00:00:00
Voice-over: 100 days to success. This is the podcast of G_NIUS, the Guichet National de l'Innovation et des Usages en e-Santé. Around Lionel Reichardt, meet e-health innovators and key experts to help you succeed in your projects.

00:00:20
Lionel Reichardt: Hello everyone! You're listening to 100 Days to Success, the podcast aimed at innovators and entrepreneurs in the digital health sector, as well as anyone curious about this field. This podcast is produced by G_NIUS, the Guichet National de l'Innovation et des Usages en e-Santé. In this episode, we'll be talking about the accessibility of digital solutions for people with disabilities.

00:00:39
Lionel Reichardt: To do this, we welcome Annie Lelièvre, in charge of access to healthcare for people living with disabilities at the Ministry of Health and Prevention. We also welcome Sébastien Vermandel, APF France Handicap project manager.

00:01:00
Lionel Reichardt: Annie Lelièvre Hello and thank you for agreeing to share your experience with us. Could you first tell us a little about your training and background?

00:01:08
Annie Lelièvre: Hello and thank you for the invitation, Annie Lelièvre, I'm in charge of access to healthcare for people with disabilities at the Ministry of Health and Prevention. I have a background in health economics and medical law and I am a graduate of the École des Hautes Etudes en Santé Publique EHESP and after ten years as a facility director, I headed the autonomy division of the Fédération hospitalière de France for four years.

00:01:36
Annie Lelièvre: It's a federation that brings together all public hospitals, mental health establishments as well as EHPAD, establishments providing accommodation for dependent elderly people and establishments providing care for the disabled.

00:01:50
Annie Lelièvre: Since 2019 now, I've been in charge of access to care for people with disabilities, autism and neurodevelopmental disorders at the Direction Générale de l'offre de soins of the Ministry of Health and Prevention.

00:02:05
Lionel Reichardt: You work at DGOS, the General Directorate for Healthcare Offerings, and co-lead a working group on the accessibility of teleconsultation for people with disabilities that your activities cover.

00:02:17
Annie Lelièvre: In fact, I'm co-piloting this working group on the accessibility of teleconsultation for all, and in particular for people with disabilities. And the principle of this group originated as part of the work of the Ségur de la santé en 2020, which followed in particular the first months of the health crisis and the periods of confinement within the framework of COVID-19 and the boom in telehealth and more particularly teleconsultations.

00:02:45
Annie Lelièvre: In fact, during this period, we saw an increase in usage as we went from 135.000 consultations in 2019 to 19.4 million in 2020. A 142-fold increase can be explained by the impossibility of visiting appointments during the crisis and periods of confinement. Telehealth has therefore enabled continuity of access to care, protecting professionals and patients from the risk of exposure to the epidemic, particularly the most fragile patients.

00:03:19
Annie Lelièvre: In a concern that this evolution of digital healthcare benefits everyone. It seemed essential to reflect on the accessibility of telehealth for all, with the aim of ensuring the autonomy of people with disabilities, whatever their handicap. Thus, universal access to telehealth was selected as a priority measure and included in the implementation of the Ségur de la santé, and was requested by the Comité interministériel au handicap as well as by several associations.

00:03:55
Annie Lelièvre: In this context, a working group has been set up and is made up of ministry departments and people concerned with disability, members of associations and representatives of people with disabilities who come from the CNCPH, the National Advisory Council for People with Disabilities, but also from the CNSA, the Caisse nationale de solidarité pour l'autonomie, the DINUM which is the Interministerial Digital Directorate and is in charge of the State's digital transformation.

00:04:30
Annie Lelièvre: Also the participation of the senior official for disability at the Ministry of Health and Prevention. Work will be carried out throughout 2021, with the aim of creating very concrete tools and recommendations by the end of the year.

00:04:46
Annie Lelièvre: These recommendations will be aimed at manufacturers, but also at healthcare professionals to support them in developing teleconsultation solutions so that they can also be a lever for access to healthcare for all. I therefore encourage you to consult its recommendations as soon as they become available by the end of this year.

00:05:06
Lionel Reichardt: Why is it important for a provider of digital healthcare solutions to address this issue of accessibility for people with disabilities?

