Introduction

The US healthcare system continues to become more fragmented and disconnected, with providers, payers, and, most importantly, patients bearing mounting costs and navigating increasingly complex care paths. Patients must be advocates and project manage their care, coordinating with multiple providers and negotiating with payers. Conversely, payers and providers fight surging payroll costs while burning through needless, costly administrative cycles, exchanging critical patient information via analog and legacy channels designed for different purposes. The solution to many of these problems is “interoperability,”  – a term which has been overused for years, if not decades. But, in its simplest form, interoperability is the ability for data to flow through different systems and channels where both sender and receiver can understand and, more importantly, use the (patient) information being exchanged. Think of it as The United Nations General Assembly Session.  Interoperability is not a tool; service payers and providers simply switch it on. Achieving interoperability is an iterative process, but even small advances quickly translate into reducing payroll, increasing employee value, plugging compliance and security gaps, and delivering better patient care. The first step for many is tackling the interoperability challenges between fax and their EHR. 

This white paper is the first of a three-part series from Documo that defines a roadmap for healthcare organizations to achieve interoperability between unstructured fax documents and structured data systems like Electronic Health Records.  As the title suggests, Part One focuses on creating the baseline for interoperability in healthcare. In short, healthcare payers and providers need a robust, reliable, secure, and compliant fax operation as a baseline for achieving better interoperability.  

Why is Fax Still Prevalent in Healthcare? 

There are three key reasons faxing remains a common patient exchange mechanism for clinical and administrative teams: security, EHR vendor revenue, and user simplicity.

Security

Faxing, whether analog or digital (Fax over IP, FoIP), remains a secure method for transmitting sensitive healthcare information. Analog faxes operate over traditional phone lines, making them safe and isolated from internet-based threats. This isolation ensures that they are less susceptible to hacking attempts.

Digital faxes enhance security through robust encryption protocols. For instance, end-to-end encryption and compliance with HIPAA, SOC 2, HITRUST CSF, and PCI DSS standards ensure that sensitive information remains protected during transmission. Faxing minimizes the risk of phishing and spear phishing attacks common in email communication, providing a more secure alternative for exchanging Patient health information.

“Law enforcement and healthcare sectors are the major drivers of the fax services market because of stringent legal requirements governing the secure transfer of sensitive data. Additionally, in 2022, nearly 3.6 million Russian internet users experienced breaches, marking an 11% increase. Such instances further propel the use of fax and its respective services to protect organizations from growing online scams and security concerns.” – Global Fax Services Market – Outlook & Forecast 2023-2028.

While faxing offers superior security during transmission compared to email, managing faxed documents, post-transmission significantly impacts their overall security. Traditional fax machines are the ultimate security blackspot; documents left in fax trays can be accessed by unauthorized individuals, leading to potential breaches of sensitive information. Additionally, faxes can be easily photocopied or misplaced, with no reliable way to track who sent, received, or accessed the documents.

EHR Vendor Revenue

Think of Electronic Health Record platforms as islands. These islands are inordinately expensive but have everything you need at your fingertips and are perfectly organized. These islands all possess one major drawback: communicating with other islands is almost impossible. Most islands speak their language and the few that share a language use different dialects. Frustratingly, Island budgets are used exclusively to invest in room upgrades, new amenities, sharks, and security fencing. Funds for translators or a communication infrastructure are consistently absent. 

“48% of PCPs cite the fragmented and disconnected nature of EHRs as the main obstacles to Achieving Long-Term EHR Developments.” Global Fax Services Market – Outlook & Forecast 2023-2028 

EHR vendors invest heavily in enhancing the internal features of their platforms to create a comprehensive and self-contained environment for their users. While EHR vendors are aware of the need to simplify the exchange of patient information with other platforms, they are not financially incentivized to do so. Simplifying patient information exchange with other systems also means simplifying the process of permanently exchanging all patient information to another platform, aka platform migration. Conversely, complex patient information exchange ensures healthcare providers (The EHR vendor’s primary customer) view the perceived cost, risk, and disruption of migrating to a different platform as outweighing the benefits of moving to a more cost-effective system to serve their needs better. EHR vendors are effectively locking customers into their current platform. This strategic isolation helps vendors retain their customer base and maintain market share despite the potential benefits that greater interoperability could bring to the healthcare industry​​​​​​​​​​.

