Faxes have been used to send documents over phone lines since the mid ‘60s, and while many medical practices have changed since then, the fax continues on with many health systems still depending heavily on the technology. 
The healthcare industry has begun understanding that fax can present a clinical risk when dealing with sensitive patient information as the faxed content can be misplaced or fall into the wrong hands. 
Hence, replacing outdated fax machines with secure messaging systems has been a focus for some in the Australian healthcare industry as information sent via the latter is sent directly to the receiver.
But there is still resistance in the uptake of secure messaging even though there is a proliferation of medical referrals in the industry, requiring the use of secure messaging systems.    
The Australian Journal of Medical Practice recently found that in 2014-15 alone, general practitioners made 15.9 referrals per 100 patient encounters, sending 9.7 million more referrals than in 2005-06, highlighting the scale of exposure to risk.
In addition, a Microsoft report in collaboration with Harvard Business Review Analytic Services, Embracing the Change Mandate: The 2020 Digital Transformation Agenda for Australia’s Health Care Sector, studied how a digitally augmented system could improve Australian healthcare and barriers to change
The report found that 44 per cent of respondents said one of the top barriers to digital transformation was resistance to change. 
As such, eradicating faxes in healthcare has been a key focus for the Australian Digital Health Agency (ADHA), with the statutory authority extending its its Secure Messaging Program across the industry over the last three years. 
The Secure Messaging Program aims to help healthcare providers across Australia communicate quickly, easily and securely, and to reduce the sector’s current reliance on outdated technologies like the fax machine.
But even though a number of vendors do offer secure digital messaging services, interoperability issues and the lack of a universal format have resulted in hospitals like Ipswich Hospital, GPs and specialists still continuing to send referrals and discharge summaries using fax.
Late last year, a panel of speakers at the Wild Health Summit in Sydney stressed the importance of digital change, but supported the use of the fax machine, saying that the industry is still in its infancy in eradicating it and that its usage could still benefit some players in the sphere.  
“We are quite conservative in healthcare. To rid the fax machine in a bigger network, we’re not there yet. There’s still a long way to go to have secure messaging systems rolled out and working efficiently in larger hospital settings,” UnitingCare St Stephen Hospital General Manager and Director of Clinical Services Darren Rogers said during the discussion.  
“It’s hard to change a system that works a great deal of the time but a unified approach is needed for improving the quality and delivery of care.”
Views of the industry 
The Royal Australian College of General Practitioners (RACGP) President Dr Harry Nespolon told HITNA that while some providers are using secure electronic communications more frequently, faxes are still required to communicate with parts of the healthcare sector that do not use electronic communications. 
“For many years, the healthcare industry has been heavily dependent on paper, so moving away from paper and fax is a significant change,” he said. 
“The majority of health services and government agencies communicating with general practice do not currently use electronic communication systems that are compatible with those existing in general practice, so the fax machine is currently as sophisticated as it gets with electronic messaging.” 
Dr Nespolon added that there are technical challenges in searching for healthcare providers to communicate with and creating a solution for interoperability that supports communication across healthcare providers.
“General practices are often required to manually transfer information from their clinical or administrative systems into paper-based or online forms. This information is then sent to the relevant agency via an online upload, by post, fax, or via standard and unsecured email. Information leaving general practice through these methods requires significant manual processing,” he said. 
“Most organisations fail to consider the implications and costs for general practices to manage information transfers safely, reliably and efficiently. The inefficiencies of current processes creates a heavy burden on GPs, diverting their time away from providing essential medical care for patients.”  
According to Dr Nespolon, there needs to be broader support to adopt and implement secure messaging across the healthcare industry to make it a success.
“Faxed reports which are scanned into clinical records and saved as an image are not easily searchable. Standard and unsecured email is not considered suitable for routine communication between healthcare providers and patients due to inadequate privacy and security features, and because the content of these messages has to be copied and manually transferred,” he said. 
“Information manually obtained from web portals presents similar issues. Documents received by general practice provide the most clinical value when they can be searched and interrogated by general practice clinical software.” 
Update on the secure messaging program 
The ADHA is aiming to alleviate the problems associated with secure messaging systems. 
Towards the end of last year, it held a workshop in Sydney for more than 50 State and Federal Government officials, industry stakeholders and international experts, to discuss the future of secure messaging and interoperability across the Australian health sector.
The workshop also saw the Medical Software Industry Association and ADHA ink a communique, committing to further collaboration on the adoption and implementation of secure messaging.
ADHA Chief Operating Officer Bettina McMahon said the deal was made to “implement a nationwide [secure messaging] solution that embraces existing solutions and unifies them seamlessly”.
“Secure messaging is a foundational capability enabling interoperability and safe, seamless, and secure information sharing between healthcare providers,” she said.
“Nationwide adoption of secure messaging will enhance the security, safety and efficiency of clinical information sharing across all sectors – ultimately aiding the provision of better healthcare for the community.
“To realise this goal… the ADHA is working collaboratively with industry, suppliers of secure messaging solutions and clinical software vendors to reduce existing barriers to adoption and to provide pragmatic and implementable solutions.”
A key priority for the ADHA, moving forward, is the creation of a transparent, national directory of service providers – the equivalent of a national ‘yellow pages’ for all registered healthcare providers – that can be used for securing messaging, enabling healthcare personnel to easily contact each other. 
The agency is targeting to deliver a “minimum viable product” by June.
“We will continue to work together collaboratively to strengthen and develop secure messaging and interoperability within the healthcare landscape, for the benefit of all Australians,” McMahon added. 
The ADHA has also started working with HealthLink, Telstra and a range of healthcare providers in the development of solutions that allow secure messaging between healthcare providers with different clinical information systems messaging vendors, in a way that can be scaled nationally.
Steps that need to be taken 
Global Health National Sales and Marketing Manager Deborah Hudson said with healthcare professionals and organisations just starting to scratch the surface of moving to a paperless system, the industry as a whole needs to come together to push for change. 
“Although faxing has worked for some time, healthcare professionals are coming to the consensus that as an industry, we have outgrown the fax machine and its limited capabilities; there is a clear need to move forward and secure messaging is the answer,” Hudson said. 
“As an industry we are all working towards the same goal. There are ongoing projects and working groups involving several different secure messaging vendors and clinical system vendors, all aiming to address interoperability challenges.”  
Hudson said the integration of secure messaging was an initiative that needed to be directed by a collaboration between government and industry. 
“The government has set national standards for health organisations and the industry as a whole will facilitate this. Like any industry, the healthcare industry will grow and adapt as technology improves.”
The next step, Hudson said, is industry working with clinical and practice management system providers to achieve better integration in exchanging clinical information. 
“There are two main challenges we still face. Firstly, the need for all secure messaging vendors to be able to exchange messages between each other, such as the interoperability that now exists between ReferralNet and Argus,” she said. 
“Secondly the seamless integration with other health software vendors’ clinical and practice management systems. As an industry, we need to work on these challenges in collaboration with the ADHA.”
Hudson said for the benefits of secure messaging to be fully realised in future, there needs to be in place a system that connects all health organisations and practitioners, allowing for the effective flow of information throughout the system, which then improves the overall patient journey and experience.
“With the support of governing bodies such as the ADHA and the RACGP we hope to be fax free by 2025,” she said. 
“Secure messaging is growing quickly and organisations are seeing real benefits. As the volume of information exchanged and organisations using secure messaging grows we expect to see others adapting to the change quickly.”  



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