HIGH VOLUME, HIGH STAKES
- Splash Box Marketing, LLC
- Apr 1
- 7 min read
Updated: Apr 14
RETHINKING PDF ACCESSIBILITY IN HEALTHCARE
In healthcare, PDFs are not secondary materials. They aren’t just “downloads” or something that’s posted or forgotten about on a website. PDFs are vital. They’re how members understand benefits, make decisions about care, browse pharmacy directories, and meet deadlines. An Explanation of Benefits (EOB) isn’t optional reading. A provider directory isn’t a nice-to-have. A notice about coverage, appeals, or eligibility isn’t “marketing content.” It’s a critical need that sits directly in the path of decision-making. And when something in that path breaks or is missing, the impact is felt immediately.
The scale only sharpens the problem. These documents are produced constantly – at least yearly, often quarterly or monthly – and across multiple teams and vendors, under tight deadlines. This combination of volume, complexity, and urgency makes accessibility less of an exercise in compliance and more of an operational requirement. Simply put, if a member cannot read or navigate a document, the fact that it was delivered on time becomes irrelevant.
One of the most important questions that most teams face today is not whether accessibility matters, but rather how we should approach accessibility. In practice, there are two distinct paths to achieve this. One is to build documents so that accessibility is embedded into the document from the very beginning. The other path is to repair documents after they’ve been created.
“BORN ACCESSIBLE” VS. REMEDIATION – AND WHEN EACH MAKES SENSE
A “born accessible” approach treats accessibility as part of the native system. Templates can be structured correctly in tools like Microsoft Word, Adobe InDesign, and Adobe Acrobat. Styles can be applied consistently with proper structure, predictable components, correct export settings, and alt text. This approach works best for documents that are produced repeatedly, like monthly explanations of benefits, recurring notices, annual membership documents, or any workflow that depends on consistency at a large scale. This helps reduce the downstream effort because the structure of accessibility is already in place before the file ever becomes a PDF.
Remediation, by contrast, is corrective. It involves taking an existing PDF and fixing the tags, reading order, tables, alt text, and form fields after the fact. This is often best for legacy documents, one-off communications, or anything that needs to go out quickly without the benefit of creating a structured source file. In truth, most organizations rely on both approaches at different stages in the content creation process. But it’s important to understand the distinction between the two stages: one builds reliability into the native process, while the other recovers from its absence.
What’s best is to begin incorporating accessible design practices into your content team’s workflow. This way, accessibility is part of the process from the building blocks to the finished concept.
THE CORE MECHANICS: WHAT MAKES A PDF ACCESSIBLE
One aspect that often gets lost in the many choices we must make when creating accessible documents is the underlying mechanics of these documents. Accessible PDFs aren’t defined by a single setting or a checklist. They depend on whatever or not assistive technology can interpret the document in a coherent way. The good news is that you don’t need to memorize every standard to improve outcomes. In practice, accessible PDFs come down to a few fundamentals that determine whether assistive tech can interpret the file.
Reading Order:The Number One Dealbreaker
Reading order is the sequence that a screen reader follows. It also happens to be the most common point of failure for a PDF. Screen readers follow a sequence, and when that sequence breaks – like if columns are read across instead of down or when sidebars interrupt the main content – the document becomes confusing even if the text itself is clear. A usable file presents information in a logical progression, starting with the title, followed by headings, then body content, and all without decorative elements interfering.
Headings Are Structure, Not Style
Structure is an easily overlooked element that’s vital to the accessibility of the document. Headings aren’t just visual styling or design preferences; they are essential navigation. A document with a clear hierarchy allows users who are and are not using assistive technology to move through sections efficiently. A document with no hierarchy at all or one that’s confusing forces the reader to follow the document linearly, which leads to missing or skipping key information. A logical hierarchy implements H1 for the titles, H2 for major sections, and H3 for sub-sections.
The same principle applies to tables, which are common in healthcare documents. They’re also a very frequent source of complaints. Without properly defined headers, a table can easily become a grid of disconnected values, rather than meaningful data or information. A logical table incorporates headers with rows and columns identified, uses consistent column meaning across pages, merges cells sparingly and intentionally, and simplifies tables wherever possible.
Form Fields (Labels and Tab Order)
Forms introduce another layer of complexity to a document. If a member needs to fill out a PDF form, accessibility is non-negotiable. This means every single fillable field must be labeled in a way that assistive technology can interpret. As such, the tab order must also follow a logical pathway. When it doesn’t, even simple tasks become, at best frustrating, and at worst impossible. Accessible forms include fields with programmatic labels, tab order that follows the visual order, identified required fields, and clear error handling when needed.
