When the fax machine was first successfully implemented in 1964, it seemed revolutionary. Long gone were the days of telegraphs and snail mail taking days or weeks to deliver documents. Now, you could fax any sheet of paper and it would deliver in minutes. The fax machine led to the telegraph eventually phasing out of existence. When the fax market took off in the late 1960s, it seemed it was here to stay. You weren’t considered a “modern” office in those days unless you had a fax machine in your office. But then a little thing called the Internet was born. It took off in the 1990s, and email followed closely behind.
Email took over as the signifier of a modern office because of it’s lightning fast speed. What took minutes for a fax machine to send and deliver a document took mere seconds with electronic mail. As such, the fax machine went the way of the telegraph. It slowly started phasing out of existence in many modern offices, except one: healthcare offices.
Healthcare still uses fax machines for sending important documents such as patient records or prescription orders. Often times, these documents contain PHI of some kind. As Sarah Kliff at Vox put it, fax machines are "the cockroach of American medicine: hated by doctors and medical professionals but able to survive — even thrive — in a hostile environment." And that's somewhat true. Fax machines have been reliable for the longest of time - aside from the busy signals, blurry printouts, and faxes being sent to the wrong place entirely. As it turns out, it was these reasons why the fax machine phased out of existence in most offices. But according to a private firm's estimate, 75% of all medical communication are faxes. Most of healthcare isn't happy about this, but changing the industry isn't easy - even if the United States government gets involved.
The Obama administration spent over $30 billion trying to encourage American hospitals and doctors to go digital. Was all that spending successful? Yes and no. On the one hand, the number of hospitals using electronic records grew from 9% in 2008 to 83% in 2015. On the other hand, hospitals and doctor offices still can't transfer electronic information to other hospitals and doctor offices. Despite billions of dollars being spent, healthcare still prints out documents and faxes them. So what failed? The Obama administration did not take into account the reluctance of competing health systems willing to share data. They now admit that this assumption was "naive". David Blumenthal, a health policy coordinator for the Obama administration from 2011 to 2013, compared health systems to large corporations: “We don’t expect Amazon and Walmart to share background on their customers, but we do expect competing hospital system to do so. Those institutions consider that data proprietary and an important business asset. We should never have expected it to occur naturally, that these organizations would readily adopt information exchange.”
In February 2009, President Obama signed a stimulus package into law. The package included a 53-page section called the HITECH Act (the Health Information Technology for Economic and Clinical Health). This act allotted $30 billion to incentivize doctors into adopting digital records. The ONC (Office of the National Coordinator for Health Information Technology) was in charge of creating a program to distribute the funds accordingly. The government believed that if doctors began using electronic records, they would be more amenable to using further digital forms of communication such as secure email. If doctors and hospitals met the criteria set by the ONC, they would receive bonus payments from the federal government taken out of the $30 billion incentive fund. As the government hoped, these incentives worked - but only for those who were able to receive them. For instance, hospitals were quick to adopt EMRs because they were qualified for incentives payments. Nursing homes were not qualified, and thus took a much slower pace at adopting EMRs. If your current doctor's office allows you to see test results online, schedule an appointment online or message your physician online, that is a positive effect of the HITECH Act at work.
Healthcare is notoriously expensive in the United States - both from the consumer and provider point of view. Hospitals and private practices are still businesses that need to stay ahead of their competitors. As a result, healthcare organizations are less likely to share patient information. If one hospital were to exchange patient information to another hospital at the patient's request, the transferred information makes it easier to for the patient to see another doctor. However, if a patient's medical record is only exchanged within one hospital system, patients are encouraged to stick with the healthcare providers within that hospital. Likewise, companies that sell electronic record makers are very competitive. Why create a medical record that connects well with other records when the electronic record company can provide an exclusive EMR altogether? Healthcare still relies on the fax machine because the fax machine makes it tedious to transmit medical information. By making information harder to transmit, patients are more likely to stay within one preferred healthcare network. The government only incentivized healthcare to transition to EMRs, not interoperability - which continues to be a hot topic in digital health today.
Farzad Mostashari, the healthcare policy coordinator who succeeded David Blumenthal in the Obama administration, had one key takeaway from his time in the White House. To get rid of fax machines in healthcare, we must outlaw faxing in healthcare. He believes that if the government intervenes and gives the fax machine an expiration date in healthcare, doctors will have no choice but to rely on secure HIPAA compliant email instead.
“I think if we want to kill the fax, we need to schedule a funeral,” Farzad Mostashari said. “I think you need a pull and you also need a push."
Turns out we were one step ahead of Farzad - we already held a wake for the fax machine at our Paubox SECURE conference. https://www.youtube.com/watch?v=E1lR3xOxk0s Now in the Trump administration, we have Donald Rucker running the ONC (Office of the National Coordinator for Health Information Technology). Rucker believes that better-designed electronic records will help data transfer more freely in the long run. He also cited a new provision in the 21st Century Cures Act that "requires electronic records to exchange data with other records in a way that requires 'no special effort.'" What "no special effort" means is to be determined. We'll have to wait and see if the Trump administration's approach to building better-designed electronic records will eliminate fax machines once and for all. Until then, join us when we say, "No more faxes!" With faster and easy alternatives like secure HIPAA compliant email, the fax machine's time has come and gone.