00:05:14
Annie Lelièvre: Firstly, because it's a universal right that was enshrined in the Convention on the Rights of Persons with Disabilities, which was adopted in 2006 by the UN and recalls the need to take appropriate measures to ensure access for persons with disabilities to information and communication, including information and communication technology systems, and to facilities and services open or provided to the public.

00:05:43
Annie Lelièvre: This is an important subject, since it has a strong ethical stakes and is based on a principle of equality, and the players in society, the players in the healthcare sector, have a real role to play in this access. It's about enabling people with disabilities to live independently and participate fully in all aspects of life, including health.

00:06:08
Annie Lelièvre: It's a challenge of exemplarity and impetus for this field of activity that is healthcare, with human DNA at the heart of its concerns. But it can also be a differentiating lever for manufacturers able to convey this image and its values. It can also be seen as a major competitive advantage.

00:06:27
Lionel Reichardt: We're talking about people living with a disability. Who exactly are we talking about?

00:06:32
Annie Lelièvre: The World Health Organization definition through to that of the 2005 Disability Act. The perimeters used to measure the population affected by disability can vary. However, a few figures give an idea of the scope of the subject and the population concerned.

00:06:52
Annie Lelièvre: Depending on the sources and the scope of disability taken into account, today between 10 and 12 million of France's 66 million people are affected by a disability, i.e. 20 of the population. Disabilities can be motor, psychological, mental or sensory. There are, for example, 1.5 million visually impaired people in France, and 4 million people with a hearing impairment. So, obviously, this classification is not compartmentalized.

00:07:26
Annie Lelièvre: The forms of disability I've just mentioned can be cumulative. They can come from birth, be acquired during the course of one's life, or be permanent or temporary as a result of life's accidents. This brings to 40% the proportion of the French population facing a temporary or permanent disability. Clearly, beyond the figures and definitions, what counts above all is the diversity of situations encountered.

00:07:53
Annie Lelièvre: And the important thing is to take the measure of this diversity of needs. This should encourage us to think in terms of healthcare solutions that are most accessible to those who need them most often. Generally speaking, we mustn't forget that when we make products accessible to people with disabilities, we are often thinking in terms of a more universal, more comfortable and often more ergonomic solution.

00:08:21
Lionel Reichardt: There is a reference framework, the RGAA, a general accessibility reference framework for administrations. This framework is the result of the accessibility obligation imposed by article 47 of the law of February 11, 2005 for equal rights and opportunities, participation and citizenship of disabled people, whose application decree was published in the Journal Officiel on May 16, 2009. The framework version of this standard was published in 2019. What does it mean to make something accessible? What does it cover?

00:08:53
Annie Lelièvre: Disability is defined as any limitation of activity or restriction of participation in life in society suffered in an environment by a person because of his or her situation, a lasting or permanent impairment of his or her functions which may be physical, sensory, mental, cognitive, psychic or a multiple disability or a disabling health disorder. Thus, we understand that the handicap, the limitation of autonomy can be increased in a non-adapted environment.

00:09:26
Annie Lelièvre: This definition applies perfectly to the digital environment, which would not allow optimum ease of use for people with disabilities. Take navigation, for example, which can be slowed down by longer reading or comprehension times. I'm thinking, for example, of people with dyslexia.

00:09:49
Annie Lelièvre: In this case, it's a good idea not to have a limited response or information consultation time to allow everyone to be able to understand and browse the site. Another example is for a person using the mouse who may have pain in their hands, or who uses other means of control such as the eyes, language or voice, the mouse click becomes costly when navigation requires too many mouse clicks, it becomes tedious.

00:10:20
Annie Lelièvre: Then it's a good idea to limit the number and think about platform ergonomics in this sense. A final example of implementing accessibility. This could involve the use of Chabot, a dialog box with a help proposal that appears when the tool detects a user blockage.

00:10:43
Lionel Reichardt: We can see that these examples cover a wide spectrum. How can we foresee and anticipate the different situations of disability in order to comply with accessibility standards?

