Abstract
This article reports on a qualitative interview-based study that set out to explore why fax has come to form such an enduring communication medium, particularly within healthcare contexts. We sought to understand the persistence of the fax within the healthcare system in the Australian state of Victoria, and to examine impediments to the take-up of modern, encrypted health communication – secure message delivery (SMD) – systems. From our study, we identified different dynamics that contribute to the persistence of fax within healthcare communications. Media systems are understood as layered and discursively rich, where older forms persist through residual logics, industry inertia, and embedded norms. Drawing from media and communication, cultural studies and transition studies approaches, we characterise these dynamics of persistence as socio-material entrenchment, institutional and regime interdependencies, and technological lock-in and infrastructural inertia.
Introduction
Despite being described as a ‘forgotten “new medium” from the twentieth century’ (Light, 2006: 355), fax persists as an important communication medium across multiple sectors of society, most notably within the legal profession, certain areas of business (e.g., finance), and healthcare (Berry, 2023; International Finance, 2024; see also Koehn, 2019).
The persistence of the fax machine within healthcare – to transmit care records, prescriptions, referrals, and other documents, request specialist services, and process payments (Mearian, 2023) – has become a source of much consternation for medical administrators and governments. This consternation stems from a sense that it is ‘archaic’ – a ‘dinosaur technology’ (Scott, 2019) – and that fax is now no longer fit for purpose. This is for at least three reasons. There is concern over transmission errors, where blurring and degradation in reproductive quality can be an issue when faxing prescriptions (Feldman et al., 2012; Kelly and Vaida, 2004). There is risk of misdirection, with one Australian coronial inquest implicating fax use in the death of a Melbourne man, whose scans, containing information vital to his cancer treatment, were sent to the wrong fax address (Cunningham, 2019). Additionally, there are security concerns (Newman, 2018), with calls to replace fax with more secure, encrypted, end-to-end communication technologies (Castillo, 2018).
In light of these concerns, there has been a concerted effort in the United Kingdom to reduce health sector reliance on facsimile with the government running a campaign to ‘axe the fax’ (Kerr, 2020), and the communications regulator, Ofcom, removing the requirement for fax services under Universal Service Obligation legislation (Hill, 2022). In Australia, the focus of this article, there have also been calls to reduce medical use of fax machines. For example, in 2019, concern was raised within the Australian Capital Territory (ACT) government's budgets estimates hearing over the continued reliance on faxes within ACT health services (Scott, 2019). The previous year, then chair of the Royal Australian College of General Practitioners’ (RCGP) Expert Committee on eHealth and Practice Systems (REC—eHPS) called for the fax machine to be ‘consigned to the scrapheap of history’ (cited in Hendrie, 2018).
And, yet, still the fax persists in the Australian healthcare sector (Smith, 2025), as it does in other healthcare sectors worldwide (Farr, 2018; Johnson, 2020; Mearian, 2023). Recent data shows the UK National Health Service recorded 9000 fax machines in active use (Kerr, 2020), while, in the US, seven in ten hospitals rely on fax to transfer patient records and order prescriptions (Mearian, 2023). Fax persists in the Australian medical context despite concerted work by Australian government agencies and various affiliated medical bodies (like the RCGP's REC—eHPS) to promote alternative, more ‘secure’ forms of end-to-end encrypted communication. In this article, we draw from a qualitative interview-based study to explore why it is that fax communication has proven so persistent in healthcare contexts. From our study, a complicated socio-technical picture emerges of significant interconnecting issues that contribute to resistance to change and to protracted technological transition.
Transformation of a socio-technical system: Technological transition and systemic change
In exploring the persistence of fax within healthcare, and in investigating why the transition from fax to newer secure message delivery (SMD) services has been so difficult to achieve, we draw from science and technology studies (STS) scholarship, particularly work within the subfield of transition studies. Emerging in the 1990s ‘at the crossroads of STS and innovation studies’ (Joly et al., 2023: 30), transition studies seeks to understand how long-term change in large socio-technical systems occurs (Borrás and Edler, 2014b; Geels, 2005a; Goulet and Vinck, 2012; Joly et al., 2023; Koretsky, 2023; Koretsky et al., 2023). Transition studies examine processes of systemic change, which includes emergence and scaling of innovations. In addition, and while not the focus of all work, transition studies also explores governance of managed discontinuation and technological decline, with decline framed not as deterioration, decrepitude or failure, but rather as ‘scaling down use to niche applications, or complete abandonment’ (Koretsky, 2023: 48). Transition studies researchers take as their deceptively simple starting premise that transition or decline ‘is not trivial’ (Koretsky, 2023: 47); they inevitably involve ‘complexity and messiness’ (Koretsky, 2023: 59). The aim of this strand of transition studies is to investigate and seek to make critical sense of these complicated and often untidy ‘socio-material dynamics of decline’ (Koretsky, 2023: 59).