While the EHR vendor space will evolve its stance on interoperability in response to government mandates such as the ONC 21st Century Cures Act and the evolution of FHIR, progress will be slower than many might expect, leaving fax as the easiest way to continue plugging the current gaps.   

“Not all EHR vendors fully use the entire range of FHIR standards, often constrained by their existing APIs. The process of creating custom integrations is both time-consuming and costly for vendors. Innovation faces hurdles – the use of legacy EHRs and paper-based systems is slowing the adoption and implementation of FHIR.” – Signify Research

User Simplicity

Fax: a universally supported and accepted communication method familiar to clinicians and administrative teams across the planet. Patient Information is printed (either on paper or as a PDF) and sent directly to the receiving fax number. The sender receives a confirmation that all pages were successfully transmitted, and the receiver gets a confirmation that all pages in the fax were successfully received. Should an error occur on either side, the fax is resent. 

The pure simplicity of fax is why healthcare providers continue using it. It is the path of least resistance and a defensible shortcut for healthcare professionals focused on other priorities. However, faxes have severe interoperability and compliance drawbacks, creating an outsized burden on payers and providers. The second white paper of the series, “Getting to One: Integrating Unstructured Fax Data into Healthcare Systems and Workflows,” will cover these topics in detail.

Legacy Fax: The Barrier to Interoperability 

Healthcare organizations often find themselves burdened with disconnected faxing technologies, from traditional analog fax machines to modern cloud fax services. These organizations must also deal with multiple telecom carriers and a mix of digital and analog telephone exchanges. These inefficiencies and the significant burden of managing and maintaining these systems in highly regulated environments can overwhelm payers and providers. To achieve interoperability between fax and EHR systems, healthcare organizations must first streamline their fax operations by adopting a unified, reliable platform operated by a proven provider. 

Traditional Analog Fax Machines 

Traditional fax machines are highly prevalent yet wildly inappropriate for the healthcare environment. The cost of maintenance and consumables is significant, with continuous expenses for paper, toner, and dedicated phone lines. Performance is unreliable, plagued by paper jams and busy signals, which delay critical patient information exchange. As noted in the “cons” section below, traditional machines are an extravaganza of compliance, security, and patient privacy issues.

Fax Machine Pros

• Reduced Cyber Threats: Immune to internet-based attacks like hacking and malware.
• Point-to-Point Communication: Direct machine-to-machine transmission reduces interception risk.
• Tangible Records: Immediate physical copies ensure prompt action on important information.
• Reliability: Long-established and reliable technology for document transmission.
• Ease of Use: Simple operation with minimal training and setup needed.

Fax Machine Cons

• HIPAA Violations: Risk of non-compliance with HIPAA due to unsecured handling and transmission.
• Unauthorized Access: Documents in fax trays can be accessed by unauthorized individuals.
• Unrestricted Access: Anyone can send, receive, or view documents.
• No Audit Trail: No tracking of who sent, received, or accessed faxes.
• Manual Handling: Increases the risk of sending incorrect numbers or losing documents.
• Improper Disposal: Risk of unauthorized access due to inappropriate disposal.
• Ongoing Costs: Telephony, Paper, Toner, Maintenance 
• Poor image quality

Fax Servers 

Fax servers initiated the first wave of innovation in faxing in the 90s. Fax servers allowed organizations to centralize and scale their fax infrastructure. While fax machines could still be hiding in smaller offices across the planet, enterprises were on-premise, deploying fax servers in great numbers. Fax servers are now far from the panacea they once were. Initial setup costs are substantial, including hardware acquisition, software licenses, and integration fees. Performance can suffer during peak times due to limited fax channels, resulting in busy signals and failed transmissions. Maintaining compliance is complex, requiring robust security measures to protect sensitive data and regular audits to ensure adherence to regulations like HIPAA. The maintenance of fax servers is labor-intensive, involving frequent updates, troubleshooting, and integration with other systems. Security remains a significant concern, as servers must be protected against breaches and ensure encrypted data transmission and storage.

