Why Is Fax So Prevalent In the US Medical Profession?

Doctors and their office managers are Luddites and cheap as shit. Did I mention stubborn? Only lawyers are worse. Only government regulations can force them to divest themselves of the obsolete technology. HIPAA might force their hands. If you could give them the equipment free, maybe brand it with Lipotor or something you might have a chance.

In my office we have transitioned from fax to sending pdf's by secure e-mail. Problems we have/had: 1. There was an initial cost to get everyone set up with Adobe professional so that we can 'print' to pdf from the EMR. 2. It is actually very time consuming to print individual reports to pdf. They have to be named and saved, sent, and then deleted. Once for the CT report. Once for the pathology report. Again for the labs. Again for the MD notes, etc., etc. If I have a big job it is faster to print everything on paper and walk it down the hall to the copier/scanner, then scan it to myself and forward it via e-mail. 3. We have to send via secure e-mail in order to avoid the liability of having someone HIPAA protected information intercepted. Secure e-mail is a pain in the ass for the recipient, and makes it impossible to forward to other people in the partner organization who justifiably need it. Plus, it often takes two or three login attempts if you can get in at all. The only thing that keeps me from reverting back to faxing is that our EMR prints in gray-scale and doesn't fax well. We have also set up an affiliated link with some of our major record recipients so that we can open a link on a shared patient and let the staff on the other end have direct access for the treatment period. (This is all for pt treatment, not for insurance, billing, QA, etc.) This has reduced our need to 'send' records enormously and is a blessing from God, IMHO.

You're asking the wrong question. You're asking why things are being faxed. But when you have handwritten paper documents, a fax is a pretty reasonable way to transmit a that document to someone else. Oh, but what if someone has EMR? Too bad. Someone else's EMR system is totally different, and has totally different file formats, so you can't just email it anyway. The question isn't "Why aren't faxes dying faster?" The real question is, what's holding back adoption of standardized EMR formats? I'm not going to pretend to have the answer to that question in my vest pocket, but I think you're looking at a symptom, faxes, when the disease is paper recordkeeping in the first place.

I am a doctor. I have posted a sign over our fax machine that reads "THE SOURCE OF ALL EVIL" 1. We respond to a lot of forms that must be filled out, signed, and faxed back. Yes, we could do this electronically, but there exists no clear standard as to what constitutes a verifiable, secure, traceable signature that everyone recognizes. 2. There are protocols in place that serve this signature function that are *widely* but not universally recognized, these are private companies like eRx and SureScripts that both doctor's offices and pharmacies must both share in order to communicate, and these services cost money. I can't say about pharmacies, but most medical practices operate on a very thin margin and the 20 year old fax machine is free. Even if you do subscribe to these services as we do, there are always places like nursing homes, medical supply places, etc that don't have these services available to them. I think many practices choose not to manage two or three information sharing systems when everyone has a fax machine. 3. Further complicating things, my state requires controlled medication refills be done via fax with a "wet" signature. 4. There currently are no standards as to how data can be shared between EMRs. Ideally, if I get records from County Hospital, the data comes and the lab tests populate my EMR's lab module, the past medical history populates my past medical history module,etc. but that is a pretty complicated IT problem. I'm told Top Men are working on it, but I've yet to seen anything practical demonstrated. If County Hospital's records come over electronically, they still need to be printed and scanned in as images into our system (so, so, so much wasted paper!). So sometimes the record is printed on their end and faxed, sometimes it is couriered on a disk and we print it. Our EMR does not, to my knowledge, have a feature where text files could be added as a Word file, or a PDF though that would seem to be a necessary step for electronic record transfer. 5. HIPAA requires that data be received/shared in a secure location where no one not bound by confidentiality laws may access this. Organizations get very concerned about emailing to a random address, not knowing how security works on the other end and who accesses that account. There are many lawsuits where information had been released to family members, lawyers, etc without patient consent because someone wasn't careful about the receiving end's security. The practical solution is to keep a fax machine in a secure part of the building that no patient can access. 6. We're freakin busy. My office struggles to get through a day not killing someone and getting everyone home at a reasonable hour. We don't have the extra money lying around or the extra time lying around to fix a system that hobbles inefficiently along well enough, especially when it involves coordinating with many other organizations who use different systems and who have varying levels of interest and ability to take this on. It's frustrating and I spend a not insignificant part of my day rustling up records quickly because I need them quickly. Fortunately I have affiliations with three additional hospitals and can access their EMRs remotely (Go to unsecure computer with Internet access--> log in securely to hospital web site --> log in to second EMR--> click privacy agreement, "oh what's that Ms Brown--you were at University Hospital not County, ok repeat above steps --> find patient -->find relevant report-->print so I can go back to exam room and discuss with patient --> later, scan into our EMR). Particularly aggravating is that all Washington State community health clinics created an IT entity in order to share the cost of an EHR and the expense of managing it, but because we operate independently, HIPAA requires the IT company we created must keep patient data walled off from each clinic. So if I have a patient transferring from another CHC to me, the data exists organized in a format that my EHR recognizes, in the same location as my data, but there is no way for my IT company to move that one persons record into my clinics database even with the patients signed consent, so it gets, you guessed it, printed, faxed, and scanned. The solution needs to involve a certain amount of top down standards being developed and enacted into law, and then some changes, or at least interpretations of HIPAA to allow for development of these standards. Things happen slowly in health care because information management isn't the primary thing we do or are trained for and a lot stuff needs legislation and tight regulation, thus depending on government and government funding. Plus, there's all the people like eRx, Iron Mountain, etc who will lose business so there's institutionalized resistance to change. Health care is a slug. But it needs fixing because I fucking hate the fax machine.

