Despite federal efforts to digitize medical records and concerns regarding data accuracy and privacy, fax machines continue to have a dominant role in U.S. health care. And now, public health officials say the machines are hindering America's response to its coronavirus epidemic, Sarah Kliff and Margot Sanger-Katz write for the New York Times' "The Upshot."

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Providers can't seem to shake the fax machine

Fax machines are far from ideal for sending data, as they often experience busy signals, produce documents that are difficult to read, and are prone to errors that can result in records being lost, misplaced, or sent to the wrong location. Faxed documents also add administrative burdens on providers, who may need to print or transcribe medical records before sending them via fax, and who must input any patient data received via fax into their own EHR systems.

Yet many U.S. providers continue to use fax machines daily to send patient referrals, consent forms, and patient records to external organizations, such as public health authorities.

One reason U.S. providers are hesitant to let go of the fax machine is persistent issues with EHR interoperability. In addition, fax machines remain compliant with federal standards on sharing health care data, and some facilities can't afford to purchase new technology, Kliff and Sanger-Katz write.

For instance, while larger laboratories often could afford software that transmits patients' test results electronically, smaller labs tend to rely on fax machines as a more affordable option, according to Kliff and Sanger-Katz.

"It's $500 versus, literally, $5,000," said Bob Kocher, a partner at Venrock, told them.

And although the federal government under the HITECH Act sought to encourage providers to transfer data electronically, the law didn't include funding to help public health departments digitize their processes.

"Money was invested to get physician practices onto [EHRs]," but "[t]here was no investment to build up a similar technology to tie public health into that system," Oscar Alleyne, chief program officer at the National Association of County and City Health Officials, explained.

'The data is moving slower than the disease'

Now, America seems to be paying the price in other ways, as public health officials say fax machines are slowing the country's response to its resurging coronavirus epidemic, according to Kliff and Sanger-Katz.

During the first several months of the epidemic, public health authorities and private labs worked to expand America's capacity to test people for the novel coronavirus, with the country now able to provide more than 500,000 tests each day. However, the health care industry's lack of digitization is making it difficult for providers and officials to process and interpret the onslaught of coronavirus test results—particularly as demand for the tests spikes.

Technological differences between doctors' offices, health departments, and laboratories mean there's no standard digital process for sending and receiving the hundreds of thousands of coronavirus test results processed each day, Kliff and Sanger-Katz write. For instance, some health departments can receive the results digitally, while others can receive the results only by phone, physical mail, or fax.

And organizations that receive the results via fax have said the antiquated technology has made it particularly difficult to report coronavirus cases to public health authorities and to follow up with patients for contact tracing—a practice that public health experts have said is essential to combating the coronavirus epidemic and should be done quickly.

Texas' Harris County Public Health, for example, is struggling to keep up with Houston's surging coronavirus outbreak, Kliff and Sanger-Katz write, noting that the county so far has recorded more than 40,000 coronavirus cases.

In addition to grappling with the rising case count, the health department is struggling with relying on fax machines to receive data regarding coronavirus test results. In one instance, a lab sent the department a large number of test results via fax, which caused hundreds of pages of results to spray all over the floor.

"Picture the image of hundreds of faxes coming through, and the machine just shooting out paper," Umair Shah, the department's executive director, said.  

Shah explained that some doctors fax coronavirus test results to his personal number, as well. "From an operational standpoint, it makes things incredibly difficult," he said. "The data is moving slower than the disease."

Mark Escott, the interim health authority for Austin and Travis County, said his office receives around 1,000 faxes each day, but the information travels slowly. He estimates that, on average, the office receives needed information regarding a coronavirus test result about 11 days—or more—after the test is administered, which is too late to effectively implement containment strategies such as contact tracing.

"When we are receiving results back 14 days after the individual became symptomatic, it's not useful at all," he said.

Further, Escott said the faxes sometimes are missing crucial information needed to investigate coronavirus cases and complete contact tracing, and some include duplicate test results or information meant for other jurisdictions.

According to Kliff and Sanger-Katz, it's easy for patients' information to get lost in data transfers between the laboratory, doctor's office, and public health authority. They write, "At each stage, technological failures can slow or disrupt the flow of vital information," and faxing usually requires that workers manually enter information, which can increase the overall "risk of errors."

And while fax machines have long caused delays throughout the U.S. health care system, during a surging epidemic, the lack of standard digitization across the industry is particularly problematic.

"You've got hundreds of laboratories and thousands of tests," former CDC Director Tom Frieden said. "This is legitimately difficult stuff that every state is struggling with" (Kliff/Sanger-Katz, "The Upshot," New York Times, 7/13).