Transition studies can be viewed as emerging as a corrective to two prevalent scholarly tendencies. The first is the perceived privileging of and preoccupation with new technologies and their impacts (Koretsky, 2023: 47), especially at the expense of interest in mature technologies and processes of change and decline. Preoccupation with the new has long been the general orientation not just of the innovation literature but also much media and communication and platform studies scholarship as well. The second is a strong concentration of interest within certain strands of STS scholarship on the emergence, development, and growth stages of technologies. For example, Large Technical Systems (LTS), as formulated by Thomas Hughes (1983), was ‘originally conceived to explain the emergence and development of socio-technical systems steered by system builders’ (Koretsky, 2023: 52). Hughes’ own scholarly concern was with electrification, while later work on LTS has been applied to investigating a range of concerns, including the emergence and expansion of telecommunication systems in different jurisdictions (see, for example, Bertho-Lavenir, 1988; Schneider, 1991; Thomas, 1988).
While Hughes’ particular conception of LTS privileges technological system development and its rise to prominence, subsequent LTS scholarship has sought to understand what occurs within and to ‘fully escalated systems’ (Joerges, 1988: 24). More recent work also suggests that, once mature, LTS can ‘undergo the (additional) phases of reconfiguration, contestation (subject to pressures such as drift and crisis), and eventually stagnation and decline’ (Sovacool et al., 2018: 1067). Within media and communication and platform studies scholarship, there is a growing body of work that explores related questions (see, for example, Acland, 2007a, 2007b; Gitelman, 2008; Lesage and Natale, 2019; McCammon and Lingel, 2022; Natale, 2016; Thorburn and Jenkins, 2003).
As media and communication and cultural studies scholars, we draw on transition studies to enrich our account of how and why technologies persist. What transition studies offers that complements existing media and communication and cultural studies approaches is systematic understanding of change, conceptualising socio-technical regimes as durable configurations of technologies, institutions, practices, and markets. The terminology (lock-in, infrastructural inertia, reconfiguration, and discontinuation governance) proves robust for explaining the persistence of legacy communication systems and the governance of their decline. Much transitions scholarship is also anchored in empirical research tracing transitional shifts over time (e.g., David and Schulte-Römer, 2021; Geels, 2005a; Koretsky et al., 2024), as is the approach adopted here. Together with media and communication and cultural studies approaches that foreground the lived experiences of transitions, transitions studies thus offers critical insight into how meaning-making and everyday practice shape trajectories of technological change. This combined approach permits a more developed understanding of media transition, one that accounts for both the structural conditions of system stability and the interpretive frameworks through which they are sustained or disrupted.
In this article, we draw from an empirical qualitative interview-based study over a period of close to 10 years to explore why fax has come to form such a persistent communication medium within the healthcare system in the Australian state of Victoria. We sought to understand the persistence of the fax and examine impediments to the take-up of modern, encrypted health communications – secure message delivery (SMD) – technologies. Prior to examining reasons for the persistence of fax, it is valuable to first glance back at its history and how it came to become such an enduring communication and transmission tool in business and in healthcare.
The rise of fax and its application within the healthcare landscape
Faxes have been understood as a truly transformational communication technology by media historians (Coopersmith, 2015; Light, 2006). Development of the fax machine dates to the mid-nineteenth century, with the first patent issued in London in 1843 (Coopersmith, 2015: 9). Over successive decades, and right up until the second half of the twentieth century, entrepreneurs and inventors competed in the development and promotion of fax technologies in multiple markets, largely without success (Coopersmith, 2015: 9). It was not until the 1980s that fax really took off (for detailed discussion of the history of fax, see Coopersmith, 2015; Schmidt and Werle, 1998). During this period, faxing ‘helped change expectations of information – increasingly including images – from rare to abundant, from hard to find to easy to acquire, from difficult to obtain to simple to create and disseminate’ (Coopersmith, 2015: 145–146). The low cost of thermal printing and simple connection via a phone line made the fax machine an office (and home office) staple. Importantly, the fax machine and faxing also dramatically transformed workplaces and work, accelerating ‘the work cycle from weeks or days to hours or minutes’ (Coopersmith, 2015: 161). The 1990s saw the replacement of thermal with plain paper, a shift driven by ‘the desire for a permanent record […] without the hassle of making a copy before the thermal fax paper faded’ (Coopersmith, 2015: 210).
