Perhaps I live in a bubble, but it seems the “destroy the fax machine” posts have been making the rounds again amongst clinical and tech folks alike, like this article from Pharmacist Zain Syed. Anti-Faxers in the healthcare space?! I was shocked too. Countless people around healthcare have wanted to blow up the fax machine for ages. So why does healthcare still use fax machines?
Fax machines are the greatest invention for exchanging actionable patient information for interactions that cannot be done in person. To date, nothing has surpassed them. It’s not about privacy, security, or because we’re resistant to change; we know tech can resolve all those concerns. Clinicians hate fax machines, but, simply put, they work! Moreover, tech hasn’t found a new solution that has the “they work!” factor yet.
So yes, fax machines are here to stay until we have solutions that have the same “they work!” factor. This may be hurtful and I’m sorry in advance for it but there will be fax deniers. The funny thing is that tech companies can replace every fax machine in every hospital or doctor's office now, they just haven’t yet. Why is this? Maybe they’re invested in toner companies (need to keep that market alive). Seriously though, it requires a re-thinking of how we utilize and interact with technology in the patient care environment, the legacy tech companies and even newer entrants have not done it yet. We need to broaden the view of solving problems in healthcare from a single person, to a whole team.
It’s all about workflow, communication and ensuring patient safety. When a system is poorly designed in a healthcare setting, who gets harmed? The patient. Who gets blamed? The clinician. We don’t want to harm our patients, nor do we want to lose our jobs or license. If you want to ensure patient safety, there needs to be multiple points to check for errors and conflicts to avoid the swiss cheese effect.
That’s where the whole healthcare team comes in, each person has a role and performs tasks that they are able/allowed to within their license limits, filtering information, considering potential safety issues, and actionable requests.
Look at the clinical workflow for a fax.
Fax is received by (usually) the clerk and the patient chart is pulled and checked against the fax.
The clerk will prioritize, if the clerk can handle the information, they do and its filed, if not it is distilled down, goes to the nurse.
The nurse will prioritize and if the nurse can handle the information, they do and its filed, if not it is distilled down, goes to the doctor.
The doctor handles the request, and it will flow back down for further action if needed.
The information gets filed.
Look at the clinical workflow for an EHR or other patient management software.
Information is received, sorted, and filed.
One of two things happen, a message is sent to a single person or whole team about new information.
Each team member goes into the EHR to look at the information, understand the patient context, and distill it down to what is needed from them.
Action is taken by each person based on what they feel they need to do or can do, not always with the knowledge of what others are doing.
Actionable tasks may flow back down the chain
This is where it becomes difficult to explain the problem if you’re not familiar with a clinical environment and how the different levels of clinicians interact and contribute to patient care and safety.
At the point the fax is received it is given context and meaning specific to the patient that is maintained throughout its journey. For clinicians to understand and prioritize a request, we need the patient’s name and the context for which they are being treated; we need their story to recall the details. Each person that handles that information has a different relationship and understanding of the patient from which they are prioritizing the information, what actions they can take based on their training and critical thinking, all while incorporating different safety concerns into this. Only information that cannot be handled by that person is passed up, along with other considerations that may not be apparent based on each individual’s knowledge of the patient. Each person’s time is prioritized to the information and action needed from them based on their role in the healthcare team.
As an example, a fax about a critical lab value may be received by a clinic, the clerk will pull the patient's chart, hand it to the nurse. The nurse will look at the history and the lab value to determine if it needs immediate attention or it can wait, the nurse will also provide additional context based on their knowledge of the patient as to why the lab value may be critical. If the lab value needs immediate attention the nurse will bring it right to the physician, if it can wait, then it will be brought to the physician when they have a minute. What is critical for one patient, may be normal for another patient. In this instance there may be some new information from each person, for example, the clerk may say “Oh I remember this patient, they were having car trouble.” The nurse may consider what this means in the context of the patient, difficult transportation, are there alternatives, and so on. The nurse may proactively reach out to the patient to ask about medication difficulty or dietary changes. The nurse will add this context when it is brought to the physician.
What has happened with current EHRs is that the information hierarchy has been turned upside down, and put each person into distinct silos of information and alert levels. Each person that receives an alert or message must go in and seek out the context of the message to understand its relative importance. A critical lab value for one patient may not require immediate attention from a physician as it does for another patient, but each is treated the same by the EHR. Part of the issue when a team, or individual, receives too many alerts or messages that are not applicable to them, they may start to just click through them to save time and focus on what they know needs their attention, health systems are realizing this and have begun to take steps to reduce this burden.
While information is received in the EHR quickly and automatically, it may get lost in an information overload. Once information is received via fax, it can be quickly prioritized and acted on if needed by the most appropriate person. The challenge for both is making sure the information was received, both can be done with a phone call or message, but the fax workflow will get handled quicker and better utilizes the time of each person.
