# Fax Integration and Workflow

The fax machine brought a revolution in communication. The fact that it maintains a place in our daily communication is a reflection of continued dependence on paper. This our health care system owes, in part, to a failure to agree on and implement the available protocols by which we could securely and privately exchange clinical communication.

Even when the above is resolved between many (and even most) points of care, some dependence on the fax machine is going to remain for the foreseeable future as is true for paper. Even in a digital office, patients may bring outside papers into the examination room. Some deaf patients will very much depend on fax machines for communication with the medical praxis.

Here are some of the considerations as they relate to EMRs…

## Incoming faxes

If the incoming fax is printed onto paper, you now have a paper record to deal with. This workflow should merge into whatever is your incoming paper workflow except that some faxes will have to be handled promptly. As with other paper, the issue will be whether the staff will digitize the paper before the doctor will see it, or whether the doctor will handle the paper, optionally mark it up and initial it with a pen, and only then direct it into another "filing" workflow that will either move it into a paper file ("hybrid medical record") or scan it at the time cost of digitizing the paper, relocating the patient to whose file to attach it, and to queue up this same information redundantly, this time digitally, to the clinician. This makes a case for the clinician, during the paper document review (perhaps during or right after the patient visit) to digitize at least those papers that are of value to digitize. The GNUmed workflow for doing so is elaborated in GmManualDocumentImporter.

Assuming that the incoming fax is not to be printed onto paper, we are talking about digital files in need of handling. Each clinical group will need to

- maintain a fax line (or eFax) through which the faxes are to arrive
  - if selecting a phone line, must maintain an always-on fax modem plus storage device (computer). Hardware problem reports by modem users are not unusual.
  - dedicated fax lines cost money they can double as extra voice lines at the risk of blocking faxes
  - remote internet fax (eFax) services can allow the fax files to be downloaded under secure methods but involve base charges plus per-page charges
- establish a notification system for newly-arrived faxes
  - in absence of such a system, one or multiple people will have to manually monitor the inbox folder
- establish a screening process to distinguish non-patient from patient faxes and to assign any priorities for handling
  - one convention could be that whoever would open an image file will at least label it, and/or designate it for action by another
  - during the time that fax image files had not yet been imported into the EMR, they could be moved into the subfolders of the doctor or personnel to whom the faxes relate
- determine how each fax file is to be split, merged, renamed, and otherwise processed, given the following variations on content:
  - multi-page fax = cover page + additional pages on a single-patient
  - multi-page fax = cover page + additional pages on multiple patients
  - single patient information is split across two fax transmissions (files)
  - patient information is partly-duplicated across two fax transmissions (files)
- determine how the person who inherits responsibility will receive notification and prioritization
  - for the clinician, this would best be a clinical inbox filtering on those documents (files) whose status remains unreviewed even if they had not yet been attached to patients. Obviously the clinicians would prefer that this attaching had already been done for them, however as part of their review the clinician should assure correct attachment
  - incoming communications that do not relate identifiably to individual patients, for example meeting information, will need to be communicated apart from unreviewed clinical documents, optionally as messages within the EMR or as communications (perhaps emails) outside the EMR
- determine what to do with each source file once it has been processed, in keeping with any retention requirements

## Outgoing faxes

One other key consideration is whether the fax device will need to be accessible from multiple local network computer users who may wish to initiate faxes. Not only will this require a shareable fax solution, which modern Mac and Windows software (and maybe Linux) do typically support, but you would also have to consider how your EMR would deal with the post-processing of the outgoing fax transmissions for anything that was patient-related.

## Recommendations

For incoming and outgoing fax handling one of the developers (K.H.) strongly suggests looking at the HylaFAX fax server software under Linux. It offers:

- several modems
- incoming faxes
- post-processing incoming faxes in any way programmatically doable
- queued outgoing faxes
- watchdogging modems for operationality
- fake printer drivers for Linux/Windows (don't know about MacOSX?)
- remote management and troubleshooting

It has served them well and ran without glitches for years. Software mentioned by other clinical groups has included, for Windows/Unix, Active Fax. While Apple's own Print and Fax drivers support native sending and receiving of faxes from desktop machines (as may require a USB modem). Any server functionality under Mac OS was not researched yet as part of this wiki page.

## External references

1. CanadianEMRBlog
2. OscarEMR list archive here
3. Threads concerning network scanners are archived
   - at an Oscar archive here and
   - at a CanadianEMR blog here