00:10:53
Annie Lelièvre: In fact, there has been a general accessibility improvement referential, more often referred to as RGAA or RG2A since 2009, the latest version of which dates from 2019. It is published by the interministerial digital department, DINUM. It is a reference framework that is mandatory for legal entities governed by public law, as well as for legal entities governed by private law and delegated with a public service mission.

00:11:19
Annie Lelièvre: In this case, the compliance notice should be displayed on the home page of the site or solution. But it's true that beyond the compulsory aspect, this reference framework groups and lists the criteria that need to be met. To design an accessible solution. And that's how it can be a tool for any manufacturer wishing to commit to this ethical approach.

00:11:42
Annie Lelièvre: DINUM produces quite a lot of content and tools available on its site: moub, awareness-raising or diagnostic tools that ensure you'll be supported in implementing this repository. To return to the reference system. In concrete terms, it is based on four principles. The design elements of the digital solution must be perceptible, usable, understandable and robust.

00:12:11
Annie Lelièvre: First perceptible principle means that the user's visual and auditory perception of the content must be facilitated. This means offering text equivalents for non-textual content, or allowing content to be presented in different ways without loss of information or structure, for example by using a simplified layout. The second principle is that design elements must be usable.

00:12:39
Annie Lelièvre: This means providing the user with orientation elements for navigating, finding content, making all functionalities keyboard-accessible, giving the user enough time to read and use the content, and above all, not designing content likely to provoke epileptic seizures. The third principle is that these elements must be understandable.

00:13:04
Annie Lelièvre: This means making pages work predictably and helping the user correct input errors. And finally, the fourth principle elements be robust, i.e. optimize compatibility with both current and future uses, including assistive and interfacing technologies. Taking, for example, software that would enable Braille transcription,

00:13:30
Lionel Reichardt: Is making your digital solution accessible to people with disabilities complex and costly? Is there a compliance cost?

00:13:37
Annie Lelièvre: It's not possible to estimate a price for compliance that would be a price, a fixed price. Obviously, it depends so much on the context of the teams, the managerial will and the size of the solution. However, it is possible to assert that this accessibility necessarily passes through the HTML code and not through external tools, and in this way to measure the importance of taking this aspect into account right from the design of the solution.

00:14:08
Annie Lelièvre: Some complementary tools can bring comfort to the solution after the fact, but they don't replace the tool itself. Accessible from the outset, this adaptation is difficult and sometimes even impossible. And in this case, it is often more costly when it is carried out retrospectively. If we take the example of building a house, it is, in fact, possible to install, after construction, an aid for climbing a staircase.

00:14:38
Annie Lelièvre: Wider space for sitting in the shower or wider doors and hallways. And this is bound to be more difficult and costly, without any guarantee that it will result in a space organization that meets all the needs of a disabled person. Whether the disability is permanent or even temporary.

00:15:02
Annie Lelièvre: This example clearly shows that if you want to take accessibility into account, you have to think about it right from the design stage. This is really what seems important, and in this case, to think about training managers, designers, developers, in short, all the members of the team so that they are all aware of this necessary accessibility.

00:15:29
Annie Lelièvre: Then, RGAA compliance must be built into the process at every stage of the project - functional specifications, layout, design, etc. - so that we don't have to go back to the drawing board later. That way, you don't have to go back and make changes after the fact. This brings us to another aspect of accessibility that seems fundamental: co-construction.

00:15:55
Annie Lelièvre: For this, an expert person can be present throughout the project where it is possible to solicit expert users during the creation of the solution. Don't hesitate to call on associations that could test the solutions and provide feedback on usage, bearing in mind that the people who will be called on are not necessarily used to working on these issues.

00:16:20
Annie Lelièvre: We'll need to make sure they feel comfortable enough to participate fully in this process.

00:16:27
Lionel Reichardt: What's the advantage of making your digital solution accessible to people with disabilities? Is it a differentiator?

00:16:35
Annie Lelièvre: This participative approach, this ethical reflection on the design of a digital health tool accessible to all, represents an ethical challenge, but also a challenge, a differentiating aspect. Designing a solution for use by healthcare professionals that takes into account the dimension of universal accessibility. This approach positions us as a committed healthcare player.

