The fax machine remains indispensable in the German healthcare system despite digitalization, revealing structural deficits.
The Fax in the German Healthcare System: Analysis of a Persistent Communication Standard
Despite decades of digitalization efforts, the fax machine remains an indispensable means of communication in the German healthcare system. Recent surveys show that 77% of physicians regularly use fax for the transmission of findings, laboratory results, and prescriptions 1 2. This remarkable persistence of a technologically outdated solution raises fundamental questions about the structural development of the healthcare system. This report analyzes the multifactorial reasons behind this development, taking technical, regulatory, and cultural aspects into account.
Historical Development of Fax Usage in Healthcare
Technological Path Dependence Since the 1980s
The introduction of the fax machine in German medical practices from the 1980s marked the first wave of digitalization, complementing analog communication methods like postal letters. The apparent legal certainty provided by transmission reports and the easy implementation without IT infrastructure led to widespread adoption 2 11. This early adoption created a technological path dependence that was inadequately addressed by later digitalization initiatives.
Institutional Anchoring in Administrative Processes
Regulatory requirements, such as the introduction of the fax number as a mandatory detail in practice equipment regulations, cemented the standard 16. Simultaneously, parallel infrastructures developed: While health insurance companies have been implementing electronic interfaces since the 2000s, smaller care facilities and laboratories often remained reachable exclusively by fax 6 14.
Current Usage Patterns and Application Scenarios
Distribution of Fax Communication by Document Type
Quantitative analyses show a differentiated usage profile:
77% of fax transmissions are related to laboratory findings and diagnostic results 1
62% involve communication with hospitals 1
44% are used for exchanges with health insurance companies 1
30 daily fax transmissions per practice are not uncommon 6
Regional Disparities and Specialty Differences
Significant differences are apparent between:
General practices (high fax usage) vs. dental practices (lower usage due to EHR systems) 1
Urban centers with TI connection vs. rural areas without broadband infrastructure 9 13
Public health departments (partially 100% fax dependency) vs. private laboratories 3 7
Structural Reasons for the Ongoing Dominance
Fragmented Digitalization Infrastructure
The lack of comprehensive telematics infrastructure (TI) with continuous compatibility remains the main obstacle. Despite the introduction of KIM (Communication in Healthcare), only 59% of practices are connected, while 37% report technical incompatibilities with existing PVS systems 1 9. The lack of interoperability among 300+ different practice management systems prevents digital alternatives 13.
Economic Disincentives
The current compensation structure according to EBM (Uniform Evaluation Standard) paradoxically favors analog processes:
Fax transmissions are flat-rated at €0.25 12
Electronic doctor letters require more complex billing codes 12
TI usage incurs additional costs for connectors and certificates 9
Perceived Security Advantages
Despite contrary expert opinions, 34% of the medical profession considers fax safer than email 1. This assessment is based on:
Misinterpretation of “physical” transmission as inherently secure 5
Lack of awareness of modern fax-to-email gateways and VoIP transmission methods 1 5
Experiences with hacker attacks on TI systems during the COVID-19 pandemic 6 17
Sociotechnical Challenges
Workflow Integration and Time Economy
Empirical studies identify the time factor as a central barrier:
On average, 23 minutes of daily time is spent per practice on fax handling 6
15% error rate in manual data entry from fax receptions 6
62% of respondents criticize the high administrative effort of digital alternatives 1
Cultural Anchoring and Change Resistance
A qualitative survey of 200 medical assistants (MFA) shows:
68% prefer fax due to familiar work routines 6
45% report resistance from older colleagues against TI systems 6
29% point to insufficient training offers for digital tools 14
Regulatory and Technical Risk Factors
Data Protection Law Gray Areas
Although the Federal Data Protection Office warns against the use of fax 1 5, there is no explicit ban. The legal situation remains ambiguous:
§ 203 StGB (professional confidentiality) is formally maintained through fax transmission 11
Art. 32 GDPR (security of processing) is violated in VoIP transmission 5
State data protection authorities impose fines only sporadically 5 6
Technical Vulnerability
Modern fax machines pose unexpected security risks:
78% of devices use outdated firmware with no security updates 6
Faxploit attacks enable RCE (Remote Code Execution) via manipulated TIFF files 6
43% of practices operate fax machines on the same network as PVS systems 6
International Comparison and Development Trends
Austria’s Fax Ban as a Litmus Test
The fax ban for health data in Austria, effective January 2025, reveals structural problems:
62% of laboratories had to resort to physical data transport by courier 1
78% of nursing homes had no alternative communication systems 4
The electronic health record ELGA works reliably in only 34% of cases 1
Proven Approaches in Scandinavia
Successful digitalization strategies show alternative paths:
Sweden's "1177 Healthcare Guide" integrates 98% of healthcare providers 13
Denmark's "Sundhedsplatformen" achieved 89% fax-free status within 5 years 13
Norway's "eResept" system reduced medication errors by 41% 13
Future Scenarios and Transformation Paths
Hybrid Models as a Transitional Solution
Combined approaches could serve as bridging functions:
Fax-to-TI gateways with automatic document conversion 4
AI-based OCR recognition for retrospective digitalization 14
Blockchain-based transmission confirmations for legally secure transfer 17
Policy Recommendations for Sustainable Change
Long-term solutions require multi-sectoral approaches:
Introduction of a fax levy according to § 291a SGB V as a steering effect 12
Comprehensive TI obligation for all service providers by 2027 9
Federal-state program for MVZ centers with shared service models 3
Medical informatics curricula at medical faculties 13
Hackathons for TI app development with €50 million funding volume 9
Preliminary Result
The persistence of the fax machine in the German healthcare system reveals fundamental systemic deficiencies that go beyond purely technological issues. It is a sociotechnical phenomenon sustained by path dependencies, regulatory half-heartedness, and cultural resistance. The solution requires nothing less than a digital paradigm shift, in which infrastructure reforms are synchronized with process innovations and skill development. Until this transformation is complete, the fax machine - despite all security concerns and inefficiencies - will continue to be the pragmatic link between the analog past and the digital future.
