As COVID-19 pushes our nation’s healthcare system to the brink, stories continue making headlines of how public health officials in many cities throughout the country are weeding through stacks of paper test results as they look to trace cases and quarantine patients. In other instances, people are waiting longer to find out if they have coronavirus because nasal swab test results are being paper faxed, which cause latency getting results into systems. To think we are relying on paper processes as the virus surges in many areas of our country is problematic. Add to the fact that 9 billion healthcare-related faxes were sent in 2018 (Nebergall, “Fax Technology is the Cornerstone of Interoperability. Here’s Why,” Open Health News, Feb. 6, 2019) and it is clear that now is the time for us to address healthcare’s Achilles’ heel – legacy paper communication systems.

Use of traditional paper fax, specifically the fax machine, is around because it is an established familiar technology that most people would agree works. After all, you can reliably send information from one person to another. However, when you are in the business of healthcare, your focus is on the quality and safety of patients and the thought of using new technologies can be a distraction which takes away from familiar workflows. Simply stated, the fax machine has proven itself year after year to be an easy way of sending and receiving information. But that doesn’t mean using paper fax the way many have been using it for decades is still the most efficient, convenient and secure way of sharing patient information between providers. If providers and public health officials are expected to stop using the fax machine as we know it, there needs to be an easy to use, reliable, affordable, secure technology that allows interoperability of all data for electronic health information to be shared.

An effective, secure and convenient alternative

The issue with paper faxes is the workflow and lack of system integration, which means added time for data to be actionable. Manual workflows needed to process paper documents are slow, laborious, error-prone and at times, incomplete. Paper faxing can be inexpensively replaced immediately with Digital Cloud Fax Technology (DCFT) which improves the digital transmission of information by eliminating paper, optimizing workflows and providing the ability for secure foundational interoperability. 

For those unfamiliar with this technology, digital cloud fax is a secure, paperless, cost effective, and proven way for medical professionals to share documents and records. When professionally installed, it is HIPAA-compliant and falls into the Health Information Management Systems Society’s (HIMSS) category of “foundational interoperability.” Due to its simplicity and universal acceptance within healthcare, digital cloud fax technology is widely used in every setting with particular importance in communities that struggle to afford sophisticated electronic health-record systems, including public health, rural healthcare organizations and financially challenged urban clinics.

Compared to physical faxing, cloud faxing works like this: An employee creates an email, types in the recipient address, types a cover letter and hits “send.” The fax is sent securely into a determined workflow for an easy queue to manage documents, with a confirmation arriving a few minutes later. There is no printing, no scanning, no dialing, no waiting and no paper to file.

If a higher level of security is required, cloud faxing can transmit documents using TLS 1.2 and store them in a secure server with 256-bit encryption. Users log in to the server to view faxes.

Interoperability: the way forward

If interoperability of systems was easy and commonplace, faxing as we know it would be eliminated. Instead, data from disparate systems within a healthcare facility doesn’t always flow into the EHR, which means that same patient data stays behind as a patient move from provider to provider. Instead, connecting a provider’s EHR to its ambulatory physician EHRs, along with imaging, labs, pharmacy and more, requires specific connections between each system and the treating provider’s core EHR. Bringing data to a common platform multiplies the number of required connections exponentially.

To help eliminate the continued burden paper holds on the healthcare industry, while at the same time helping make provider systems more interoperable, earlier this year, we introduced a platform that connects healthcare organizations through the continuum-of-care. Called Consensus, the platform offers one comprehensive connection with a simple, inbox-like dashboard to manage all incoming and outgoing patient documents including digital cloud faxes, Direct Secure Messaging, patient query and API integration into health exchange networks. With Consensus, providers can access leading EMR/EHR systems through CommonWell and Carequality, plus connections to ACOs and HIE data, allowing for the digital exchange of electronic health information between physicians, public health departments and labs.

Conclusion

Moving beyond paper eases operational and technological burdens that cause bottlenecks which impact patient care and threaten to cripple a public health system that has classically been underfunded by our nation’s healthcare system. What is happening with the lack of effective data sharing at several public health departments and what will undoubtedly happen elsewhere as the virus continues to surge in other areas of our county – including rural populations – can be avoided with a comprehensive interoperability system at our fingertips. One that integrates traditional faxing technology with efficient document management so that providers can exchange patient information electronically. And do so both safely and efficiently.

Kamran Shafii

Content Manager

In part 1, we described the debate on the role of APIs and FHIR that took place during the 4^th Annual Current and Future State of Interoperability, a panel discussion sponsored by eFax Corporate® and hosted by HealthcareNOW Radio.

The panel included moderator Matt Fisher, attorney with Mirick O’Connell; John Nebergall, vice president of Consensus; Chris Muir, director in the Standards Division of ONC; Dave Cassel, executive director of Carequality; and Jeff Coughlin, senior director of federal and state affairs for HIMSS.

In this post, we’ll focus on the panel’s discussion of proposed information blocking rules and how healthcare organizations can prepare for the broader information sharing inevitably coming to healthcare.

Not surprisingly, ONC’s Muir couldn’t speak to some information blocking questions, as the rule is currently under review. He did say that when meeting with patients and caregivers, he frequently hears complaints about getting access to information and expects the 21^st Century Cures Act to mitigate some of those challenges.