In 2024, most fax server vendors generate the bulk of their revenue through expensive support and maintenance contracts rather than acquiring new customers and winning through product innovation. Buyers should carefully evaluate fax server EHR integrations and connectors to verify system compatibility and production performance.

Fax server technology may still be viable for a subset of healthcare organizations. For most, however, the benefits of fax servers are vastly outweighed by the cost, burden, complexity, and risk of operating servers on-premise. 

Fax Server Pros

• Tried and Tested Technology: Fax servers have a long, established history in complex environments.
• Scalable (with Pre-defined Limits): Offers excellent upfront scaling.
• Rich user features: decades of user-driven enhancements have produced countless options for users to refine their faxing environment. 
• Non-variable Costs: Fixed costs for hardware, software, and maintenance over the contract period, aiding budget predictability.
• Perpetual licenses: customers own the software (patches and updates require an additional annual support and maintenance plan)

Fax Server Cons

• Legacy Technology: Outdated client-server technology. Not a cloud-native. 
• High Initial CAPEX Investment: Significant upfront costs for hardware, software, and integration.
• Increasing Support and Maintenance Costs: Annual costs can be as high as 33% of the initial investment.
• No Included Hardware/Software Redundancy: Additional investment is needed to ensure redundancy and reliability.
• Service Reliability and Deliverability Issues: Quality depends on the customer and the customer’s telecom provider.
• Fixed scaling capacity; faxing fails when traffic exceeds pre-defined limits, leading to busy signals and failed transmissions. Customers must scale their fax server implementation to handle their highest potential traffic volume, leading to significant additional upfront and ongoing annual costs.  
• Per-Call Charges: Costs for every outbound and inbound toll-free fax add to operational expenses.
• Slow Product Release Cycle: Updates and new features are released slowly, often lagging behind technological advancements.
• Service Disrupting Upgrades: Maintenance and upgrades can cause disruptions to service, affecting reliability and uptime.

Fax-Enabled Multifunction Print Devices

Fax-enabled MFPs, while seemingly efficient, present several drawbacks. Older MFP devices may include a fax board or card, enabling the device to send and receive faxes like a traditional analog fax machine.  MFP vendors have recently partnered with fax servers, hosted fax, and some cloud fax vendors to integrate faxing capabilities into the MFP software. Compliance, security, reliability, and scalability vary greatly based on the fax partner’s product or service and the method of sending and receiving faxes from these devices. 

Fax is not a core competency for MFP providers; their strengths lie in managed service provider contracts. These contracts spread the cost of MFP devices, consumables (such as ink and toner), and hardware maintenance over the length of the contract. MFP providers also seek to increase revenue from MSP agreements by bundling third-party hardware, software, and services. 

In short, Multi-Function Print devices coupled with Managed Service Provider contracts provide a simple and effective model for printer/copier requirements but present multiple interoperability challenges.   

Multi-Function Print Devices Pros

• Inclusive Contracts: Faxing can be included or added to an MSP contract.
• Cost Distribution: Fax hardware, software, support, and repair costs are spread across the contract’s life.
• Single Accountability: Managed service provider models provide a single point of accountability when issues arise.

Multi-Function Print Devices Cons

• Variable Standards: Fax capabilities, security, reliability, scalability, and compliance standards vary widely based on the MSP provider’s fax partner.
• Limited EHR Integration: Integrating fax with an EHR via MFP may be limited or unsupported.
• Scope of integration: Limited or no support for Integrating fax with an EHR on devices other than MFPs.
• Single Accountability: While managed service provider models provide a single accountability point, they rely heavily on their fax partner for subject matter expertise and troubleshooting. This can lead to the MSP acting as little more than a go-between customer and fax provider. 

Hybrid Fax Solutions 

Hybrid fax cloud deployments, which combine on-premise fax servers with cloud fax services, were initially attractive to organizations looking to balance the benefits of both approaches. Some healthcare providers selected hybrid solutions to leverage existing on-premise infrastructure while utilizing cloud services’ scalability and remote access. This model seemed to offer a flexible, cost-effective way to manage fax communications. However, hybrid deployments often fail to deliver the optimal benefits of either approach and introduce complexities that outweigh their intended advantages.