Long documents bring their own challenges, requiring remediators and designers to place bookmarks that function as a navigational map. This allows users to jump between sections instead of scrolling through dozens of pages. Think of bookmarks like the table of contents. Bookmarks should mirror headings, include a usable outline, and have names that are descriptive.
Metadata
Lastly, it’s important to remember that even the non-visible or less visible elements matter. Metadata is information like the document’s title and language, often found within the settings or properties. It’s important because metadata helps assistive technology present the document correctly. Without it, tools may misidentify the content or fail to provide context altogether. These details are easy to overlook, but they shape the user experience in ways that are immediately noticeable to anyone who relies on it. When setting metadata, make sure to include a document title set that’s not just the file name and that the language is set correctly.
HOW TO CHECK QUALITY QUICKLY BEFORE PUBLISHING
Because of the pace at which healthcare documents are produced, quality assurance cannot become an open-ended process. It must be fast, repeatable, and focused on what most commonly blocks access. A quick review can reveal the most critical issues. From there, testing for quality can expose whether the document works not just in theory, but in practice as well.
Healthcare teams need a realistic quality assurance approach: one that’s fast, repeatable, and focused on what blocks members. That’s why we’ve created the Three-Pass QA Test. Essentially, you review the document three times: once for triage, once for navigation, and once for usability.
Pass 1: The 60-Second “Triage”
In other words, this first pass is testing for all the major, emergency issues that would render a document completely unusable. Use the following questions as a guide for this first pass:
Can you select text (or is it a scanned image)?
Does the file have a real title (not just a filename)?
Does the first page read like a coherent start (title, introduction, not a random sidebar)?
Pass 2: The “Navigation” Pass
The second pass is focused on how the document navigates. These issues may not completely break a document, but they are significantly detrimental and will ensure the document fails accessibility compliance standards.
Check bookmarks and verify:
Bookmarks exist for documents nine pages and over.
Bookmarks for shorter documents are still beneficial and recommended regardless of document length.
Open the tags/structure view and confirm:
Headings exist and are in order.
Lists are real lists.
Tables are tables (not tabbed text).
Pass 3: The “Member Task” Pass
Last but not least is the third round, focused on the member experience.Choose the most important part of your document, and use the following questions to test the document end-to-end and help understand the member’s point of view:
Can a keyboard-only user reach key information?
Can a screen reader user find the section they need using headings?
Are tables understandable(headers announced rationally)?
If it’s a form, do fields announce labels and follow a logical tab order?
WHERE HEALTHCARE PDFS MOST COMMONLY BREAK
If you’ve created a document that doesn’t pass remediation or has broken in some way, don’t panic.Certain document types tend to fail in very predictable ways. Explanation of Benefits documents often have dense tables, repeated headers, and inconsistent reading order.Provider directories can become unwieldy, with long page counts and inconsistent structure. Notices are frequently distributed as scanned files with missing metadata, while member materials often rely on icons and visual callouts without providing textual equivalents. These are not fringe cases, but rather, they are recurring patterns that reflect how the documents are produced.
The most effective response to these breakages is not to treat accessibility as a final step or an end goal, but to make it part of the workflow itself.That usually means addressing immediate needs through remediation while gradually standardizing templates so that future documents are accessible by design. Adding a quality check before publication helps prevent known issues from reentering the pipeline.
Accessibility in this context is not a feature layered on top of a document like icing on a cake. Instead, like the flour, eggs, and sugar of cake batter, it’s the structure that determines whether the document works at all. When organizations treat accessibility in this integrated, holistic way, it becomes something that can scale alongside the volume it’s meant to support.
TOP 10 PDF TIPS AND TRICKS FOR ACCESSIBILITY
Use this checklist as your ready to publish gateway. It’s designed as a practical final pass to confirm that the file isn’t just technically compliant, but usable. It focuses on the elements that most directly affect how assistive technologies interpret and navigate the document and the issues most likely to trigger complaints, helping your team catch what matters most before publishing.
Verify text is real (not just an image). If scanned, OCR is applied and verified.
Set document title and language via metadata and that they match the content.
Ensure tags exist, are logical, and are more than a flat list of paragraphs.
Confirm reading order is correct. Look at columns, sidebars, callouts, and footers.
Double check that headings are hierarchical, with H1/H2/H3 used for structure, and that tables have readable headers.
Verify that lists are real lists – not manual dashes or line breaks.
Test links and make sure they are descriptive – not raw URLs or “click here.”
Check images for appropriate alt text or that they are marked decorative.
Label form fields and check that their tab order follows the visual order.
Ensure bookmarks match the section structure. ●