Time warp: The lingering legacy of fax in medical practices

Amid all the changes in the U.S. healthcare industry, one means of communication has managed to cling to relevance in physician clinics and payer offices long after it stopped being used in everyday business in most other industries: the fax.

The Medical Group Management Association’s most recent MGMA Stat poll asked healthcare leaders: “Does your organization use a fax machine?” The majority (89%) answered “yes,” while 11% reported “no.” Respondents who answered “yes” were asked the primary reason for using a fax machine. The top responses included:

• Record sharing
• Referrals
• Communicating labs/tests/results
• Payer communication
• Pharmacy communication

The poll was conducted on November 5, 2019, with 1,581 applicable responses.
 
While these statistics might be shocking to some, it’s unlikely to surprise anyone who works in a medical practice. Despite broad adoption of EHR systems in the past decade and other areas in which paper processes have been digitized and/or automated, fax remains a significant means of transmitting patients’ protected health information (PHI) to support numerous administrative tasks. At least one private estimate put the amount of medical communications conducted by fax at 75%.

In August 2018, the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma announced that CMS and the Office of the National Coordinator for Health Information Technology (ONC) were taking steps to remove barriers to sharing data between patients, providers and payers, including the goal of making “doctors’ offices a fax-free zone by 2020.”

Why? Beyond just the hassle of moving paper and ensuring you get a dial tone and a clear connection to transmit any type of information via fax, there are multiple compliance and best-practice considerations:

• Faxing results in a flat image, often requiring reworking into actual data that is structured and then must be manually inputted to an EHR or practice management system.
• Paper-based faxing also runs the risk of being illegible to the end user, resulting in calls back and forth between the sender and the recipient. Note that X-rays and other imaging results sent via fax may be next to useless.
• Sending PHI to an incorrect number could be a violation of the HIPAA Privacy Rule. Physician practices, as a “covered entity,” may share PHI via fax and other methods “as long as they use reasonable safeguards when doing so,” according to the Department of Health & Human Services (HHS). A “reasonable safeguard” would include confirming a fax number before attempting to transmit PHI to it.
• Faxing can lead to delays in the transmittal of prior authorization paperwork or referral documents can disrupt the continuity of care, interfere with the physician-patient relationship, and increase costs for practices.

Faxing contributes to the burden of prior authorization on medical practices, a burden that is only increasing, as noted in two recent MGMA reports:

1. A Sept. 17 MGMA Stat poll found that 90% of healthcare leaders reported payer prior authorization requirements increased in 2019.
2. The 2019 MGMA Annual Regulatory Burden Report, released in October, found that the top regulatory burden faced by medical group practices is prior authorization. The survey report found that 83% of group practice leaders reported that PA requirements are either very or extremely burdensome, compared to 10% reporting them as “moderately burdensome,” 5% as “slightly burdensome” and 2% as “not burdensome.” As one respondent noted in the survey, “during the past year we have added three new employees to handle just the prior authorization requirements.”

The Council for Affordable Quality Healthcare (CAQH) — which works to improve automation of prior authorization processes — estimates there are 182 million PA transactions per year in the commercial medical market alone, with the majority (51%) generated through a manual process, such as phone or fax.

Electronic alternatives

Despite being available for more than a decade, CAQH reports only a small percentage (12%) of prior authorization transactions are conducted using the HIPAA electronic transaction (the 5010 X12 278 Prior Authorization Request and Response). That lack of adoption is very simple: the transaction doesn’t do all that practices need it to do and not all health plans support it, forcing practices to use fax machines.

One emerging modality for shifting information transmission off fax machines is Direct Secure Messaging, which are enabled within all EHR systems meeting the 2015 Edition Certified Electronic Health Record Technology (CEHRT) standards. Various EHR vendors may rebrand this functionality within a proprietary platform, but the framework will be that of a HIPAA-compliant Direct Secure Message. Secure messages can be sent between clinical care sites in the case of patient transitions of care or between the practice and the health plan, in support of a prior authorization.

A recent report from DirectTrust, the nonprofit group that works to advance use of the Direct Secure Messaging framework, notes that there were more than 197 million Direct Exchange transactions in the third quarter of 2019 — a sizable increase since last year.

Practice leaders are encouraged to reach out to their EHR/practice management system vendors and their health plans to determine if they support the X12 278 transaction, Direct Secure Email, or both.
 
Would you like to join our polling panel to voice your opinion on important practice management topics? MGMA Stat is a national poll that addresses practice management issues, the impact of new legislation and related topics. Participation is open to all healthcare leaders. Results of other polls and information on how to participate in MGMA Stat are available at: mgma.com/stat