Digital accessibility in medical software: what to check

Electronic health records, patient portals, telehealth apps, scheduling systems: almost all healthcare today goes through a screen. When that screen only works for those who see well, hear well and use a mouse precisely, some patients and professionals are left behind. The Brazilian Inclusion Law defines a person with a disability as someone who has a long-term physical, mental, intellectual or sensory impairment that, in interaction with barriers, can hinder their full participation in society (Law 13.146/2015). Poorly designed software is one of those barriers.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

This guide summarizes the open standards that guide digital accessibility, what studies have found on health websites, records and apps, and what to check before adopting or developing a system.

Key points

• The international reference is the WCAG, from the W3C, organized into four principles and three levels of conformance.
• In Brazil, the Brazilian Inclusion Law requires accessibility on the websites of companies headquartered or represented in the country and of government agencies, and eMAG guides federal government websites.
• Studies of health websites, records and apps find repeated failures: low contrast, links and buttons without names, images without alternative text and incomplete keyboard navigation.
• Many failures are found with a short test: keyboard, screen reader, magnification and color.
• Involving people with disabilities from the design stage of the system is the most consistent recommendation of the reviews.

Table of contents

• What digital accessibility in health is
• The reference standards: WCAG, Brazilian Inclusion Law and eMAG
• Where health software fails, according to studies
• What to check in medical software
• Accessibility in NEXO
• Frequently asked questions
• Accessibility checklist for medical software

What digital accessibility in health is

The Brazilian Inclusion Law defines accessibility as the possibility and condition of reaching, with safety and autonomy, spaces, transport, information and communication, including their systems and technologies, by a person with a disability or reduced mobility (Law 13.146/2015). In software, this means that every function can be perceived, operated and understood by those who use a screen reader, magnification, keyboard, voice command or captions.

WCAG 2.2 states that following its recommendations makes content more accessible for people who are blind or have low vision, who are deaf or hard of hearing, with limited movement, with speech disabilities or photosensitivity, and in part for people with learning disabilities or cognitive limitations (W3C, WCAG 2.2).

Who depends on accessible software

Editorial reading: in the healthcare environment, accessibility serves at least three groups. Patients, who schedule appointments, read results and talk to the team through portals and apps. Professionals with disabilities, who need to record, prescribe and consult the health record with the same safety as their colleagues. And anyone in a temporary situation, such as an immobilized arm, a small screen during a shift or a noisy environment.

The reference standards: WCAG, Brazilian Inclusion Law and eMAG

WCAG 2.2, from the W3C

The WCAG (Web Content Accessibility Guidelines) is the W3C recommendation for accessible web content; the published version 2.2 is dated December 12, 2024 (W3C, WCAG 2.2). The recommendations are organized into four principles (W3C, WCAG 2.2):

1. Perceivable: information and interface components must be presented in a way that the user can perceive.
2. Operable: components and navigation must be operable.
3. Understandable: information and interface operation must be understandable.
4. Compatible: content must be interpreted by a wide variety of programs, including assistive technologies.

Each success criterion has a level: A (the minimum), AA and AAA (the highest), and level AA requires meeting all A and AA criteria (W3C, WCAG 2.2).

WCAG for software that runs outside the web

Records installed on computers and native apps fall outside the direct scope of WCAG. For them, the W3C published WCAG2ICT, a note that explains how to apply the principles, guidelines and criteria of versions 2.0, 2.1 and 2.2 to documents and software that are not web; the text is informative guidance, not a standard (W3C, WCAG2ICT).

Brazilian Inclusion Law (Law 13.146/2015)

Article 63 of the law makes accessibility mandatory on internet sites maintained by companies headquartered or with commercial representation in the country or by government bodies, in line with the best practices and accessibility guidelines adopted internationally, and requires sites to display an accessibility symbol prominently (Law 13.146/2015). The definition of accessibility in article 3 includes information, communication and their systems and technologies (Law 13.146/2015).

eMAG, the federal government model

eMAG (Accessibility Model in Electronic Government) is at version 3.1, from April 2014, and presents itself as a specialized version of WCAG aimed at the Brazilian government (eMAG). Ordinance No. 3, of May 7, 2007, made compliance with it mandatory on Brazilian government sites and portals (eMAG). Unlike WCAG, eMAG groups its 45 recommendations by area (markup, behavior, content, presentation, multimedia and form), not by priority level (eMAG).

