Death to Faxes: COVID-19 Highlights the Need for Interoperability

On December 5, 2020, Alaska state health officials reported 933 new COVID-19 cases, a new high for the number of cases reported in one day in Alaska. It was also a significant jump from the previous high of 760 cases, which had been reported earlier that week.

These numbers may have represented up to a 50 percent underestimate of the true count, as state health officials said they didn’t have enough personnel to process all of the data. Part of the issue is the lack of electronic processing for COVID-19 labs. Lab orders come in via fax and have to be reported back out by fax, all of which requires manual work to process the thousands of faxes received per day.

The Health Information Technology for Economic and Clinical Health (HITECH) Act invested more than $35 billion to encourage electronic health record (EHR) adoption over a decade ago. The majority of physicians and hospitals are utilizing an EHR, but even with this widespread adoption, interoperability between these systems has been elusive. There are a number of efforts to promote interoperability and improve data standards, but seamless exchange is still not commonplace. The current pandemic has highlighted the lack of interoperability and electronic connectivity.

According to the New York Times, the absence of a standard digital process is hampering case reporting and contact tracing, which are crucial to slowing the spread of the disease. Many labs joined the effort but had limited public health experience, increasing the confusion.

At the height of the pandemic, the Alaska Public Health Lab was receiving around 1,000 faxes a day, sometimes including duplicate results. The documents were often missing crucial information needed for the state to investigate cases. Faxes were coming into a traditional fax machine—which someone had to monitor—as well as to a computer where the information needed to be printed and manually entered into public health databases. This process created a significant workload for an already taxed public health staff.

In Austin, the health authority reported receiving a similar number of faxes each day. On average, at the height of the pandemic in June 2020, their office was getting all the information needed to pair with a test result 11 days after the test was taken—far too late to make contact tracing worthwhile.

Elsewhere in Texas, the machine at the Harris County Public Health department in Houston became overwhelmed when one laboratory sent a large batch of test results, spraying hundreds of pages all over the floor.

Dr. Umair Shah, executive director of the department, was quoted in the New York Times, “Picture the image of hundreds of faxes coming through, and the machine just shooting out paper.”

The flood of paper led at least one state health department to request additional resources. In July 2020, Washington State brought in 25 members of the National Guard to assist with manual data entry for results not reported electronically.

Before the pandemic, nearly 90 percent of laboratory test results for diseases tracked by public health departments were transmitted digitally, according to the Centers for Disease Control and Prevention. But the need for widespread coronavirus testing brought many more players into the public health arena, including companies that usually run tests only for employers and small clinics that usually test for diseases like the flu and strep throat. That pushed up the share of lab tests coming to public health departments in other forms.

The state of Alaska is currently undergoing a crucial connectivity project, facilitated by the state health information exchange healtheConnect Alaska. Through this project, which is due to be online in June, hospitals and health centers will be able to electronically order labs via their EHR systems and receive the results back to their EHR in real time. Because the information is electronic, automated notifications can be sent to providers, case managers, or even patients as the results come in. The data entry required at the state lab will be significantly reduced, and the providers will be able to focus on getting patients timely care.

To support true interoperability, all lab results will be searchable via the health information exchange, and real-time notifications can be leveraged to any treating provider. This project will support lab order sets beyond COVID-19, ensuring that the investment in technology supports future outbreaks and allows the state of Alaska to react quickly in times of need. Projects such as these will help us “kill off faxes” and embrace true interoperability in healthcare.

Laura Young is the executive director of healtheConnect Alaska.