in place by themselves.  Midmark's Ritter 222/223 Barrier-Free Power Examination Table and 623/623 Barrier-Free Power Examination Table offer the option of articulating knee crutches. 

9. Is there a need for separate standards for bariatric medical equipment and furniture in the Department's equipment and furniture regulation?  If so, what equipment and furniture are necessary to address the needs of patients with disabilities who are obese?

The ideal of universal design, as well as the principle of full inclusion, calls for the design of medical equipment and furniture that can meet the examination and treatment needs of all individuals, including those who are heavier.  Most equipment and furniture that works for the bariatric population will work for all persons, and health care entities should be strongly encouraged to acquire equipment and furniture that not only meets the disability accessibility standards established by the Department, but also meets the following standards required by bariatric patients:

At the same time, a provider, clinic, or hospital department that specializes in bariatric patients must be capable of accommodating disability needs that may or may not typically accompany obesity.  Such entities must also meet the accessibility and scoping standards (e.g., barrier removal, availability of ancillary equipment, provision of effective communicate aids and devices, policy modification, etc.) that are applicable to all facilities. 

Examples of bariatric equipment and furniture include:

10. What are the key criteria for scoping in different types of medical settings? What are appropriate scoping requirements for each of the types of medical equipment and furniture discussed above?

            Introduction

Our scoping and triggering recommendations below cover the need for regulatory standards on accessible medical equipment and furniture in a full range of health care facilities.  The Department has issued regulations on scoping for architecturally accessible patient and resident rooms in medical facilities where the stay exceeds 24 hours (2010 ADA Standards, §§ 223 and 805).  These existing regulations are clearly pertinent to medical equipment regulations, given the relationship between equipment and architecture already discussed in the general introduction to the medical equipment questions.  However, the Department has not issued specific architectural scoping requirements for outpatient facilities.  In that regard, our outpatient facility recommendations are based on two critical pieces of information that we would like to draw specifically to the Department's attention.

First, outpatient health care services and nonhospital settings are extremely significant for people with and without disabilities.  The National Ambulatory Medical Care Survey found that "[a]mbulatory medical care in physician offices is the largest and most widely used segment of the American health care system."[19]  In 2006, over 900 million visits to office-based physicians took place, and over 50 percent of these were made by patients who had one or more chronic conditions such as hypertension, arthritis, or depression.  Outpatient physician services ranged from primary care to highly specialized surgical and medical consultations and care, and approximately four-fifths of these services took place in a range of physician offices such as private practices, urgent care centers, public health centers, family clinics, mental health centers, community health centers, and family practice plans.  In addition, 83.4 percent of the visits surveyed were to practices "either owned by a physician or a group of physicians."[20]  As the National Council on Disability has noted, "[i]t is critical that offices involved in delivering ambulatory care be physically and programmatically accessible, given the wide-ranging types and amounts of services delivered in those offices and clinics."[21]

Second, accessible medical equipment is profoundly absent from outpatient offices and clinics.  The following information comes from a very recent study[22] that reviewed data from the on-site facility site reviews collected between 2006 and 2010 by 5 health plans serving California Medicaid enrollees in 10 counties.  California's Department of Health Services requires the facility site review (FSR), which is conducted when a primary care provider first joins a plan, and every 3 years thereafter.  Through the influence of California's disability advocates, these 5 plans chose to administer an optional 55 item add-on questionnaire, designed to assess disability access, in conjunction with the required FSR of their primary care provider sites.

The study used 2389 reviews from primarily urban sites.  The primary care providers' surveyed had specialties in general medicine, internal medicine, family practice, pediatrics, or obstetrics and gynecology.  While the add-on tool included questions relating to various accessibility elements such as parking and restrooms, the critical elements for the purpose of this ANPRM pertain to examination equipment (i.e., exam tables and weight scales) and examination room space.

The findings on the availability of accessible equipment are stark.  Across all primary care specialties and locations surveyed, 8.4 percent have an accessible exam table, and 3.6 percent have an accessible weight scale.  Interestingly, accessible exam tables appear to be more common in rural areas:  17.9 percent of non-urban offices have an accessible exam table, while only 7.8 percent of urban offices have such a table.  The percentage of practices that have an examination room with sufficient clear floor space for a person using a wheelchair to perform a 180 degree turn and no door that swings into the space is somewhat more encouraging: 89.6 percent in urban offices and 97.6 percent in rural offices.  Across primary care specialties, general medicine practitioners consistently had the lowest rates of compliance with exam clear floor space requirements (88.6 percent), and the smallest percentages of accessible tables (8.4 percent) and accessible scales (2.2 percent).  Obstetrics and Gynecology practitioners had somewhat greater amounts of compliance with exam clear floor space (96.6 percent), accessible tables (18.4 percent), and accessible scales (10.3 percent).