00:17:00
Annie Lelièvre: This aspect is particularly topical at a time when the digital health space is being set up. What is this digital health space or ENS? Starting in January 2022, the ENS will contribute to the development of the digital health ecosystem in France. With, for users, access to their shared medical record, secure messaging, a health diary for consolidating various medical appointments.

00:17:30
Annie Lelièvre: But also, and this is an important point, access to a catalog of services referenced by the public authorities. An ENS Store that will enable users to choose to give access to data, including health data, from their ENS to the applications of their choice, and conversely, to record data from the applications in their analysis. This desire to promote accessible tools and platforms will be reflected when referencing a digital solution in the ENS.

00:18:02
Annie Lelièvre: It will be required to comply with criteria including access for people with disabilities. These criteria will provide transparency for users, who will know which solutions are accessible and to what extent. This will therefore be a particularly interesting way of differentiating ourselves, since the ENS will make us very visible in a global way.

00:18:25
Annie Lelièvre: This accessibility of digital healthcare solutions will gradually be reflected more and more in calls for projects, calls for expressions of interest that encourage and value entrepreneurs to make all solutions accessible.

00:18:40
Lionel Reichardt: To conclude, Annie Lelièvre, what advice would you give to a healthcare innovator who wants to make their solution accessible to people living with disabilities?

00:18:49
Annie Lelièvre: When we think about a solution, taking into account this accessibility and specific needs, and especially when it's a healthcare solution, we mustn't forget that it's potentially aimed at people with permanent or temporary disabilities. By making it accessible, we ultimately ensure a better user experience, greater comfort, simple and beneficial use for all.

00:19:14
Annie Lelièvre: In practice, this is what seems unavoidable today and has been clearly identified by the experts on the teleconsultation accessibility working group. These are three principles. First and foremost, it means relying on the Référentiel général d'amélioration de l'accessibilité (RGAA). The RGAA, bearing in mind that an accessible digital service is certainly easier to use for people with disabilities, but ultimately of better quality for everyone.

00:19:38
Annie Lelièvre: The second tip is to think about this accessibility right from the start of the project, right from its conception, right from the design of the solution. As we've already discussed, making something accessible after the fact is more costly, and sometimes even more difficult to achieve. And finally, the third recommendation is to consider co-design with a diversity of publics who will be users of the solution, including people with disabilities.

00:20:04
Annie Lelièvre: In order to adjust the solution to all uses. You'll find all this advice in the recommendations produced by the working group, Universal Access to Teleconsultation, which will be produced and published by the end of 2021.

00:20:19
Lionel Reichardt: Annie Lelièvre Thank you for this information. You're wondering about the accessibility of digital health solutions for people with disabilities. Sébastien Vermandel, APF France Handicap project manager, provides some answers.

00:20:37
Lionel Reichardt: Sébastien Vermandel, hello and thank you for accepting our invitation. First of all, could you tell us a little about your background and training?

00:20:45
Sébastien Vermandel: I'm the monitoring and consulting manager at TechLab APF France Handicap, I'm a biomedical engineer from the Université de Technologie de Compiègne and I did a PhD in biomedical engineering at the same university. After that, I was successively a research engineer in a medical instrumentation company.

00:21:05
Sébastien Vermandel: Then I was in charge of corporate relations at GIE Eurasanté, which is an economic interest group promoting the healthcare sector in France. I then had a short stint in a start-up. And then I finally joined APF France Handicap, almost three years ago.

00:21:24
Lionel Reichardt: You're actually a project manager at APF France Handicap. Could you tell us about this association and your missions?

00:21:29
Sébastien Vermandel: APF France handicap, it's a huge association. It's not widely known, but it's the second largest association in France, just behind the Red Cross. To give you an order of magnitude, there are some 14,500 employees managing 13,000 members and around 25,000 users. So, I'm making a distinction between members and users because the APF is mainly two big activities.

00:21:51
Sébastien Vermandel: A historic activity linked to representing people with disabilities, defending their rights, what we call the movement. Hence the 13,000 members. The association's other major activity is the management of medical-social establishments. The association manages some 450 establishments throughout France, including the French overseas departments and territories, which now account for the bulk of the 14,500 employees.

