Technologies like appliances, televisions, and medical devices used to be controlled with analog knobs and switches. These controls each had a discrete function, and nothing ever changed about how they worked on their device. This is pretty good for accessibility because all of these controls had a one-to-one mapping to their functionality, but pretty bad if you want your device to do more than a few simple functions. So, the digital revolution brought about the digital display and on-screen menus. Now, arrow keys were used to navigate menus and "soft-keys" changed their function based on the context of the application. This is better for building more complex devices with many functions, but, because a physical control could now represent many different functionalities, in order to provide access for users with visual impairments a device would need speech output or some kind of audible feedback. Unfortunately, manufacturers rarely include this functionality in mainstream devices, so accessibility for this type of device is usually nonexistent, or limited to specialized, low-volume products.
Now, a new trend has emerged that is again changing the way we interact with some types of devices, and this time accessibility may actually be enhanced. Some physical devices that otherwise would have required buttons and a screen are now designed to connect wirelessly and be controlled by a smartphone app. This eliminates the need to invent a clunky interface (that probably isn't accessible) and offloads control responsibility on to the polished, accessible smartphone interface in the form of an app. That's the idea anyway.
We took a look at one of the most problematic areas of technology, home health devices, to check out a few mobile-connected solutions. Healthcare access is an important priority for AFB, and it builds on our previous work assessing the accessibility of standalone insulin pumps, blood glucose meters, health information and insurance websites, and advocating for accessible prescription drug labeling.
In this article, we review six different health devices that connect and share data with mobile apps:
- Withings Blood Pressure Monitor with the Withings Health Mate app
- Sanofi-Aventis iBGStar Blood Glucose Monitor
- LifeScan OneTouch Verio Sync Blood Glucose Monitor
- Telcare Blood Glucose Monitor
- Fitbit One
- UP24 by Jawbone
We will describe the form and function of each device and its companion app (on both iOS and Android, if available), and provide a quick overview of the accessibility of each. All of these apps worked well with the built-in zoom features and color enhancements of the mobile operating systems, so we do not specifically mention the accessibility of the apps to people with low vision in most cases. We do make some observations about the displays of the blood glucose meters that can be used as standalone devices, however. This article has two purposes: first, we want to give some practical information about the accessibility of the devices we tested, and second, we want to draw some conclusions about the impact that mobile-connected devices may have on the accessibility field in the near future.
Wireless Blood Pressure Monitor and Health Mate app by Withings (iOS and Android)
Withings produces many devices for tracking various health statistics, from sleep patterns to weight. The Withings Health Mate app collects the data from various Withings devices and can also collect some data using sensors in an iOS or Android device. For this evaluation, we focus on the features in the app related to the blood pressure cuff.
The wireless blood pressure cuff consists of a padded sleeve that fits around your arm like any other blood pressure cuff. Connected to the cuff is a dense metal cylinder, the length of the cuff itself, that contains all of the device's electronics. The device charges using a micro USB port located where the cylinder meets the cuff. The power button and status light are located on one end of the cylinder. There is a cap for the battery compartment on the other end of the cylinder.
Evaluation
There is only one button and one status light on the device, which actually creates an accessibility snag. When turning on the device and setting it up for pairing, the light flashes or changes color to alert you of its status. Since there all of the cues to the device's status are visual, it proved difficult to determine when the device was on and ready to pair. Withings produced a wired blood pressure cuff that was similar but connected to an iOS device through a cable. This made it much easier to use, as the device only turned on when connected to an iOS device. Unfortunately, this device is no longer sold and only connects to devices using an Apple 30-pin connection such as the iPhone 4S and previous. If you can find one and have a 30-pin-to-Lightning converter you can use the wired cuff on modern devices.
The device connects with the app automatically when connected with Bluetooth through the iOS Bluetooth menu. The controls for starting the cuff are accessible and the results are readable with VoiceOver, but they are interspersed among controls that clutter the interface. To save your results, you must sign up for a Withings account. The account creation process is not accessible on the device so you need to sign up on the Withings website to create an account. Overall, there are inaccessible elements in the Withings app and the device can be somewhat difficult to connect to a tablet or smartphone. The app interface outside of taking a measurement is riddled with issues, so none of the additional functionality, such as logging, is available. Because of this, you might as well use a talking blood pressure monitor. If the developers fixed the app, however, users would have access to the powerful tracking features that are available visually.
