Judge a health data standard by the fax it retires. Standards are usually measured by adoption, such as how many vendors certified to them or how many endpoints are live. Those numbers matter, but they can all rise while the fax machine keeps running in the same office. The better test is simpler. It asks which fax line or phone queue the organization could turn off after the standard went live.
By that test, health care has a long way to go. When the Office of the National Coordinator for Health IT surveyed hospitals about 2021, mail or fax was the most common method they used to exchange summary of care records. In that survey, 69% of hospitals said they often or sometimes sent records by mail or fax, and 78% said they often or sometimes received them that way. That was long after nearly every hospital had adopted certified health IT.
Electronic methods were common too. The same survey found 68% of hospitals sending records through Direct messaging and 65% through a health information exchange. The problem was not that hospitals lacked electronic options. They used them alongside the fax, not instead of it.
The gap between sending and receiving is telling. A hospital can choose how it sends. It cannot choose how its partners send to it. Receiving is where the fax lives longest, because retiring it there requires every sender to move.
Adoption counts measure the wrong thing
A standard can be adopted and still retire nothing. When an electronic path covers most cases but not all of them, the organization keeps both. Staff learn 2 workflows and watch 2 inboxes. The fax remains the path of last resort that everyone trusts because it always works.
Prior authorization shows the pattern clearly. HIPAA named the X12 278 as the standard for electronic prior authorization requests in 2000. Its existence did not retire the fax. The 2024 CAQH Index, which covers 2023, found that 35% of medical prior authorizations were conducted fully electronically. The rest moved through web portals and manual channels. The report estimated that a provider spent 24 minutes on each fully manual prior authorization request.
Data standards have the same problem. A content standard such as USCDI v3 defines what certified systems must be able to exchange. It does not, by itself, make anyone stop printing the records that the standard was meant to carry.
The fax survives on the hard cases
The fax persists because it accepts anything. A sender needs only a number, not an agreement or a matching system on the other end. It carries signatures and handwritten forms without anyone deciding in advance what the fields are. When a structured exchange cannot carry an attachment, or rejects a record because a code does not match, the fax is how the work gets done anyway.
There is a quieter reason too. A fax leaves a receipt that both sides accept. A transmission report with a time stamp settles most arguments about whether something was sent. Electronic exchange can do better than that, with acknowledgments that confirm a message was received and processed, but only when those acknowledgments are implemented and kept. Where they are not, staff fall back to the channel whose receipt they trust.
That means a standard that handles only the clean cases leaves the fax with exactly the cases that are hardest to automate. Retiring the fax requires the standard to handle the exceptions too, such as a request that needs a clinical note attached or a receiving system that asks for more information.
The prior authorization rule CMS finalized in 2024 points in this direction. Starting in January 2027, impacted payers must offer a prior authorization API that shows whether authorization is required and what documentation the payer needs. The API must also support the full exchange of request and response, including a request for more information. CMS recommended the Da Vinci implementation guides for that work, and those guides cover the documentation questions, not just the final yes or no.
Measure retirement, not adoption
Organizations can measure this directly. For any workflow, such as referrals or prior authorization, 3 numbers say more than an adoption count.
- End-to-end share. The percentage of transactions that complete through the standard from request to final answer, with no fax or phone call along the way.
- Fallback reasons. Every time a transaction falls back to a manual channel, a coded reason why, such as a missing attachment or an unmatched code. The reasons are the backlog for the next release.
- Lines shut off. The fax numbers and phone queues that have been removed from provider manuals because the electronic path no longer needs them.
The third number is the hardest to move, and the most honest. A fax line that stays open is a public admission that the electronic path still fails often enough to need a backup.
Getting started does not require a program office. Pick one workflow and one month. Count the faxes that arrive for it and tag each one with the reason it did not come electronically. The top few reasons often point to a small number of fixable gaps, such as a document type the interface cannot carry or a partner that never finished onboarding.
A standard has not replaced the fax until someone can unplug it.
What we build for
We build tools that health plans use in utilization review, and much of that review still begins with documents that arrive by fax or through a portal upload. We design for that reality rather than around it. We think a clinical note that arrives as an image should still become reviewable data, with each fact traced back to the page it came from, so the reviewer can check the source in a click.
We also hold our own integrations to the retirement test. When we connect to a plan’s systems through a standard interface, the question is not whether the interface works in a demonstration. It is whether the cases that used to arrive by fax now arrive through it, and what is still falling back. The fallback list is where the next piece of work is.
That is also how we would want our own work judged. A plan that adopts a new review tool should be able to say, a year later, which manual steps are gone, not only which new screens exist.
The fax machine is not the enemy. It is a measurement. Every page it still prints is a case the standards have not yet learned to carry.