Quick comparison

Standard	Who publishes it	What it applies to
WCAG 2.2	W3C (WCAG 2.2)	Web content, with levels A, AA and AAA
WCAG2ICT	W3C (WCAG2ICT)	Guidance for documents and software outside the web
Law 13.146/2015, art. 63	Presidency of the Republic (Planalto)	Sites of companies headquartered or represented in the country and of government bodies
eMAG 3.1	Federal government (eMAG)	Brazilian government sites and portals

Table source: official pages cited in each row, accessed on 10/11/2026.

Where health software fails, according to the studies

Health sites

In a sample of 139 health sites among the most accessed in the world, 91.3% of home pages had detectable accessibility failures, and the most common were low contrast, empty links, images without alternative text, empty buttons and form fields without labels (Mason et al., 2021).

In an Australian study of 185 pages of services that care for people after a stroke, 81.1% had at least one WCAG error, and the most frequent, on 49.7% of pages, was the empty link, which the screen reader is unable to announce (Giummarra et al., 2025). Only 17 sites published an accessibility statement, and government body sites had fewer problems than those in the private sector (Giummarra et al., 2025).

During the pandemic, an automated evaluation of 54 official covid-19 vaccine scheduling sites in the United States found compliance below expectations with versions 2.0 and 2.1 of WCAG (Alismail and Chipidza, 2021).

Electronic health record

A study tested three open-source electronic health records with automated and manual tests and with three screen readers (JAWS, NVDA and VoiceOver). The three systems were only partially accessible, and the main points to improve were keyboard navigation and screen reader compatibility (Moncy et al., 2023).

Health apps

In a pilot with three weight control apps well rated in the stores, nine people with visual, dexterity or cognitive disabilities tested each app; people with visual disabilities gave the lowest accessibility scores and reported more difficulties (Radcliffe et al., 2021).

How digital health services are developed

A scoping review on digital health services included 15 publications, of which 2 defined accessibility and 5 used WCAG to evaluate it (Jonsson et al., 2023). Another review, with 25 sources, concluded that needs vary according to the type of disability and that participatory design, with people with disabilities from the idea stage, leads to more accessible solutions (Henni et al., 2022).

A scoping review published in 2026 gathered 80 documents and pointed to accessible design, co-design with users and international accessibility standards as the factors that most favor equitable digital health (Umucu et al., 2026).

The health record can also register accessibility needs

In an ophthalmology outpatient clinic, a questionnaire in the electronic health record asked, at scheduling, whether the patient needed any accessibility support; of 250,932 visits, 9.4% had some request, most often for mobility (Varadaraj et al., 2022). The authors consider that this standardized record can be taken to other services (Varadaraj et al., 2022).

How to read these studies

Question	What the studies above allow us to say
Are the failures common?	Yes, on health websites in several countries, with most pages having at least one error
Which failures appear most?	Low contrast, links and buttons without a name, images without alternative text, forms without labels
And the health record?	In a test with three open-source systems, accessibility was partial
What helps?	Participatory design, international standards and tests with a screen reader

Table source: synthesis by the Editorial from Mason et al., 2021, Giummarra et al., 2025, Moncy et al., 2023, Henni et al., 2022 and Umucu et al., 2026.

What to check in medical software

The criteria below come from WCAG 2.2 and cover the failures that appear most in the studies. The example column is editorial reading.

Essential criteria

WCAG 2.2 criterion	What it requires	Example in health
1.1.1 Non-text Content (A)	Text alternative for all non-text content (WCAG 2.2)	Allergy icon with a name read by the screen reader
1.4.1 Use of Color (A)	Color is never the only means of conveying information (WCAG 2.2)	Critical result in red and also with the word "critical"
1.4.3 Contrast (Minimum) (AA)	Contrast of at least 4.5:1 for normal text (WCAG 2.2)	Light gray text on a white background fails
1.4.4 Resize Text (AA)	Text can be enlarged up to 200% without loss of content or function (WCAG 2.2)	The prescription remains readable with zoom
2.1.1 Keyboard (A)	Every function operable by keyboard (WCAG 2.2)	Signing and sending the prescription using only the keyboard
2.4.11 Focus Not Obscured (AA)	The item with keyboard focus stays visible, at least in part (WCAG 2.2)	Fixed bar of the health record covering the field being edited fails
2.5.8 Target Size (AA)	Touch or click targets of at least 24 by 24 CSS pixels, with exceptions (WCAG 2.2)	Small dose buttons stuck to each other fail
4.1.3 Status Messages (AA)	Status messages announced by assistive technology without changing focus (WCAG 2.2)	"Prescription saved" announced to the screen reader

