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January 2019

Breaking Up Is Hard to Do
By Elizabeth S. Goar
For The Record
Vol. 31 No. 1 P. 22

Convenient and bereft of HIPAA concerns, the fax machine remains a fixture at many health care organizations. However, a spirited CMS initiative aims to send the technology packing in short order.

When Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announced the agency's desire to see digital health information replace fax machines by 2020, she wasn't exactly wading into controversial waters. When it comes to faxing, you'll find few that are vehemently opposed to its elimination.

"This is something we've been calling for, literally, for 15 to 20 years, so it's nothing new. But it is refreshing to hear—it's long overdue," says Robert Tennant, MA, director of HIT policy with the Medical Group Management Association. It's also somewhat ironic, since CMS has delayed issuing a HIPAA-required standard enabling secure document sharing that would quickly render faxing obsolete.

"The proposed rule was issued back in 2005 but never finalized. Since then, the entire industry has been calling on CMS to issue this standard," Tennant says. "The Patient Protection and Affordable Care Act, in Section 1104, called for the government to issue the standard by 2014. That came and went with no standard. … It's continual foot-dragging on the part of [CMS]. So yes, we're very pleased the fax machine has been identified as one of the culprits, but [Verma] needs to release this standard."

A Call for Change
In a speech at the Office of the National Coordinator for Health Information Technology (ONC) Interoperability Forum last August, Verma challenged software developers to "help us make every doctor's office in America a fax-free zone" by 2020.

According to a CMS spokesperson, "Phasing out fax machines to bring health information exchange into the 21st century aligns with the governmentwide MyHealthEData initiative led by the White House Office of American Innovation. As part of MyHealthEData and the agency's own Promoting Interoperability Programs, CMS is working to achieve a patient-centered health care system where health information flows easily between clinicians and patients, and patients have the information they need to make decisions about their own care."

Among these efforts are recent changes to Medicare payment rules that make provider requirements regarding EHRs more flexible and less burdensome, emphasize performance measures that require health information exchange between providers and patients, and incentivize providers to make it easier for patients to obtain their medical records electronically.

Ultimately, these changes will make it less onerous to wean providers off their long-standing reliance on faxing by making it easier and more efficient to manage everything electronically while eliminating the risks inherent in the antiquated technology.

"Faxing is an outdated, burdensome, inefficient, and error-prone method of manually exchanging data between clinicians that can lead to medical errors when data are transcribed from the fax to the patient medical record and can also lead to a breach in privacy if the data are inadvertently sent to the wrong fax number," notes the CMS spokesperson. "CMS believes moving away from faxing information would actually reduce the burden on clinicians, as they would no longer need to manually scan, receive, or input data. Instead, information would be shared through more efficient electronic means."

The Allure of the Fax
The fax machine has been ubiquitous in health care for decades, a relationship that remained unbreakable even as EHRs and other clinical and administrative systems have become commonplace. It's not just physician practices that remain fiercely loyal to the fax; ancillary providers, hospitals, and health plans all remain steadfast in their refusal to pull the plug.

Faxes are most often used for provider-to-provider and provider-to-health plan communications, such as record-sharing, prior authorization, and referrals. It's effective, comfortable, and, because it's excluded from HIPAA security requirements, affordable.

Faxing is the most effective way to connect with ancillary providers, who are often overlooked in discussions around electronic exchange, according to Neil Simon, chief operating officer of Aprima.

"When we focus on faxing, we focus on doctor's office to doctor's office or hospital, but most [transmissions] come from ancillary providers like physical therapists, speech counselors, [and other] people in health care who don't have access to technology," he says.

Dawn Paulson, MJ, RHIA, CHPS, CPHI, director of HIM practice excellence at AHIMA, points out that faxes are also the most common channel for release of information between health care organizations—a necessity given the varying levels of EHR adoption among providers and limited interoperability between different EHR offerings.

For that reason, she says, "I don't think you will see a complete elimination of faxing until you've got a secure alternative. … Everyone ideally would love to get rid of fax. No one is disputing that. But there needs to be a good alternative available to health care organizations of all sizes."

Benefits of Eliminating the Fax
Many industry experts believe breaking the fax machine's hold on health care will start a ripple of benefits for providers. "By eliminating faxes, you begin to eliminate paper records and [increase] the push to electronic records," says Stanley Nachimson, MS, of Nachimson Advisors. "It's much easier for a health plan, on a workflow basis, to handle electronic transactions, even if it's a PDF of a paper record."

Those workflow benefits would extend to providers by eliminating the need to manually send faxes and scan or file received faxes. "It should be much more efficient to send electronically," Nachimson says, noting that such a development would do away with the need for follow-up calls and "knowing that the information is almost immediately processed rather than sitting in a fax machine or on an e-fax system."