That fax workflow, or manual workflow, has not been replicated, creating a barrier to collaboration. It’s why outcomes have not improved, and efficiencies have not been realized despite throwing more tech innovations in the healthcare space. Information has been siloed and moved into a number of different tabs, screens, menus and flowsheets that need to be accessed each time to provide a context and understanding. Adding to the volume of information will not help improve patient care or outcomes without addressing the workflow issue. Much of healthcare works in spite of technology, the clinical staff make it work because we have to, it does not make things better or easier or safer. That’s why we still use the fax, it just works.
Would it help if CMS determined that the fax is not HIPAA compliant? It might get rid of the fax, but it would not solve the underlying workflow issues. Clinicians would likely just turn to secure messaging for document transmission so it can be printed out, and many large systems have a way to exchange securely integrated with their email. I have seen this done before with vendors and it is handled much like the fax workflow.
Can tech solve this problem?
They already have, in many disparate parts, the pieces are there, but nobody is putting the pieces together in a relevant way. In this article Brendan Keeler talks about a headless EHR, it seems it would allow an almost infinite number of user solutions that can capture and display information in a way that is relevant and works. It’s a good solution, and ironically there was already something very similar out there. The VA system is trying to kill it though. Yes, that vast government bureaucracy had the best EHR ever developed, and it’s still the best thing out there. But it seems they are getting rid of it. The key part of the VA’s system was that it allowed clinicians and developers to work together to solve the problem. Will there be hope for the VA’s more open development system in some form? Is this where Oracle is going? Maybe. Time will tell on that one.
The tools to enable team collaboration and escalation are already out there in the business world. Tools that enable better interfaces and documentation within the EHR are already out there. They have not been combined yet to solve the workflow issue. Even among institutions that utilize the same EHR, faxing still occurs because it just works. Greater interoperability has hope in that it will allow for the easier creation of more solutions and transfer of data which will likely improve competition and force innovation toward more collaborative tools.
Is it up to clinicians or tech companies to put the pieces together? It’s a good question, and the answer is both.
Is it time for health systems to have a head of clinical technology, a dedicated clinician that can help identify solutions and work with their peers on integration? This can go a long way toward effectively utilizing the tools out there and piecing them together as well as scaling solutions. Clinicians providing direct care don’t have time to do this, nor do their managers, but effectively utilizing the tools can be of great help to those frustrated with the current state. In this video from WTF Health Roger Jansen, from MSU Healthcare, discusses some of the challenges with tech solutions in a large health system (13:30 mark), the whole video is a good listen though!
What about the tech companies? This is where tech companies can be creative and help smaller practices and large systems alike, offering a solution that is clear and relevant. Be able to show quickly and effectively how the different technologies can help them, concrete solutions that can be implemented and scaled. When vendors would come to sell me something, I didn’t want to try and come up with solutions, I wanted concrete solutions to purchase that just worked. Clinics are busy, there’s a lot of competition for time and attention, dreaming up new ideas is not high on the priority list. Should tech companies have a clinical strategist to help with this? Some already do, done right, they can be a real asset to the organization, and maybe even help with creative ways around interoperability issues.
Look at what the tech sector has already done in healthcare. We’ve seen some really cool things out there, AIDoc, CareAlign, Zus Health, Diagnoss, WellAI, Notable, HIA Technologies, Turquoise, Olive, MeshAI, and many others who are creating awesome tools. Add in the companies that are creating diagnostic tools for imaging, risk discriminators, telemedicine services… The pieces are all there, tech is revolutionizing diagnostics, accessibility, research, it’s just not revolutionizing care coordination and safety yet.
Pieces are there to fix the interface, but there is nothing that can be integrated to fix the workflow with the EHR yet. If that can be fixed there can be meaningful movement away from the fax machine. Is it more complicated than that? Sure is, I get that it's not easy, but the answers are out there and can be utilized in the workflow to ensure and enable safe and effective patient care, then you can get rid of the fax machine.
Help the Physician, Patient and whole Care Team write a good story.
On a side note, if anyone has a desire to help healthcare workers and burn through 20-30 million in a couple of years, we could do it (probably?), it would be really cool, reach out to me on Linkedin! Healthcare workers everywhere will rejoice for a functional EHR interface that allows us to focus on patient care, then we will turn our energies toward fixing the broken structure of healthcare to really improve outcomes. Seriously, if tech and clinical professionals come together to rethink how the tech is built and used for healthcare, then we can kick our faxing habits.
Thank you to Brendan Keeler and the editors below, please check them out.
You make valid points but I am still on a quest to rid the world of them!