Computer access technology (CAT) allows people who have trouble using a standard computer keyboard, mouse, or monitor to access a computer. CAT is critical for enhancing the educational and vocational opportunities of people with disabilities. Choosing the most appropriate CAT is a collaborative decision-making process involving the consumer, clinician(s), and third party payers. The challenges involved and potential technological solutions are discussed.
Importance of computer access technology
Computer access technology (CAT) allows people who have trouble using a standard computer keyboard, mouse, or monitor to access a computer. CAT includes inexpensive devices, such as trackballs and small-footprint keyboards, and sophisticated technologies, such as automatic speech recognition, eyegaze tracking, and brain-computer interfaces. CAT services are provided by a range of rehabilitation professionals, including rehabilitation engineers, occupational therapists, speech-language pathologists, special educators, and vocational rehabilitation counselors.
CAT is critical for enhancing the educational and vocational opportunities of people with disabilities. In addition, CAT has been shown to contribute to improved health status by providing access to health information and interaction with clinicians and peers. CAT can reduce social isolation by eliminating physical barriers, facilitating communication, and providing a forum for the exchange of information. Individuals with disabilities often appreciate the anonymity of the Internet, where they can be evaluated for the strength of their contributions rather than their physical appearance or disability. The Internet also provides protection against self-consciousness and social anxiety, and active participation can lead to greater levels of self-acceptance and decreased feelings of isolation.
Fifty-seven percent (74.2 million) of working-age (between 18 and 64 years of age) computer users are likely or very likely to benefit from the use of CAT :
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17% (21.9 million) of working-age computer users have a mild visual difficulty or impairment, and 9% (11.1 million) have a severe visual difficulty or impairment.
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19% (24.4 million) of working-age computer users have a mild dexterity difficulty or impairment, and 5% (6.8 million) have a severe dexterity difficulty or impairment.
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18% (24.0 million) of working-age computer users have a mild hearing difficulty or impairment, and 2% (2.5 million) have a severe hearing difficulty or impairment.
Choosing the most appropriate CAT is a collaborative decision-making process involving the consumer, clinician(s), and third-party payers. The challenges involved in a successful computer access intervention include
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Evaluating and documenting client abilities and specific difficulties with the standard computer interface
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Choosing the most appropriate assistive technology to address these difficulties
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Configuring the technology to the user’s needs
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Training the user in appropriate use of their system and
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Providing continuous follow-up to ensure that the interface remains well suited to the user
The consequences of failing to successfully meet any 1 of these challenges include wasted human and material resources spent in the intervention process, unnecessary obstacles placed in the individual’s path toward their goals, technology abandonment, and a lack of computer use amongst individuals with disabilities. By all reported measures, we are largely failing to meet these challenges.
People with disabilities do not use computers at the same rate as people without disabilities. Whereas 85% of working-age adults without disabilities use computers, computer usage among those who have mild impairments is 80%, and 63% among individuals who have severe disabilities and are likely to benefit from the use of CAT.
Many people with disabilities who do own computers do not take advantage of CAT. One study found that only 24% of working-age computer users with severe disabilities use CAT. A significant barrier to obtaining CAT is cost. Twenty-eight percent of working-age computer users with mild difficulties/impairments and 32% with severe disabilities report there is a CAT that they do not own but would purchase if it became more affordable.
A second obstacle is awareness. Of computer users with mild or severe disabilities, 20% were not aware that CAT appropriate for them existed. Awareness of the free, built-in accessibility settings offered by the Windows and Mac operating systems is even lower. Of computer users with mild or severe disabilities, 36% were unaware of the available adjustments for the mouse and 35% were unaware of the available keyboard adjustment options.
Amongst computer users who do own and use CAT, there is ample evidence that it is not configured correctly. For example, Trewin and Pain reported target acquisition error rates of greater than 10% for 14 of 20 users with physical disabilities, and observed that 55% of the dragging tasks made by these users were unsuccessful. An average of 28% of clicks in this study included a mouse movement, which is a potential source of error, and 40% of multiple click attempts were unsuccessful.
