In case you missed it, CMS Administrator, Seema Verma challenged the audience at the Interop Forum hosted by ONC to “make every doctor’s office fax free by 2020.” Many in healthcare celebrated this challenge with statements like the following:
“It is inconceivable that providers still rely on technology that should have faded away at least 10 years ago.”
Statements like this make it seem like doctors and other healthcare leaders are luddites that are holding on to their fax machine out of some principal. They make it sound like healthcare professionals love their fax machines. Let me assure you that neither thing is the case. The reason faxes are so prominent in healthcare is a complex issue. However, the core problem is that there’s no better solution.
Everyone calls for the end of faxes in healthcare. The problem with this is that when you slam faxes, you’re slamming the most interoperable piece of healthcare. That’s sad, but true.
Faxes aren’t the problem. The lack of better solutions is the problem. So, instead of slamming fax machines, we should better understand the qualities that make faxes the interoperability choice of healthcare.
Here’s a look at why fax is so common in healthcare:
Faxes are HIPAA Compliant – The reality is that case law and other HHS comments have declared Faxes to be HIPAA compliant. That’s not to say that faxes are secure. We could talk over whether it’s secure or not and even edge cases where it’s still not HIPAA compliant. However, what’s clear to everyone in healthcare is that you can fax PHI and there’s no HIPAA violation. At least that’s the perception and how people treat it in action. This is a powerful idea that can’t be understated. Perceptions deeply influence people’s behaviors. Especially in risk-averse doctors’ offices.
Published Fax Numbers – Every practice has a fax machine and they all publish their fax number on their website. Thanks to Google, there’s basically an online directory where I can search any doctor and find their fax number.
Faxes Are Standard – Unlike so many other healthcare interoperability standards, every fax machine knows how to call and talk with another fax machine. There’s no need to ask what version or flavor of the fax standard you are using. There’s no need to ask where you’re storing certain information. Every fax uses the same standard and delivers the same result regardless of organization.
Every Practice Has a Fax Workflow In most cases, practices have their fax machines integrated directly into their EHR. Regardless, they all have some workflow that gets from the fax machine to the provider. Don’t underestimate the power of this workflow.
Faxes are Free – Ok, this has evolved a little over the years as healthcare organizations have moved to secure fax and fax servers which might charge a monthly fee. However, faxes are relatively cheap and have a known cost structure behind them. In many cases, it’s a cost that’s already been incurred. There’s no incremental cost to send more faxes.
That’s a pretty compelling feature set and I’m sure I’ve missed something. If healthcare provided a solution that offered all of these things, healthcare organizations would happily take this replacement. Plus, a replacement could and should do things that faxes don’t do like granular data.
However, direct messaging taught us a really important lesson about granular data which also highlights why fax machines are still so popular and direct messaging is not. Machines love granular data. That’s why machines are ok with a massive CCDA document that’s chock full of data. However, those CCDA documents are almost impossible for a human to read and cause doctors to say that CCDA is an abomination that doesn’t improve care. They’re right if you’re talking about a human reading a CCDA.
Humans need healthcare documentation designed for humans! Leave the XML health data files to machines.
When you understand this idea, it’s easy to see why doctors still love to receive faxed notes and hate CCDAs. Faxed notes are generally human-readable documents (EHR note bloat aside). CCDAs are not. The ideal solution is that we could have both. We just haven’t gotten there yet, but we could get there if we could overcome many of the other compelling fax features listed above.
What About Patients?
There’s a common problem we have when discussing technology in healthcare. Healthcare is so complex that we often confuse various uses of the same technology. The fax machine is a great example. All of the above analysis was how healthcare providers use a fax machine to communicate with other healthcare providers and other healthcare organizations. All of these entities have a fax machine and know how to use it. This is why the fax is a compelling option in healthcare. However, when you add the patient to the mix, it changes the equation.
Many of the people who want to ax the fax are talking about it from the perspective of a patient. That’s a totally different equation than the one described above. Many patients don’t have fax machines anymore and they’re unlikely to ever get one. It’s not unreasonable to say that healthcare should abolish trying to fax healthcare information to patients. A fax is rarely the best workflow for a patient. Healthcare providers should consider patient-friendly options.
When talking about faxing, we need to separate the discussion of patient interoperability and provider interoperability. They are very different beasts and not separating them confuses the discussion.
All in all, Seema Verma can call for the end of fax until she’s blue in the face. Until there’s an alternative that’s better than the fax, we’re not going to see faxes out of healthcare. It’s no inconceivable or even ridiculous that healthcare organizations continue to use the best workflow they can find for their organization. In many cases today that workflow is the fax. Once that equation changes, every healthcare provider I know will change. I’ve never met a single provider that’s nostalgic for faxes. They hate them as much as the next person but don’t see a better option.
Of course, as Ed Gaines pointed out on Twitter, Seema may want to start by taking a good look in the mirror. How about CMS stops using fax as the only option for some of the things they do? Once CMS abolishes faxes from their organization, that will give her a more powerful platform to call on the rest of healthcare to do the same. Unfortunately, I think Seema will quickly realize that there’s a reason that faxes are still so popular, there’s nothing better.
If Seema does away with faxes in healthcare, she’ll be doing away with the only form of nationwide healthcare interoperability that we have today. What’s going to replace it?