Why Is Fax So Prevalent In the US Medical Profession?
July 30, 2013 7:41 PM   Subscribe

Looking for The Magical Technology Adoption...

This question may interest the community. I hope so; I'm looking for an answer which could postively affect healthcare delivery in the States.
Most of our health records here in the US are exchanged by facsimile - an unreliable, point-to-point protocol delivering 75-150 DPI images dating from Blondie and The Pet Shop Boys to today.
There have been incremental improvements such as t.38 and g.711, but the story is still rather sad. Fax has, at best, a 97% transmission success rate.
You may ask why am troubling the exalted hive mind over what seem such trivialities. Allow me to explain.
I work for a medical informatics company whose main customers are healthcare plans. These plans must report care risk-adjusted physician payment data to CMS (Centers for Medicare and Medicaid, a Government entity), and care quality measurements to NCQA (National Committee on Quality Assurance, a nonprofit).
In addition, we engage in clinical interventions, where we reach out to providers, and sometimes health plan members, to be evaluated for probable disaeses or their co-morbidities. Over 70 percent of what we receive from practitioners is by fax. This is killing us and it could be killing people.
So, I ask, what trends do you believe will drive aging MDs and aging office managers, who take care of aging patients, to ditch fax as though it were semaphore signaling?
posted by nj_subgenius to Computers & Internet (27 answers total) 4 users marked this as a favorite
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.
posted by Tomorrowful at 7:45 PM on July 30, 2013 [5 favorites]

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.
posted by Ruthless Bunny at 7:47 PM on July 30, 2013 [7 favorites]

Response by poster: Well put.
Clearly the US medical profession does not think much of Meaningful Use. 17% of Phase I adopters dropped out of Phase II. Obvious dysfunction there. The only paralel I can draw to your point is the very rapid adoption of SWIFT in the mid-70's last century by the Federal Reserve. The banks fell into place rather rapidly.
posted by nj_subgenius at 7:50 PM on July 30, 2013

Response by poster: Hilarious, RB! To complete the analogy, get hottie pharma sales people to promote this on Pill Hills everywhere. And lawyers are the next worst offenders.
posted by nj_subgenius at 7:53 PM on July 30, 2013

Mod note: 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.
posted by LobsterMitten (staff) at 7:57 PM on July 30, 2013 [2 favorites]

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.
posted by SLC Mom at 8:00 PM on July 30, 2013 [7 favorites]

Doctors and hospitals are paid for doing tests and imaging and treatments. They are not paid to coordinate care, make efficient choices, or share results with others.

American patients have demonstrated consistent preferences for privacy and fee-for-service care, and not for open and efficient sharing and coordination.

This has resulted in a system that would rather pay to repeat testing than to share results. Thus faxes and HIPPA, rather than a national integrated EMR.
posted by sanderman at 8:02 PM on July 30, 2013

Response by poster: Protocol observed forthwith.
posted by nj_subgenius at 8:06 PM on July 30, 2013 [1 favorite]

A lot of offices aren't set up to easily scan. My mom is a bookkeeper, and I asked her why she still has a fax machine, and she said it's because it's a lot easier to just pop something in the fax machine. If your scanner is confusing or unreliable, or doesn't play nice with your computer, faxing seems like a better solution. That said, I hate them as well.
posted by radioamy at 8:07 PM on July 30, 2013

Clearly the US medical profession does not think much of Meaningful Use.

To be honest, it doesn't really matter what they think, they have no choice. In another few years, the bonuses on Medicare and Medicaid payments for Meaningful Use will turn into penalties, escalating each year, for not meeting MU, and even the most Luddite provider will have no choice but to go up unless they want to see their margins eaten away completely.

It'll probably be a good decade after that before the EMR vendors can iron out all of the kinks in interchanging structured data for complete health records, but once everybody's on MU, people should mostly at least be using .pdfs and and extract reports and not faxes.
posted by strangely stunted trees at 8:08 PM on July 30, 2013

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.
posted by RobotVoodooPower at 8:17 PM on July 30, 2013 [3 favorites]

Response by poster: As to fax error rates-they vary wildly, based on four essentials:
-The sending fax machine and its age
-The telco central office originating. Money center exchanges, great. Podunk, lousy.
-The PSTN provider: AT&T, Level3,etc.
-The receiving end: analog via T1, or digital via SIP or other VoIP protocol.
posted by nj_subgenius at 8:25 PM on July 30, 2013

Best answer: I'm an office machines dealer. Faxes are dying pretty quickly, and more rapidly each year. Ten years ago, I used to sell 50-60 commercial-grade ($1000 and up, not your Costco models) faxes a year. So far this year, I have sold one. In general, faxing is being replaced by scan-to-email on networked MFPs (either direct scan-to-email, or scan to a user's local computer, where the file is then dragged into a message as an attachment.) There are several things which have tipped the scales:

• Up until a few years ago, fax-transmitted documents could be accepted as legally-binding copies, but e-mailed copies could not. With this change, more and more heavy fax users (real estate, financial, medical, etc.) are switching to e-mail. It's much faster, more reliable, and offers more flexibility for archiving sent/received documents. This doesn't happen overnight, though, because many offices have equipment budgets, equipment may be on leases, etc. so it is often several years before the heavy-duty fax is replaced by an email-capable MFP.

• It's only in the last few years that broadband has been widely adopted in nearly every office, down to the smallest Mom-and-Pop. But just about anyone could afford a fax line (or even share a phone line with the fax.) Prior to this, you might have one PC with a dialup modem, perhaps using ICS to share (painfully slow) access to other PCs. While there were networked options for sharing a dialup modem, these were not widely adopted. It's only in the last 5 years or so (and thus, in the latest 5-year equipment leasing cycle) that a lot of small businesses have had the network infrastructure in place to really take advantage of scan-to-email.

