“E in EHR does not stand for Fax” — Steve Hess, CIO

I constantly enjoy the creativity of my colleagues. In this case, Steve Hess, our CIO at UCHealth, made this statement during a discussion about our fax-server software linked to our EHR. As our organization has grown, we have added hundreds of clinics, and now we’re approaching a dozen hospitals in our network, all on a single instance of an EHR.

Consequently, our communication and IT architecture is primarily based on within-EHR communications, the so-called Inbasket. However, we often communicate with healthcare entities (insurance companies, out-of-network clinics and hospitals, skilled nursing and rehab facilities, etc). To force others to use our EHR’s inbasket is unrealistic.

So, even in this 21st century, the lowest common denominator for communication between healthcare entities is … FAX. Our organization faxes millions (yes, MILLIONS) of virtual sheets of paper each month, a veritable blizzard of paper. Furthermore, our faxing volume now is bumping against our licensing limit, and Steve, very rightly, is pushing back against any increase in our faxing capability, and this is where he notes:

“The E in EHR does NOT stand for Fax.”

Which is hilarious. And sad at the same time. Where is our national interoperability? Haven’t we been working toward electronic seamless communication for over a decade as we furiously install EHR’s in every clinic, every ER, every hospital? Yes, and nothing is ever that easy.

So, thinking through our fax problem, several things became clear:

  1. Faxing STILL is the lowest common denominator. If our clinic notes and other messages to other clinicians MUST go through, fax is still the best most reliable method. Who wants to go back to stamps and envelopes? (let’s not talk about mailing test results to patients, as we still do that for some patients: don’t get me started)
  2. For all clinics and hospitals willing to use our web-based secure portal, what we call “Provider Connection”, we can set our communication strategy to send e-messages through that portal. Independent clinics and hospitals who are closely affiliated with use, do use this, and this works well.
  3. For all clinics and hospitals (independent of us) who use their own licensed version of the Epic EHR, we are gradually learning to turn on between-organization messaging, and these e-messages will gradually replace fax. This is getting going.
  4. For all clinics and hospitals on our instance of our EHR, we should be sending ALL notes and messages electronically through EHR e-messaging to our respective inbaskets.
  5. For all clinics that have connected to CORHIO (the Colorado Regional Health Information Organization and other Health Information Exchanges cannot get up to speed fast enough for us) we should be able to turn off our point-to-point communications like Fax because we deliver all notes and results from our EHR to CORHIO’s exchange, which then can deliver results to ANY EHR in the state.
  6. There are still hundreds of organizations out there who use a non-Epic EHR with no capacity for electronic interconnection to CORHIO, or who still use NO EHR. Then, these clinics only have ONE method to send or receive all these incoming messages: FAX. Sad.

Here is where we run into some surprises. Turns out, not ALL of our clinicians in our OWN ORGANIZATION have agreed to use e-messaging and still rely on Fax. What? Old habits die hard. It turns out, while our attention was elsewhere, some of our clinicians and clinic managers were able to convince someone in the IT organization to alter the setting for delivery of test results and referral letters from e-messages BACK TO FAX. On the one hand, I can see a reason why. Some clinicians are used to having the sound of the fax and the presence of paper in the fax-received tray as their TO DO task list, and never “got into email” (really?!). Some clinicians work at multiple healthcare organizations and do not want to check the inbasket of their general email, and the inbasket of the EHR for hospital 1, and the inbasket of the EHR for hospital 2, etc. I could see this being a huge hassle, where ONE fax machine could be the single TO DO list. SO, THIS PROMPTS SOME ACTIONS on our part:

  • All employed clinicians at UCHealth MUST use e-messaging. We will embark on a clean-up of our internal process. Why install an EHR and then let people continue to fax within our organization? It is like buying a Porsche and then cutting out the floorboards and pushing with our feet like Fred Flintstone.
  • Re-examine every affiliate clinic and hospital and figure out how to switch as many communications from fax to e-messaging with Provider Connection. In some cases, like the clinician with multiple hospitals, such a switch might dramatically worsen their clinical work, and we would make exceptions there.
  • Push on CORHIO and other HIE’s to improve between-organization messaging and link our EHR to their systems to make such messaging seamless.
  • Accelerate our investigation of Epic EHR interconnect messaging so that we can send/receive messages from other organizations that also use Epic.
  • Consider a drop-dead date (like “killer app”, this is a terrible term in healthcare) when we might say: “Fax is dead. In order to receive clinical messages from us, you must use Epic EHR or Provider Connection.” I think we’re not quite there yet.

CMIO’s take? Quotable quips are easy to say, and make us feel ridiculous sometimes. But then you have to take a hard look at yourself, and your organization, and the state of healthcare technology, and decide what to do. Do you have a similar story? Let me know.

Author: CT Lin

CMIO, UCHealth (Colorado); Professor, University of Colorado School of Medicine

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