Note that these findings were made 16 to 20 years after the passage of the ADA.  The surveys were administered in California, arguably a state that has a higher degree of architectural accessibility, greater awareness of accessibility needs, and a lengthier history of accessibility legislation than many other states.  It would be surprising if the numbers are significantly better in terms of access in any other state.  Also keep in mind that the "accessible equipment" being surveyed consisted only of exam tables and weight scales, two of the most basic tools used in medical care, both of which existed in readily available accessible versions at the time.  The logical conclusion is that providers, even those who may be well-intentioned about providing accessibility, are disinclined to take concrete steps to provide access unless the required actions are clearly defined, explicitly regulated, and incentivized either through the stick of enforcement and/or the carrot of tax breaks or deductions.

America's concern over steadily rising health care and insurance costs has led to an increasing focus on preventative care and health maintenance among health policy experts, medical experts, and all levels of government.  More is being discovered and reported every day on how individuals, together with their health professionals, could better manage their health.  Obviously it is important for people with disabilities to have access to accessible hospital rooms and long term care facilities, but it is equally or more important for people with disabilities to receive full and equal access to the timely outpatient care that will enable them to stay out of hospitals and remain in their communities.  People with disabilities will be left behind and experience more and more health disparities if the nation's health care infrastructure and provider cultural competence is not improved urgently and effectively.  The following scoping and triggering recommendations are made with these goals in mind.

10 a). What are the key criteria for scoping in different types of medical settings?[23]

The two most important criteria for scoping that apply to both inpatient and outpatient medical settings are the type of medical specialty being practiced, and the type of medical equipment/furniture being regulated.

            Medical Specialty

The Department has already recognized the first criteria, medical specialty (or no specialty), as a critical element in its existing regulation of accessible patient rooms required in new construction and alteration of medical facilities where patients stay longer than 24 hours.  If a medical facility specializes "in the treatment of conditions that affect mobility," then "100 percent of the patient sleeping rooms shall supply mobility features."[24]   Where a medical facility does not specialize in mobility-related conditions, it is required to have mobility features in at least ten percent of its patient rooms, but no fewer than one, in any event. [25]  The Department's newly revised regulations on new construction and alterations in medical care facilities, in both Title II and Title III, states that "medical care facilities that do not specialize in the treatment of conditions that affect mobility shall disperse the accessible patient bedrooms required by section 223.2.1 of the 2010 Standards in a manner that is proportionate by type of medical specialty."[26]

The easily understood rationale for this is that if a practice primarily caters to people with or at risk of mobility impairments, then all of the practice's patients have a clearly demonstrated need for accessible rooms. Even if a medical practice is more general in nature, the dispersion requirement is necessary because "[w]hen accessible rooms are not fully dispersed, a person with a disability is often placed in an accessible room in an area that is not medically appropriate for his or her condition, and is thus denied quick access to staff with expertise in that medical specialty and specialized equipment."[27]  The Department therefore recognizes that people with disabilities need accessible rooms across the full gamut of specialty practice areas, and "[a]ccessible rooms should be dispersed throughout all medical specialties, such as obstetrics, orthopedics, pediatrics, and cardiac care."

Just as the Department has taken regulatory action to require a specific degree of architectural access for people with disabilities across all of a long term care facility's departments, the Department should require specific degrees of medical equipment access across all of a medical facility's departments/units and across all primary care and specialist outpatient offices and clinics.  People with disabilities must have disability access across specialists and specialized equipment from providers who are also geographically and contractually accessible (e.g., who accept Medicare, Medicaid or the health coverage in question).  However, it is not really possible to simply require an overall accessible equipment percentage figure for outpatient practices owned by physicians or physician groups since, unlike a medical facility or hospital, they do not fall under a common administrative umbrella.[28]  As a result, each office or clinic must be required to meet its own medical equipment and furniture scoping obligations, though the Department could provide some leeway for how a clinic or practice fulfills this obligation (see response to 10(b)).

