The FAX and the case for regulating EMRs as common carrier utilities.

Primary care and community medicine remains totally dependent on the FAX machine.  Doctors orders are FAXed to providers and suppliers, various approval forms and lab work are FAXed back.  Referrral letters, test results, prescriptions, scheduling, you name it, it all goes by FAX. Reams and reams of FAX paper drive the life of primary care medicine and the associated network of pharmacies, suppliers and labs and facilities that together make up most of community medicine.

Why do we rely on an obsolete technology?  FAXes are slow, error prone, insecure and expensive.  An electronic prescription can be sent to the pharmacy during a patient visit.  A FAX order has to be printed out, picked up by someone in the office, they need to verify the correct FAX number, write out a face page, put them in the FAX machine, dial the number and wait for the FAX to go, hopefully on the first try.  At the other end, someone needs to sort through the pile of incoming FAXes, assign a patient ID to each of them, read the request and dispatch the paper accordingly.  Hopefully the machine did not jam or miss-feed on either end.  Hopefully, it got sent to the right number.  Hopefully two sheets of paper did not stick together and get miss-sorted.  Hopefully the discarded paper FAX will be appropriately shredded and disposed.  And if all goes well, the message is communicated.

Again, why do we rely on FAXes in health care?  The answer is simply that FAXes are the highest common denominator of information exchange between all of the various physicians, nurses, labs, suppliers and facilities involved in community medicine.  Yes, we have been making significant progress in electronic prescribing, but the sad reality is that most electronic medical records (EMRs) still cannot talk to each other.  We rely on FAXes because they are a common carrier standard.  You can go to any store, buy a FAX and be relatively confident that you will be able to send and receive messages from everyone else’s FAX machines.

With EMRs, there is no expectation, much less a guarantee of interoperability.  The fact that vertically integrated health systems can impose a standard organization wide gives them a huge advantage and is driving consolidation in health care.  It also creates problems every time a patient needs to change providers and strongly discourages patients from exploring their care options.  It also leads to huge duplication of effort because every time a patient does change providers, the best that we can hope for in most cases is that there past medical records will be printed out and stored as scanned documents in their new providers EMR.  Of course those scanned documents are slow to access, poorly legible and cannot be indexed or searched.

If EMRs were regulated as common carrier utilities, we could greatly enhance competition and transparency in healthcare markets.  Basically impose the same requirements that we impose for a FAX machine; if you are going to sell and EMR it needs to be able to communicate patient records reliably and without data loss to anyone else running a standard EMR.  Patients would then be in a much better position to maintain their own personal medical records (PMR) and to shop for services and providers that best meet their needs.  When patients change providers, the new provider would not have to rerun all of the recent test because they could access them from the previous provider.  Meaningful Use requirements are moving incrementally toward interoperability, but entrenched resistance is strong and progress has been very slow.

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