Worst of all, approximately a third of computer users who do receive CAT eventually abandon it. A study of 115 individuals with disabilities who received 136 assistive technology devices in a 5–year period, including computers, communication devices. and adapted software, reported a total abandonment rate of 32.4%. The abandonment rate within the study for computer access and communication devices was 30.8%.
Challenges to computer access service delivery
The Cost of CAT and Clinical Services
A significant obstacle to obtaining the most appropriate CAT is cost. CAT (for working-age adults) is often funded through vocational rehabilitation agencies, which have small budgets relative to the demand for their services. Funds spent on clinician time and CAT for 1 client are unavailable to other clients, so maximizing each dollar spent is critical. Consumers who are retired, or not seeking employment, are equally cost sensitive as they may have to purchase their own equipment. As the population ages, an increasing number of older computer users will potentially benefit from CAT but are unlikely to be candidates for vocational rehabilitation and are thus likely to be using their own funds.
The Variety of Devices Available
Another challenge for computer access is the simple fact that there are too many options for any consumer to reasonably compare. There is a nearly limitless variety of alternatives to the traditional computer keyboard and mouse. Within each of these categories of devices there are multiple products, and each product has its own unique set of configuration options.
Given this variety of options, a consumer could spend weeks or months comparing devices, but a decision is often needed after 1 or 2 clinical sessions. In particular, consumers who need to obtain CAT to return to work or school often need to make decisions quickly to meet other deadlines. Beyond that, most consumers lack the patience or funding for multiple clinical visits. It is therefore critical to make optimal use of the time that client and clinician spend together in the clinic.
Consumer Needs Change Over Time
Even if a consumer who needs CAT receives a successful technology intervention, it is unlikely that the solution will remain effective indefinitely. Indeed, a consumer’s needs can change long before he or she has the opportunity to be reevaluated by a clinician. Regular follow-up evaluations are critically important, but often do not occur because of various barriers, such as the time and travel required and a lack of funding.
In addition, a single configuration may not be appropriate for a user at all times. A user’s needs may change as a result of changes in his or her abilities, which may happen over the course of a day (eg, fatigue) or longer (eg, because of progression of the disability, recovery of function, or other factors). The user’s needs may also change based on the user’s desired tasks (eg, some computer activities may require greater precision than others). Even if a clinician is available to recommend an initial configuration, he or she may not be available every time adjustments to the configuration are desirable. If a user is responsible for his or her own adjustments, he or she may not notice, or know how to respond to, a gradual decline in performance.
Challenges to computer access service delivery
The Cost of CAT and Clinical Services
A significant obstacle to obtaining the most appropriate CAT is cost. CAT (for working-age adults) is often funded through vocational rehabilitation agencies, which have small budgets relative to the demand for their services. Funds spent on clinician time and CAT for 1 client are unavailable to other clients, so maximizing each dollar spent is critical. Consumers who are retired, or not seeking employment, are equally cost sensitive as they may have to purchase their own equipment. As the population ages, an increasing number of older computer users will potentially benefit from CAT but are unlikely to be candidates for vocational rehabilitation and are thus likely to be using their own funds.
The Variety of Devices Available
Another challenge for computer access is the simple fact that there are too many options for any consumer to reasonably compare. There is a nearly limitless variety of alternatives to the traditional computer keyboard and mouse. Within each of these categories of devices there are multiple products, and each product has its own unique set of configuration options.
Given this variety of options, a consumer could spend weeks or months comparing devices, but a decision is often needed after 1 or 2 clinical sessions. In particular, consumers who need to obtain CAT to return to work or school often need to make decisions quickly to meet other deadlines. Beyond that, most consumers lack the patience or funding for multiple clinical visits. It is therefore critical to make optimal use of the time that client and clinician spend together in the clinic.
Consumer Needs Change Over Time
Even if a consumer who needs CAT receives a successful technology intervention, it is unlikely that the solution will remain effective indefinitely. Indeed, a consumer’s needs can change long before he or she has the opportunity to be reevaluated by a clinician. Regular follow-up evaluations are critically important, but often do not occur because of various barriers, such as the time and travel required and a lack of funding.