He adds that a large part of getting providers to transition away from faxing is to establish a true business case and demonstrate a return on investment. "We haven't done a good job in the industry of showing the true cost of faxing," Nachimson says.

Simon concurs that making faxing obsolete would eliminate a sizable financial burden, especially in terms of staffing costs.

"One of the significant costs in the faxing world is having someone looking at that document, figuring out what type it is, who the patient is, and getting it to the right person," he says. "Electronic exchange will eliminate that [cost]. In the EHR, you can skip that whole step and that's where you can really save the office money. That's another key benefit—when you eliminate that piece you save the office money."

Viable Alternatives on the Horizon
Establishing the financial value of eliminating fax machines is one action that will help convince physicians and other providers to give them up for good. Another is CMS issuing the HIPAA X12 275 electronic attachments standard, according to Tennant.

"The standard is essentially like a FedEx envelope. It's a standardized approach but they don't dictate what you put in your envelope. It's a very elegant solution to a very serious problem," he says. "Here's the rub and the real problem in the industry: The 1996 HIPAA law required [Health and Human Services] to issue the X12 275 transaction standard. A pilot was done in 2005 to tremendous success, [but] the proposed rule was never finalized and was later withdrawn. Since then, the entire industry has been calling on CMS to issue this standard."

Until the standard is released, faxing will likely remain the go-to method for sending documentation to support claims, prior authorization, referrals, and other clinical information. But there is an option that is slowly gaining traction: Direct messaging, the brainchild of DirectTrust, a collaborative nonprofit association to support secure, interoperable health information exchange.

"There is no question that practices will send things via e-mail right now, but traditionally those transactions aren't secure, so it could be a violation of HIPAA," Tennant says. "What Direct does is create a network, so it's a point-to-point, secure e-mail approach that requires the receiver to have the key to unencrypt the data."

The ONC included Direct messaging in the EHR certification program, which was a huge boost to its appeal. "It's still growing and gaining traction, but not quite ubiquitous in the industry," Tennant says. "It's secure. It's a great way to exchange information between clinical sites for referrals and other purposes, so it's a great way to replace fax machines."

Despite incremental growth, Direct messaging is helping to reduce the volume of faxes flying between provider organizations. In addition, this type of secure e-mail is more efficient than faxing because the receiving system can determine who the patient is from the document's header, saving time and eliminating human error.

"So that's definitely a way to [eliminate faxing]. [And it's] the preferred way as part of [the Merit-Based Incentive Payment System]," Simon says. "Another way is that CMS is working on a new initiative to provide a transportation highway that will be universal."

Unlike Direct messaging, which is pushing documentation out, the "transportation highway" pulls documents into a central point, reducing the need for faxing. It also overcomes the challenge of needing to know the e-mail address of every organization with which the provider may need to interact via e-mail.

"This changes the workflow," Simon says. "Everything goes to one point and goes out from there."

Another option from CMS is Blue Button 2.0, which allows patients to access and share their health information, including prescriptions, treatments, and procedures with their providers. More than 100 organizations are already using Blue Button 2.0 to develop applications, ultimately helping patients securely manage their health information.

According to Paulson, "secure transmission is what we need" to eliminate faxes. "What CMS is really pushing for is a targeted focus that will benefit a much broader group. They want to ensure there is communication between providers and payers.

"The efforts CMS is putting forward with Blue Button [and] working on the transmission of information is a really good start," she adds.

Baby Steps
Eliminating the need for faxing is one of the few technology-centered initiatives where there is near-universal agreement. Nevertheless, it's not enough to just say faxing must go and here are new solutions to take its place. There needs to be a transition process, particularly for smaller and more resource-strapped practices and facilities.

Aprima has partnered with Kno2 on a cloud-based solution that centralizes fax workflows into a single solution integrated with the EHR. Inbound faxes are routed, processed, and filed to the patient chart while outbound faxes are sent directly from the EHR through Kno2, which also supports Aprima's Direct messaging process.

"The mission is really to bridge the gap" between faxing and fully electronic information exchange, Simon says.

It's important for the industry to avoid one-off solutions that will ultimately create chaos in the clinical and administrative workflows rather than create cost-saving efficiencies. Health plan web portals, for example, are excellent for one-to-one document exchanges. But when one practice must manage portals for the hundred or so health plans with which it contracts—each with different logins and URLs—it can be overwhelming.

"Once we have [the 275] standard in place, which health plans will be required to support, you'll be able to capture the clinical data from the EHR, attach it to the transaction, and it's done," Tennant says. "It will be a major disruption in a positive sense."

— Elizabeth S. Goar is a freelance writer based in Tampa, Florida.