Fax machines represent medical waste, error, and expense

In a scene from the 1999 cult classic “Office Space,” three burned-out cubicle drones take a baseball bat to a malfunctioning printer.  While I do not condone violence against innocent peripheral hardware, I admit I secretly fantasize about destroying medical center fax machines.

Recently, a chronically non-compliant end stage kidney disease patient on dialysis was admitted for minimally elevated troponins and non-ST segment EKG changes in the setting of a hypertensive emergency.  The patient knew little of his medical history besides the name of a hospital where he had an extensive cardiac workup.  Over the phone, the primary team learned that a nuclear stress test from earlier this year was negative for signs of coronary artery disease, reducing the likelihood that any invasive procedures would be required for further management of his current issues.

However, for medicolegal reasons, until that report physically sat in the patient’s chart, he was set up to be processed like any patient presenting with the same signs, symptoms, and comorbidities, with worst case scenarios and contingency plans in mind – a reasonable course of action considering the indefensibility of verbal reports.

Somewhere uptown, the patient’s nuclear stress test results exist in the form of thinly-pressed, ink-covered tree pulp, stored in a filing cabinet.  Obtaining a copy of the information would be virtually impossible if it weren’t for a miraculous machine that takes a paper chart, converts it to 0s and 1s, and sends it to a remote location, provided a number of conditions are met.

As a medical student, I have learned that a successful transmission depends on obtaining a signed HIPAA consent, calling the outside hospital’s records department between lunches and coffee breaks, estimating a reasonable date range that may contain the desired information so as to maximize the likelihood of prompt return by minimizing the “burden” of pulling the files, and then verifying that there is paper, toner, and a dial tone before the records clerk, who has assembled the chart faster than you can say “heart attack,” hits “send.”

Obtaining records from an outside hospital also depends on knowing that such records exist, which is easier said than done with the way some patients choose to obtain their care.  In the end, if all things go according to plans, I might have a portion of a chart within a few hours, usually after the patient’s plan has been discussed on morning rounds.

In the case of the patient described above, the nuclear stress test arrived after the patient had been whisked off for a another nuclear stress test, which turned out to be negative.  I shudder to think that a false positive test could have sent him on the road to angiogram city, with all of its associated complications and costs.  One can debate the merits of doing a pre-discharge stress test in this particular patient with questionable NSTEMI, but the fact of the matter is that information was not accessible when the primary team needed it.  The fax transmission process I described represents the only avenue, in many hospitals, to the receipt of a valid medicolegal document, short of physically mailing a paper chart.

When I see a fax machine, I can’t help but wonder: Are physicians not ashamed that paper charts, nine-to-fivers, and ancient technology stand in the way of instant decision-making?  Do they understand that their time and training is too valuable for this inefficient form of communication?  Are they not embarrassed that barriers to information sharing put patients at risk for the morbidity associated with repeat diagnostics?  Do they not feel foolish when they perform the same tests that were done recently at an outside hospital? It frustrates me to no end that so much valuable information, which can be mined for clinical insights, collects dust in hospital record rooms.

To me, fax machines represent waste, error, and expense.  Fax machines mean redundancy of efforts.  They mean delay, uncertainty, anxiety, and longer hospital stays.  They represent small-mindedness, bureaucracy, regulations.  They represent a lack of imagination.  They represent why people very close to me can no longer afford health insurance.

When my children grow up, I hope they never hear the soul-sucking chirp of the fax machine.  In this dream world, actionable information — downloaded instantly — informs subtle clinical decisions.  Medical records are stored in online databases and are used to answer complicated clinical questions on the fly.  In this world, creating a retrospective study is as easy as a few clicks of the mouse.  This world is possible, but it’s going to require considerably more rage against the fax machine.

Jason Theobald is a medical student.  He can be reached on med*t3ch.

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  • Ron Smith

    Hi, Jason.

    “To me, fax machines represent waste, error, and expense. Fax machines mean redundancy of efforts. They mean delay, uncertainty, anxiety, and longer hospital stays. They represent small-mindedness, bureaucracy, regulations. They represent a lack of imagination. They represent why people very close to me can no longer afford health insurance.”

    I think what you really mean is that for the transmission of a medical record, that fax machines are a choice which could, if the technology was in place, be a poor choice of medical data communications between different medical care providers of any type.

