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In the real world of ambulatory practice, the most popular provider-to-provider communications technology is still the fax machine.1 Think about this—the fax machine was invented in 1842; 30 years before the telephone.2

Newer, more sophisticated methods of communication can help ambulatory practices become more efficient and provide better care to patients. In fact, on August 6, 2018, Centers for Medicare and Medicaid Services Administrator, Seema Verma, posed a goal for the digital health information industry to replace the current use of fax machines in physician offices to send patient information.

How can your practice go beyond the fax?

Your first step forward: Direct messaging

Federal mandates regarding EHR use are helping drive dissemination of new communications technology in ambulatory care. According to CMS requirements, to qualify for meaningful use stage 1 incentives, practices are required to have an EHR that enables them to send Direct secure messages.

Direct secure messaging (Direct) refers to a specific protocol introduced by the US Department of Health and Human Services. This protocol provides standards for sending authenticated, encrypted health information to trusted recipients over the Internet. A patient’s chart can be attached to the message.

While Direct messaging via EHR started off slowly, it is picking up speed. More than 70 million messages have been exchanged via Direct protocol with NextGen Healthcare technology alone. Practices now commonly receive unsolicited Direct messages; for example, from local pharmacies where their patients received immunizations and urgent care centers where their patients received care. In many areas, providers are regularly sending referrals to each other via Direct messaging.

These trends will only continue. My advice: Find out how to send and receive Direct messages using your EHR. Go one step further—find out how to incorporate structured data, such as medications or problems, from a consolidated-clinical document architecture (CCDA) attachment into your patient’s chart using your EHR.

Your next frontier: crossing system boundaries with Carequality

Practices, health systems, and facilities on different computer platforms struggle with the electronic exchange of data. To remove this roadblock, new networks are emerging to promote seamless data exchange—also referred to as “interoperability.”

NextGen Healthcare participates in the Carequality network, a data-sharing network, along with several other EHR vendors. Carequality is supported by many organizations: provider groups, regional data-sharing networks, standards development organizations, and others.

Here’s how Carequality works:

  • When a patient arrives at a practice, staff can query the Carequality network (this process can be automated).
  • Carequality performs authentication and patient matching and sends out a query to all network practices and facilities.
  • Suppose, for example, a hospital that treated the patient the previous month receives the query. This hospital uses an automated process to package a patient summary and put it in CCDA format.
  • The patient summary is delivered to the practice.
  • Structured data in the summary can be incorporated into the patient’s electronic record.

In the near future, Carequality will connect with the Commonwell network, which shares similar goals, to provide an even stronger framework for more efficient, cross-platform provider-to-provider communication. My advice: Find out from your EHR vendor how to get started with Carequality or Commonwell.

Future horizons: getting targeted data directly into your clinical workflow

Commonly, a healthcare provider will sift through a 20-page fax when all they’re seeking is the medication list on page 19. New technologies are just now emerging to promote delivery of more concise, actionable information.

This is a major shift from the usual health information exchange (HIE) approach, which aggregates a patient's medical record from available sources and has it ready to go should a query arrive. The future model will be a query-and-response system in which a provider will see who has the specific information they want and ask for and receive only the components of the record needed to perform their jobs.

Get rid of your fax machine (eventually)

Here are some tips for going beyond the fax:

  • Make sure you're on an EHR that can support interoperability. Ideally it should be a 2015-certified EHR.
  • Make sure you have a Direct address for all providers in your practice.
  • Every time you receive a fax, call the practice that sent it and say, "Here's my Direct address. In the future, please send this information over Direct messaging.”
  • Rather than faxing information to other practices, ask for their Direct address. (Make sure you and your staff know how to use your EHR to send requested information.)
  • Find out if your EHR vendor participates in Carequality or Commonwell. Learn about opportunities created by these networks.

Final thoughts

Adoption of more advanced—or at least post-Civil War—communications technology is essential to improving the delivery of ambulatory care. Our goal at NextGen Healthcare is to help ambulatory practices discover technologies available now as well as developments on the horizon that can help them communicate more effectively and improve patient care.


1 Sarah Kliff. “The Fax of Life: Why American Medicine Still Runs on Fax Machines,” Vox Media, updated January 12, 2018,

2 Chris Baraniuk. “Why the Fax Machine Isn’t Quite Dead Yet,”, February 25, 2015,

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Headshot of Robert L. Murray, PhD, MD, FAAFP
Robert Murry, PhD, MD, FAAFP
Chief Medical Officer
Dr. Robert (Bob) Murry joined NextGen Healthcare in July 2012 and was appointed chief medical officer in December 2021. He brings to this position more than 20 years of extensive clinical experience and background in health IT. Previously, Dr. Murry served as the company’s Chief Medical Information Officer (CMIO) since May 2017. During his time as CMIO, he was the "Voice-of-the-Physician" ac...