One significant issue with hybrid deployments is the dual compliance and security challenges. Ensuring regulatory compliance across both on-premise and cloud components is more complicated and risk-prone than maintaining a unified system. Organizations must continuously monitor and enforce security policies to ensure that both parts of the hybrid solution meet HIPAA and other healthcare regulations, increasing the risk of non-compliance and potential data breaches​​​​. Additionally, hybrid solutions can suffer from inconsistent performance due to the reliance on local hardware and internet connectivity. This can lead to disruptions, latency issues, and higher operational costs for maintaining and supporting dual infrastructures​​​​.

The financial implications of hybrid fax solutions are another primary concern. While these solutions can leverage existing on-premise infrastructure to reduce upfront costs, the long-term total cost of ownership (TCO) can be significantly higher. Organizations must bear the expenses related to hardware upgrades, energy consumption, physical space, and potentially dual maintenance contracts, leading to higher overall costs than purely cloud-based models. 

Hybrid Cloud Fax Solution Pros

• Flexibility and Scalability: Can handle varying fax volumes efficiently, accommodating peak times without needing additional on-premise hardware​​.
• Enhanced Business Continuity: Provides better business continuity options, ensuring fax operations continue even if on-premise hardware fails​​​​.
• Incremental Transition to Cloud: Allows organizations to gradually transition to cloud services without abandoning their existing on-premise investments, potentially minimizing disruption to operations​​.
• Localized Control with Cloud Benefits: This option allows users to maintain local control over critical fax infrastructure while taking advantage of cloud solutions’ scalability, disaster recovery, and remote access features.

Hybrid Cloud Fax Solution Cons

• Complex Compliance and Security Risks: Ensuring regulatory compliance across both on-premise and cloud components is challenging, increasing the risk of non-compliance and data breaches​​​​.
• Inconsistent Performance and Scalability Issues: Reliance on local hardware and internet connectivity can lead to performance inconsistencies and disruptions​​.
• Over-provisioning resources can result in underutilized capacity during off-peak times​​.
• Increased Costs: Long-term costs for hardware upgrades, energy, and dual maintenance contracts can be higher than maintaining a single system​​.
• Shifting some or all costs from CapEx to OpEx complicates budgeting and increases overall expenses​​​​.
• Vendor Management Complexity: Managing multiple vendors for on-premise and cloud components complicates vendor management and increases the potential for downtime​​.

Fax Technology Scorecard

Detailed descriptions of each category and the criteria used for scoring can be found in the appendix of this white paper.

Cloud Fax: The Optimal Baseline For Interoperability 

Cloud fax technology provides the ideal baseline for achieving interoperability in healthcare due to its hands-off dependability. Unlike fax technologies, which require significant maintenance and oversight, cloud fax solutions are managed by the service provider. The service provider also assumes many risks and responsibilities shouldered by the customer (e.g., The HIPAA Business Associates Agreement).  Cloud fax allows IT departments to focus on more critical tasks, such as enhancing interoperability and supporting clinical and admin staff, rather than managing fax infrastructure. According to HealthITSecurity, cloud faxing enables healthcare providers to eliminate the need for physical fax machines and related manual processes, making the entire workflow more efficient and secure.

Security and compliance are also paramount in healthcare; cloud faxing excels in these areas. Cloud fax solutions offer end-to-end encryption and adhere to stringent regulatory requirements, ensuring that sensitive patient information is protected during transmission and at rest. This significantly reduces the risk of data breaches associated with older fax technologies, which are often vulnerable to unauthorized access and hacking. 

Furthermore, cloud fax technology provides scalability that traditional systems cannot match. It allows healthcare organizations to handle varying volumes of fax traffic without additional hardware or infrastructure. This flexibility is particularly valuable during peak times or periods of unexpected demand. Additionally, cloud fax solutions offer a competitive volume-based cost model, which means customers only pay for the value they get from the service. 

