The fax machine has proved to be difficult to remove from the healthcare communication chain, though efforts to do so are increasing.

When J.D. Whitlock told physicians who refer patients to Mercy Health that the Cincinnati-based system’s providers would be required to start sending patient information digitally, rather than by fax, some of those physicians said to go right ahead—they’d just start referring their patients to a competitor. Ditching the fax would mean the referring physicians’ practice would have had to log into a secure site to get patient test results, said Whitlock, who at the time was vice president of enterprise intelligence at Mercy. “It’s not completely crazy from their perspective that they’re not excited about this.”

So while a lot of people in healthcare want faxing to go away, many doctors draw a line in the sand in front of their fax machines, and hospital executives don’t want to cross it. “Hospitals can’t stand on principle in opposition to faxing if their business is going to go away,” said Whitlock, who’s now chief information officer of Dayton (Ohio) Children’s Hospital.

The problem is that for physicians, faxing works, but for healthcare as a whole, it doesn’t. Sending patient data and other health information digitally would result in more complete patient records. Those records would contain more information that could be analyzed by machine-learning tools. And providers, in turn, would cut costs by doing less repeat work, reading the same things on screens that they’ve already read on paper. They’d also lose the big risk that what they’re sending will go to the wrong recipient.

“The irritating thing is I’m getting as much faxed paperwork as I did a decade or two ago,” said Dr. Thomas Lee, chief medical officer of Press Ganey Associates. As a practicing physician, Lee gets faxes mostly related to signing off on physical therapist treatment, prescription renewals and insurance company noti?cations about potential gaps in care. “I don’t particularly want someone to send me faxes telling me everything that’s happened, because there’s no way I can absorb all that information.”

Now the chorus of faxing opponents includes not only large health systems but also federal regulators. CMS Administrator Seema Verma called on developers at the Office of the National Coordinator for Health Information Technology’s Interoperability Forum to help make doctors’ offices “a fax-free zone by 2020.” And Steven Posnack, executive director of the ONC’s Office of Technology, mostly seriously declared Oct. 12 No Fax Friday.

Those may sound like good ideas, but to some, they also sound like wishful thinking. “I told (Verma) to keep dreaming,” said Rush University Medical Center CIO Shafiq Rab. Nevertheless, he said, the end is in sight (he predicts it will come by 2022).

In order for that to happen, hospitals and clinics will have to just say no to faxing, slowly phasing it out until it’s truly a relic of the past. Until then, as providers seek greater interoperability, they must contend with workarounds and accept that they’ll duplicate information in some cases and miss it in others.

The fax’s rm grip

Decades ago, faxing was hailed as the future in healthcare. A CEO quoted in a 1989 Modern Healthcare column called “Competitive Edge” hailed fax machines as an “unbelievable success.” The CEO noted that fax machines in a couple of years won’t seem any more esoteric than telephones and copiers.

Yet some providers were reticent to adopt the tool. When Lee was CEO of Partners Community Healthcare and network president for Partners HealthCare System, he considered making having a fax machine a requirement for inclusion in the network. But outside physicians resisted, fearing that with the fax machine would come an in?ux of overwhelming information. “They were just trying to restrict information flowing in,” Lee said. “That’s the same reason people don’t want to give up fax machines today.”

In the end, Lee and others at Partners decided to let the market and peer pressure work on their behalf, forcing those practices to ultimately adopt fax machines.

Now, physicians are loath to let go of the machine they were once afraid to install. Bolstered by the lack of interoperability of health records, they’re still faxing regularly, especially for referrals, consent forms and patient records from outside organizations.

“There’s nothing as permanent as a temporary solution,” said Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center in Boston.

Advances in technology that allow faxes to be easily received and stored electronically actually is a bad thing. “We are feeding the beast of faxing by allowing it to come in and digitizing it,” Rab said.

But as provider organizations in the U.S. take on risk, turn to team-based care, and call for greater interoperability, faxing is increasingly not good enough. There’s often just too much information coming in and not enough time or cognitive ability to understand it all. “There was a time when physicians felt like they should know everything,” Lee said. “Now what they really want is to be able to look things up when they need it,” he said. “Because it’s impossible to know everything, you want to be able to access information.”

Electronic health records enable that access, giving providers patient information in the form of discrete data elements that are polluted by unstructured data from digitized faxes.

Whether paper or digital, for the information to be useful, someone must parse the document into pieces. That’s time and effort that could be used elsewhere. “Ultimately, everyone wants to get to an electronic health exchange so information is exchanged provider to provider, where you’re not involving staff time to pull that record, where you can just get it yourself,” said Dawn Paulson, director of informatics for the American Health Information Management Association.

Fax- ghting FHIR

As the call to rid healthcare of faxes grows louder and more insistent, people figure out ways to continue using them.

“We’re kind of in that in-between period where we have a paper-based healthcare system and an electronic-based healthcare system,” Posnack said. “Right now, faxing still appears to be the easy choice. When you go to send something, it’s easy for the sender; you just stick it in the machine and hit the button and hope it goes over to the other side. It’s hard on the receiver. They have a big cognitive load.”

EHR vendors play an important part in easing the burden by integrating third-party electronic faxing modules into their software. That way, faxing can more seamlessly fit into workflows, Whitlock said.

For some, an EHR with faxing capabilities is enough. “Fax is still a good technology to communicate because of the security,” said Dr. Andrew Rosenthal, medical director of plastic surgery for Modernizing Medicine, an EHR and faxing software company. “The key is how you make that work in today’s workflow,” said Rosenthal, a private-practice plastic surgeon.

Machine learning might play a role, with health systems using it to interpret faxes automatically.

To encourage adoption of alternatives to faxing, the government might also step in to regulate their use. Already, the ONC, in response to the 21st Century Cures Act, is encouraging the use of standards, such as FHIR, for information exchange. That could ultimately spell the end of faxing, since standardized data traveling in standardized ways would obviate the need to send anything as a single document in a fax.

Standards-based direct messaging has also been touted as playing a role in finally killing off faxing by giving providers a secure way to essentially email each other information—including information they would otherwise fax.

“The tricky part is what to do about these ‘lowest common denominator’ practices that are not getting signed up for direct addresses and connected to their local” health information exchange, Whitlock said. “How can we come together as an industry to make it as reasonably easy for these independent practices as it is for larger systems?”

For health systems that want to cut the cord with faxes, they can’t just decide to quit faxing at once and be done with it. “You can’t just say ‘no faxing now,’ ” Lee said. “You have to set a date and create a work plan.”

“I’m optimistic we can do this type of thing, because look at EHRs. There was a lot of angst, but we got there.”