The transfer of medical records by fax was explored as early as 1948 (Light, 2006: 365), yet it was not until the late 1980s that fax’s potential for the health sector was more fully appreciated. In a 1988 trial at Southwest Texas Methodist Hospital, the hospital pharmacy installed fax machines at three nurses’ stations in order to ‘reduce delays in processing prescriptions’ (Coopersmith, 2015: 169). During this trial, ‘turnaround dropped from four to eight hours to one hour’, tracking of orders was improved, and, as a result, all 36 nurses’ stations were equipped with fax machines (Coopersmith, 2015: 169).
Digitalisation and automation contributed to the decline (if not complete disappearance) of fax use within offices and other large organisations. ‘After 2000,’ Coopersmith (2015) writes, ‘fax seemed an obsolete technology, increasingly replaced as a technological essential by all-digital communications’ (p. 207). However, as Light (2006) points out, when one looks across the history of the fax, the difficulty one faces in characterising the fax machine as an old or outdated medium – a ‘dinosaur technology’ (Scott, 2019) – is that this history is in fact unfinished.
A recent report found that ‘up to 75 per cent of global fax traffic comes from medical services’ (Smith, 2025). A 2025 UK House of Commons Committee of Public Accounts report into NHS financial sustainability found that, despite calls to ‘axe the fax’, ‘a number of NHS trusts continue to rely on […] fax machines’ and that the introduction of new technologies had been ‘glacially slow’ (House of Commons, 2025: 7). To address this, the Committee recommends that a ‘specific deadline should be set to end the use of fax machines within the NHS’ (p. 7). Meanwhile, a survey study of oncology departments across three German-speaking European countries (Germany, Austria and Switzerland) found significant variation across the three nations when it came to continued fax use, with 80% of German radiation oncology departments reporting that they ‘relied heavily on fax for communication with external partners’ (Janssen et al., 2024: 501) compared to 8% in Switzerland (p. 501) and 13% in Austria (p. 502). The high level of continued fax use in German oncology departments reflects a similarly high level of fax use with the German business sector, with a study of 505 businesses finding that 82% of companies were still using fax as a means of communication, and approximately 40% of the companies reporting that they used fax often or very often (Berry, 2023). This does represent a downward trend, however, with the frequency of intensive fax usage decreasing from 62% in 2018 to 40% by 2023 (Berry, 2023).
Approach
In exploring technology transition within the healthcare landscape, we draw on an exploratory study involving 10 semi-structured interviews (Green and Thorogood, 2018) conducted over a period of almost 10 years, from 2014 to 2023. This extended time period resulted from this unfunded study having to fit around other, larger-scale, funded research and other commitments. In addition, interviews for this project were suspended during the height of the COVID-19 pandemic. In 2020 and 2021, Melbourne experienced six lockdown periods, more than any other city in the world, and the Victorian health system was operating under severe strain. Conducting fieldwork involving medical practitioners was not feasible over this period. After each interruption, we resumed interviews uncertain whether previous findings would still hold—yet they consistently did, prompting us to continue, and continue again. Interviews are a common method to capture nuanced, first-person perspectives in transition studies (Zolfagharian et al., 2019), while also situating lived experiences within broader social, cultural, and institutional landscapes (Mason, 1996).
These interviews were with Australian health communication technology consultants, and with health professionals – five were in clinical settings as medical specialists and allied health professionals (a broad category that includes social workers, physiotherapists, psychologists, among many other roles and professions [Turnbull et al., 2009: 29]), four were medical technology experts, and one was in healthcare system administration. Interviews lasted between 30 and 90 min. Ten participants might be regarded as a small sample size, yet as Crouch and McKenzie (2006: 483) explain, ‘since such a project scrutinizes the dynamic qualities of a situation […] the issue of sample size – as well as representativeness – has little bearing on the project's basic logic’.
As Figure 1 illustrates, facsimile machines are part of an ensemble of technologies used within the Australian healthcare system. These range from paper records to high end diagnostic equipment, and sit alongside email, secure messaging systems, encrypted medical practice software, photocopiers, fixed-line phone and mobiles, pagers, and pneumatic tubes. The focus of interviews was on fax use, specifically, within that ensemble. As the project evolved, we interviewed health communication technology consultants and policy makers who spoke to the systemic complexities in healthcare landscapes.