If an individual with a disability is "denied quick access to staff with expertise" when he is placed in an accessible facility room outside of the particular unit where he is receiving treatment, the situation is even worse for an individual who cannot receive fundamental health care services at the provider of his choice because there is no accessible equipment.  For example, a pregnant wheelchair user decides upon a obstetrics-gynecological practitioner that she is comfortable with based upon the provider's birthing philosophy and level of expertise, but the provider's office lacks an accessible weight scale.  The situation in this case is akin to the need in public transit to have every bus on a transit route accessible, and not simply a percentage of buses overall.  A transit rider who will only have access to every second or third bus simply does not have full and equal access to the public transit service.  Similarly, a person with a disability does not have full and equal access to medical services if basic accessible medical equipment is only available in certain outpatient offices, there is inadequate or no dispersion across specialty practice areas and geographic boundaries, and the burden lies on the person with a disability to figure out who does and does not have accessible equipment.

While the Department's amended 2010 regulations require 10 to 100 percent accessible patient rooms in newly constructed and altered medical facilities, the lower limit of 10 percent should not comprise the lower scoping limit for accessible equipment and furniture in medical facilities or outpatient offices.  Again, there is a clear distinction between the burden and expense associated with architectural alteration and the acquisition of equipment and furniture.  Even more importantly, 10 percent very likely underestimates the need for accessible equipment across all types of medical facilities.  Individuals with and without chronic impairments admitted to inpatient facilities are likely to have conditions that can at least temporarily affect mobility, balance, and/or muscle control.  Outpatient services are needed by people with disabilities, people recovering from orthopedic injuries or surgery, seniors with joint paint or fatigue, heavier individuals, and other who will all benefit from accessible medical equipment.  Accessible patient rooms in long-term medical facilities clearly must come with a full range of adjustable equipment such as beds, exam tables, weight scales, lifts, shower benches and commodes.  These categories of equipment must at the same time be readily available for the use of other patients who because of personal choice, demand outstripping availability, or because architecturally accessible rooms are not readily achievable in existing facilities, are not occupying an accessible room but require accessible equipment for effective examination and treatment.  The same reasoning holds true for outpatient office and examination rooms.   

            Type of Equipment

There are relevant distinctions within the broad category of medical equipment and furniture for scoping and triggering purposes.  Certain equipment categories such as exam tables and chairs, weight scales, gurneys, hospital beds, commodes, and lifts (either portable or track) are essential to basic medical examination and treatment services.  EIT items necessary for effective communication, such as nurse call buttons operable by those with limited manual strength or movement, audible information formats, and accessible healthcare computer kiosks, should also be considered basic since effective communication is fundamental in the medical context.  For the most part, these categories of equipment are currently available in accessible versions, and are relatively inexpensive.  Given the dearth of this equipment in the field, the urgent need, and the relative ease of acquisition, these categories should have higher scoping and more urgent triggering requirements that are not simply dependent upon the end of the item's useful life or its replacement.

Another important point is that what comprises "basic" equipment under this factor may interact with the type of specialty.  That is, some equipment such as exam tables, weight scales, and beds generally cut across all types of primary care and specialty practices.  However, within a particular department or unit, such as a maternity ward, a birthing chair could be considered an item of "basic" equipment such that it should be subject to the scoping and triggering requirements applicable to the basic equipment category.  Obviously a birthing chair is unlikely to be considered a basic item in an oncology department, but infusion pumps and infusion recliners could be subject to higher scoping and triggering requirements as basic equipment in an oncology department or outpatient laboratory.  The Department should specify those pieces of specialty equipment that serve a basic function within different specialties.

Highly specialized and expensive radiological diagnostic equipment such as MRI machines are certainly needed, but accessibility features and design modifications on the equipment itself may not yet be commonly available or fully realized.  In addition, these items of equipment are most analogous to architectural features because often they are costly to modify or replace, are highly regulated, and raise significant issues of interaction with the architectural environment because of their bulk of configuration.  While accessibility features for these items are still urgently needed, they potentially could have lower scoping requirements, and triggering that is tied to the end of the equipment's useful life, its voluntary replacement, or the purchase of new pieces of equipment.  Moreover, the lift equipment and staff assisted transfer policies that enable this equipment to be used by people with disabilities even when the equipment lacks inherent accessibility design features should still be subject to higher scoping and triggering requirements.

Some of the additional equipment categories needed in the medical context, such as waiting room furniture, sanitizer dispensers and vending machines, in-patient sleeper chairs, and emergency evacuation equipment, needs to be accessible, but is not quite so centrally critical to the receipt of equal and effective medical care.  Some of these equipment categories simply require more effective and consistent monitoring and enforcement of existing applicable regulations (i.e., reach range for sanitizer dispensers and vending machines).  Others, such as in-patient sleeper chairs, are important because they reinforce the need for companion accessibility in the medical setting, and acknowledge the reality that spouses, parents, and other family members and friends can also be people with disabilities that must be accommodated in the medical setting.  These equipment categories could have scoping and triggering requirements that are not as urgent as those set for basic categories of medical equipment and furniture.