Table source: WCAG 2.2 criteria cited in each row; examples by the Editorial.

WCAG also has a level AAA criterion that requires that animations triggered by interaction can be turned off, except when they are essential (W3C, WCAG 2.2).

A quick test before adopting a system

Practical suggestion by the Editorial, for those who assess software before buying or implementing it:

1. Disconnect the mouse and try to do the main task, such as opening a patient, recording a progress note and saving, using only the keyboard.
2. Turn on the operating system screen reader and check whether buttons, fields and alerts are announced with a name.
3. Enlarge the screen to double and see whether something disappears, overlaps or requires side scrolling.
4. View the screen in grayscale and check whether alerts and statuses remain clear.
5. Ask the vendor for the accessibility statement and the WCAG conformance report.
6. Test with those who will use it, including professionals and patients with disabilities.

For those who develop or buy

• Test early and with people. Automated tests find part of the failures; combining them with manual tests and screen readers was the method of the study with health records (Moncy et al., 2023).
• Define what accessible means. The review on digital health services found few publications with a clear definition of accessibility (Jonsson et al., 2023).
• Publish an accessibility statement with the level sought and a channel to report barriers.
• Record the patient's needs in the health record itself, as in the questionnaire at the ophthalmology outpatient clinic (Varadaraj et al., 2022).

Accessibility in NEXO

NEXO publishes an accessibility statement in which it says it seeks WCAG 2.1 level AA and lists site features: semantic structure with heading hierarchy, minimum contrast for regular text, a layout that adapts to screen size and zoom, alternative text on meaningful images, and media that only plays when the person asks. The same page provides an email to report accessibility barriers.

In the game, each guess shows the proximity level with color, icon and the written name of the level, and animations respect the operating system's reduce motion preference.

How the game works

In NEXO, each case arrives in up to six clues, one at a time, and you give your guess by the diagnosis name or the ICD-10 code. With each wrong guess, the game shows the proximity in five levels, from different chapter to exact ICD, and opens the next clue.

The Daily brings one case per day, the same for everyone, and the Archive gathers previous daily cases. Multimedia brings image, audio and other exams, and Continents changes the background epidemiology. Adrenaline adds time. How each mode is unlocked is on the NEXO Economy page.

Save, discuss and take part

The Anki button creates the card straight from NEXO and opens it in the Anki app, searches the cards you already have and, when the case has an image, takes the image to the card. The Group tab of the ranking, which gathers invited colleagues, lets you compare at which clue each one got it right. General practitioners or specialists with an active license can review cases in their area through NEXO Curator. If you coordinate a residency, a league or a medical school, check out NEXO Closer; researchers in accessibility and medical education can propose studies through NEXO Researcher, and those who produce medical content can check out NEXO Creators.

Frequently asked questions

What is digital accessibility in medical software?

It is the condition of a health system, such as an electronic health record, portal or app, being able to be perceived, operated and understood by people with disabilities, including with assistive technologies. The international reference is the WCAG, from the W3C (W3C, WCAG 2.2).

Does Brazilian law require accessibility on health websites?

Article 63 of the Brazilian Inclusion Law requires accessibility on internet sites of companies with headquarters or commercial representation in the country and of government bodies (Law 13.146/2015). For questions about a specific case, consult your institution's legal counsel.

Which WCAG level should health software seek?

Level AA is the most cited as a goal, including in studies that assess health websites, and it requires meeting all A and AA criteria (W3C, WCAG 2.2).

Does the WCAG apply to an electronic health record installed on the computer?

The WCAG deals with web content. For non-web software, the W3C published WCAG2ICT, which explains how to apply the same criteria (W3C, WCAG2ICT).