The situatedness of workplace technologies: a multifunction fax machine in the home office of an allied healthcare professional, sitting alongside other communication technologies. Photo: authors.
The extended duration of the study serves to underscore the persistence of the fax in medical contexts even as more new technologies come on board, something we could not have anticipated in 2014, but continued to document with each detailed interview. This ultimately proved advantageous insofar as the issue of fax’s presence within the health system in Victoria did not recede nor go away over this period, despite repeated suggestions that it would. To account for this temporal landscape, the year in which interviews were conducted is given when quoted or discussed.
The persistence of fax in Victorian healthcare contexts
What emerges from the study is a complicated socio-technical picture, with significant interconnecting issues contributing to resistance to change and to protracted technological transition. In transition studies, persistence is typically conceptualised at the systemic or regime level, referring to the stability of socio-technical configurations (such as healthcare infrastructures). These systems are treated as integrated assemblages of technologies, institutions, and practices that co-evolve and resist change. In media and communication studies, persistence is more often cultural, institutional, and infrastructural, focusing on the continuity of symbolic forms, practices, and technologies. Media systems are understood as layered and discursively rich, where older forms persist through residual logics, industry inertia, and embedded norms. Drawing on both disciplines, we characterise these dynamics of persistence as socio-material entrenchment, institutional and regime interdependencies, and technological lock-in and infrastructural inertia, addressing each in turn.
Socio-material entrenchment: Dependencies and interdependencies
Across all interviews, fax remained a core communication (and finance) technology and was entrenched within daily practice. The reliance on fax spans the Victorian health care sector (from hospitals to allied health), revealing the ‘embeddedness’ (Borrás and Edler, 2014a: 1) of fax within daily practice. As one medical specialist (interviewed in 2019), pointed out: ‘The hospitals, they survive on faxes, basically… It's just this big internal fax system’. An administrator in an osteopathic clinic detailed the back-and-forth process of faxing referral and care provision agreement forms between doctors and healthcare providers (interviewed in 2015). Similar processes were echoed in other clinics for provision of care or treatment apparatus. A hospital payroll manager interviewed in 2014 described how employees would fax medical certificates to his team to expedite leave payments, with the original certificate later submitted by internal post.
These insights from participants reveal the fundamentally combinatorial nature of intra- and inter-organisational communication, with fax forming a crucial part of a wider ensemble of communication technologies (see Markus et al., 1992; Stephens et al., 2008; Suchman et al., 1999: 397). They also all highlight the relational (Star and Ruhleder, 1996) character of fax within the Victorian health care system. Within this system, fax has come to constitute a tried-and-tested and relied upon referral and records transfer system, most especially for allied health professionals and medical specialists.
As an example of this, an endocrinologist detailed how she used specific methods of faxing for different medical processes and services. Letters of referral could be electronically faxed, but radiology requests, infusion orders for patients, orders for district nursing would be written and completed manually. Her reasoning for fax was ‘because of the confidentiality issue and because it is instant and much cheaper than “snail mail”’ (interviewed in 2019). She described receiving referrals from primary care physicians by fax and sending up to 100 faxes each week out to other specialists. It was, she said, a good form of communication for ‘urgent results’ (interviewed in 2019).
The reliance on the fax as a primary form of healthcare communication is not just a product of procedural norms, it is also reflective of sector-wide interdependencies. This is particularly evident in Australia’s hub-and-spoke model, with general practice (GP) doctors at the core, who interact with specialists and allied healthcare providers. Fax is a technology that has become firmly embedded within the everyday communication practices of GP clinic staff (especially receptionists), specialists, and allied health workers.