Fax has, at best, a 97% transmission success rate. I haven't heard that statistic, but it sounds pretty good, especially given the ability of the fax machine to report errors and/or redial. Also you can't install browser toolbars that screw up your Adobe Reader plugin on your fax machine. I would rather killed by a smudgy fax than a browser toolbar.

[Friendly reminder nj_subgenius, AskMe threads are not really for back-and-forth discussion, unless you need to clarify a parameter of your question. Thanks.]

Protocol observed forthwith.

Xedrik is quite correct about VOIP killing fax -- to underscore that, there is no phone "line" in VOIP -- so the digital-over-analog fax signal is again being digitized, which is to say sampled, by a lossy VOIP codec (maybe more than one, along the way), and then reassembled into an approximation of the fax tones (but maybe with some audio jitter or other artifacts) which the fax codec then makes back into a digital picture (itself a lossy representation of the analog paper page, which itself might not have been a first generation copy). We should possibly be surprised it works as well as it does. Hey, something I'm kind of an expert in. With voip you can configure ATA's that have faxes connected to them to use either inband or out of band. In inband, it's just transmitted as audio, which only works with a decent lossless audio codec. You can also configure it to use an out of band codec, where the adapter actually converts the incoming audio to a digital format and transmit's that directly, which is beautiful as long as every carrier along the path supports it. If they don't, then what happens is it gets converted back to audio, and then maybe back to digital and back to audio again, depending on how each carrier configures their gateways. Faxing is a ridiculous clusterfuck, and it was the bane of my existence when I worked for voip companies. All of that said -- Lawyers, Banks and Medical offices refused to get rid of them, largely because of, they said, privacy concerns over email (and perhaps some beliefs about the validity of faxed signatures). (Although a surprising number of them were perfectly happy with receiving and sending faxes by email).

In the UK it's not simply because of 'the system not being set up for it', it's because of our stifling data protection and information governance laws. I can only email anything patient-related if the recipient is on the same internal email system or if we're both using the secure nhs.net system. Few trusts have adopted nhs.net and even fewer GP practices use it, so it is not used. I did work in one NHS Trust that went to electronic records for the community trust, but even then the hospital still used paper notes and the GP practices chose to use all sorts of electronic systems, so I would find myself printing out my paper report and sending it, only to be able to see it scanned into the patients electronic record by their GP practice a week later. My current trust is moving away from using fax because it's such a pain to verify correct transmission. My old trust required us to phone fax phone, which was a huge pain in the neck. Consultants and their resistance have less to do with it than you might think, because they largely dictate their referral letters, so it's their secretaries that sort out typing, sending and receiving. Here's hoping for email to take off.