In addition, a single configuration may not be appropriate for a user at all times. A user’s needs may change as a result of changes in his or her abilities, which may happen over the course of a day (eg, fatigue) or longer (eg, because of progression of the disability, recovery of function, or other factors). The user’s needs may also change based on the user’s desired tasks (eg, some computer activities may require greater precision than others). Even if a clinician is available to recommend an initial configuration, he or she may not be available every time adjustments to the configuration are desirable. If a user is responsible for his or her own adjustments, he or she may not notice, or know how to respond to, a gradual decline in performance.
Potential technology solutions
The problems with the computer access assessment process will not be solved through technology alone. The assessment process should be based on each client’s individual priorities, taking into account preferences, physical and functional needs, social environments, and related issues, which makes the involvement of a trained clinician crucial. A clinician will always be needed to work with the consumer and other stakeholders to choose the most appropriate technology. Similarly, a clinician or other caregiver is essential for training in many circumstances. Funding and reimbursement issues are public policy problems rather than technology problems.
In other areas, however, technology can play a prominent supporting (or even leading) role. These include computer access assessment tools that clinicians can use to evaluate and document a client’s abilities, utilities to automatically configure technology for each client’s individual needs, and technology to provide follow-up services through remote client-clinician interaction. Research in each of these areas is discussed in this review.
Assessment Tools
Many different methods are currently employed in assessments for computer access. Informal clinical observation is the oldest method and is characterized by brief trials with candidate systems in a clinic setting and qualitative judgments of client performance during these trials. The lack of an explicit objective framework in this approach makes it likely that appropriate candidate systems may not be considered, that criteria for selecting candidate systems may not be clearly defined, and that objective data to guide the ultimate selection may not be available, particularly when evaluations are performed by inexperienced clinicians.
The need for a systematic approach to delivering assistive technology services has long been recognized. The systems and approaches developed to date are diverse and can be categorized on the following dimensions
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types of information gathered (qualitative vs quantitative)
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method of data collection and management (manual vs computerized)
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focus of approach (assessment of ability vs prescription of “best” device)
Several conceptual models for the “ideal” assistive technology assessment process have been developed. These conceptual models are designed to structure the evaluation to ensure that important considerations are not overlooked. Forms and worksheets are often provided to help guide the evaluator’s activities and lead to a recommendation of the most appropriate device. A weakness in this approach is that little or no support is provided for measuring specific aspects of client performance, such as speed and accuracy. The procurement and management of objective quantitative data are left to the evaluator, who may or may not perform this task in a consistent or valid way.
Generalized qualitative assessment models (applying to all aspects of assistive technology) include:
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The Student, Environment, Tasks, Tools (SETT) model . A general framework (rather than an actual protocol) for evaluating a person, environment, and goals to identify the most appropriate assistive technology.
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Matching persons with technology (MPT) . A validated measure that evaluates how individuals judge their own functional and health status. The MPT measures quality of life and predisposition toward assistive technology (AT) use, and has been shown to successfully predict satisfaction with AT 1 month after discharge.
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Considering AT . A flowchart to guide professionals through consideration of AT by asking a series of questions.
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Assessing students’ needs for AT . A protocol for evaluating a child’s assistive technology needs in the context of an individual education plan (IEP).
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Education Tech Points . Assessment forms and a manual documenting the components of effective AT service delivery.
As shown in Table 1 , several assessment tools have been developed specifically for computer access. Qualitative assessment methods designed specifically for computer access include:
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Alternative computer access: a guide to selection . A decision tree that guides clinicians through the assessment process. Decision points prompt the clinician to evaluate the client’s motor, sensory, and cognitive skills. The leaves of the tree are suggestions of appropriate types of computer access devices.
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Control of computer-based technology for people with physical disabilities: an assessment manual . A manual with data collection instruments, procedures for client observations, testing procedures for various computer access methods, and guidelines for matching client needs and device characteristics.
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Assessment of computer task performance . A series of tests and measurement criteria for assessing computer skills. No software is provided to support testing. Instead, the tests are administered using icons present on the computer desktop and standard word processing software. A series of transparencies are provided, which can be placed on the computer monitor to support the tests (eg, indicating a path that the client should follow with the cursor).
