Is Faxing the Solution to the Health IT Usability and Interoperability Crisis?

Have physicians figured out a way around the lack of EHR usability and interoperability?

Roger A. MaduroThe Healthcare industry is in profound crisis as the HITECH Act of 2009 led medical facilities across the United States to spend in excess of $3 trillion on the purchase and implementation of expensive electronic health records (EHRs) under the Meaningful Use program. Yet, the most fundamental goals of electronic records Nirvana that were promised have not been achieved. For multiple reasons, EHRs have turned out to lack usability and be non-interoperable. In fact, most EHR vendors are engaged in what is commonly called “data blocking.” In most cases physicians are unable to obtain medical records for the patients they are seeing and patients have a hard time getting a hold of their own medical records. That means that the medical records are not available at the most important moment, the caregiver/patient encounter, and are not available to the patients themselves and their family members.

This is such a profound crisis that Jared Kushner, President Donald Trump’s son-in-law, has focused the efforts of the Office of American Innovation to give "citizen access to health records and interoperability a top priority," as he said at the annual HIMSS18 conference in Las Vegas, Nevada. Kushner said, "The time is now to align every facet of the federal government and the private sector to ensure information is communicated and shared seamlessly.” “Simply put, interoperability is about our shared bottom line: saving lives," he said. The new administrator of the Centers for Medicare and Medicaid Services (CMS), announced a series of initiatives to promote interoperability and patient ownership of their own medical records.

Jared KushnerSpeaking to the press following her keynote presentation at the conference, Verma said, “What we’re envisioning is being able to gather all of your healthcare data in one particular place, not just one portal. In the future it could be from wearables, claims data, medical records, with an API format across the board. I also envision a world where there’s quality data and hopefully somewhere in there cost data.” Verma's speech highlighted her own personal experience as her husband suffered a major medical condition, and they were unable to obtain a full copy of his medical records to take home. The plan is to make interoperability a top priority through legislation and regulation.

Yet, physicians across the United States are not waiting for all these efforts. In order to circumvent the lack of EHR interoperability and EHR vendor data blocking, they are taking things into their hands. As a result of more than 75% of medical records that are being exchanged, are being exchanged through faxes. This situation has elicited a hue and cry from leading health IT technologists as evidence of the technological backwardness of physicians and the healthcare industry as a whole. The belief is that every other industry in the planet has moved beyond faxes except for medicine.

This issue has been raised in several recent articles. One of these blog posts was authored by Kim Bellard, one of our favorite bloggers and one of the most insightful health IT experts out there. The article is titled Signatures are No Longer Required for Credit Card Transactions...How Come Most Medical Records Exchanges Still Require Fax Machines? Trillions of dollars spent on EHRs, but medicine still relies not only on faxes but other antiquated technologies, as Bellard points out. The same theme is addressed by another well-known blogger, Sarah Kliff from Vox. Her article is titled The fax of life: Why American medicine still runs on fax machines.

Paul Akhavan, CEO of Envoi Networks Reading these articles I was stumped like most technology folks are regarding this paradox. But then I had one of those famous aha! moments. That moment came courtesy of Paul Akhavan, the CEO of Envoi Networks. Paul’s company is a leading provider of cloud-solutions as well as unified communications based on Voice over IP (VoIP) technologies. Paul was explaining to me how their customers in the healthcare field benefit from their solutions. I raised the issue of faxing as the primary mode of medical records exchange. Without missing a beat, Paul started talking about extraordinary benefits of faxing. His comments were, of course, as dissonant as could be, so I had to pay close attention to what he was saying, which was followed up by additional materials regarding the technologies his company sells, sent via email.

It turns out that Paul was not talking about those old fax machines sitting in the corner with yellowing paper. Paul was talking about the faxing capabilities of the communications revolution that has taken place over the past decade as a result of Voice over IP (VoIP), also referred to as Fax over IP (FoIP) when the system is set up specifically as a fax system. This is where it all gets really interesting. In their drive to provide their patients with quality medical care, whether provided at their practice, or another physician or specialist’s practice, physicians have discovered that they can do an end run around all the obstacles and outright blocks that EHR vendors impose on their ability to exchange medical records. And they have discovered that they can not only exchange medical records using VoIP faxing, they can also securely exchange high-quality digital images. Turns out that VoIP faxing is becoming the solution to the healthcare interoperability crisis.

Now we need to explain…

The VoIP Unified Communications Breakthrough

To understand, one first has to change the definition of faxing. While the belief is that doctors are sending and receiving paper faxes, Paul is talking about the migration of medical offices to digital faxing. Digital faxing is just one of the many capabilities of modern VoIP systems. A simple explanation is that VoIP is the transmission of phone calls over the Internet instead of using traditional telephone landlines. Most people are familiar with this technology through the use of Skype, for example. But telephone calls are just one of the many benefits of VoIP. Medical facilities, from physician offices to clinics, to hospital systems, are experiencing a technological revolution by switching their old phone systems, using old “landline” telephony technology, to advanced phone systems taking advantage of the Internet and networks. Modern digital technologies that can be hosted on site, or hosted on the cloud.