The implications of these dependencies and interdependencies are important for understanding attempts at socio-technical transition and change. The embeddedness of health communication technologies can only be understood in relational terms. Changing one element of a technological mix impacts the whole ensemble in significant ways. Indeed, the more embedded technologies become, the greater the difficulty in achieving technological change. And the stronger the investment in an embedded technology, the more it is likely to harden into resistance to change. Hommels (2005: 331) refers to this as ‘closed-in obduracy’. We see this, for example, in the following response from an occupational therapist in a private practice. As an allied health specialist, she was very resistant to calls to displace fax use: That is one thing that makes me cross: when I hear people who are outside the medical set saying, ‘oh, it’s old-fashioned, it’s antiquated. Everybody should get with it.’ … [I]t's annoying when people go, ‘oh, nobody uses fax anymore’. Well, the fact is the medical profession use it extensively, as I believe the legal profession still prefer fax for security reasons. So, that's frustrating when they come up with that sort of comment. (interviewed in 2019)
Beyond hardened attitudes towards technological change, resistance to technology transition can also manifest as the (inadvertent or conscious) continued reliance on and reproduction of these (inter)dependencies. The occupational therapist quoted above stated that, while the bulk of their work is now handled through email, they feel they ‘have to maintain fax to receive and send communication with doctors’ clinics’. Another participant, a receptionist in a physiotherapy clinic (interviewed in 2015), expressed the view that, rather than dispense with the fax, ‘it’s better to have it’, just to ‘keep that option open’. A state government health department spokesperson (interviewed in 2019) was dismayed by such responses, suggesting that, in doing this, these practitioners were ‘cooperating in the maintenance of those systems’ that continue to rely on fax.
Resistance to technology transition and change can also occur at the point at which new technological solutions are introduced, particularly when initial engagement with the new communication technology presents the user with a greater level of complexity than that which it seeks to replace. A clear example of this, relayed to us by a GP with a keen interest in health informatics policy, involved a CEO at a regional hospital investigating why staff within a central triage point had not adopted the new secure messaging system they had been instructed to use, and discovering the following: Apparently, the triage administration people had made a unilateral decision that they weren’t going to deal with this system because it was too complicated, and that they had then two systems in place at the same time. They just wanted to go to the fax, and that was all they wanted to deal with, and so [the new secure messaging system] just gradually faded away. (GP and Practice Technology Management Expert, interviewed in 2021)
In Australia the fax has come to constitute a vital connecting technology within a larger health communications ecosystem. This is also the case in the UK, where the directive to ‘axe the fax’ proved difficult to implement. Despite bans on the purchase of new fax machines, and threats of punitive measures for those who did not comply, transitioning away from faxes was complicated by the fact that they have come to form ‘an essential network across the NHS – and other healthcare institutions – over decades’ (Johnson, 2020).
The participant’s responses echo two pertinent observations made by Greenhalgh et al. (2019) about health information infrastructure. The first is that it is ‘collectively learned, known, and practiced’ (p. 3). The second is that, through this process, it becomes ‘embedded’ within established organisational systems and ways of doing things (including through the establishment of norms, protocols, and compliance requirements). Thus technology not only supports tasks but also shapes and is shaped by the institutional practices it becomes embedded in, highlighting why it is valuable to consider ‘technologies as social practice’ (Suchman et al., 1999: 392) and the ‘social circumstances of machine use’ (p. 395) that influence how technologies are encountered, and how they are enrolled into and resisted, through everyday practice, particularly in work contexts.
Institutional and regime interdependencies
A further, significant contributor to the enduring and continued reliance on fax is the severe fragmentation of the Australian healthcare ecology, and the sectorial complexities that follow from this fragmentation. In Australia, the health system is jointly run by all three levels of government: federal, state and territory, and local (Australian Government, 2019). Among the key responsibilities of state and territory governments is managing and administering public hospitals (Australian Government, 2019). As a result of this, each state and territory has taken its own approach to addressing health communication infrastructure needs. Victoria, for instance, has not mandated a single, encrypted, state-wide health communication system, as other states have done. As further clarification on the complexity of these multiple systems for paper and electronic records, we interviewed a general practice doctor and technology management expert who sits on various medical practice-related technical committees. He explains: In Queensland, they’re digitally connected across the whole state. They use one record system for an individual. […] Whereas, we can’t do that in Victoria. We’ve got paper records and electronic records and different systems. […] They’re completely independent, and they can’t share information at all at present. They have to photocopy your paper record and put it in a folder and send it with you. […] They can’t transfer digital images of patients’ x-rays, blood tests, and so on – it all gets printed out. It’s just absurd. (GP and Practice Technology Management Expert, interviewed in 2021)
One result of the fragmented and disconnected Victorian public health system is that it has fed an ongoing reliance on the fax as a relatively straightforward and expedient way of transmitting information – of ‘shuffling paper around’ (GP and Practice Technology Management Expert, interviewed in 2021) – that might otherwise have occurred via a secure records transmission system, were such a system implemented. With no universal arrangement for electronic medical records transfer across diverse health services, there has long been a belief that ‘faxes worked for hospitals and they were reliable’ (Program Director for a national health agency, interviewed in 2021).
