1,000 Faxes a Day: America's Health System Still Runs on Fax

What the pandemic exposed

In July 2020, The New York Times reported that the fax machine at the Harris County Public Health department in Houston had become so overwhelmed by incoming coronavirus test results that a single large batch from one laboratory sent hundreds of pages spilling across the floor. Dr. Umair Shah, the department's executive director at the time, told the Times that some doctors were faxing results directly to his personal number, with the pages then carried by hand, marked confidential, to the epidemiology team. Harris County had recorded more than 40,000 coronavirus cases by that point.

The problem wasn't confined to one county. In Austin, Dr. Mark Escott, the city and county's interim health authority, told the Times his office was receiving around 1,000 faxes a day, many of them duplicates or missing information needed to trace a case — and that, on average, it took 11 days to assemble everything his office needed about a single result, far too slow for contact tracing to still matter. Washington State brought in 25 members of the National Guard specifically to help enter results by hand that weren't arriving electronically.

According to the Centers for Disease Control and Prevention, roughly 90 percent of laboratory results for diseases the agency normally tracks were already being transmitted digitally before the pandemic. What changed in 2020 was scale: smaller labs and clinics that had never reported to a public health department before were suddenly part of the system, and many had never had reason to invest in the software to do it electronically. Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists, told the Times that nationally, close to 80 percent of coronavirus test results were arriving without demographic information, and half were missing an address.

Why fax survived where email didn't

Part of the reason, the Times found, was cost. Bob Kocher, a venture-capital partner who was advising California's testing effort in 2020, put the gap at roughly ten to one: a fax line cost a laboratory around $500, against roughly $5,000 for software that could report results electronically. For a small lab that had never reported to public health before, fax was simply the option that already worked and was already paid for.

There was also a funding gap nobody had closed. The HITECH Act, passed in the early 2010s, put billions of federal dollars behind moving doctors' offices onto electronic health records — but it never funded public health departments to build systems that could receive those records automatically, and it never required hospitals or labs to send results to local health officials in a standard digital format. A smaller, later program — about $13 million in Affordable Care Act funding in the mid-2010s — helped some state and city health departments modernize, but reached nowhere near all of them.

Outside the pandemic, fax has held on in American medicine for a related pair of reasons: it satisfies federal privacy rules for health information in a way plain email does not, and it carries a signature the way email cannot. The New York Times reported in 2005 that CVS, one of the country's largest pharmacy chains at the time, already considered fax its most common way of receiving prescriptions from doctors — because, a company spokesman said, it gave the pharmacist a written record of exactly what had been ordered, something a phoned-in prescription couldn't guarantee.

A pattern older than the pandemic

None of this started in 2020. The Times ran a piece in 2005 under the headline "The fax machine refuses to die," describing an office culture — accountants sending signed tax returns, lawyers sending contracts — that had already quietly outlasted a decade of predictions of the fax's demise. A former Konica product manager, by then the editor of a business-equipment review magazine, recalled that consultants in the mid-1990s were already comparing the fax to the horse and buggy.

The sales figures told a different story. The Consumer Electronics Association counted about 1.5 million stand-alone fax machines sold in the United States in 2004, plus roughly half a million more multi-function machines combining fax with copying and scanning — well down from a peak of 3.6 million stand-alone units in 1997, but still a real market well into the email era. Hewlett-Packard had left the fax business in 1994, convinced it was obsolete, and returned in 1998 after concluding, as a company product manager put it to the Times at the time, that the fax was not going away.

Not only an American habit

The United States isn't the outlier here — if anything, it's further along in letting go. The Times reported from Tokyo in 2013 that Japan's Cabinet Office found almost 100 percent of business offices, and 45 percent of private homes, still had a fax machine, and that Japanese households had bought 1.7 million new fax machines in the year before that report. A manager at NTT Communications, which helped develop the technology in the 1970s, told the Times the fax had grown unusually deep roots into Japanese society precisely because it had worked so well there to begin with.

The same article noted, almost in passing, how far the two countries had already diverged by 2013: in the United States, fax had become enough of a historical curiosity that the Smithsonian was adding two machines to its collection. Seven years later, American public health departments were still running theirs at capacity.