10 b). What are appropriate scoping requirements for each of the types of medical equipment and furniture discussed above?

Our recommendations for scoping requirements for medical equipment and furniture are as follows:

One final scoping recommendation concerns medical equipment and furniture that is not yet in common use or is in development.  As DREDF has indicated in other places, including our overall comment to the ANPRMs and in the general introduction to the medical equipment questions, we hold the strong opinion that any equipment, device, or medium commonly used in services offered to the general public, including something that is not explicitly mentioned in the law or regulations because it was developed or become ubiquitous after the ADA was enacted, is already subject to the accessibility requirements of the ADA.  Nonetheless, the Department's specific guidance and actual regulation on critical new technologies and equipment is often very helpful for the disability community and covered entities.  We would welcome the Department's general acknowledgement that medical equipment and furniture, including items which remain in research and development phases, is usually accessible if universal design principles are kept in mind.  There may also be some larger covered entities that are following an equipment and capital replacement schedule which includes items which do not yet have a widely recognized fully accessible version, and could benefit from some guidance on the alternative equipment models currently available.

Some of this guidance could be accomplished through a straightforward list of list of fundamental dos and don'ts as follows:

In conclusion, the above scoping provisions will not affect the operation of the defenses given to covered entities under the ADA.  These defenses take into account the needs of medical facilities to consider the financial, architectural, and practical impact on their practices as they work to fulfill their obligations under federal disability law.  The above requirements are designed to level the playing field and no longer leave practically all the risks of lower quality or inaccessible health care on people with disabilities, who historically have had to constantly call providers with inquiries about accessibility and advocate for themselves merely to get the basic examinations and medical treatment that non-disabled peers take for granted.  Medical facilities and providers should at least educate themselves about the accessibility needs of patients with disabilities and the equipment options that exist, review their own policies and procedures, and engage in an assessment of their own ADA obligation to provide full and equal access to their services.  These obligations have been in existence for over 20 years.

11. Triggering Events

11 a). How could medical providers time replacement or modification of equipment and furniture to ensure that individuals with disabilities receive equal access to healthcare without undue delay?

Given the urgent and widespread need for basic accessible medical equipment, the Department should mandate that every outpatient medical provider, across all general practice and specialist categories and sizes, have at least one accessible exam table, weight scale, and mechanical lift within one year of the date on which the regulations take effect.  In addition, specialist facilities must have at least one accessible piece of every item of "basic" equipment for that particular specialty (e.g., a mammography machine for a mammography or breast cancer clinic, accessible infusion chairs for dialysis, radiology or other treatment clinics, MRIs for imaging laboratories) within the same one year timeframe.  Newly constructed and altered general inpatient medical facilities must have sufficient accessible items of "basic" equipment to service every accessible patient bedroom, dispersed by type of medical specialty, within one year of the date on which the regulations take effect.  This will at least provide an initial breadth of accessibility across the health care system that is absent at this point.

These limited amounts of accessible equipment in each basic equipment category, however, will not address the depth of accessibility needs in the disability community and the growing senior population.  Inpatient and outpatient medical facilities, therefore, must acquire sufficient accessible medical equipment and furniture to meet specific scoping requirements (addressed in greater detail in 11(b) below) within two years after the date on which the regulations takes effect.  If a covered entity voluntarily chooses to replace or alter any of its medical equipment or acquires additional items, then those pieces of equipment should be fully accessible.  If a covered entity has a defense to its obligation to replace or acquire accessible equipment, for example, items of medical equipment that meet the accessibility standards are not yet available or have not yet received regulatory approval, then the entity should acquire equipment that fulfills as many universal design requirements as possible.  We would like to emphasize that an accessible medical equipment and furniture regulation will have little or no impact on the availability and usability of medical equipment and furniture overall since accessible medical equipment is almost always fully useable by people without disabilities.

We highly recommend that the medical equipment and furniture regulations as a whole specify that all covered entities have an ongoing obligation to acquire accessible equipment and furniture.[31]  Therefore, even if a particular facility may face current limits on its ability to acquire accessible equipment due to the current state of technological development, regulatory issues, product pricing, resources and entity size, and/or other factors, the facility may be obligated to replace and/or modify inaccessible equipment in future as those limitations resolve or diminish.  We also strongly encourage the Department to establish clear standards for accessibility even for equipment that may not yet be readily available on the market, with the anticipation that such standards will increase demand for accessible medical equipment overall, and encourage technical innovators and medical engineers to incorporate universal design and accessibility considerations earlier rather than later in the process of medical equipment design and manufacture.