In conclusion, cloud fax is the best choice for healthcare organizations aiming to achieve interoperability. Its seamless integration capabilities, robust security features, hands-off dependability, and scalability make it superior to traditional fax technologies. By adopting cloud fax, healthcare providers can focus on their primary mission of delivering high-quality patient care while ensuring efficient and secure data exchange.

Initial Steps and Considerations for Moving to a Cloud Fax Solution

Assessment of Current Environment

1. Evaluate current fax infrastructure and identify pain points.
2. Conduct a comprehensive audit of existing fax hardware and software.
3. Identify any financial lock-ins with incumbent fax vendor (e.g., multi-year support agreements)
4. Provide the existing fax vendor with an opportunity to present a solution for the proposed integration project. This approach will either validate moving to the cloud or raise questions that need to be answered. 
5. Assess the volume and types of faxes sent and received to understand usage patterns. Determine the impact on short-term and long-term costs compared with the existing fax solution. 

Cost

1. Analyze the total cost of ownership, including any hidden fees.
2. Compare the pricing structures of different providers.
3. Consider both initial setup costs and ongoing operational expenses.
4. Evaluate the cost-effectiveness relative to the benefits offered.
5. Identify indirect cost savings by either remaining on the existing platform or moving to the cloud:
6. Hardware costs, operating system/database / other third party licenses and support agreements)
7. Telecoms, support, training, and maintenance resources
8. Business opportunity costs associated with downtime

Planning

1. Develop a transition plan, including timelines and resource allocation.
2. Set clear objectives and goals for the transition.
3. Create a project timeline with key milestones and deadlines.
4. Allocate necessary resources, including budget and personnel.
5. Delineate all items owned by the cloud fax vendor

Vendor Evaluation

1. Choose a cloud fax provider that meets security, compliance, and integration requirements.
2. Research and shortlist potential vendors.
3. Request proposals and conduct detailed evaluations based on security, compliance, scalability, and integration capabilities.
4. Ensure the provider meets all relevant security and compliance standards.
5. Verify HIPAA, HITRUST, and SOC 2 certifications.
6. Ensure the provider uses end-to-end encryption for all fax transmissions.
7. Check for features like secure document storage and detailed audit trails.

Scalability

1. Assess the provider’s ability to scale services to match organizational needs.
2. Evaluate the provider’s capacity to handle peak fax volumes.
3. Ensure the solution can scale vertically (increasing capacity) and horizontally (adding new functionalities).
4. Check for flexible pricing models that align with usage patterns.
5. SLA agreement
6. Evaluate for uptime commitment, support coverage hours and response times, call escalation policy, and critical emergency contact.
7. Confirm the provider’s uptime guarantee (e.g., 99.9x%).
8. Evaluate the provider’s disaster recovery and business continuity plans.
9. Assess redundancy measures and failover capabilities.

Integration Paths

1. Compare API and turnkey connectors. 
2. APIs may elongate the integration timeline and require specific coding resources but may deliver a rich, highly customized integration.
3. Connectors may offer a rapid path to integration but may not support specific, required capabilities.
4. Check for compatibility with other healthcare IT systems and workflows.
5. Conduct thorough functional testing to ensure compatibility and smooth operation.
6. Stress test the integration to ensure it supports production-level usage and traffic. 

Training

1. Train staff on the new system to ensure smooth adoption.
2. Develop comprehensive training programs for end-users.
3. Provide ongoing support and resources to address any issues that arise post-implementation.
4. Monitor and evaluate the system’s performance and user satisfaction regularly.

Conclusion

CIOs have long understood the fragmented nature of our current system and the significant burdens it places on providers, payers, and patients alike. CIOs equally see the future: Interoperability is the key to addressing patient information exchange issues, yet it remains an elusive goal. Despite advances in Electronic Health Records (EHRs), fax remains the dominant method for transmitting patient information due to its inherent security and simplicity. However, fax created almost as many problems as it solved, including inefficiencies, process delays, security risks, and the need to create manual workarounds.

Cloud faxing is not just a modern alternative but a foundational step towards achieving true interoperability in healthcare. By adopting cloud fax solutions, CIOs can move towards the secure, compliant, and efficient exchange of patient information. These solutions offer enhanced security through end-to-end encryption, reduce costs associated with maintaining outdated fax infrastructure, and provide the scalability needed to handle varying volumes of fax traffic seamlessly. Leading healthcare cloud fax service vendors have also shown to be passionate about solving interoperability issues and have the resources and experience to deliver. 