Echoing issues in healthcare structures beyond Australia, there are commercial incentives to be found in, and system dependencies that benefit from, maintaining the present, fragmented structure (Geels, 2005b: 450). For instance, another study participant, a health communication infrastructure consultant interviewed in 2019, also pointed out how Victoria’s health services (Eastern Health, Northern Health, etc.) operate as umbrella structures that manage a range of other, smaller health providers, with each of these larger entities competing. For this reason, every individual umbrella organisation wants their own systems to work; they do not necessarily want to share information with other systems (Geels, 2005b: 450). What is more, one Victorian health service might an get ‘off-the-shelf’ IT solution and create their own ‘instance’ of it that does not share data with a second health service system, because the second health service created their own ‘instance’, using the same software, but these two ‘instances’ do not speak to each other.
Then there are satellite organisations and actors. Digital health solutions vendors, for example, benefit from the complications that come with a convoluted health communication ecosystem, and ‘it is a disincentive for [these] commercial organisations to have [health services] working together and sharing information and sharing knowledge’ (health communication infrastructure consultant, interviewed in 2019). As the healthcare communication infrastructure consultant further elaborates, systems unification and consolidation reduce repeat processes, and thus profits (interviewed in 2019).
What these participant insights reveal is complicated, multi-stakeholder investment in maintaining the status quo, or what is elsewhere referred to as ‘tightening patterns of functional [dependence and] interdependence’ (La Porte, 1991: 1). In such situations, maintenance of continuity becomes ‘a constant mobilization of resources by those that are advantaged by the present system’, and ‘who may seek to protect and maintain their advantages’ (Sovacool et al., 2018: 1089). The transition governance challenge here is to develop effective strategies (policy initiatives, technology solutions, etc.) that contribute to a ‘socio-technical destabilization’ (Joly et al., 2023: 31) of these sectorial dependencies and interdependencies.
Technological lock-in and infrastructural inertia: The interoperability challenge
A further reason that fax use persists in the Australian healthcare sector is due to the ‘complexity around secure messaging’ (Practice Technology Management Expert Committee member, interviewed in 2021) as an alternative to fax. Secure medical messaging systems have proven difficult to develop and implement (Program Director, interviewed in 2021). Among the many technical difficulties to overcome include establishing interoperability standards (getting different systems to talk to each other), payload standards (being able to send and receive messages, or information packets, with diverse forms of content), addressing (ensuring a message is going to the right recipient), and receipting (acknowledging successful arrival of a message) (Program Director, interviewed in 2021). Each of these issues underscores the point that ‘all data are first shaped by formats’, and these formats ‘influence clinical medical records’ and their storage and transmission (Koopman et al., 2022).
Medical systems interoperability remains an international healthcare challenge (Hammami et al., 2014). In the US there is an expanding market of secure messaging systems, and in the UK secure messaging vendors include the NHS App, Hospify, EMIS and TPP clinical systems. In the Australian market, there are four main competing secure messaging vendors (Argus, Global Health, HealthLink, and Medical Objects) and around 300 or so different clinical systems used for the generation of medical messaging content. With the four messaging vendors, the challenge has been to get their proprietary systems to interoperate, despite commercial disincentives to do so. This challenge – which Coopersmith (2015: 187) characterises as ‘the classic issue’ of whether to ‘promote a proprietary or open standard’ – delayed the widespread diffusion of fax (and computer faxing after it) and has resurfaced as an impediment to the diffusion and widespread take-up of SMD as an alternative to fax.
In addition to the above interoperability challenges, it is worth noting here how interactions between two large technical systems can, on occasion, work – even if unintentionally – to hasten change. In Australia, the roll-out of the National Broadband Network (NBN) did just this in relation to fax use. The NBN is an AUD $51 + billion Australian Federal Government project to provide high-speed broadband infrastructure. Consumers receive access to the network through a telecommunications service retailer. In most Australian urban and suburban settings, fixed-line telephony is superseded by Voice over Internet Protocol (VoIP) telephony services, which are often bundled with a NBN subscription. Installation instructions explain that ‘faxes and alarm services will not work on your new plan and should be disconnected from all telephone wall sockets’ (NBN, 2019). In short: NBN spells trouble for phone-line based fax communications.