00:22:21
Sébastien Vermandel: I'm in a particular department of the association called Tech Lab, the innovation hub, which is a very recently created department that actually brings together two previously existing entities. One entity, which I manage and which is based on rue de France in Tourcoing, is called Tech Lab veille et conseil. Our activity consists of monitoring and providing information on what we call digital technical aids.

00:22:46
Sébastien Vermandel: This is an activity that, historically, has existed in the region since the mid-90s, and which then brought together occupational therapists, speech therapists in the team. The main mission is to monitor and evaluate everything that comes out in the field of technical aids for digital access, which results in the production of Fact sheets that are published bimonthly.

00:23:07
Sébastien Vermandel: And we also carry out a number of training and consulting assignments on these subjects. The other activity within the Tech Lab is an activity that is more present at the Paris headquarters of APF France Handicap, called Ateliers de l'Innovation (Innovation Workshops). The general idea is to enable companies of all sizes, from start-ups to major corporations, to collaborate with disabled people in their innovation process.

00:23:33
Sébastien Vermandel: So, we're making available both panels of users with diverse and varied profiles, but all disabled, what we call "Extreme Users". And we're also making methodologies available, because data collection methodologies necessarily have to be adapted to the different types of disability that can be encountered.

00:23:50
Lionel Reichardt: Following this work. You have published over 500 Fact sheets evaluating solutions for people with disabilities. You also have a YouTube channel featuring some sixty video tutorials. Why is it important to do this accessibility assessment work?

00:24:08
Sébastien Vermandel: This is important for two big reasons. The first is that professionals working with people with disabilities don't necessarily have the time to do this work, even though it's all about new technologies. There's something new almost every day. Just as an anecdote, Apple held a keynote last night, where they announced around twenty new features on IOS related to accessibility, of which we are of course the recurring ones.

00:24:33
Sébastien Vermandel: As a result, the association has chosen to keep its teams informed through us. This is really, really important. It's at the very heart of the association's project. This notion of digital inclusion is really asserted, and that's why our structure exists. The second point is that, in fact, we realize that to have the right tool, you need the right information.

00:24:58
Sébastien Vermandel: And so, it's also very important for us to deliver both qualitative and objective information on all the tools that come out to avoid a default choice. Just because you're disabled doesn't mean you don't have the right to the best possible access to digital tools. It's become essential, so maybe eight or nine years ago.

00:25:22
Sébastien Vermandel: First and foremost was the mobility of people with disabilities and their rights. Recent events have accelerated this. Digital technology has become indispensable. Clearly, we can't work. We can't have access to training, education, schooling if we don't have access to digital tools.

00:25:39
Sébastien Vermandel: Now, the confinements we've all experienced will further accentuate this digital pressure, and so as a result, is really important to keep the information up to date for all these tools.

00:25:51
Lionel Reichardt: Within the TechLab. You talk about inclusive innovation. Can you define this concept? What questions should a digital health project developer ask himself if he wants to make his solution accessible?

00:26:02
Sébastien Vermandel: The aim is to take into account the needs of all users, including the needs of so-called "extreme" users. People with disabilities are truly extreme users. But overall, we can take into account the needs of people in precarious situations, the needs of people who are illiterate, and the needs of the elderly. In the end, we realize that these needs generally converge.

00:26:26
Sébastien Vermandel: Taking into account the need of a person who for physiological reasons has a tremor. Either an elderly person or someone with a disability. And this will have an impact on the design of a website, for example, because if the buttons are too small and the person has tremors, they'll never manage to click on them.

00:26:47
Sébastien Vermandel: It's vital now, right from the design phases, whether it's hardware or software, to take these particular needs into account. The main question an entrepreneur has to ask himself is: is the solution I'm developing really going to be usable by everyone?"

00:27:07
Sébastien Vermandel: And so we go out and contact local authorities and businesses, explaining to them that it's important for everyone to be able to access the services that will be offered or the software, or that that's the answer we often get is anyway, people with disabilities don't come here where they don't use this type of object.

00:27:29
Sébastien Vermandel: In fact, it's a mistake because we realize that it represents a significant market. It's estimated that around 20% of the population has a disability. What kind of disability? What's really important is that it also represents a financial market. We found, for example, that the first users of online sales services were people with disabilities because it was going to revolutionize life.

