Fax elimination or evolution?
Thursday, February 20, 2020
Facsimile technology is as old as the hills. The first U.S. patent issued related to fax was issued in the 1800s. There are multiple steps and multiple components related to historic and current fax processes in businesses around the world. Yet most of the people who talk about "fax elimination" either don't understand the multiple components, drivers and incentives adequately enough to articulate them, or they don't take the time.
This article takes one step in the direction of taking the time to explain the components and some of the resulting challenges related to fax elimination, and then suggests some steps in fax evolution that will be more palatable in the healthcare market.
Origin — the starting point
The first fax component we will assign a label of origin. The origin of any facsimile transmission ("fax") is the conversion of a paper document or online content (whether alphanumeric characters or image/s) into an electronic bitmap or page-of-dots (i.e. pixels).
When scanned at 600 x 600 dots per inch (dpi) there are 360,000 dots or pixels per square inch. This conversion creates a lot of data. And the result is a page of black and white pixels (dots) that become difficult to precisely interpret if the document started out as a single page of the English alphabet with an uppercase "A" at the top and a "Z" as the last meaningful information somewhere down the page. Significantly, using contemporary computer technology that has been developed in the past 75 years, that same page of A through Z letters can be represented using only 208 (26 x 8) bits (i.e. pixels or dots) and that type of data can be precisely interpreted by a recipient computer. We will refer to this as "coded" data.
In the bitmap scenario of fax, the number of bits required to represent those A through Z letters are ~7,000,000, which even after compression can be potentially 50,000 or more. So, in common business transactions, alphanumeric characters are typically used and some third-grade math calculations prove that it is much less work to transmit coded data than it is to transmit bitmap data. There are some reasonable exceptions, but in general there is compelling evidence to support the conclusion that the origin of fax documents/files and pages is inefficient.
Once we have converted our origin document to a bitmap, current compression technologies include a Tagged Image File Format (TIFF) compression algorithm being applied to reduce the size of the bitmap that we have created from our source document page. The explains how we end up with a 50,000-byte file when we started with a page of 7,000,000 bits in the earlier explanation.
Transmission — the journey
The second component we will assign a label is transmission. If I have a 20-page fax document with each page made up of a bitmap of an average of 90,000 bits after compression (this is a reasonable scenario), then I have more than 1.8 million bits I need to transmit to a recipient somewhere. Though there are some technical nuances in how this occurs, you can assume you have a 225KB TIFF file that you will be sending down a telephone line to a recipient.
To do this, the fax technology will break that 225KB file down into "packets" and send them, serially, one at a time, down the phone line, performing handshakes and quality checks along the way, in an extremely tedious and slow process. The common result experienced in this process is that a single page of documentation takes an average of 1 minute to send. Thus, our 20-page 225KB file will take about 20 minutes to deliver, and it will consume 100% of the phone line upon which it is travelling.
Since errors do occur periodically in any electronic transmission, simple math supports a conclusion that, based on the time factor alone, a 20-minute transmission transaction is 200 times more likely to encounter an error than a 6 second transmission transaction. Given a quick assessment of these data, fax transmission is slow, error-prone, and expensive.
Destination — the end point
The third and final component we will assign a label is destination. When a fax is received, it is initially received as a collection of packets of data that are reconstructed into pages of images. The image pages may be printed — as was the case for the first 100 years or so of faxing, or they may be stored electronically as uncompressed image pages. They also might be compressed and presented as a TIFF file or as a PDF file in an email inbox.
The options are many once the packets are received, assembled and processed, and stored in a human readable format. However, a problem resides in the fact that these image data are not always easily interpreted by computers.
To address the challenge of computer-interpretation and translation of images (bitmaps), Optical Character Recognition (OCR) software engines have been developed to do the work of interpreting image data and converting it back into [its original] coded data so other systems can effectively manage the now re-engineered coded data.
So, the introduction of human labor (or OCR technology) is required to look at the data to determine what was intended by the sender. Thus, destination processing of fax transmitted data is tedious and time consuming.
But what about the virtues of fax? Indeed, fax has been generally considered secure because it is a point-to-point communication means that is not typically vulnerable to sniffing or hacking. This has allowed fax transmissions to escape scrutiny as a HIPAA vulnerability.
This [security] has been true because, until recently, most fax transmissions have not been part of the internet; this has been changing over the past decade and more, but encryption and security of fax transmissions remains a standard expectation and a standard practice in most industries, and in healthcare in particular. However, while the fax transmission may be secure, there is a common, real vulnerability at the destination point in the fax transaction.
Fax is often too easily accessible at the endpoint because there are often no credentials or authentication required to receive a faxed document; so, the obstacles to access are few. And we should recognize here that there are reasons the status-quo is the status-quo; it is usually protected rigorously with standard operating procedures (SOPs), familiarity, consistency, comfort and predictability — regardless of efficiency or optimization or lack thereof. So, in a fair assessment with all things considered, we can declare that fax is easy from an end-user’s perspective and secure from a HIPAA compliance perspective.
The Next step in fax evolution
So, if fax is inefficient, slow, error-prone, tedious, and time consuming, then the title of this article, and CMS Administrator Seema Verma's 2018 challenge to achieve "fax free" zones in healthcare by 2020 are worthy objectives. So long as we do not forsake the virtues of easy and secure on the altar of progress, then we should be able to take meaningful and significant steps forward in fax evolution. I am proposing an initial step that faces the fewest obstacles and therefore least resistance.
Let us first change the transmission mode and the associated problems of slow and error-prone in the movement of data. We can do this by maintaining the current and historic user experience, both for sender and receiver.
But instead of sending packets down phone lines, let's send an encrypted file across the public internet. That's basically it.
We have gone from slow to fast and eliminated most transmission errors. So long as we have the sending technology and receiving technology in place at both ends, the users and business processes do not have to change immediately. As all human experience has proven, change is hard, and it requires more revolution than evolution.
It is interesting that this is one of the costliest problems in the world of fax, and solutions are available, but they have not generally been implemented.
This author believes the reason for this delay in utilizing efficient and low-cost transmission alternatives is that the industry elites are attempting to solve the entire fax problem as a single problem. By recognizing the distinction between origin, transmission, and destination, we are able to “eat the elephant one bite at a time” as we make progress with a thoughtful evolutionary approach.
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