11 b). What types of triggering events are appropriate for different types of medical equipment and furniture?

DREDF recommends the following specific triggering events:

We also ask the Department to clarify that whenever an obligation to acquire accessible medical equipment and furniture is triggered, the covered entity will have a simultaneous programmatic obligation to develop publicly available policies, practices, and procedures on how the facility and its staff will provide notice of, schedule for use, train staff on operating, and store accessible equipment.

11 c). Should the Department require the purchase rather than the replacement of some accessible equipment and furniture at a certain point?  Should the replacement of inaccessible medical equipment or furniture be triggered only by the end of the useful life of the equipment or furniture?

The replacement of inaccessible medical equipment or furniture should not be triggered only by the end of the useful life of the equipment or furniture.  The functionality of certain types of equipment such as exam tables and some exam chairs does not inherently require "updating" in the same way as technologically dynamic scanning equipment such as mammography or MRI machines.  As a result, frequently used exam tables and chairs may rarely reach the end of their functional life and may be the last pieces of equipment in an office to be replaced, despite their fundamental medical necessity.  A regulation that requires acquisition of at least one piece or 10 percent of basic medical equipment within one year, and meeting scoping requirements of 25 percent, 50 percent, or 100 percent within 2 years, will insure that equipment that has an extended functional life will not remain wholly inaccessible in a medical facility for that extended life.

Given the layered scoping and triggering requirements for medical equipment and furniture acquisition outlined above, healthcare facilities should be required to develop a transition plan for achieving their required scoping obligations in a timely manner.  The transition plan must state the covered entity's priorities for categories of equipment replacement and/or new additions for the three years following the effective date of the regulation, within the broad parameters of the Department's prioritization of "basic" medical equipment over other medical equipment and general equipment and furniture categories.[32]  The plan must cover interim accommodation plans for the period before accessible equipment and furniture is in place, and include policies and procedures for training medical staff on providing lift assistance, and assessing the potential for sharing accessible equipment such as tables and portable lifts, and/or developing in-house or shared lift teams.  If the covered entity defers or plans to defer fulfillment of its scoping requirements in the timeframe required by the regulation, the entity must provide its reasons for doing so and the interim goals and policy modifications that the entity will undertake in lieu of meeting its scoping requirements.  The transition plan must be available for public and Department review upon request.

Please also see the answer to 11(a) above.

Questions 17 and 19

17. Should the standards be different for adjustable beds, such as hospital beds, and for fixed height beds?  Should the Department treat beds in nursing homes in the same manner as beds in hospitals?  Should the Department treat beds in nursing homes or hospitals in the same manner as it treats beds in places of lodging?  Should all accessible rooms have adjustable beds?

We recommend that the Department apply the standards for accessible beds in hospital rooms and inpatient health care facilities to nursing homes and other long term care facilities that require similar levels of skilled nursing care.  Beds in assisted living and other kinds of group living arrangements that may require licensure, but do not offer similar levels of skilled nursing care, at a minimum should be subject to the same accessibility and scoping standards as places of lodging (see comments on Beds in Accessible Guest Rooms and Sleeping Rooms).[33]  As a basic rule for both categories of hospital beds and beds in places of lodging, accessible rooms should have beds that are capable of height adjustment and compatibility with portable lifts (i.e., below-bed clearance), even though the mechanism, minimum height, and range of adjustability may ultimately vary between the standards established in the two main categories.

The scoping requirements for beds in nursing homes should follow the same principle underlying the scoping of beds in inpatient medical facilities that specialize in the treatment of conditions that affect mobility or conditions that affect communication disabilities, given the likely high proportion of nursing home residents with mobility and/or communication disabilities.  That is, nursing homes should be required to have 100 percent accessible "basic" medical equipment and furniture within 24 months of the date on which the regulations take effect, and sufficient items of accessible "basic" medical equipment to readily service every accessible patient bedroom in the facility within 12 months of the date on which the regulations take effect.  The new acquisition of beds in nursing homes after the effective date of the medical equipment and furniture regulations, and before the 100 percent target date of 24 months, should trigger a requirement for the item(s) to be accessible.

DREDF also recommends that all accessible rooms in nursing homes, skilled nursing long term care facilities, and assisted living and other group living homes, be equipped with adjustable beds.  An adjustable bed that conforms to the Department’s anticipated accessibility standards will not only facilitate independent transfers for those individuals who self-transfer, but also make assisted transfers needed for sanitary, recreational, and health maintenance reasons safer and easier for all parties involved.  Obviously no person with a disability should be left for any period of time without the ability to transfer out of their beds for necessity and choice.  If nursing homes, skilled nursing facilities and group/assisted living homes are required by either the Department’s current or updated 2010 ADA regulations to have only a certain percentage of their rooms accessible, all of those rooms should contain adjustable beds in the anticipation that demand for such rooms and beds could easily outpace supply when mobility impairments are so common in the nursing home context.

