To observe Facsimilus mechanicus in its natural habitat, just visit a medical office in the US, Canada, Germany, or Australia.

Once identifiable by its piercing mating call (“EEEE-yoooooo…SKREEEEEE…kshhhhhhhhh”), the common fax machine is known for its ability to persist in its environment despite vanishing from much of the world over the past three decades.

F mechanicus has long been marked for extinction in healthcare.

“We still can’t reliably send a patient’s record from one system to another without a fax,” said N. Lance Downing, MD, internal medicine and clinical informatics physician and clinical assistant professor at Stanford University School of Medicine, Stanford, California. “The fax machine is medicine’s broken window. Everyone sees it, knows it shouldn’t be there, and has learned to walk past it.”

Will anything ever change? US federal government officials think so.

Earlier this month, they finalized plans to phase out fax machines and snail mail from medical offices over the next 2 years, saving taxpayers an estimated $782 million annually.

Mehmet Oz, MD, administrator of the Centers for Medicare & Medicaid Services (CMS), had a ready quip in a statement: “The 1980s called, and they want their fax machines back.”

But physicians who study medical office technology aren’t rushing to cancel orders for toner and fax paper. While the widespread use of medical faxes continues to spark frustration and astonishment, getting rid of them quickly is a big ask.

Promises, Promises

During the Obama administration, then-CMS Administrator Seema Verma challenged developers to make medical offices fax-free by 2020. That didn’t happen.

The problem is that the fax machine allows providers and others to securely (or at least somewhat securely) tell each other about what’s going on with patients, something that’s still a challenge for other systems.

“Fax is the primary means by which clinical information is transferred from one institution to another, unless those two institutions share the same electronic health record [EHR],” Seppo Rinne, MD, associate professor of pulmonary and critical care medicine at Boston UniversityChobanian & Avedisian School of Medicine, said.

Older Than the Transistor Radio

Some things have changed in fax world over the past few decades, such as the rise of e-fax and the decline of screeching, landline-based machines.

But faxing itself is hardly new. The modern fax is older than NATO, the transistor radio, and King Charles III, and fax technology itself dates back to 1843, according to HowStuffWorks.com.

Faxing remains pervasive in medicine despite its endangered status.

“A single patient visit can generate multiple incoming faxes — lab results, a specialist note, an insurance denial, a prior auth request — none of which arrive in a predictable format or timeframe,” Downing said. “There’s no threading, no tagging, no routing logic. Someone has to manually touch every page. In a larger practice, that’s hours of staff time per day. In a small practice like mine, it falls on me or my MA [medical assistant].”

To make matters worse, he said “The fax machine also fails at exactly the wrong moments: poor transmission, missing pages, illegible handwriting. You often don’t know something went wrong until a patient is in the room asking about a result you never received.”

The Full-Time Job of Fax Handling

Rinne is studying one smaller healthcare system with a 397-bed hospital and outpatient facilities where the volume of incoming faxes can reach 3000 per week.

Someone’s entire job, he said in an interview, can be just to open PDFs that have been converted from paper faxes, read their contents, rename the files, and find a place to store them.

Rinne said he’s currently evaluating an AI tool to handle these tasks.

The Costs for Patients

Medicine pays a price for sticking with big fax.

Ted Melnick, MD, associate professor of emergency medicine and biostatistics at Yale School of Medicine, New Haven, Connecticut, who studies EHRs and clinician workflow, said “Faxing is not just inefficient. It changes behavior.”

The problem? “When getting outside data is too burdensome, clinicians may not pursue it,” he said in an interview. “That has real implications for decision-making and patient safety.”

Rinne remembers treating a patient who arrived one night at his hospital while vomiting blood, needing more than 12 units transfused overnight. The patient had been hospitalized elsewhere in the preceding weeks, but getting those records quickly proved to be impossible.

“I was trying to manage him while he was actively spewing out blood,” Rinne said. “It was hard to pause, get on the phone and call Mass General, then get the medical records phone number, talk to the medical records person, and ensure they felt comfortable releasing the information. At that point, it was probably 3 in the morning.”

Medical records finally appeared hours later by fax, revealing an anatomical anomaly in which a structure had eroded into a major artery in his biliary tree.

Rinne doesn’t blame the patient’s eventual death on the communication hassles. However, “had I known that information, I would have totally treated him differently.”

A Quick Timeline and a ‘Heavy Lift’

The new CMS regulations create a standardized, “consistent, easy-to-use” electronic framework for transmitting clinical documentation. Compliance is required by May 28, 2028.

“Two years is really quick. It’s ambitious,” said Shawn Ong, MD, assistant clinical professor of general internal medicine and biomedical informatics at Yale School of Medicine. “I would love to see it happen, but I can imagine it will require a heavy lift from IT teams, not just in the initial build and implementation and all the testing, but in the subsequent maintenance.”

The technical challenges are significant. Identifying patients across systems, when they can share the same names and same birthdates, is just one challenge, Ong said. “How do you, with any certainty, reconcile that the document coming in truly belongs to that particular patient?”

Stanford’s Downing pointed to another obstacle — money. “Right now, the incentive structure is murky. Payers, health systems, and EHR vendors all have competing interests. Until someone is clearly on the hook for funding the transition, progress will be slower than it should be.”

Too Soon?

Sudeep Bansal, MD, internal medicine physician in Glastonbury, Connecticut, who writes about medical office technology, argues that in the near term, the rule may do more harm than good.

“CMS has gone down this path before and failed. If they outlaw faxes, this will create tons of problems, as there is no technology today that is a direct replacement,” he said. “We use e-faxes and e-sign, and most EHRs have built workflows around e-fax. This rule will upend all these workflows, make them worse, and stall any progress in e-fax and AI-based interoperability.”

He believes the market, not regulatory mandates, is a better mechanism for solving this problem. “The market,” he said, “will solve the problem.”

The remarkably resilient F mechanicus, however, has long relied on the market’s failure to do so.

Ong, Rinne, and Bansal reported having no disclosures. Melnick disclosed having relationships with the National Institutes of Health and the Agency for Healthcare Research and Quality.