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Lifespace access profile . A team-based assessment tool that uses worksheets to measure physical, perceptual, cognitive and emotional skills, support resources, and environmental considerations. The worksheets are computerized, but data consist of subjective ratings from each team member.
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EvaluWare . A software package that presents evaluation exercises for a range of computer access skills. Despite the use of computerized tests, EvaluWare does not automatically record performance data.
| Tool | Recommends Assessment Protocol | Computerized Skill Evaluation | Automatic Report Generation | Recommends Devices | Skills Evaluated |
|---|---|---|---|---|---|
| Compass | N | Y | Y | N | Use of text entry pointing devices; sensory abilities; cognitive abilities |
| REACH interface author | N | Y | Y | N | Use of text entry and pointing devices; switch skills |
| Alternative computer access: a guide to selection | Y | N | N | N | Use of text entry and pointing devices; sensory abilities; cognitive abilities |
| Control of computer-based technology for people with disabilities | Y | N | N | N | Background; environment; text entry, pointing, and switch skills |
| Lifespace | Y | N | Y | N | Physical, cognitive, emotional, support resources, and environmental characteristics |
| Assessment of computer task performance | Y | N | N | N | Text entry and pointing skills |
| EvaluWare | N | Y | Y | N | Looking, listening, pointing, switch, some text entry skills |
| VOCAselect | Y | N | Y | Y | Criteria for an appropriate AAC device |
| Computer access selector | Y | N | Y | Y | Criteria for an appropriate computer access device |
Several computerized systems attempt to support the evaluator through all stages of the assessment process, producing a recommendation for the most appropriate assistive device. Examples of these systems include:
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Computer access selector . Uses device criteria chosen from a series of prompts by a clinician to identify the most appropriate device from a list of known devices.
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Assistive technology expert system . Presents a series of questions to the clinician based on rules in an expert system. Answers to each question determine subsequent questions, until a device is identified.
Systems with a primary focus on device prescription generally use assessment data only as a means to that end, which tends to limit the main use for these systems to one-time major evaluations lasting several hours or more. They are not easily applicable to assessments that take place in a single therapy session and are not designed to track performance across multiple assessments. Furthermore, the systems developed to date are limited to recommending a single device at a time, and are unable to coordinate a multifaceted approach to computer access.
What most models, protocols, guidelines, and tools uniformly lack is a means of collecting detailed quantitative performance data for use in decision making. As a result, computer access assessments primarily consist of brief trials with candidate systems resulting in qualitative judgments of client performance. Some clinicians collect quantitative data with a stopwatch, typing test software, or video games, but these approaches do not necessarily produce valid comparisons between devices.
The Compass software system, which measures users’ skills in various kinds of computer interaction, is designed to help clinical and educational professionals perform computer access evaluations with their clients by providing them with a clear picture of a client’s strengths and limitations. Compass tests the skill families of text entry, pointing, and switch use through a hierarchy of tests that tap into successively more complex aspects of each skill. A hierarchy of complexity helps accommodate differing client abilities. For example, matching single letters of the alphabet may be a more appropriate assessment of keyboarding skill in a young student than transcription of full sentences. The hierarchy also provides a way to isolate the physical component of the test from its perceptual and cognitive aspects. As one moves up the hierarchy, tests incorporate more perceptual and cognitive skills. Performance on higher level tests may be compared with performance at the lower level of the hierarchy to reveal how perceptual and cognitive issues affect keyboarding and pointing for a particular client.
Automatically Adapting Device Configuration
The behavior of most computer input devices, such as keyboards and mice, is adjustable. Because each person’s disability is unique, tuning these devices to a user’s strengths and limitations is critical for success in many cases. Ideally, configuration is performed in consultation with a clinician who has expertise in computer access for people with disabilities. However, a trained clinician may not be available, and even when one is available, proper tuning of a device to the needs of a particular user can be a difficult and time-consuming task. The challenge is magnified because the user’s needs and abilities may change over time, whether in the short term caused by factors such as fatigue or in the long term because of factors such as changes in the individual’s underlying impairment. For these reasons, input devices are often not appropriately configured to meet users’ needs, with consequent negative effects on user productivity and comfort.