00:27:51
Sébastien Vermandel: There was no need to go to a physical location to be able to buy a product. So it's good to bear in mind that any action we can take to make life easier for this audience is bound to have an impact on the general public. In the field of inclusive innovation, we're often used to considering that the situation of disability may be permanent, but it can also be transitory.

00:28:11
Sébastien Vermandel: Typically, you can have hemiplegia and not be able to use your left arm. You can have a broken arm, or you can simply come home from the shops, carry a parcel and not be able to use your left arm. And in all three cases, you're in some form of disability and so any design that takes into account this particular event of saying, I can't use my left arm would be beneficial for the whole population anyway.

00:28:37
Lionel Reichardt: Sébastien Vermandel, to conclude, what advice would you give to an entrepreneur who wants to make their digital health solution accessible to people with disabilities?

00:28:46
Sébastien Vermandel: The first piece of advice is to get involved as early as possible and make contact as early as possible with "extreme users", people with disabilities. To do this, there are some relatively simple solutions. You can go through TechLab, as we have a series of co-creation workshops that make it easier for companies to meet these "extreme users".

00:29:07
Sébastien Vermandel: You can also get in touch with any local disabled people's association, because most of the time, they'd love nothing more than to help you in this area. So why should you do it early? Because the longer you delay, the more advanced your idea and product will be, and the more expensive it will be to make changes.

00:29:28
Sébastien Vermandel: A concrete example, we were asked a few months ago to evaluate a check remittance counter that was supposed to be accessible to people with reduced mobility. And when the machine arrived, it was delivered by a manufacturer who had already completed a production run, and it was tested in a facility with people with reduced mobility, and after three days. The device left and went back to the design office because it wasn't that accessible.

00:29:58
Sébastien Vermandel: Typically the more you take into account specific needs, the cheaper the impact on your product development. So do it early. The second piece of advice is not to take refuge behind technical repositories, often when developing an application, a web application or a desktop application. There are so-called technical repositories for saying my application is accessible.

00:30:28
Sébastien Vermandel: Typically, the RG2A repository ensures Web development or the WCAG for the International Web repository. These are technical standards. It's not because an application complies with this standard that it can be considered accessible, and it's really complicated to understand until you've experienced this inaccessibility.

00:30:47
Sébastien Vermandel: The best example is a mutual insurance company's website, which would be 100% compliant with this standard, and in front of which you put a mentally handicapped person with reading and comprehension difficulties. I suppose you're like me: most of the forms on mutual insurance websites are already incomprehensible, whereas I have normal comprehension skills.

00:31:12
Sébastien Vermandel: So, there's a real effort to be made to go beyond these so-called technical references and to really understand what accessibility is all about. The third tip is a fairly standard one in the field of product or service development. But we tend to forget. When it comes to disability-related development, it's all about taking stock of the state of the art. Take a good look at what exists around you, at the solutions that have already been developed.

00:31:37
Sébastien Vermandel: In fact, it'll save you reinventing the wheel. There are plenty of ready-made solutions already on the shelf, or at least ones that have already been tried and tested. There's no point in trying to develop something if someone else has already done it very well, so don't hesitate. There you go. You mentioned earlier to go and consult our Fact sheets, which are a good way of quickly taking stock of the state of the art.

00:31:58
Sébastien Vermandel: But also to have a look at patent databases by putting in the right keywords or also go and search at specific manufacturers. If solutions don't already exist, it's important to take a look at the state of the art. It'll also cut costs, because you won't have to develop things that won't be useful because they've already been done by others.

00:32:16
Lionel Reichardt: Sébastien Vermandel, thank you for this information.

00:32:23
Lionel Reichardt: Our episode is coming to an end. Thank you for listening. We thank our two guests for their availability. Don't hesitate to subscribe to the podcasts they themselves are available on listening platforms. We look forward to seeing you soon for a new episode of 100 Days to Success.

00:32:43
Voice-over: Those who are making e-Health today and tomorrow are on the G_NIUS podcast and all the solutions to succeed are on gnius.esante.gouv.fr