This development was a cause of great consternation for one participant, an occupational therapist in private practice (interviewed in 2019) working out of a home office, who relied on the successful operation of their fax for much of their core business: referrals from GPs. Their partner, who served as their tech troubleshooter, had spent considerable time and effort researching what to do and transitioning their fax from a fixed line telephony to a VoIP-compatible service. He was convinced that medical practice (GP) clinics were not actively responding to the challenges wrought by the introduction of NBN broadband/VoIP, and that they were largely unaware of how it affected correspondence between GPs and allied health professionals. In response, and out of concern that they were losing business due to missed communications, he sent test (VoIP-compatible) faxes to every clinic they dealt with on a regular basis. He then contacted each clinic, requesting confirmation of the fax’s arrival (a read receipt). From this process, he laboriously mapped on a spreadsheet which practices still operated a standalone fax machine (left column) and which had made the transition to online fax (right column) in an effort to understand whether or not they were missing out on referrals (see Figure 2).
The arrival of Australia’s National Broadband Network meant that VoIP replaced fixed-line telephony, thus affecting conventional fax operation. Prompted by these disruptions to fax communication, one allied health professional set out to map which general practice clinics they routinely dealt with, and on whom they relied for referrals, had made the switch from fixed-line fax (left column) to online fax (right column). Photo: authors.
As the above example reveals, the arrival of the NBN meant that faxes either did not work or tended to work unreliably. While this is distressing for those allied health workers and specialists who are reliant on faxed referrals, it has had the effect of ‘slowly, surreptitiously’ bringing about technological change (Program Director, interviewed in 2021). Put differently, ‘contingencies push systems in new directions’ (Hughes, 1983: 16). The arrival of NBN broadband/VoIP is serving as a ‘change agent’, accelerating efforts to combat technological obduracy and fax dependence.
Discontinuation governance: Transitioning from fax communication to SMD systems
There are lessons here for fax and other legacy technologies. Sovacool et al. (2018: 1070) make the point that inertia tends to ‘direct systems along established lines of development’, which is to say that the status quo is unlikely to change as there is little motivation or incentive for change. In the transition studies literature, discontinuation, if it is to be effective, must be actively negotiated and enacted. A key mechanism through which this can occur is via ‘discontinuation governance’. Stegmaier, Kuhlmann and Visser are transition scholars whose work focuses on the governance of socio-technical systems and the discontinuation of established systems. They describe discontinuation governance as a process that is shaped by the following twin dynamics: ‘the “governance of a problem” and a “problem for governance action”’ (Stegmaier et al., 2014: 112). In the present context, the first of these (the problem requiring governance) is the enduring reliance on fax for healthcare messaging, while the second (the problem for governance action) is that of determining the best strategies in order ‘to exert pressure and alter system dynamics’ (Sovacool et al., 2018: 1089; Van der Vleuten, 2006: 302) such that reliance on and commitment to fax is weakened or abandoned in favour of other, preferable alternatives (such as secure message delivery (SMD) systems). In governance terms, the second of these questions can be reposed as follows: ‘What policy mixes can dismantle or actively phase out undesirable mature systems so as to provoke their decline?’ (Sovacool et al., 2018: 1087)
Discontinuation governance initiatives to diminish reliance on fax within the Victorian healthcare sector have taken a number of different forms. At a federal level, the Australian Digital Health Agency (ADHA) has worked for several years to address many of the technical barriers preventing fuller take-up of SMD technologies, and ‘putting GPs on notice’ to phase out fax use in favour of updated SMD systems (GP and Practice Technology Management Expert, interviewed in 2021). ADHA have approached this by using a combination of working parties and other forms of collaboration to arrive at stakeholder consensus, alongside targeted use of industry incentives. The result of work by ADHA is (at time of writing) broad agreement on interoperability standards and payload standards (these standards are encouraged rather than mandated or enforced), and resolution of the centralised address book and receipt generation issues. In this way, standards development forms a valuable governance tool that serves as a ‘coordinator of system change’ (Daemmrich, 2014: 49) and ‘institutional reordering’ (Pelizza, 2016: 314).