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.[34]

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:

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,[35] 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:

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.[36]

23.  The Department seeks input regarding the impact the measures being contemplated by the Department with regard to accessible equipment and furniture will have on small entities if adopted by the Department.  The Department encourages you to include any cost data on the potential economic impact on small entities with your response.

24. Are there alternatives that the Department can adopt, which were not previously discussed, that will alleviate the burden on small entities?  Should there be different compliance requirements or timetables for small entities that take into account the resources available to small entities or should the Department adopt an exemption for certain or all small entities from coverage of the rule, in whole or in part.  Please provide as much detail as possible in your response.

DREDF recognizes that regulatory requirements for acquiring accessible medical equipment, and ensuring sufficient notice of, maintenance, and training for the effective use of accessible equipment, will have a financial impact on covered entities.  We would like to reiterate, however, that these are not new regulatory, requirements, per se, but are detailed technical clarifications of existing obligations that all medical facilities have had for at least two decades.  Covered entities, both large and small, and people with disabilities alike benefit when the Department provides explicit appropriate standards to exemplify a covered entity's obligations under the ADA.

The following information is also pertinent in considering the financial or administrative impact that the medical equipment regulations may have on small entities:

DREDF does not support exempting small entities from the general compliance requirements and timetable of the medical equipment regulations because the lesser resources available to some small businesses are already fully accounted for in the carefully wrought balance of the undue burden, fundamental alteration, and readily achievable defenses available to covered entities.  If the additional expense involved in purchasing accessible rather than inaccessible medical equipment and furniture, as required by the Department's medical equipment regulation, constitutes an undue burden to a particular business, then the entity is not required at that time to make the required purchase or perform the requested action.  The Department's adoption of one generally applicable set of medical equipment regulations and timelines has the advantage of greater simplicity and predictability.  Moreover, a uniformly applicable regulation places an appropriate burden on medical facilities of all sizes to assess their capacity to provide the equipment access, effective communication, and disability cultural awareness that is fundamentally linked to effective health care.  The dearth of accessible healthcare in the U.S. today, despite repeated warnings on the implications of the status quo for an aging American population from such respected institutions as the Institute of Medicine and the U.S. Office of the Surgeon-General, calls for this assessment sooner rather than later.

In light of this, we recommend that the Department work cooperatively with the IRS to:


[1] DOJ Advance Notice of Proposed Rulemaking, Nondiscrimination on the Basis of Disability by State and Local Governments and Places of Public Accommodation; Equipment and Furniture (E&F ANPRM), Section IV. Background, Subsection B Legal foundation for equipment and furniture coverage.

[2]See 28 CFR §§ 35.104, 36.303 (2010).

[3] A five year study undertaken by Marquette University from 2003-2007, and funded by the National Institute on Disability Rehabilitation Research (NIDRR), resulted in the work of the Rehabilitation Engineering Research Center on Accessible Medical Instrumentation (RERC-AMI).  RERC produced a number of technical reports on specific medical equipment items that are available at http://www.rerc-ami.org/ami/.  Even though the results have not been updated since 2007, the project's findings and recommendations remain informative and thoughtful.The RERC website has publicly available technical reports on a number of classes of medical products, including examination tables, cardiopulmonary exercise equipment, infusion pumps, weight scales, medical imaging, and medical beds.

[4] For additional information, see http://www.canon.com.au/en-au/Business/Specialist-Equipment/Medical (last visited January 4, 2010).

[5] DREDF strongly recommends that group homes and group living arrangements that purport to specialize in providing housing and care for people with conditions that affect mobility should be subject to the same accessibility and scoping requirements for accessible beds as inpatient medical facilities that specialize in the treatment of conditions that affect mobility, irrespective of the level of skilled nursing care required.

[6] 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

[7] 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.

[8] 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.

[9] According to a population report released in 2008, people aged 55 to 64 were nearly three times (30.1 percent) as likely to have a disability as people aged 15 to 24 (10.4 percent).  The report also detailed an increase in the likelihood of severe disability in successively older age groups, ranging from 3.6 percent for the population under 15 years to 56.2 percent for the population 80 years and older.  See Matthew Brault, 2008, "Americans with Disabilities: 2005," Current Population Reports (Washington, DC: US Census Bureau).

