Monday, July 23, 2018

Will Faxes never Die?

A very old fax machine
A question comes to me from a former colleague that I found interesting:

Can you convert a fax document into a CCDA for Direct Messaging?

Yes.  Here's how, at three different levels of quality:

Unstructured Document

This is the simplest method, but it won't meet requirements for 2014 or 2015 Certification.  It's still somewhat useful.

  1. Convert the image into a bitmap file format such as PDF or PNG.
  2. Create a CCDA Unstructured Document.  Optionally, apply the IHE Scanned Document requirements to the content as well.
  3. Include the document into a Direct Message

Getting to Electronic Text

Getting the content to meet 2014 or 2015 requirements for certification means doing quite a bit of additional work.  First step is to get to electronic text.
  1. First, you have to apply text recognition technology to the output to turn it into electronic text.  This converts the image content into letters and symbols that the computer can recongize.
  2. From this, create a bare-bones narrative structure with headings and section content.  Apply some very basic Natural Language Processing (NLP) to recognize headings and section content.  Signals such as line spacing, paragraph formatting and font styles are helpful here (that would often be included in a more than basic text recognition pass).  From here, you could create a Level 2 CDA (note, NOT a C-CDA yet) that would be MORE useful to the receiver.

Getting to Certification

After getting to electronic text, now you need to get to CCDA Entries.  It can be done, I've been there and done that more than a decade ago.
  1. From the previous step now you need to code the section headings to LOINC, and match the document content to an appropriate C-CDA template (knowing that you can also mix and match sections from other C-CDA documents into the base C-CDA CCD requirements).  At this point, you are at level 2 with coded sections.
  2. So finally, you need to run some specialized NLP to recognize things like problems, medications, allergies, et cetera ... and THEN
  3. Convert the specialized content to match the C-CDA template chosen in step 3.
And now, you COULD meet 2014 or 2015 Certification requirements.

Would I do this?

The question not asked, but which I will answer is:

Would you convert a fax document into a CCDA for Direct Messaging?

Probably not, AND certainly not for the structured content option.  Current NLP algorithms being what they are, you could probably get to about 95%  accuracy with the structured markup, which means about 1 error in 20 items.  That's MULTIPLE structure recognition errors per page, NOT a level of accuracy appropriate for patient care. The level of effort involved in cleaning up someone else's data is huge, the value obtained from it is very rarely worth the cost.  You are better off figuring out how to give your high volume fax senders a way to send you something better.

I might consider implementing the Unstructured Document mechanism as a feature for providers that are getting faxed today, as many would find it of some use.  It's not really much more though than giving them an e-mail end-point attached to a fax number, so again, of very little additional value.


  1. Very helpful information..have to evaluate the effort for the value. Perhaps the best approach is to use the CCDA content from the EHR and send via Direct Message and fax the same content when Direct is not available

  2. Check out Doximity, we offer a free digital fax line for all physicians.