Envoi Networks Unified Communications VoIP PlatformFaxing is a major component of VoIP, but it seldom involves paper any more. Digital faxing is about using internet protocols (IP) and advanced open computer systems and software to move files that are digitized in multiple formats from one system to another. A well-designed VoIP system allows doctors to receive all their patient’s records, from old paper charts to radiology images in their computer, or their tablet, or even their smartphone.

Digital fax file formats are standard, which means that any digital fax system can read any digital fax. And produce digital faxes that can be read by other Digital fax systems. Digital faxes use standard file formats. They can even use and transmit common formats for images, searchable documents, such as PDF, etc. And these files can be encrypted. In other words, VoIP has already partially solved the medical records interoperability problem.

Most EHRs in use today are 40-year-old medical billing systems that have had some EHR capabilities added on, mainly to increase billable fees. These EHRs were developed before the existence of the Internet and are built as “siloed” applications. They use obtuse proprietary file formats, proprietary data formats, proprietary protocols, proprietary API's (although that is changing due to FHIR). Thus they cannot share files or data. This situation is referred to as “lack of interoperability.”

What medical facilities are discovering that they can do an end-run around EHR lock-in by implementing VoIP systems. And at the same time have state of the art telecommunications technologies while saving significant amounts of money when replacing their old systems. There are many aspects of how this disruptive technology can transform healthcare.

We are just going to touch on a few key capabilities in this article. We are planning a series of articles on the subject to expand on these capabilities.

Leveraging the best features of paper faxing and digital faxing

Back to the issue of digital faxing vs. paper faxing. Medical practices that migrate from old telephone and fax technologies to VoIP systems can leverage the best features of legacy paper faxing as well as digital faxing, all at the same time.

Advantages of paper faxing include:

  • Permanency of the documents
  • Legal admissibility
  • Direct point-to-point transmission
  • Ease of use

Advantages of digital faxing (Fax over IP) include:

  • Improved document security (no paper laying around in a public place)
  • Faster and secure transmission
  • Content filtering and routing. Digital faxing allows medical practices to receive and store inbound faxes electronically. The system can be configured to automatically distribute those faxes to where they need to go.
  • Direct-to-recipient delivery
  • Audit trailing
  • Activity logging
  • Patients can access their own folder with electronic documents
  • Integration with other applications locally, or in the cloud
  • Disaster preparedness and relief (VoIP and unified communications systems offer a secure, electronic repository for all of the practice’s documents, images, and faxes that can be stored in the system. If hosted, or backed up to the cloud, all the faxes, and other medical records can survive the kind of flooding that just happened in Houston, and can be accessed from other locations).

VoIP as the Integrated Health Record (IHR)?

One of the fascinating aspects of the migration to VoIP is that physicians and medical practices are discovering that they can leverage VoIP systems as open platforms where they can add all kinds of applications and capabilities that cannot be added to EHRs, which are largely old silo-based and primitive. Now, there is a caveat here in that there is great innovation taking place in many areas of healthcare. For example, cloud-based technologies are emerging that can function as platforms. New EHRs such as MedicaSoft, for example, have been built from the ground up as modern open platforms. When we say EHRs here we are discussing the predominant dinosaur EHRs

And why are open platforms important? Open platforms are what the eHealth futurists call an Integrated Health Record (IHR), or an Integrated Patient Record (IPR). That is where the future of “EHRs” is expected to be, yet because of open systems nature of VoIP and use of the cloud, VoIP is becoming a “Software-as-a-Service” platform of choice.

All kinds of systems are being connected through VoIP, and VoIP can be leveraged to provide all kinds of advanced capabilities that otherwise would require very expensive add-ons to existing EHRs as well as complex and expensive integrations. One of these, for example, is the VoIP capability of Video Conferencing. The fancy name for this is telemedicine. And we are just at the beginning of the possibilities, as, unlike EHRs, VoIP systems are open and put physician and medical practices in charge.

Some of the capabilities, systems, and other applications that can be integrated into a VoIP unified communications platform include:

  • Electronic Health Records (EHRs)
  • Practice Management Systems (PMS)
  • Billing systems
  • Personal Health Records (PHRs)
  • Personal Health Information Exchanges (PHIEs)
  • Health Information Exchanges (HIEs)
  • Customer Relationship Management systems (CRM)
  • Enterprise Resource Planning (ERP) systems
  • Laboratory and Imaging files and systems (LIS)
  • Electronic prescribing
  • Access to hospital records
  • Document Management Systems
  • Telemedicine (through video conferencing)
  • Patient and staff education (video services)
  • Mobile apps

The reason so many different applications can work with VoIP unified communications systems is that VoIP was developed using an open platform and open systems approach. This is very much the approach proposed by Rep. Pete Stark through his bill HR 6898. This approach is described in detail by Dr. Bruce Wilder in this article titled The Politics of the EHR: Why we’re not where we want to be and what we need to do to get there. HR 6898 was defeated by a massive lobbying campaign carried out by EHR vendors, who instead backed the HITECH Act. In many respects, the rise of VoIP in healthcare is proof that Rep. Stark's approach was the right approach. The repeal of the failed HITECH Act is long overdue, and HR 6898 should finally be adopted with some minor modifications.

As noted, this is the first of a series of articles. We are going to explore some of the other capabilities of VoIP and unified communication systems in future articles.