[10]  Debra J. Sheets, 2005, "Aging with Disabilities: Ageism and More." Generations 29, no. 3: 37-41.

[11] Long Term Spinal Cord Injury and Diabetes, Dr. Bill Bauman, www.craighospital.org/sci/mets/ diabetes.asp.  See also, Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf.

[12] Optometric Clinical Practice Guidelines, Comprehensive Adult Eye and Vision Examination, American Optometric Association, Second Edition 2005 (citing Parker S., The Eye and Seeing, Rev. Ed. New York: Franklin Watts, 1989:4).

[13] The Early Treatment Diabetic Retinopathy Study Research Group. How Effective are Treatments for Diabetic Retinopathy? Ferris, I., Journal of the American Medical Association 269(10):1290-1291, 1993. PubMed; PMID 8437309; See also, American Diabetes Association, Clinical Practice Recommendations, 1999.  Diabetes Care 22 (Suppl. 1):S70-S73. PubMed; PMID 10333970.

[14] The Nurse and Health Care Worker Protection Act is an example of relevant legislation that has been introduced in the Senate to preserve the occupational well-being and reduce injury for health care workers engaged in providing lift assistance.  The act explicitly refers to the critical importance of acquiring, and encouraging the use of, lift equipment to reduce injuries among staff.

[15] The predecessor department to HHS.

[16] For example, see Summit Training Source, Inc., "Patient Lifting and Transfer Video/DVD." April 1. 2009. http://complianceandsafety.com/shop/patient-lifting-and-transfer-videodvd-1625.html, and Vanderbilt University Medical Center's "Smooth Moves" program at http://www.mc.vanderbilt.edu/reporter/index.html?ID=3417.

[17] See http://www.visn8.va.gov/patientsafetycenter/safePtHandling/default.asp (last visited December 27, 2010).

[18] See http://www.osha.gov/ergonomics/guidelines/nursinghome/final_nh_guidelines.html for guidelines applicable to nursing homes (last visited December 27, 2010).

[19] Lifting by untrained staff, or non-medical staff such as security guards or parking attendants, should never be considered or offered as a legitimate lift/transfer assistance option.

[20] See http://www.ems.stryker.com/detail.jsp?id=10 for additional information (last visited December 27, 2010).

[21] For additional information, please see Rehabilitation Engineering Research Center on Accessible Medical Instrumentation (RERC-AMI) at http://www.rerc-ami.org/ami/ (last visited December 27, 2010), and RERC's Technical Report on Infusion Pumps, author Megan Conrad, coordinating editor Dr. Jack Winters.

[22] Rehabilitation Engineering Research Center on Accessible Medical Instrumentation (RERC-AMI) Technical Report on Cardiopulmonary Exercise Equipment, authors Lora Mielcarek and Elizabeth Omiatek, coordinating editors Dr. Jack Winters and Dr. Jill Winters at http://www.rerc-ami.org/ami/tech/tr-ami-mu-003_cardio-exercise/ (last visited January 1, 2011), in part citing North Carolina Office on Disability and Health. (2002). Removing Barriers to Health Clubs and Fitness Facilities. North Carolina. North Carolina Office on Disability and Health.

[23] Harris Family Center for Disability and Health Policy, Using a Fitness Center Does Not Have to be an Exercise in Frustration: Tips for People with Mobility and Visual Disabilities at: http://www.cdihp.org/products.html#fitness.  This article describes some of the usability barriers experienced by people with mobility and visual disabilities in fitness facilities, presents ways to remove or reduce barriers, and describes low or no cost solutions as well as more involved long-term solutions.

[24] Donald K. Cherry et al., "National Ambulatory Medical Care Survey: 2006 Summary." National Health Statistics Reports 3 (August 6, 2008), p. 1. While the word "ambulatory" can be used medically in the narrow sense of the ability to walk, the NAMCS survey targets the offices of non-Federally employed physicians "who were classified by the American Medical Association (AMA) or the American Osteopathic Association (AOA) as 'office-based, patient care.'" The specialties of anesthesiology, radiology, and pathology were excluded, but visits to private, non-hospital-based clinics and HMOs were included in the scope of the survey. Ibid., p. 7.

[25] Ibid., pp.2-4. Of the remaining offices, 5.9 percent were owned by another health care corporation, 3.4 percent were owned by another hospital, 2 percent were owned by a medical or academic health center, 1.7 percent were owned by an HMO, and 1.6 percent were owned by a community health center. The remaining 2 percent of offices appeared to be owned by a local government entity or charitable organization, or had left the question unanswered.

