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.