Axe the fax: A primer on fax tech in the 21st century, an Ontario’s healthcare system perspective

Beth Gerritsen

During the COVID-19 pandemic, fax technology failed spectacularly across the healthcare system.

Providers who were cut off from their fax machines couldn't communicate. A massive shift to e-faxing caused overloaded fax servers and system failures with estimates of 15% to 25% of faxes sent not being received.

Before the pandemic, the healthcare system’s reliance on the fax was embarrassing, but now it's a critical failure point for the entire system. As part of the post-mortem of the pandemic we need to figure out a better way forward.

In my recent Master’s thesis I detailed 2019 fax usage in Ontario and showed that:

• 35% to 40% of primary care administrative time is fax related;
• Every month, approximately two million e-faxes are sent from our EMRs;
• Regional home care service requests and coordination occur mostly by fax, estimated at 1.7 million a year; and
• Ontario’s Cancer Screening programs depend highly on fax, with over 750,000 faxed orders for Colon Cancer Screening Kits sent between July 2019 to July 2020.

It's been clear that the fax machine wasn't working well for healthcare practitioners for years.

Some further highlights from my research of the current fax issues in Ontario include:

• 63% of all unauthorized disclosures of personal health information is due to misdirected fax;
• Roughly 10% of fax referrals go to the wrong place causing risks with a delay in care; and
• Approximate 20% faxes fail when sent from a traditional fax machine on any given day.

Faxes represent a technology trap for healthcare. We use the fax because everyone else in healthcare does and no one is happy about it. Fax creates blind spots, with inability to track or provide real-time digital analytics of wait times. It will always lack the ability to include patients in the circle of care in data transmission. Patients don't have fax technology in their homes. The only other industries using faxes have moved on to electronic signatures as a result of the pandemic. Many students entering the workforce in 2021 have never operated a fax machine (except to submit their medical records).

Our system of digital connection was already broken prior to the pandemic. But, left in current state, it's downright dangerous to continue the status quo of fax use. Paper based lab ordering and fax use for COVID-19 lab results reporting in Public Health is just one highlight of Ontario’s failures to fully operationalize a digital integrated healthcare system. The recent auditor general’s report showed this bottleneck issue was part of two former audit reports, yet fax use remains mostly unaddressed.

Clinicians stepped up with a quick shift to virtual care in order to support patients and are continually working out the kinks to do this better to ensure patients get safe, competent, high quality care during this crisis. But quality virtual care needs proper support from digital infrastructure. A fax failure of a prescription or lab order after a virtual visit critically impacts a patient, especially now. In 2020, clinicians shouldn’t have to duplicate their work due to a fax issue. Nobody should experience a delay in a referral for specialty care because of a misdirected or a failed fax transmission.

This means we need a take a concerted effort to axe the fax. And clinicians can make this happen. Every medical association should call on governments to axe the fax. We have international examples like the U.K.'s NHS that has done it so successfully. In some countries fax was never even used in healthcare and others replaced it decades ago. Digital lab and prescription ordering and an integrated digitalized referral system are the parts the system needs right now. We have to believe we're capable of doing so much more digitally. We need to commit to do the heavy lifting to get this done together.

In my thesis, I proposed such a shift would require four components. First, recruitment of a dedicated ‘Axe the Fax’ taskforce leadership team to build the strategy and oversee the work. Second, complete a due diligence investigation on fax use to ensure a clear understanding of what it does and what's required to support a system-wide fax replacement. The NHS' tactic of ‘Map the Fax’ should be used, converting every fax number to a secure email address. A third part is to implement a risk mitigation strategy for the migration phase. We must ensure every digital replacement is building towards a connected system, not creating digital silos. Finally, perform a focused examination of all outdated policy and align new policy to consistently support a digital-first approach in Ontario.

This is a tall order and we're in the middle of a pandemic. But what can Ontario Health’s digital leadership do to help support clinicians?

Here are three pragmatic next steps for 2021 to move the system away from dependency on fax technology:

1. Let’s set the aim to axe the fax, give it a clear timeline for collective effort.
2. Ensure there's a low barrier approach for clinicians to adopt digital tools. These tools should outperform fax; require low tech skills and be easily integrated into clinical workflow.
3. Clearly define minimum standards for secure sharing personal health information while not using fax. Specifically, address and promote how emailshould be used in healthcare instead.

Ontario Health’s mandate is better health for Ontarians. A fully digitally connected healthcare infrastructure needs to be a key part of building capacity in achieving the quadruple aim. A 21st century healthcare system should leverage digital technology to achieve efficiency, transparency and accountability to the public. This won’t happen using fax.

The quadruple aim:

1. Improving the patient and caregiver experience;
2. Improving the health of populations;
3. Reducing the per capita cost of health care; and,
4. Improving the work life of providers.

Beth Gerritsen is a nurse practitioner, passionate about quality health care using digital technology. Her full Axe the Fax Report can be foundhere.