There have been at least five major waves of digital transformation in the past three decades, each of which was predicted to displace fax as a business communication channel. EHR adoption was supposed to replace it. Health information exchanges were supposed to replace it. Secure email was supposed to replace it. Unified communications platforms were supposed to replace it. FHIR-based interoperability is supposed to be replacing it now.
None of them have. Fax volume in healthcare has held steady or grown through each of these waves. Understanding why is not an exercise in nostalgia. It is a practical analysis that explains where fax actually fits in the communication infrastructure of modern organizations and why that fit has proven durable against repeated attempts at displacement.
Wave 1: EHR Adoption
The HITECH Act and Meaningful Use programs of the late 2000s and early 2010s drove EHR adoption to near-universal levels in US hospitals. The expectation was that as clinical documentation moved into electronic systems, the need to transmit documents by fax would decline because structured data could flow through EHR-to-EHR interfaces.
What actually happened is that EHR adoption generated more document volume, not less. The EHR produced better discharge summaries, more complete referral packets, and more detailed clinical records than the paper-based systems it replaced. Those documents still needed to reach external organizations that were not on the same EHR and had no direct integration. Fax remained the channel that reached those organizations without requiring a bespoke integration for each relationship.
Fax volume increased alongside EHR adoption in many organizations because the EHR made it easier to generate the documents that fax transmitted.
Wave 2: Health Information Exchanges
Regional Health Information Organizations and health information exchanges were built to solve the cross-organizational data sharing problem that fax addressed manually. Connect every provider to the HIE, and clinical data could flow between them without fax.
HIE adoption was inconsistent and the network effects that made fax universal never fully materialized for HIEs. A hospital connected to one HIE was not automatically connected to every provider its patients saw, because not all providers joined the same HIE and HIEs did not fully interoperate with each other. Fax continued to reach the providers the HIE did not.
Wave 3: Secure Email and Direct Trust
The Direct Trust secure messaging standard, built on S/MIME email encryption, was developed specifically to provide a fax replacement for healthcare. Direct messaging allowed providers to exchange clinical documents over a secure, standards-based email channel without requiring the point-to-point integration of EHR interfaces.
Direct Trust adoption grew among larger health systems and some physician practices, but it required both sender and receiver to have implemented compatible Direct messaging infrastructure. Small and independent practices, behavioral health organizations, post-acute facilities, and the long tail of healthcare providers did not all adopt Direct messaging at the pace that would have been needed to displace fax. Fax continued to reach the providers Direct messaging did not.
Wave 4: Unified Communications Platforms
Microsoft Teams, Slack, and similar unified communications platforms transformed internal communication within organizations. They created the expectation that all business communication should happen within a single platform, and they extended that expectation to include fax through integrations like Lane’s Passport Fax App for Teams.
The important distinction is that unified communications platforms changed how fax is accessed, not whether fax is used. The Passport Teams integration allows users to send and receive faxes from within Teams, which reduces friction and improves adoption. It does not replace fax. It makes fax more convenient within the digital workplace where staff already operate.
Wave 5: FHIR-Based Interoperability
The current wave centers on FHIR-based APIs mandated by CMS for payers and providers. FHIR APIs enable structured data exchange between organizations that have implemented compatible APIs, and the policy momentum behind FHIR is substantial.
The structural limitation is the same one that has constrained every previous alternative: FHIR API connections require both parties to have implemented the API. The long tail of provider organizations, community practices, behavioral health providers, post-acute facilities, and specialty clinics that generate significant cross-organizational fax volume are not all implementing FHIR APIs on the timeline that payer and large health system mandates suggest.
Fax will continue to reach those organizations while FHIR adoption expands, for the same reason it has continued to reach organizations that did not adopt every previous alternative.
What the Pattern Reveals
The consistent factor across every wave is that fax provides universal reach without requiring the receiving party to have implemented any specific technology. Every alternative that has emerged requires bilateral adoption to function. Fax requires only a fax number on the receiving end, which essentially every organization in healthcare has had for decades.
That is not a temporary gap that the next wave of interoperability investment will close. It is a structural property of how fax works as a communication protocol, and it is the reason that fax has not been displaced despite being predicted to be displaced repeatedly.
The organizations that have navigated each wave most effectively are the ones that have invested in modern fax infrastructure alongside their interoperability investments, treating fax and interoperability as complementary rather than competing. Passport and Fax 2.0 represent what that modern fax infrastructure looks like: cloud-based, encrypted, monitored, and integrated with the EHR and business systems that the organization has also invested in.
Schedule a strategy call with the Lane team to discuss how Passport fits into your organization’s broader technology strategy.