He went on to say that although his agency seeks to address things like the security of APIs and potential problems stemming from deliberate information blocking, what he and his colleagues are really trying to do is create the preconditions for truly transforming healthcare—in which patients play a larger role in their healthcare and there is more competition in the healthcare technology field.

Meanwhile, there was a lively debate over the seven exceptions to information blocking penalties proposed by ONC, which include protecting patient safety, promoting the privacy of EHI, promoting the security of EHI, allowing recovery costs, excusing an actor from responding to infeasible requests, permitting the licensing of some interoperability elements, and allowing temporary exceptions for maintenance or improvements.

HIMSS’s Coughlin says his organization is mainly concerned with ensuring that the seven exceptions are focused in the right direction and had asked ONC for more information about what “broad sharing” would look like.

Carequality’s Cassel said he believes the information blocking rule will have some benefit in expanding on some of the progress already made, especially with regard to provider-to-provider interoperability and potentially opening up the interoperability to patients and others.

But Consensus’s Nebergall disagreed. “It’s a fragmented environment, with organizations in various stages of moving to value-based reimbursement. Laying out a clear and enforceable rule for what constitutes purposeful withholding of patient data would be nearly impossible,” he said.

Nebergall went on to point out that in addition to federal rules, healthcare leaders must consider state laws, sometimes for multiple states, making compliance even more complex. “Short timelines like compliance in 2020 could prove very costly for providers,” he said.

Proper preparation

The panelists differed in their advice for healthcare executives preparing for broader information sharing and information blocking penalties. Cassel said he encourages providers to begin work on the documentation to qualify for exceptions, should they be needed. He also said healthcare organizations should look at how information blocking fits within their overall compliance framework. “Have a compliance plan in place so that you can prioritize your technology-based efforts on the greatest risk or the greatest opportunity,” he said.

Coughlin said the organizations he regularly speaks with are preparing based on the proposed rule. “I think people are primed and ready and just waiting to see the final rule,” he said. He also noted the connection between  interoperability and other policy issues, such as value-based care.

“You can’t deliver value-based care without broad information exchange, and the burdens on providers are such that it’s important to minimize the amount of time clinicians spend trying to share information with other health systems.”

Nebergall had a different view, encouraging those involved with rulemaking to consider encouraging small steps that will lead to more participation at the provider level. “The reality of our healthcare system is that we have a very large middle-of-the-pack that is still dealing with highly manual paper processes,” he said.

“I think there is a ton of work left to do to adopt electronic workflows into the real world of how care is delivered, not only in hospitals, but also post-acute care and home healthcare. The idea of being able to share information like this is light years away from the reality of what these caregivers deal with every day.”Fax is the fiber of who work gets done at the clinical level—electronic transactions of any kind are dwarfed by fax, he said. “And if we keep focusing on the edge of the spear, we’re not going to provide what the “middle” needs, which is getting the information into electronic form so they can think about transmitting it.”

Kamran Shafii

Content Manager

Bring technologists together to discuss interoperability, and you’re going to hear a lot of acronyms, some words of wisdom, and a considerable amount of dissent.

That was the case at the 4^th Annual Current and Future State of Interoperability, a panel discussion sponsored by eFax Corporate® and hosted by HealthcareNOW Radio.

Indeed, there was little consensus on the first question asked by moderator Matt Fisher, an attorney with Mirick O’Connell. Fisher asked where APIs fit into current and future healthcare interoperability. “Connectivity is a big plus for APIs, giving healthcare organization the opportunity to expand their ecosystems,” said John Nebergall, vice president of Consensus. “But APIs are not going to solve your integration problems.”

Chris Muir, director in the Standards Division of ONC, agreed. “It’s not a full solution, but it’s helpful when patients need to access data from an ERHs or providers are using more than one EHR,” he said.

Dave Cassel, executive director of Carequality, saw things differently. “APIs are useful across the board,” he said. “There are challenges on the patient-access side, but they’re solvable. And giving patients more control over data access has benefits, including fewer HIPAA problems.”

Shifting the discussion slightly, Nebergall said the real issue is creating a way for patients to gather and exchange information in a way that’s useful to them. This is where technology other than APIs can be useful, providing a way to deliver information directly to patients rather than making them go from place to place to find it, he said.

FHIR’s semantic side

Asked about the Fast Healthcare Interoperability Resources (FHIR) standard, Cassel said while there are always arguments about any given standard, there’s a lot of support in the industry for it. ONC’s Muir concurred, saying that people are supporting it and talking about trying to use it. “We’re seeing a lot of adoption of open APIs based on FHIR,” he said.

But Nebergall said there are serious issues on what he called the semantic side of FHIR. “FHIR holds great promise, but there’s not full consensus,” he said. “We see the use of different coding systems with prior data normalization.”

Jeff Coughlin, senior director of federal and state affairs for HIMSS noted that ONC is asking what version of FHIR should be used and that he expects to see version specification in ONC’s Final Rule.

Cassel pointed out that version specification is not sufficient, that users must take a further step. “FHIR is, more or less, a transport standard, telling you how to get information from point A to point B. It doesn’t say how to define the payload in terms of the data set,” he said. “FHIR can do semantic, but the user has to specify. He or she has to go into Resources and say ‘Thou shalt use Terminology X.’ You can’t leave it unspecified, for example just saying ‘Send medication.’”

In part 2 of this post, we’ll report on the status of information blocking regulations and how organizations can prepare for broader information sharing, including state and federal regulations and moving away from traditional fax.

Kamran Shafii

Content Manager