By Christopher Brown
Health IT pros and federal regulators dream of a health-care system in which the flow of information happens seamlessly through a simple mouse-click, with just the right data flowing in an instant to just the right provider in just the right form.
But getting to health IT nirvana will mean dealing with the fax machine—and with the limitations of current technology that make fax machines necessary.
At least 70% of health-care providers still exchange medical information by fax, according to federal officials, and some providers, such as nursing homes and skilled nursing facilities, rely heavily on the outdated technology.
Electronic health records and other modern health IT tools hold much promise, but they under-deliver when it comes to moving information across boundaries of the health-care system: between hospital systems, between providers, between competing technology platforms.
That’s where the fax machine comes in, bridging the gaps in its own clunky way. Effective—but limited, slow, inefficient, and increasingly seen as a roadblock to improved care and to more ambitious goals for the use of health information.
Regulatory changes are on the way that will start pushing the health-care system away from the fax machine in the direction of “interoperability.”
But the full replacement of the fax machine likely won’t occur until the design of health IT technology shows as much concern for provider communication and care coordination as it does those of billing and compliance, analysts say.
“The health IT focus up until now has been on electronic medical records systems,” said Will O’Connor, chief medical information officer at TigerConnect, a health IT company focused on collaboration. “But EMRs are really a billing tool more than a tool to help doctors and other providers.”
“To get fax machines and other antiquated tools out of health care, we’ll need new tools focused on the moments of communication and collaboration where the fax machine currently plays a role.”
No one seems to know the exact extent of fax usage in the U.S. health-care system, but there is broad agreement that most providers and organizations still use the technology.
Recent research suggests that around 70% of health-care organizations still use faxes, according to Steve Posnack, deputy assistant coordinator in the Office of the National Coordinator for Health Information Technology.
Reliance on faxes is particularly strong in sectors of the health-care system where the adoption of electronic health records systems has lagged.
This includes the public health sector, which depended on faxed case reports from providers in the early stages of the Covid-19 pandemic as local and state health departments struggled to keep abreast of the rapidly spreading disease.
A key factor is funding: some sectors, including skilled nursing facilities and behavioral health providers, didn’t receive federal funds for EHR adoption that was provided through the 2009 Health Information Technology for Economic and Clinical Health Act, known as the HITECH Act.
Providers also routinely share health information outside the health-care system, with law enforcement agencies, social services agencies, employers, and other entities that don’t use EHR systems. This is typically done by fax, Posnack said.
And faxes are still routinely exchanged between hospitals and health-care providers outfitted with the latest EHR technology, he said.
This is because EHR systems from different makers can’t talk to each other.
The result can be absurd, Posnack said. It’s not at all unusual for a provider to print off records from an electronic health records system and fax them to another provider, who then faces the task of extracting the information from the faxed records for entry into the provider’s own EHR system.
The stack of faxed records that can follow a patient being discharged from one health-care facility to another can be 200 pages or more, according to Subha Airan-Javia, a hospitalist with Penn Medicine who is also the founder and CEO of CareAlign, a developer of communication tools for health-care providers.
“Just last week we received faxed medical records for a patient that made a stack two inches thick,” she said. “And it came in two or three different faxes, because they ran out of paper half-way through, and it was all disorganized, and there were missing sheets. It was a mess.”
“And there I was, trying to put all this information together, it was like sorting through a year’s worth of credit card information for 20 different cards, and being expected to immediately balance your checkbook and know how much money you have in every account, right now. It’s just about impossible.”
A regulatory fix for the problem of sending health information between EHR systems is on the way, in the form of new information-blocking rules that require EHR makers to open up their systems through the development of software gateways that will allow patients to access and control their own health information.
The Office of the National Coordinator for Health Information Technology released the final rule in May 2020, with deadlines that were later extended due to the pandemic. Implementation began in April 2021.
But the problems with EHRs go beyond their inability to share information across platforms, said Airan-Javia.
“EHRs weren’t designed to help clinicians do their job of providing care,” she said. “They were designed for billing and coding. They’re really focused on the business of health care and the compliance needs of the organization.”
The poor fit between EHRs and the needs of clinicians shows up in myriad ways, and gives them ample reason to continue relying on outdated tools, Airan-Javia said.
EHRs are basically databases of information related to past health-care encounters, she said. But they aren’t designed to provide clinicians with useful information to guide their care-giving decisions in the present moment.
“If I want to do a search and find out if you’ve ever had an HIV test, it should show up, right?,” she said. “But that’s not what happens. The information is hidden from view, it takes a lot of clicks to get to it, and it’s error prone in a lot of systems. The EHR just doesn’t give us what we need.”
EHRs also attempt to be an all-in-one solution, but many of the most important functions are merely “perfunctory add-ons,” such as mobile capabilities to help the clinician at the bedside, she said.
“Mobile workflows should be central to helping the clinicians, because if they’re not, you’re back in the world of paper and faxes, and doctors walking around with note pads,” she said. “The mobile capability we get from the EHR is clearly an afterthought.”
Mobilizing doctors and other health care providers in the effort to replace the fax machine and other outdated tools will require a focus on their needs as opposed to the needs of the billing department, O’Connor said.
“We’ve spent billions and billions of government dollars on these EHRs, and in many ways we’re back to where we started, with doctors and nurses still unable to communicate in an efficient way,” he said.
“It’s time to focus on new tools that solve the problems that providers have.”
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