Quest Diagnostics offers laboratory services. At a doctor’s request, patients visit a Quest location for blood draws and other lab procedures. The company installed digital self-service touchscreen kiosks in its locations. These kiosks allow patients to check in for an appointment.
The American Council for the Blind (ACB) filed a class action lawsuit against Quest Diagnostics for creating an inaccessible touchscreen kiosk experience. The ACB press release explains these kiosks prevent blind and low-vision patients from equal access to Quests’s services. ACB believes these kiosks are inaccessible and don’t comply with the Americans with Disabilities Act (ADA).
“Self-service kiosks are being used more and more in many aspects of daily public life,” said Dan Spoone, Executive Director for the American Council of the Blind. “The Court’s decision that Quest violated the ADA and that the check-in services of these kiosks must be accessible to people who are blind is a significant step towards ensuring that the rights to full and equal enjoyment and effective communication are protected.”
After a week-long bench trial in Los Angeles, the federal court found Quest Diagnostics violated Title III of the ADA. In this episode of A11y Insights, Ken Nakata from Converge Accessibility and Equal Entry CEO and founder Thomas Logan talk about a decision in a lawsuit against Quest Diagnostics around kiosk accessibility.
Why Was Quest Sued by the American Council for the Blind (ACB)?
Thomas Logan: Starting off, Ken, what is a self-service kiosk and why was this company sued?
Ken Nakata: A self-service kiosk allows patients to check in and have a phlebotomist come out and call you and draw your blood.
It was intended to take the place of the old process that Quest used to have, which was a paper sign-in process. And it created a bit of controversy because it asks basic things like first name and last name. But it was difficult to access by people with disabilities, notably people who are blind or who have visual impairments.
Thomas Logan: It’s very interesting, and from what I can see from the technology itself, the kiosk is an iPad, just running inside of a casing. And it’s a place where someone can walk up to it and interact with it in any of the Quest Diagnostics locations around the U.S.
Ken Nakata: Exactly. They were eventually sued because Mr. Vargas, who is a blind individual, wasn’t able to access the kiosk. And as a consequence, in the beginning, he had to go and ask other patients for assistance or wait until a phlebotomist came out and try to just get their attention. And then they would try to help him log in through the kiosk.
It was quite a long process. It took him much longer than anybody else. Quest tried to make some improvements to the kiosk after that, to create a more accessible experience. And that’s where they came up with this whole three-finger swipe idea.
How Kiosk Mode Works
Thomas Logan: Well, speaking of the three-finger swipe idea, let’s start with just what are the barriers that exist for people who are blind using kiosks.
Ken Nakata: So the kiosk was an iPad, but it was in a special case so that people wouldn’t steal the iPad and it was completely sealed so that you couldn’t access the headphone jack. You couldn’t access the home button or the volume controls. It was just a sealed unit with a screen that could be interacted with by touch.
And so it didn’t provide any voice output. So, if you were blind, you would be confronted with this piece of glass, essentially, that you could touch, but you didn’t get any feedback on what you were doing. So, it was a worst-case scenario for someone who was blind or visually impaired.
Thomas Logan: It’s unfortunate. A starting point of using an iPad may be different from other kiosks I’ve experienced in my work. The iPad does have functionality available inside of it to enable this support, but it’s not something, in that place where you’re talking about having the home button removed or having access to the different buttons removed, and when you are just dealing with the glass surface.
I think that’s something that removed the ability to take advantage of some of the shortcuts or maybe some of the familiarity that some patients would have had with an iPad interface or an iOS interface if they could have had that available. So, just from the initial design not thinking about how people with disabilities or specifically people who are blind are going to be using it.
Ken Nakata: Exactly. So, these iPads and iOS devices have something called a Kiosk Mode, which is designed just for this kind of situation. It makes all of the special features in an iPad unavailable to the user because you can imagine the scenario of trying to check people in at a diagnostic lab like Quest, where if they hit the home button, then the next person wouldn’t be able to access figuring out how to launch the application to use the Quest diagnostic process.
So Apple came up with this Kiosk Mode that once you’ve set up your iPad this way, the moment you turn it on or turn it off just immediately goes into that application. It doesn’t allow you to just go into your settings like every other iPad.
Thomas Logan: Right. I would also imagine this has implications in the traditional argument of security versus accessibility. Additionally, having things running additional other than the kiosk app itself, the same way someone could press the home button, potentially running other applications such as a screen reader or screen magnifier.
There could be unintended operating system consequences where someone can’t get the device out of the Kiosk Mode or put it into a mode where the next patient or next person can’t use it.
Ken Nakata: Exactly. And that causes a lot of the problems.
Three-Finger Swipe Interaction
Thomas Logan: Alright, so then what was the three-finger swipe idea from Quest to make the kiosk work better for people who are blind?
Ken Nakata: The three-finger swipe idea was that if a person with a disability just swipes in any direction with three fingers on the surface of the iPad, the system would just automatically create an anonymous appointment for that person.
And that person would be put at the top of the queue when the phlebotomist comes out. And it would also ring a bell in the back so that they knew that there was somebody out there who had a disability who made that three-finger swipe.