• There are still, in certain specialized markets like medical and financial offices, very complex, proprietary, and expepnsive systems that were put into place years ago. Generally these setups are found in businesses with multiple locations or a set group of frequent senders or receivers. They may be using T.33 sub-addressing, so faxes are automatically routed to the correct destination. Heck, we still have some clients with polling set up. There are a lot of people who either want to squeeze every last dime out of an expensive equipment purchase or integrated solution, or are just very resistant to change (or both.) In a lot of these setups, the fax is a very mission-critical device, and just cannot be down. Trying to replace the whole system, even with something better, just doesn't happen because the downtime would be (or is perceived to be) too risky/costly. So they slog on with what they have.

In a sort of ironic twist, VOIP is killing faxes. The absolutely wretched phone lines provided by Comcast and other VOIP companies are fine for voice, but are not suited to faxing (or credit card terminals, or any other analog modems.) Interestingly, even if you have a "real" analog line from a real telco, long distance and even regional calls may be switched to VOIP for some segments of the connection, which can still cause issues with modems. It's almost impossible to have a "pure" end-to-end connection (especially long-distance) without any VOIP in the middle. As a result, credit card terminals, faxes, and other analog modems are becoming less and less capable of doing their jobs, which often leads to their replacement.
posted by xedrik at 8:31 PM on July 30, 2013 [13 favorites]

The psych hospital I work I doesn't have electronic medical records. Everything we do (except for billing and printing out transcribed medical evals) is handwritten. So we have to rely on fax if we are sending info from the chart.

Yes, we have some really old school admin frightened of newfangled technology and it drives the rest of us bananas.
posted by MultiFaceted at 8:42 PM on July 30, 2013

It's the same in the UK - all referrals from GPs to specialists are by fax or, worse, snail mail. Very few are by email because the system isn't set up for that, unfortunately. It will undoubtedly change over the next few years but for now, it's not worth getting worked up over because that's just how it is (and most consultants are old...).
posted by goo at 9:06 PM on July 30, 2013

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.
posted by kadia_a at 11:16 PM on July 30, 2013 [1 favorite]

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.

As to the cost/clunkyness problems mentioned by SLCMom, there are lower cost or free alternatives to Acrobat Pro for a PDF print driver (notably Ghostscript with an OS specific print subsystem interface -- CutePDF Writer implements this for Windows, and is free for both commercial and non-commercial use, here's another way); and simple scripts can be used to automate handling of PDF copies printed to a target folder or temp folder.
posted by snuffleupagus at 11:30 PM on July 30, 2013

There are voip codecs that can handle fax, but they need to be configured and you need to have a phone adapter thing to give the fax machine something approximating a phone line to talk to.

What keeps fax going is the fact that it's dead simple, and follows the copier paradigm: it's just like making a copy, except you are sending it to someone else's machine. Stick the paper in, dial a number, hit the green button.

Only until very recently have the MFP machines had scan to email capabilities that worked almost as simply. I'm sure Adobe has a mode where you can scan directly to email with one step, but it doesn't seem as easy.
posted by gjc at 1:02 AM on July 31, 2013

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.
posted by Slarty Bartfast at 1:28 AM on July 31, 2013 [5 favorites]

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).
posted by empath at 1:52 AM on July 31, 2013 [1 favorite]

When you reach out to providers as part of your clinical interventions, could you ask to talk their office managers or other admins about why fax is such a big part of their workflow?

This could give you insight into the interoperability gaps, and it may also reveal some upcoming trends (like if those practices are planning to sign on with another EMR vendor that's better connected).
posted by cadge at 8:45 AM on July 31, 2013

I'm a fairly tech positive, early 30's guy and I followed NONE of the tech lingo here :D

Also, in addition to the above, the offices with paper files- mountains and mountains of them- who will digitize the thousands to millions of pages?
posted by Jacen at 8:49 AM on July 31, 2013

Adding to the chorus of "faxing is considered secure" in the medical field.

Also, as mentioned before, we all have different EMRs and different email clients. It's hard to rely on my hospital's encryption method to work with another hospital's decryption method, as they may have a completely different client for this.
posted by kuanes at 9:43 AM on July 31, 2013

Mostly privacy law as I understand it. Legally compliant email of records is possible but complicated. On a few transfer pts I have gotten the 100s-1000s of pages generated by Epic or cerner either as a stack of paper in a box (did you actually wait for all this crap to print before tranfering a critically ill patient?) or burned to cd.
posted by Ms Vegetable at 4:27 PM on July 31, 2013

In general, the medical profession will often stick with a technology that seems hopelessly antiquated (e.g. a pager for contact, when they have a smartphone, or a flip phone that's literally the same size as the pager) because it's reliable, or at least its idiosyncrasies are known and somewhat predictable. Given the huge potential consequences, both personal and financial, if there's a serious fuck-up while they're adapting their workflow to a new paradigm, there's a lot of pushback to new tech being introduced.
posted by Halloween Jack at 8:29 AM on August 1, 2013

Response by poster: All of you, thanks for your beautiful brains!
posted by nj_subgenius at 4:35 PM on August 3, 2013

Response by poster: Jacen, this is rather wide of the app for that milieu. Thus, we must go to the fundamentals, which I'm sure you might be able to assimilate, being tech positive, as you say, and putting in a bit of elbow grease.
posted by nj_subgenius at 9:40 PM on August 6, 2013

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