This article is part of Update or Die, a series from Future Tense about how businesses and other organizations keep up with technological change—and the cost of falling behind.
Among the retro symbols on the iPhone’s emoji keyboard is the humble facsimile machine. But the fax machine holds a different place than the transistor radio, the floppy disk, and the vintage picture tube: It is both outdated and yet, for those who have to interact with the U.S. medical system, not an ancient relic at all.
Right now in medical facilities across the country, surgeons, obstetricians, GPs, nurses, and staff are placing physical medical records in a tray, dialing in a number, pressing send, and hoping to avoid a paper jam. If you’ve ever watched a medical drama, you’d be forgiven for thinking that hospitals are full of cutting-edge technology, but the system is still reliant on paper and fax, technologies that were cutting-edge 2,000 and 50 years ago, respectively.
Of course, not all records are sent by fax—many doctors’ offices already have switched to digital, or are in the process. But most still need a fax machine in the office in order to communicate with those that haven’t. Chantelle, who works at Brooklyn Bridge Pediatrics, says they now mainly use email to send information, but they are still receiving multiple faxes per day, usually from larger hospitals. Often, there are pages missing. Anna at Kofinas Perinatal, which very recently switched over to digital, says that it’s frustrating having to wait for faxes as well as having to resend failed faxes.
The telephonic transmission of scanned material as audio-frequency tones has long gone out of style—most industries migrated over to email years ago. So what explains the unreliable fax machine’s prolonged endurance in the U.S. medical system? Depending on whom you ask, it’s a symptom of regulations, technological limitations, financial disincentives, or good old-fashioned mulishness.
The medical industry’s longtime preference for fax may have something to do with the Health Insurance Portability and Accountability Act, which was passed by Congress in 1996. The law required the Department of Health and Human Services to create privacy standards for health information—the ensuing Privacy Rule, which became effective in 2001, required health care providers to take “reasonable safeguards” when sharing patient data between labs, hospitals, specialists, and insurers. A post about the HIPAA Privacy Rule on the HHS website explicitly names fax as an acceptable method of transmission of medical records, test results, instructions, and treatment regimens. According to PC Mag, some interpret the wording of the rule to mean that fax is an acceptably secure medium while email is not. Though electronic mail has come to be a commonly accepted way to send information in most industries, email has been considered too insecure a medium—too susceptible to hacking—for medical records. Fax, meanwhile, is difficult to hack.
Though emails can now be encrypted, faxing is the simpler process. Peter Alperin, a practicing internist and the vice president and general manager for connectivity solutions at the medical networking platform Doximity, says that fax has stuck around because “sending an encrypted email is a much more complicated process than sending a fax.” Doximity’s online platform includes a “HIPAA-secure” feature called DocFax that allows doctors to send and receive faxes using their smartphone. When I ask why this new tech bothers to link to such old equipment, Alperin says it’s necessary to still be able to communicate with the old system, given that fax machines are still found in every emergency room around the country. He says faxes are on their way out, though “whether that’s a steep slope or a gradual one is hard to tell.” His own use of the machine is dwindling, he says, “but when I need it, I do need it.”
Not only are faxes considered a more “secure” medium than email, they can also be more convenient when dealing with physical patient files. After all, fax machines collapse scanning and sending an attachment (as well as opening and printing it) into one easy step for those seeking a copy of a document to put on file, where “on file” has traditionally meant in the physical sense—until recently, most patient records were stored on paper. And though there was a major push under the Obama administration to digitize America’s medical records—taking the number of hospitals keeping electronic medical records from 9 percent in 2008 to 83 percent in 2015—this has been little help when it comes to the sharing of records. As Sarah Kliff points out in this in-depth Vox explainer, these competing systems still don’t speak to one another, having a strong financial incentive to keep patient information to themselves (therefore making it harder to see a different doctor). When a patient visits a health care provider that runs on a different electronic health-record vendor, it’s back to the fax machine: Staffs still need to request their records from the old provider, who must send them over, only to be uploaded into the new provider’s system.
But why fax them, especially now that they’re already digitized? There may also be a generational component here. According to a CNBC report, millennial doctors are baffled by the “technology,” many having never encountered a fax machine before. The report blames their endurance in part on older doctors, stuck in their ways. “Part of the reason is tradition, as many older doctors simply feel comfortable with the technology and refuse to let it go,” writes Christina Farr. As Vox’s Kliff told Marketplace, “A lot of the doctors I talked to say it has to do with routine. They’ve become so used to faxing … that they don’t really understand the email product.”
So is there anything that could finally kill the fax machine off? Farzad Mostashari, who coordinated health care policy under the Obama administration, told Kliff that the machines ought to be outlawed. Trump’s Healthy Information Technology coordinator, Donald Rucker, disagreed, arguing that “better-designed electronic records” are the way to go—though it’s unclear how that would compel competing medical-record companies to collaborate. Startups like Doximity want doctors to use their encrypted messaging services to send e-faxes, while others are looking to blockchain as the solution to this (and all other) problems.
The potential solutions are as numerous as the perceived causes, so for now, it doesn’t look like the fax machine is going anywhere, and neither is its corresponding emoji. It’s still right there on the keyboard, immediately—and fittingly—after the pager emoji.
Also in Update or Die:
• “How Hospitals Can Protect Themselves Against Ransomware”
• “Why the Military Can’t Quit Windows XP”
• “The Museum That Found a Genuinely Good Use for the Much-Maligned Stylus”
