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How DirectTrust is embracing fax for health data exchange

Industry stakeholders are working with DirectTrust to create a data standard for secure cloud fax to address health data exchange barriers and enhance data security.

The fax machine is not dead, despite the healthcare industry's efforts to transition to electronic health data exchange.

Indeed, fax machines are still among the most common forms of data exchange. According to ONC data, approximately 70% of hospitals used mail or fax to send and receive health information in 2021.

"I'm actually shocked that fax is still here, to be brutally honest," Robert Cichielo, CTO and co-founder of etherFAX, a vendor that provides secure cloud fax services, said in a recent interview.

But until EHR systems are truly interoperable, healthcare organizations will continue to use fax to share data, Cichielo stressed.

According to ONC, 64% of hospitals reported health information exchange (HIE) challenges in 2021 due to a lack of interoperability with their exchange partners' systems. Further, 72% of hospitals experienced greater barriers when sharing data across different EHR vendor platforms.

When electronic HIE fails, fax is the least common denominator between these systems, Cichielo said.

What's more, not every healthcare organization has access to EHRs, making fax a feasible way for these organizations to share patient data.

"Everybody has a fax number," said Barry Clark, CEO of WestFax, a vendor that provides secure cloud fax services. "You don't need to buy an EHR to be able to send patient health records securely."

With fax's ubiquity also comes security, Clark added.

Many consider fax less vulnerable to cyberattacks than email or other internet-based data exchange methods because connections are point-to-point through the public switched telephone network. On the other hand, HIE networks connect many organizations simultaneously.

"Your phone number is a very powerful, globally unique identity, so when I send a document to your fax number, I'm reasonably assured and reasonably certain that this document is going to get where it needs to go and it's going to get there reasonably secure," Cichielo said. "There's no other system that does that today."

The evolution of fax

According to Cichielo and Clark, fax technology has advanced beyond squeaky office appliances and thermal paper rolls.

Healthcare organizations send most faxes today via secure cloud fax. Traditional fax operates over phone lines, while secure cloud fax transmits information digitally.

Everyone has tried to rip out fax, but you can't rip and replace. It doesn't work. There has to be a transition.
Robert CichieloCTO and co-founder of etherFAX

"In the age of internet and cloud, we have telephony in the cloud," Cichielo said. "This way, people don't have to plug machines into a phone line."

Secure cloud fax systems offer benefits over traditional faxing, including integration with EHR platforms and elimination of physical paper handling.

Instead of manually faxing patient records through a fax machine, providers can enter their referral partners' fax numbers into the EHR and send the data via cloud fax. The receiving system could be another EHR, a fax machine, a printer or another device capable of handling fax data.

"You don't have a user walking up and playing with crinkly paper," Cichielo emphasized. "They're working inside existing medical systems, and fax almost becomes a metaphor, a euphemism, this nebulous entity where it's just the transport."

The future of fax

As healthcare organizations continue to fax billions of documents every year, a group of industry stakeholders, including Clark and Cichielo, have come together to develop a standard to enhance fax security and interoperability.

Convened by the healthcare industry alliance DirectTrust, the Interoperable Secure Cloud Fax Consensus Body aims to create a data standard for exchanging documents via fax across different cloud fax platforms.

This standard will enhance fax through cross-platform and cross-organizational identity assurance, standards-based exchange of metadata and federated security standards.

"This consensus body will enable us to lay the groundwork to send more metadata and more identity assurance in a way that enhances the innate security features that fax already has," said Clark.

"Whether fax is here for another decade or more, it's the transition step that we're making now through DirectTrust while incorporating fax rather than demonizing it that is the way to the future," he said.

Cichielo echoed Clark, underscoring the importance of embracing fax rather than dismissing it.

"Everyone has tried to rip out fax, but you can't rip and replace," said Cichielo. "It doesn't work. There has to be a transition."

"Rather than everyone having these conversations trying to kick fax to the curb, let's use the power of DirectTrust as an entity that provides an overarching framework for identity assurance and minimum compliance," he continued.

Cichielo noted that creating a standard for interoperable secure cloud fax will help support the application of advanced technology to enrich data sharing, including through the application of large language models.

For instance, the cloud fax industry could adopt AI to help route faxes to the correct department within a hospital. Currently, staff must sort through fax inboxes manually, which can sometimes take 15 to 30 minutes per document, Cichielo said.

By modernizing fax through a secure cloud fax standard, DirectTrust and industry stakeholders are not only preserving fax's reliability and security but also paving the way for a seamless transition to more advanced health data exchange.

Hannah Nelson has been covering news related to health information technology and health data interoperability since 2020.

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