What is the difference between eMAG and WCAG?

eMAG is a specialized version of the WCAG for the Brazilian government and groups the recommendations by area, not by level (eMAG).

Is NEXO accessible?

NEXO publishes an accessibility statement with a WCAG 2.1 level AA goal and a channel to report barriers. To get to know the game, read what NEXO is.

Accessibility checklist for medical software

1. Every image and every icon with a text alternative.
2. Information conveyed by color also conveyed by text or icon.
3. Sufficient contrast between text and background.
4. Text that enlarges without breaking the screen.
5. Tasks completed by keyboard, with focus always visible.
6. Buttons large enough and with space between them.
7. Alerts and confirmations announced to the screen reader.
8. Animations that can be reduced.
9. Accessibility statement published, with a contact channel.
10. Tests with people with disabilities before and after every major change.

Want to train diagnosis with a short case per day? Play the case of the day on NEXO.

References

1. Mason AM, Compton J, Bhati S. Disabilities and the Digital Divide: Assessing Web Accessibility, Readability, and Mobility of Popular Health Websites. J Health Commun. 2021. https://pubmed.ncbi.nlm.nih.gov/34657585/
2. Giummarra MJ, Brown E, Rose TA, et al. How accessible are the websites of health services for people who have had a stroke? Int J Equity Health. 2025. https://pubmed.ncbi.nlm.nih.gov/40275299/
3. Alismail S, Chipidza W. Accessibility evaluation of COVID-19 vaccine registration websites across the United States. J Am Med Inform Assoc. 2021. https://pubmed.ncbi.nlm.nih.gov/33993310/
4. Moncy MM, Pilli M, Somasundaram M, et al. Evaluation of accessibility of open-source EHRs for visually impaired users. AMIA Annu Symp Proc. 2023. https://pubmed.ncbi.nlm.nih.gov/38222344/
5. Radcliffe E, Lippincott B, Anderson R, Jones M. A Pilot Evaluation of mHealth App Accessibility for Three Top-Rated Weight Management Apps by People with Disabilities. Int J Environ Res Public Health. 2021. https://pubmed.ncbi.nlm.nih.gov/33915917/
6. Jonsson M, Johansson S, Hussain D, et al. Development and Evaluation of eHealth Services Regarding Accessibility: Scoping Literature Review. J Med Internet Res. 2023. https://pubmed.ncbi.nlm.nih.gov/37590050/
7. Henni SH, Maurud S, Fuglerud KS, Moen A. The experiences, needs and barriers of people with impairments related to usability and accessibility of digital health solutions, levels of involvement in the design process and strategies for participatory and universal design: a scoping review. BMC Public Health. 2022. https://pubmed.ncbi.nlm.nih.gov/34991540/
8. Varadaraj V, Guo X, Reed NS, et al. Identifying Accessibility Requests for Patients With Disabilities Through an Electronic Health Record-Based Questionnaire. JAMA Netw Open. 2022. https://pubmed.ncbi.nlm.nih.gov/35394512/
9. Umucu E, Lee B, Vernon A, et al. Inclusive Digital Health Strategies for Persons With Disabilities: A Scoping Review. JAMA Netw Open. 2026. https://pubmed.ncbi.nlm.nih.gov/42742940/

Official pages consulted

1. W3C. Web Content Accessibility Guidelines (WCAG) 2.2, accessed on 10/11/2026. https://www.w3.org/TR/WCAG22/
2. W3C. Guidance on Applying WCAG 2 to Non-Web Information and Communications Technologies (WCAG2ICT), accessed on 10/11/2026. https://www.w3.org/TR/wcag2ict-22/
3. Brazil. Law No. 13,146 of July 6, 2015 (Brazilian Law for the Inclusion of Persons with Disabilities), accessed on 10/11/2026. https://www.planalto.gov.br/ccivil_03/_ato2015-2018/2015/lei/l13146.htm
4. Federal government. eMAG, Accessibility Model in Electronic Government, version 3.1, accessed on 10/11/2026. https://emag.governoeletronico.gov.br/
5. NEXO. Accessibility Statement, accessed on 10/11/2026. https://nexo.wiki.br/accessibility