[26] The Current State of Health Care for People with Disabilities (September 30, 2009), pp 103-104, available at http://www.ncd.gov/newsroom/publications/2009/HealthCare/HealthCare.html (last visited January 5, 2011).

[27] From Mudrick, N.R.; Breslin, M.L.; Yee, S.; and Liang, M. (2010). Accessibility of Primary Health Care Provider Settings for People with Disabilities: Information from Health Plan Audits [Slides]. Presented at the annual meeting of the American Public Health Association, Denver, CO, November 8, 2010.

[28] 28 CFR 35.151 (h) (new subsection on T II new construction and alterations that specifically addresses medical care facilities): Medical care facilities. Medical care facilities that are subject to this section shall comply with the provisions of the 2010 Standards applicable to medical care facilities, including, but not limited to, sections 223 and 805. In addition, medical care facilities that do not specialize in the treatment of conditions that affect mobility shall disperse the accessible patient bedrooms required by section 223.2.1 of the 2010 Standards in a manner that is proportionate by type of medical specialty.  As amended by DOJ's revised ADA Title II regulations, published Sept. 15, 2010, and taking effect March 15, 2011.  28 CFR 36.406(g) is the equivalent provision for new construction and alterations in Title III public accommodations.

[29]  Department of Justice, 2010 ADA Standards § 223.2.2.

[30] Department of Justice, 2010 ADA Standards § 223.2.1.

[31] 28 CFR 35.151 (h) and 28 CFR 36.406(g).  As amended by DOJ's revised ADA Title II regulations, published Sept. 15, 2010, and taking effect March 15, 2011.

[32] Section-by-section analysis in Final Rule on Nondiscrimination on the Basis of Disability in State and Local Government Services, as published in Federal Register: September 15, 2010 (Volume 75, Number 178) at p. 56217.  The section-by-section analysis of the Title III regulations has the same analysis pertaining to the equivalent dispersal requirement in Title III, in F.R., September 15, 2010 (Volume 75, Number 178) at p. 56309.

[28] There is a possible exception for individual providers or provider groups who contract with a managed care organization that could help potentially facilitate and ensure compliance with required percentages of accessible offices and accessible equipment across all primary and specialty practices in its provider network.

[29] This phrase is intended to cover inpatient hospitals and rehabilitation facilities that specialize in treating conditions that affect mobility, or units within either that specialize in treating conditions that affect mobility.

[30] Please see answer to 10(a) above for discussion on what comprises "basic" medical equipment and furniture categories.

[31] As an example, readily achievable barrier removal by Title III covered entities carries an ongoing obligation, so that a business which faces financial insolvency, for example, and therefore has a defense to undertaking barrier removal, must continue with barrier removal when the business's financial circumstances improve. See DOJ, ADA Technical Assistance, Common Questions:  Readily Achievable Barrier Removal (August 1996) at 11, which also recommends that public accommodations "establish procedures for the ongoing assessment of their compliance with the ADA's barrier removal requirements".  Id. at 9.

[32] We recommend that the Department provide guidance to covered entities on the kinds of factors that the entity should consider in prioritizing its accessible equipment purchases.  For example, exam tables, weight scales, gurneys, and commodes will all fall within "basic medical equipment" as they are frequently used and essential for both examination and treatment purposes.  If a particular outpatient office already has adjustable tables that go to a minimum height of 20 inches, falling short of the required minimum height of 17 to 19 inches, a gurney with a weight capacity that does not reach the required 500 to 800 pounds, and no weight scales with any accessible features, the facility  may prioritize the acquisition or replacement of accessible weight scales in its transition plan, though it will still have to meet scoping requirements for the other pieces of basic equipment according to applicable deadlines.  In other words, a facility may prioritize the most frequently used and least accessible equipment for replacement and purchase and not simply target the oldest or lowest cost equipment.  The department should also offer guidance to covered entities by cataloguing low-cost barrier removal strategies and best practices that can improve access before an office renovation and/or procurement of accessible equipment is complete.  Best practices can exceed current minimum standards and incorporate universal design elements.  For example, grab bars can be installed for fall prevention on the walls adjacent to where an exam table is stationed.  Office staff can be trained to notify patients of the availability and features of all existing adjustable equipment in the facility, and put scheduling procedures into place that will maximize its use, even if equipment currently available does not yet meet the applicable accessibility standards.

[33] DREDF strongly recommends that group homes and group living arrangements that purport to specialize in providing housing and care for people with conditions that affect mobility should be subject to the same accessibility and scoping requirements for accessible beds as inpatient medical facilities that specialize in the treatment of conditions that affect mobility, irrespective of the level of skilled nursing care required.

[34] 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

[35] 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.

[36] 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.