November 30, 2012
U.S. Access Board
Food and Drug Administration
On behalf of the Blinded Veterans Association (BVA), we appreciate this invitation to present our views to the U.S. Access Board on the issue of making information on prescription drug containers accessible to individuals who are visually impaired. BVA is the only congressionally chartered Veterans Service Organization exclusively dedicated to serving the needs of our Nation’s blinded veterans and their families for 68 years. My fellow veterans who have lost sensory function could all testify, the reactions to blindness and disability are varied. Fear, overwhelming stress and anxiety, depression, and anger are some of the typical responses to the loss of vision.
Loss of vision is initially accompanied by the sudden loss of freedom to move around safely and independently function. In order to overcome the limitations imposed by vision loss, it has been necessary for us to undergo the type of continuous and comprehensive rehabilitation that is always changing as we adapt to new challenges— and as the field of rehabilitation and adaptive technology evolve. New access methods and techniques are necessary in order to optimize their relevance for us personally and to live independently. With various degrees of visual loss come greater difficulty to clearly adjust and see the environment, resulting in increased risk of injuries from falls, loss of functional ability, and danger of medication errors. Impairments range from losses in the visual field, visual acuity changes, loss of color vision, light sensitivity (photophobia), and loss of the ability to read and recognize facial expressions.
Vision loss in America due to age related degenerative eye diseases of macular degeneration, glaucoma, diabetic retinopathy, and cataracts over age 40 affects an estimated 2.6 million, of those estimates are 1 million are blind.1 Vision loss is a leading cause of falls in the elderly. One study found that visual field loss was associated with a six-fold risk of frequent falls.2 While only 4.3% of the age 65 and older population live in nursing homes, that number rises to 16% of those who are visually impaired, and 40% for those who are blind.3 The annual economic impact for these age related degenerative eye diseases, refractive errors, visual impairments, and blindness in adults age 40 and older is estimated at $35.4 billion-$16.2 billion in direct medical costs, $11.1 billion($11billion in nursing home costs) in other direct costs, and $ 8 billion in lost productivity.4 Anything that can done to prevent these higher costs of nursing home admissions will result in cost savings to the health care system and especially in Medicare expenses.
On this subject of accessible audible prescription containers utilization in the VA system BVA is proud of the fact that we worked closely with the Office Under- Secretary Health, and Office of Clinical Programs back in 2005-2006 to begin the development of the VA’s accessible prescription container program so blinded veterans have audible instructions and warnings when being provided medications from any VA pharmacy. Currently as of the end of FY 2011 our most recent data, VA has enrolled 50,304 blinded veterans within VA Blind Rehabilitation Services multidisciplinary programs.5 The average age of blinded veteran entering one of the thirteen VA Blind Centers in 2011 was 69 years, and average income level for 35.7% of these older veterans was less than $20,000 per year.
These blinded veterans enrolled in the VA system are assisted by Visual Impairment Service Team (VIST) that coordinate health care access and order prosthetics that the veteran requires. The mission of each VIST program is to provide blinded veterans with the highest quality of blind rehabilitation training and coordination of health care. To accomplish this mission, each VIST established mechanisms to maximize the identification of blinded veterans and to offer a yearly review of benefits and health care services for which they are eligible. VIST Coordinators are in a unique position to provide comprehensive case management and also Seamless Transition services to returning Operation Iraq Freedom and Operation Enduring Freedom (OIF/OEF) blinded or visually impaired service personnel for the remainder of their lives.
The VIST system now employs 119 full-time Coordinators and 43 who work part-time. VIST Coordinators nationwide serve as the critical key case managers and work closely with VA pharmacy service on ensuring that medications provided to visually impaired veterans are in accessible containers. Primary Care Team (PCT) providers are assigned to every veteran being cared for in any VA medical center or outpatient clinic and with the VA Computerized Patient Record System (CPRS) the VA version of Electronic Health Record. It is VHA Directive 2009-049 updated October 6, 2009 that provides policy that visually impaired veterans have access to audible prescription reading devices and equipment for all prescriptions that are transmitted to pharmacy service. The VIST identifies those blind veterans who may be appropriate for training with audible prescription device and coordinates this with the nurse educator, and pharmacy delivery and use of the device.
The VA currently utilizes for audible prescription devices ScripTalk, the system involves an encoding unit housed at the pharmacy that is attached to the computer that pharmacists use to create print prescription labels. This unit creates a prescription label containing a tiny chip in which information is embedded. The label is read by a battery-powered radio frequency identification reader in the possession of the person who is blind or who has low vision impairment.
In broader challenges here from the National Council Disability report in 2009 on Current Status of Health Care for Disabled, in addition to these barriers we examine also include inaccurate provider attitudes about blindness and vision impairment; physical barriers such as inadequate or lack of transportation and physically inaccessible health care facilities and fitness equipment and programs; limited educational and instructional materials in accessible formats; inadequate access to vision rehabilitation services, programs, and related accessible technologies; and inadequate access to prescription drugs and specialty care.6
Development by the working group of recommendations for best practices for accessibility of information on prescriptions for blind or visually impaired consumers is vital to ensuring safety and independence of those with a visual disability. While Braille, ‘talking bottles’ digital voice recorders, radio frequency identification tags and large font or contract printing have been utilized in the past as ways to approach this there are new emerging technology applications that are also possible solution as long as accessibility is designed into those new apps. As we examine the aspects of how to develop these best practices BVA recognizes that those blind citizens utilizing the health care system, providers, pharmacists and retailers face challenges in making recommendations that are not like the VA health care system with universal electronic medical record.
1. Prevent Blindness America, 2008Vision Problems in America
2. Ramratten, Raan, Et.,al. 2001 Prevalence and Causes of Visual Field Loss in the Elderly and Associations with Impairments in Daily Functioning Arch Ophthalmology 119(12):1788-94.
3. Rein David, et.,al. 2006 The Economic Burden of Major Adult Vision Loss in the U.S. Arch Ophthalmology 124(12):1754-1760.
4. Ibid Rein,
5. Department Veterans Affairs Blind Rehabilitative Service Data Utilization FY 2011
6. National Council Disability, 2009 Current State of Health Care for People Who Are Disabled, Chapter 1, Section 3.