A user’s system is typically configured in 1 or more of 3 ways. The first, and perhaps the most common, is to use the default values for the device. Moderately inappropriate values may result in multiple keyboarding errors and/or difficulty selecting targets with the mouse, decreasing user performance and satisfaction. In a more extreme case, the system may be virtually unusable at the default values.
A second scenario is when the user makes his or her own adjustments. This requires that the user knows what parameters are available and how to adjust them. This is a complex task. Performing all possible adjustments for keyboard and mouse within Windows XP requires accessing 3 separate Control Panel applications with 12 tabbed panels; making objects larger for easier selection would require accessing several additional Control Panel applications. Terminology can be ambiguous; for example, to invoke BounceKeys, the user chooses to “ignore repeated keystrokes,” whereas to adjust the repeat settings, the user must select “ignore quick keystrokes.” Another potential source of confusion is that the repeat settings can be adjusted in 2 different control panels, with the accessibility settings overriding the keyboard control panel settings. Even if the user can successfully navigate the options, knowing the most appropriate values for all applicable settings may be even more difficult. Users may not understand how the parameter settings relate to the interface problems they are having, or if they do, the best choice of specific values may be unclear. Recent versions of the Windows operating system include an accessory program called the Accessibility Wizard, which does provide some help in reducing the complexity of configuration for keyboards, pointers, and the visual display. However, it does not include all available settings (eg, the key repeat settings are not available), and does not give specific suggestions about how to appropriately set parameter values based on user performance.
A third scenario occurs when a clinician or teacher is available to assist with the configuration process, using clinical observations and knowledge of the possible accommodations as a guide. However, most users with physical disabilities do not have a qualified clinician available to them. Trewin and Pain found that only 35% of 30 computer users with physical disabilities had a computer teacher. Further, not all clinicians have the skills to assist effectively. Even when a clinician or other advisor with relevant expertise is available, input device configuration often requires considerable trial and error.
Under each of these 3 approaches, it may be difficult to define appropriate settings for a user’s initial configuration. It is equally difficult, if not more so, to address changes in the user’s abilities over time, which may happen over the course of a day, a month, or a year, depending on the nature of the user’s disability. Current methods may lead to appropriate input device configurations in some cases, but it does take special knowledge, additional time, and continued maintenance to do it right. As a result, input devices are often not appropriately configured to meet users’ needs, with consequent negative effects on user productivity and comfort.
An automated agent on the user’s computer could help ensure that input devices are properly configured for the individual, and reconfigured as the user’s needs change. Such an agent would need a means to observe the user’s performance and predict appropriate input device configuration settings based on that performance. Several groups have been working toward configuration agents that would support this process. A configuration agent models a user’s strengths and limitations, and based on the model, helps configure the user’s input devices appropriately.
Automatically configuring keyboards
Tuning a keyboard to a user’s strengths and limitations may yield significant performance and comfort benefits. Conversely, the potential consequences of inappropriate settings are many. (Desktop sharing refers to the ability of 1 computer user to remotely operate another computer while seeing the windows and icons on the remote computer’s desktop). For example, for someone who types with a mouthstick, not having StickyKeys active makes it cumbersome to type capital letters and impossible to use other key combinations such as Ctrl-C.
Trewin and colleagues have been developing a configuration agent for keyboard settings. The agent creates a user model based on free typing and determines settings for a range of parameters such as StickyKeys, Repeat Delay, and BounceKeys ( Table 2 ). The agent’s recommendations were evaluated with 20 keyboard users who have physical disabilities. For StickyKeys, the agent’s recommendation correlated significantly with users’ opinions on how useful StickyKeys would be for them. However, the discrimination of the agent was imperfect, as 9 users felt that StickyKeys was useful for them, even though the agent did not recommend it for them. For repeat delay, use of the agent-recommended settings significantly reduced key repeat errors (from 2610 to 151 errors). The agent accurately recommended use of BounceKeys for 5 of 7 subjects who made bounce errors. Effects on productivity measures, such as typing speed, were not measured.
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