IBGStar Glucose Meter (iOS) by Safoni-Aventis
The IBGStar is a blood glucose meter with accompanying iOS app for logging glucose levels. The app can store glucose levels and provide pattern results for glucose levels as well. Results can also be shared with others. The device itself is rectangular and around 3 inches long and .5 inch tall, and contains one button to scroll through information on the display. The display on this device is very small with fonts as small as 2 mm high. On one side, the device has a 30-pin connector for connecting to compatible iOS devices. The other side contains the charging port and the port for inserting test strips. The iPhone 5, iPad Air, and newer devices will need a Lightning-to-30-pin adapter.
Evaluation
The physical device does not pose an accessibility barrier if you're using the app. The device activates automatically when connected to an iOS device, and simply inserting a strip will initiate a test and upload the results to your iOS device. The app itself, however, is fairly problematic. The glucose level is listed in a summary tab, but in most instances the result text is not accessible to VoiceOver. This is true when entering results manually as well. To find a result, you must find it in the logbook. Many buttons are also unlabeled and tabs content is placed as partial overlays over screen content when activated, which is difficult to navigate. In its current state, this device is difficult to use because of the app.
OneTouch Verio Sync and OneTouch Reveal app by LifeScan (iOS and Android)
The OneTouch Verio Sync is a blood glucose meter that can connect with the OneTouch Reveal app to collect blood sugar data. The app allows you to store your results and categorize them by time of day (e.g., before breakfast, after lunch). Patterns in glucose levels can be generated and results can be shared with others. The Verio Sync is a rectangular device approximately 2 inches wide and 4 inches long. There is a single button is on the right side of the device and a charging port further down on the same side as the button. The physical device contains a square display of about 1 inch. The glucose reading "big number" is large at 12 mm high and is displayed with contrast high enough to be sufficient for most low vision users. The date and unit label peripheral text is much smaller at about 3 mm high, however.
Evaluation
The OneTouch device itself is partially accessible. The PIN needed to connect the device through Bluetooth is printed on the device's label, so a user with a visual impairment would need sighted assistance to connect the device for the first time. Once the app and device are paired, inserting a test strip will initiate a reading that will be automatically uploaded to the app once completed. Measurements are accessible immediately after taking a reading, and the app itself has a logical tabbed layout. The majority of buttons in the app are unlabeled, however, which makes navigation difficult. When attempting to review older results in the logbook, even time slots that have no associated measurements are focusable by the screen reader. This is confusing, and also makes it difficult to find the actual results because there are so many blank, but focusable, elements to wade through. Because this is a table layout, exploring by touch would be a good way to navigate, but, because the cells of the table are small, it is very difficult to accurately find the one you're looking for. The small cells would also likely pose a problem to people using the app visually as well. Overall, a determined person could use most of this app's features with a screen reader, but it would be frustrating.
Blood Glucose Meter and Diabetes Pal App by Telcare (iOS and Android)
This solution is unique amongst the devices we tested because the Telcare meter itself does not directly connect to a mobile device. Instead, it sends results through a cellular network to a server. The app can access this data and display a measurement log with averages. The device hardware looks similar to a bulky smartphone about 2 inches wide and 3 inches tall with a display that covers the front face of the device. A power switch lies on the right side of the device and a set of Up and Down arrow keys are on the left with an Enter button in the center. The device does not have any speech feedback for actions but audio tones are played for certain events and actions.
Evaluation
For this product, the hardware posed the most accessibility issues. The meter plays a sound when powering on and a tone prompts you to add blood to a strip once it has been inserted, but, after a reading has been taken, you are prompted to select a time of day for the reading (before breakfast, after lunch etc.). There is no audio feedback for these selections, and there is no feedback to alert you that the measurement was successful, or that a selection should be made. Eventually, a tone will sound indicating that the strip should be removed, and then result will be sent without a time selection. The Telcare apps were fairly accessible, but there were some unlabeled items in the iOS app, and when swiping through the interface, the page content changed without warning. This can be confusing if you attempt to find an item by touch and the screen has changed without your knowledge. From our testing, there were no major usability barriers in the Android app. Overall, the main accessibility barrier to using this meter is the meter itself.