    I think though that it is a reach to say that we should be ashamed of it. Remember it is a technology that, when introduced, was a great time saver. Even today, I use fax technology to send prescriptions directly from my practice to a patient’s pharmacy. My practice is in McDonough, Georgia. As I write today, the week before Christmas, I’m in Gulf Shores, at a funeral and just two days ago I was in Arkansas visiting my parents for Christmas. Now I’m a solo Pediatrician and I do have nurse practitioners who work with me. But this is my week to take call.

    I’ve had two pages that both required prescriptions and both times, I fired up my PaperCutPro emr software and clicked on the patient’s phone number, which opened Skype and dialed it. While talking with the mothers each time, I’m looking at the record, and before I finish the call, I’ve created the needed prescription, sent it to our fax server, and watched the confirmation of receipt, all before I hang up the Skype phone.

    Now, most physicians would have taken the page, returned the page using a land line or cell phone, discussed the patient with the parent, obtained and called the pharmacy voice phone number, and recorded the prescription orders to their answering machine.

    I hardly think that you would say we should be ashamed of or imply that we should get rid of answering machines an pagers, just because I can use the fax machine to streamline and optimize the prescription process.

    We must be very, very careful when we look at the array of electronic technologies. Your generation can only see a better way, but my generation remembers when we didn’t even have fax machines.

    I say we optimize existing technologies for the best application. Faxes are great for prescriptions. HIEs (Health Information Exchanges) are the hope of the future, but though I want this to happen, I am becoming less positive as time goes on when I see Obamacare. The integration process is so very complex.

    Whether the technology is fax, portable electronic records, or whatever, I’m ready to put any technology away like an old, worn-out wrench. Tools are tools, and just when you think you’ll never need a particular piece again, a situation presents itself which requires it.

    Warmest regards and Merry Christmas,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Don’t blame the fax machine, because it has nothing to do with why people can “no longer afford health insurance”, or with this particular story.
    Obviously the admitting team had all the information they needed from actually talking on the phone with the previous hospital, but they couldn’t act on it because of “medicolegal reasons” and “the indefensibility of verbal reports”.
    What makes health care expensive is this type of bureaucracy and regulations where having one physician speak to another is frowned upon as a method of care coordination, most likely because communication not mediated by a computer fails to transfer a large enough portion of health care dollars to some technology company.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Hi Jason,
    You don’t have to convince me of the benefits of that big database in the sky (see here for one example: http://onhealthtech.blogspot.com/2012/01/arguments-for-universal-health-record.html ).

    I agree that the technology has been there for quite sometime. The problem is that what sits in hospitals today is the wrong technology, and that’s by design. It really is a medico-legal-business decision to keep the fax machine, so to speak. And today, with the incessant revelations of a secret government gone security crazy, it’s also a fear driven decision.

    The new/old business models of ACO/HMO and the narrow network paradigms have every financial incentive to make it difficult for patients to step outside the system/network, not to mention old fashioned customer retention (try opening an account at BofA and see if you can access your transaction history at Chase, or if you can pay bills from BofA account with Chase money on the fly).

    Medicine, just like the banks, has morphed long ago from serving at the pleasure of its customers, and it now exist solely to enrich its owners. You will have as much technology as can be shown to increase corporate profit.

    • th3o6a1d

      Hi Margalit,

      Thanks for the link to an excellent blog article, and for your points. I’m optimistic that technology will ultimately break down a lot of the medico-legal-business barriers you describe.

  • heartdoc345

    My only beef with fax machines is — when I have the same EMR in my whole hospital system, why on earth do I receive faxed reports from our own echo lab, stress lab, etc. which get scanned in — they are already digital PDFs, high resolution, and the image quality gets very degraded.

    And part and parcel of this problem is they get filed into the wrong place constantly.

    Gets even more fun when I want to write a CPOE order for an echo only to find out that the process is for it to go to a printer, and then get faxed, to the echo lab that is right next door to my office, rather than electronically get there as soon as I press “send” (which gets even more fun when nonclinical personnel send the echo order to the nuc lab and then the patient doesn’t get their test at all!)

    Would be nice if the faxes were only for things that were truly from the “outside hospital.” Faxes are nice when there is truly no alternative – still better than getting no information, or waiting several days to get something in the mail.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      That’s just bad, bad implementation and configuration. Even if the EMR is horrible and can’t do a pure electronic transfer, there is absolutely no reason to use physical printers and fax machines as intermediaries between two electronic system, or between two modules of the same system. Misfiling is a not an easily solved problem, but you shouldn’t have to put up with the degradation.