By doing this, it allows people with disabilities to be able to log in just like everybody else. It was anonymous in the sense that it just didn’t require the person to put in any information about themselves, again, because the kiosk is inaccessible. But that way, when the person goes back with the phlebotomist, they provide all the same information and they get the proper tests done and things like that.
And to make sure that everybody knew about the three-finger swipe, the television monitors inside the Quest Diagnostics’ waiting room would repeat a message every five minutes or so that said that if you had a disability, go up to the kiosk and use that three-finger swipe gesture and someone will come right out and help you.
Thomas Logan: Okay. That’s interesting. And not sure if this was mentioned, but how do they come out and identify the person with a disability in that case?
Ken Nakata: Well, they would come out and look around. If they couldn’t tell immediately, “Oh, somebody’s blind there,” because they have a guide dog or they’re using a white cane, then they would ask, “Did somebody make a three-finger swipe on the iPad?” and then they would identify the person that way.
How Did the Quest Kiosk Case End?
Thomas Logan: Interesting. So how did this case end up?
Ken Nakata: Even though ACB asked for the kiosks to be made accessible, the court ultimately decided that Quest didn’t have to go back and make them accessible. It determined that doing so would constitute an undue burden for Quest, especially because the Justice Department potentially has some regulations that they may issue about kiosks.
The judge said, “Well, that means that you might have to change your kiosks twice,” and that would certainly be an undue burden.
It is just as effective to just allow you to just use the three-finger swipe, as long as you implement it correctly. I should add that there were some problems that Quest had with the three-finger swipe that allowed the phlebotomist in the back to ignore the person who made a three-finger swipe.
The court ordered that Quest disable those kinds of bypasses and make the three-finger swipe a much more effective system. So, the court did beef up the three-finger swipe idea, but ultimately it said that using the three-finger swipe was perfectly fine and it met the requirements of the ADA.
Thomas Logan: Right, and that’s pretty surprising to me in the sense of what’s possible to be done to make this interface accessible. But then it’s also not surprising to me that the people who make the decisions aren’t working with technology day to day like someone like myself is. But that’s interesting in the sense that the three-finger swipe is the only interaction on the device.
And I think the lack of privacy with respect to someone coming out, let’s say brought up earlier and saying if they haven’t found someone or visually identified someone saying, “Hey, did someone do a three-finger swipe,” as a notice? It’s just kind of strange.
But on the same side, I can acknowledge that with any type of health situation, being able to use a screen reader, which is typically what someone who’s blind would be using to access a touchscreen, the speech output might not be announced out loud.
Typing someone’s name in and having that read out in a lobby, not having the ability to connect headphones, to the device, that would be something that I would also understand from a technical side is still challenging today with like current kiosk systems and might also be another rationale for why this is a good solution.
But, ultimately seeing what the functionality is that’s available in the kiosk, one thing that I was able to see is there’s a preference on the kiosk to say that you’re waiting outside or waiting inside. Maybe that’s being addressed by the fact that you’ve moved to the top of the queue.
But that does for me, like ring as an option that someone who’s not disabled has the ability to select, “I’d rather wait outside than inside.” And someone with a disability has to do the three-finger swipe and wait inside.
Ken Nakata: Yeah, it does create a separate but equal kind of solution, which I don’t like. It would’ve been nicer had Quest made their kiosks accessible. But going up to a kiosk if you’re blind and you are confronted with this glass slate, it just does seem like a kludgy solution for people with disabilities, even if they made it accessible.
The three-finger swipe does make some sense, but it still doesn’t seem like a perfect solution. One of the other things that bothers me about it is what are the implications ultimately for other technologies.
If the companies don’t have to make their technologies accessible when they first design them, and they come out with workarounds like this, then they may never have to make their technologies accessible.
Thomas Logan: I agree, I have the same concern, and I haven’t done research on this, but I would go back also to the standard thing I’ve said in some of our other discussions that Apple in this Kiosk Mode that they support bears responsibility as well for thinking this through for people that build on top of it.
And if Quest Diagnostics, I’m sure, is just one of many people using iPads to produce this type of kiosk solution. Has Apple done the work to explain the right way to do it? And I do think that it would be the people making the device.
It’s more their responsibility than even Quest to be thinking this through and solving it and then teaching the people that build solutions on top of their technology, “Here’s how you use our technology as a standalone kiosk in an accessible way.”
And if the three-finger swipe was Apple’s recommendation, that could become a standard or become something more consistently implemented. But it could be confusing if it’s very specific to this one solution and then it’s like, “Okay you listen to the notification on the TV to know to do that gesture.”
And when you’re somewhere else, “Okay, listen, to do this gesture.” I do think that there’s room for standardization and ideally it would be coming from the manufacturer of the platform that’s producing the solution.
Ken Nakata: Okay, I think that’s a wrap, Thomas.
Thomas Logan: I do too.
I’m curious what you think. So, let us know in the comments. Have you used one of these Quest kiosks? And can you think about other kiosks that use iPads this way? Have you ever seen an accessible solution? Let us know and we’d love to continue the discussion.
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Oddly enough, I have had trouble at my local Quest where they had nothing audio wise to tell someone blind what to do once arrived. It seems completely silly that they did away with how they were doing things during Covid though. You could quite literally check in via the link in your e-mail on your phone.
Checking in on your phone seems easier than needing to find and identify the kiosk to perform the three finger swipe.