In addition to ADHA’s standards-setting work, the Australian Federal Government also established My Health Record (first launched in 2012 and then rebranded and revamped to make it opt-out) in 2018 (Taylor and Corderoy, 2020). My Health Record is a national electronic health record system that can be accessed by patients and by patients’ healthcare providers at the point of care (Australian Government, 2022). While My Health Record has faced its own technology transition and take-up difficulties (Taylor and Corderoy, 2020), it forms part of a coordinated policy response addressing challenges of secure transmission, storage, and accessibility of medical records (see Figure 3). A state government health department spokesperson we interviewed in 2019 stated that fax was not regarded as the ‘prime driver’ behind the development of My Health Record, yet long-term continued reliance on fax forms a key part of an ‘interrelated’ suite of issues that it seeks to overcome. For this government spokesperson, development of My Health Record serves obliquely as a ‘reconfiguration driver’ (Sovacool et al., 2018: 1076) that, it was hoped, would accelerate the shift away from fax use.
During interview, a Victorian State Government spokesperson produced this network architecture diagram of the My Health Record system in order to illustrate the sorts of medical records transmission and storage issues it is designed to address and its role in diminishing fax reliance. Photo: authors.
And, in a related vein to My Health Record, the Victorian State Government passed legislation in 2023 to implement technical systems that would address the fragmented nature of Victoria’s health care system and continued reliance on the faxing of medical records. In the Second Reading Speech of the Health Legislation Amendment (Information Sharing) Bill 2023, the Leader of the House of Victorian State Parliament noted that, Currently in Victoria, critical health information is spread across different health services, in separate systems and in paper-records. This fragmentation of patient health information often means that clinicians manually gather patient health information through fax or phone calls. This is inconsistent with modern health record sharing standards, and the approach taken by other [Australian state] jurisdictions […]. (Parliament of Victoria, 2023: 168)
Conclusion
This article has drawn from an interview-based study with health and technology experts to understand the factors that have contributed to the persistence and ongoing reliance on fax in Australian healthcare contexts and the challenges faced by attempts to transition to more modern secure message delivery (SMD) technologies. What emerged from this examination is an understanding of continued fax use as shaped by socio-material entrenchment, institutional and regime interdependencies, and technological lock-in and infrastructural inertia. These factors help to explain why it is that faxes persist in hospitals and other Victorian healthcare contexts, and why the transition to newer SMD technologies has been so difficult to achieve.
For a long time (indeed, for the extended life of this research project), fax has appeared as if stuck in a ‘perpetual cycle between contestation and reconfiguration’ (Sovacool et al., 2018: 1089). However, as we have sought to document, things are slowly shifting: the accumulation of external pressures on incumbent technologies, strategic responses from actors within those systems, the (gradual) weakening of institutional and cultural commitment to incumbent technologies, mitigation of negative effects linked to detachment, and technological substitutes for those undergoing detachment (Joly et al., 2023; Turnheim and Geels, 2012, 2013) all seek to contribute to diminished (if not disappearing) fax use. Australian government agencies and industry bodies have pursued a range of long-term discontinuation governance initiatives that are designed to (sometimes obliquely, if not always directly) dislodge fax as a key healthcare communication technology. While these initiatives have addressed some of the core sectorial complexities, and have sought to overcome key technological challenges (around interoperability and standards alignments), there are no guarantees that these will result in the complete discontinuation of fax because they have often failed to address the more persistent embedded routines, infrastructural inertia, and asymmetric integration of technologies in healthcare communication.
Despite advances, the replacement of legacy technologies often face significant barriers. Systems tend to follow ‘established lines of development’ (Sovacool et al., 2018: 1070), with little incentive for change unless actively negotiated and implemented. The persistence of fax technology in healthcare exemplifies these dynamics:
The above dynamics are just some of the indications that technology transition and discontinuation governance need to be ongoing. Until then, fax may well continue to serve as a valued (if perhaps no longer vital) health communication technology, one that while outmoded nevertheless remains active in the present. As transition studies highlights, socio-technical transitions are ‘messy’ and iterative, requiring active governance. The persistence of fax technology illustrates how resistance, resilience, and structural inequalities shape the trajectory of technological decline. As such, managing transitions demands ongoing attention to ensure mature systems are effectively phased out while addressing the broader socio-material dynamics at play.
Decline, as Sovacool et al. (2018: 1082) note, can be absolute, relative, or partial. (What’s more, as Howe et al. (2016: 550) remind us, ‘in many, if not most, cases, we live and work among various kinds of ruined or faltering infrastructure’.) Indeed, there is clear evidence from our interview data that, in one form or another, legacy technologies such as fax may continue to persist – if only as one component of an expanded technological ensemble – despite concerted efforts at displacement and discontinuation. Their survival does not reflect a simple failure of innovation, but the enduring power of institutional interdependencies, uneven transitions, and the socio-material and practical logics of system stability.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/ or publication of this article.