How to “Axe the Fax” in Health Care

Recently, Globe and Mail Health Columnist Andre Picard wondered why fax machines are still the norm in health care.  Electronic communication is faster and more efficient than faxing.  In the past, it was thought that faxing was at least more secure.  However, with the emergence of “faxploit”, and reports showing how missed results are worse, it’s clear that secure electronic communication is safer.  Britain has moved to “axe the fax”in health care, acknowledging that using fax machines is farcical.

So why are faxes used so often in health care?  I can’t speak for other provinces (although the answer is likely similar) but in Ontario, it’s because the IT infrastructure for health care was so poorly thought out by the previous Liberal government that there really is no choice.  There is a mis-mash of different software for different health care providers, none of which interacts with each other.

Physicians in Ontario currently are able to purchase one of twelve Electronic Medical Record (EMR) services. NONE of these services is actually able to communicate with each other electronically.  Going from one doctor to another, means that your records are not interchangeable.

Hospitals in Ontario have the choice of even more products, though generally pick one of the three most physician unfriendly versions.  The Home Care system uses a Province wide system, but can’t interface with hospitals and physicians.  Then there’s Public Health, multiple allied health care agencies, nursing homes and so on.

The result is a byzantine system with no easy co-ordination and absolutely no interchangeability.  Hence, I fax referrals to Home Care, specialists fax me with their consult notes, and nursing homes fax me three month drug reviews.

The most commonly suggested solution for this problem is to develop something called a Provincial Electronic Health Record (EHR).  The idea is to have every health care provider get rid of whatever software they are using now, and use one Province wide system only.  The system would be cloud based, and allow you only to access the information that you have privileges for.  For example, family doctors could see the whole chart, but a pharmacist could only access the medication record (and some relevant lab work), a personal support worker would only be able to access notes they had written and so on.

In an ideal world, this makes the most sense of course. However, proponents of this solution fail to recognize that this will be exceptionally costly.  There are the initial costs of development of such software. But there will be additional hidden costs to such a solution.  EVERY health care provider in the province will have to get re-trained on this new software.  We’re talking all 30,000 doctors, 100,000 nurses, goodness knows how many PSWs, Pharmacists, Pharmacy Technicians, radiology technicians, clerical staff etc.

Unfortunately, the reality is also that when people go from one system to another, mistakes are going to be made and there will be a number of errors.  These errors will also have a cost to them.

But what can be done then?  Clearly the current system of archaic faxing is unacceptable. Turns out there is a solution that is relatively easy, relatively in-expensive and has already been piloted with great success in my neck of the woods (Georgian Bay, Ontario).  The government should mandate that all health care software providers must have an Application Programming Interface (API) that meets a rigid province wide standard, by the end of this year.

As I’ve written about before, when I was Chair of the Georgian Bay Family Health Team, my colleague Dr. James Lane piloted a project that allowed pharmacies limited access to our Electronic Records and allowed secure communication between pharmacists and physicians. There were numerous efficiencies and safety benefits, including an unexpected 90% reduction in drug diversion (selling/stealing of opiod prescriptions).

In 2014 we used an API to allow us to communicate securely with our nursing homes.  The result was an over 50% reduction in admissions to our local hospital from nursing homes.  The cost of the API was about $35,000 a year. The funding ended in 2018 and for whatever reason our LHIN has chosen not to continue funding it – and of course hospitalization rates are going up again.

Having a provincial standard for an API can be done easily (there are multiple existing standards out there).  Forcing the software providers to add this to their software will take a little intestinal fortitude, but I suspect the current government has that.  By doing so, it means that a physician, can continue to use whatever EMR he has, but transfer relevant data electronically to home care, public health, hospitals and so on.  It will mean that the agencies can communicate directly and quickly with each other on the patient’s chart, without the mess that was caused by faxing. Our system was actually compatible with smart phones, so home care nurses could message a physician’s office right from the patient’s home.  And, it will be far less expensive than developing a brand new system.

The time to mandate a Provincial API Standard probably came 8 years ago.  Hopefully 2019 will be the year it happens.

Author: justanoldcountrydoctor

Practicing rural family medicine since 1992. I still have active privileges at the Collingwood Hospital. Currently President-Elect of the Ontario Medical Association.

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