The display on this device is of similar type and quality of clamshell-style feature phones. It is a color LCD that produces bright colors with well-defined characters. The "big number" is large at 8 mm high, but menu items have much smaller fonts down to 3 mm. A person with low vision would have difficulty selecting the time range after taking a reading because of the small fonts on the menus.
Fitbit One (iOS and Android)
Janet Ingber reviewed the Fitbit Flex in the The Fitbit Flex Offers Access for Blind People Who Want to Track Their Fitness. The Fitbit One is very similar. The Fitbit app can track various data including exercise time, steps taken, sleep patterns, weight, and caloric intake. The app can be paired with a Fitbit Fitness Tracker to log data such as steps taken and sleep patterns. The Fitbit One is a small, rounded rectangular device roughly three inches long and a half an inch wide. A small display covers the front and a single button stretches across the top of the display. The device can be clipped onto a belt or piece of clothing, or fit into a wristband so that it can be worn comfortably.
Evaluation
The sign-up process is not accessible because information such as height, weight, and birth date are not rendered in a way that VoiceOver can interact with It is possible to create an account through the Fitbit website, so this step can be bypassed. Past the account creation function, the app is fairly usable if you use contextual information to figure out what the unlabeled controls do on both iOS and Android. There are unlabeled buttons in the Android app, but these do not interfere with the app's function, as often there is a text equivalent that can be activated instead. Overall, the app and device is one of the most accessible that we tested, and if you are in the market for a fitness tracker, the Fitbit One with accompanying app is a good option.
UP24 and UP app by Jawbone (iOS and Android)
The Up app connects with various Jawbone fitness trackers to provide health data such as steps taken and sleep patterns. For our evaluation, we connected the Up app with an UP24, which continually uploads data to the phone throughout the day. The UP24 is a flexible rubber wristband with a textured exterior. The band maintains its shape, and is simply slipped over the wrist. One end of the band contains a button for switching the band from "Day" to "Night" so that the band knows whether to track steps or sleep. The band charges by plugging into an adapter that looks similar to a headphone jack attached to a USB plug. A cap fits over the plug when you're ready to wear the device.
Evaluation
The UP app for iOS is mostly inaccessible. Most interface controls are unlabeled. When connecting a band for the first time, the instructions are inaccessible, so the process cannot be completed. When attempting to set goals for tracking, values are read as percentages in the pickers instead of the actual values (e.g., "75 percent" instead of "7,500 steps"), which makes setting accurate goals very difficult. The Android app is slightly more accessible as there is more contextual information to help with figuring out unlabeled controls. The UP24 band has a button that toggles between day and night modes so that the app can record different types of data for each. Even though the device doesn't have a display, an icon alerts the user which mode is selected. A vibration indicates this change, but it is the same for each mode so that the user would not know which mode was selected. This problem could be fixed by displaying a notification on the phone, or by differentiating the two modes with different vibrations. Overall, the app could be accessible with the addition of labels but is nearly unusable in its current state.
The Bottom Line
At this time, and for the devices that we tested, most of these products will require a level of memorization and guesswork to use. Only the FitBit provided an adequate level of accessibility to warrant a recommendation. Those who are not familiar or comfortable with mobile devices will prefer or require a standalone device with built-in accessibility.
That being said, however, this trend of connecting physical devices to a mobile phone will provide technologically proficient consumers with much greater choice, and device manufacturers have a greater chance to "accidentally" make an app accessible than to "accidentally" make a device with a digital display accessible. Moreover, an app is much easier to fix at a later date to enhance accessibility than a piece of hardware is. In general, we found that devices that were intended to be connected to a mobile app had simplified physical controls and displays, or no display at all. Most accessibility issues in the apps that we tested were errors with labeling and focus control, both of which are fairly simple for a developer to fix. The physical devices need to have switches or audible beeps in addition to the status lights to indicate power and other simple states, otherwise a user will be uncertain about the device's status until it connects to the app.
While the results of our survey of these devices are interesting, we still are finding that the medical device industry hasn't addressed the needs of people with vision loss. There are few, if any, readily available and fully accessible devices that offer built-in accessibility. Even though there is an intrinsic accessibility built-in to mobile platforms, none of the apps that we tested were fully accessible, and we found problems with each of the physical devices. Additionally, a mobile-connected solution will not work for everyone. It is still critically important for health companies to make accessibility a priority when designing products.
