The Documents Patients Can't Read

The Collision Course

Two federal mandates are converging on U.S. healthcare organizations simultaneously — and most haven't reconciled the tension between them.

The first is the 21st Century Cures Act. Its information blocking provisions, fully enforceable since 2023, require healthcare providers to give patients electronic access to their health information without delay. Patient portals are now the primary delivery mechanism. According to the Office of the National Coordinator for Health IT, nearly all U.S. hospitals have enabled patients to electronically view their health information. By 2020, approximately 40 percent of individuals nationwide had accessed a patient portal — a number that has grown every year since, reaching 65 percent by 2024.

The second is the HHS Section 504 final rule, published May 2024. For the first time, the Department of Health and Human Services established explicit, enforceable digital accessibility standards for organizations that receive federal financial assistance. The standard is WCAG 2.1 Level AA. The deadline for organizations with 15 or more employees is May 11, 2026. The deadline for smaller entities is May 10, 2027. The rule covers web content, mobile applications, kiosks — and documents.

What "Inaccessible" Means in Practice

A PDF without proper tag structure, reading order, and text layers is not partially usable to someone navigating with a screen reader. It is functionally empty. JAWS, NVDA, and VoiceOver cannot interpret a scanned image. They cannot parse a document with no heading hierarchy. They cannot distinguish a data table from a paragraph when the structural markup doesn't exist.

In healthcare, the documents affected are not peripheral. They include lab results, discharge instructions, medication lists, surgical consent forms, explanation of benefits statements, appointment summaries, and billing notices. These are documents that inform treatment decisions, that patients are legally entitled to access, and that in many cases require a signature indicating informed consent.

According to AHIMA (the American Health Information Management Association), older adults and patients with disabilities face documented barriers to accessing their health information electronically, with many struggling to use hospital websites and patient portal systems even when the intent to provide access exists.

The gap is not a matter of willingness. It is structural. EHR systems export documents in formats that were designed for print, not for assistive technology. Billing platforms generate PDFs that render correctly on screen but contain no semantic structure. The result is a document pipeline that satisfies the Cures Act's letter — information is technically available — while failing Section 504's requirement that it be accessible.

Enforcement Is Not Theoretical

HHS is already acting. In December 2024, HHS's Office for Civil Rights entered into a Voluntary Resolution Agreement with MultiCare Health System to resolve a complaint regarding effective communication with patients with disabilities. In February 2026, OCR reached a similar agreement with Bayhealth Medical Center for the same category of failure.

These are not outliers. According to Grand River Solutions' analysis of OCR enforcement activity, 35 of the 53 resolutions published by OCR between January and mid-July 2025 were disability-related. The trajectory is accelerating.

The Section 504 final rule strengthens OCR's position considerably. Before May 2024, healthcare accessibility enforcement relied on general anti-discrimination language without specific technical standards. The final rule now defines exactly what accessible means — WCAG 2.1 AA — and exactly when compliance is required. That specificity makes enforcement simpler, complaints more actionable, and organizational risk more concrete.

OCR has authority to investigate complaints, conduct compliance reviews, and refer cases to the Department of Justice. For healthcare organizations that derive revenue from Medicare or Medicaid — which includes virtually every hospital in the country — the ultimate enforcement mechanism is the potential loss of federal funding.

The Scale Problem

Healthcare is one of the most document-intensive industries in existence. According to Clinical Architecture, a single hospital generates approximately 137 terabytes of data per day. A significant portion of that data reaches patients as PDFs.

The American Hospital Association's 2026 Fast Facts report lists more than 6,100 U.S. hospitals. Each one operates multiple document-generating systems — EHRs, billing engines, lab information systems, imaging platforms, pharmacy systems — that produce patient-facing PDFs through independent workflows. The documents are generated at scale, automatically, without human review of their accessibility.

Any organization that remediates its current documents without changing the systems that produce them will be back in the same position within months.

The Population Most Affected

More than 70 million Americans report having a disability, according to the CDC. People with disabilities use healthcare services at significantly higher rates than the general population. They have more appointments, more prescriptions, more diagnostic tests, more documents to navigate.

A 2024 study published in the AMIA Annual Symposium Proceedings found that accessibility barriers in open-source EHR systems are pervasive for individuals who are blind or visually impaired, extending beyond the patient-facing portal to the underlying systems themselves. The problem is not confined to one layer of the technology stack.

The 21st Century Cures Act was designed to put patients in control of their health information. For the estimated 7 million Americans who are blind or have significant visual impairments, that promise is hollow if the documents they receive cannot be read by the assistive technology they depend on.

What Compliance Requires

The Section 504 final rule is explicit. Covered entities must ensure that their web content, mobile applications, and — critically — their documents meet WCAG 2.1 Level AA. The deadlines are phased: May 11, 2026 for organizations with 15 or more employees, May 10, 2027 for smaller entities.

• An audit of what currently exists — how many patient-facing PDFs are in circulation, where they originate, and what percentage meet WCAG 2.1 AA. Most healthcare organizations have never conducted this assessment. The number is almost always larger, and the failure rate higher, than anticipated.
• Remediation of the existing document inventory. At the scale healthcare operates, manual remediation is not viable. Automated remediation — correcting tag structure, reading order, and text layers programmatically — is the only path that matches the volume. Published estimates for automated remediation range from $1–4 per page, a fraction of the cost of a single OCR resolution agreement.
• A change to the document generation pipeline. The EHR exports, billing templates, and reporting tools that produce inaccessible PDFs today need to be configured — or replaced — to produce accessible output going forward. Compliance is not a one-time remediation project. It is an operational change.

The Deadline Is 11 Weeks Away

As of this publication, healthcare organizations with 15 or more employees have until May 11, 2026 to meet the Section 504 digital accessibility standard. OCR is already enforcing disability-related effective communication requirements against health systems. The final rule gives that enforcement a specific, technical standard to measure against.

The organizations that begin now will remediate proactively, at lower cost, and on their own timeline. The organizations that wait will remediate reactively — after a complaint, after an OCR letter, or after a resolution agreement that dictates the terms.

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The documents are already being generated. The patients are already trying to read them.