While the path to full interoperability is complex and ongoing, starting with cloud fax solutions provides an immediate and pragmatic improvement. It sets a robust foundation for further advancements, driving us toward a future where patient information flows effortlessly and securely across the healthcare continuum.

Integrating advanced technologies like Artificial Intelligence (AI) and Natural Language Processing (NLP) with cloud fax solutions will further enhance data exchange capabilities as we move forward. This ensures that all healthcare providers can participate in a connected and interoperable healthcare ecosystem regardless of digital maturity. By taking these steps now, you address immediate inefficiencies and pave the way for a more connected, efficient, and effective healthcare system.

Appendix

Appendix A – Category Descriptions

1. Interoperability Readiness: Measures how well suited the fax technology is for integrating with other systems, particularly EHR (Electronic Health Records) systems, ensuring seamless data exchange and reducing manual data entry.
2. Planned Scalability:: Evaluates the technology’s ability to scale smoothly with planned growth and increased usage, such as adding new users or proactively adding capacity for higher fax volumes.
3. Unplanned Scalability: Assesses the fax technology’s flexibility to handle unexpected spikes in usage or rapid organizational growth without performance degradation.
4. Compliance: Description: Determines the technology’s ability to meet regulatory requirements such as HIPAA, SOC 2, HITRUST, and PCI DSS, ensuring secure and compliant transmission of sensitive information.
5. Security: Evaluates the level of security provided by the fax technology, including in-transit and at-rest encryption, access controls, and protection against cyber threats.
6. Availability / Redundancy: Measures the reliability and uptime of the fax technology, including redundancy features that ensure continuous operation even during failures or maintenance.
7. Fax Deliverability: Assesses the reliability of fax transmissions, including the rate of successful deliveries, handling of busy signals, and error correction mechanisms.
8. Initial Deployment Cost: Considers the upfront costs associated with implementing the fax technology, including hardware, software, professional services and setup fees.
9. Initial Deployment Complexity:: Evaluates the ease or difficulty of deploying the fax technology, including the time, resources, and expertise required for installation and integration.
10. Recurring Costs:: Measures the ongoing operational expenses, such as subscription fees, maintenance costs, and consumables like paper and toner.
11. Support Burden Placed on Customer: Assesses the level of support and maintenance required from the customer, including retaining in-house fax and / or telecom expertise for troubleshooting, updates, and general upkeep.
12. Telephony Dependence: Evaluates the reliance on traditional telephony infrastructure, such as phone lines and analog systems, which can impact flexibility and modernization.
13. Technology Innovation: Measures the extent to which the fax technology incorporates modern innovations, such as cloud computing, AI, and advanced integrations.
14. Upgrade/Patching Disruption: Considers the impact of software updates and patches on the operation of the fax system, including downtime and user disruption.
15. Environmental Impact: Measures the environmental sustainability of the fax technology, including energy consumption and the use of consumables like paper and toner.
16. User Experience: Assesses the overall user-friendliness of the fax technology, including the interface, ease of use, and customer satisfaction.
17. Fixed, Predictable Costs:: Evaluates the consistency and predictability of costs associated with the fax technology, helping organizations budget more effectively.

Appendix B – Fax Technology Score Card Criteria

The “Fax Technology Score Card” evaluates various fax technologies across multiple categories. Each category is rated on a scale from 1 to 5, with 1 being the lowest and 5 being the highest. Here is an explanation of what each score represents:

Score of One: Poor – Buyers Should Avoid: 

A score of one indicates that the fax technology performs poorly in the given category. It does not meet the requirements and poses significant challenges or risks. This score suggests buyers should avoid this technology as it could lead to inefficiencies, security vulnerabilities, or high operational costs.

A Score of Two: Below Average – Meets Fewer Requirements than Other Fax Methods

A score of two denotes below-average performance. The fax technology meets some basic requirements but falls short compared to other methods. It may offer limited functionality, have notable drawbacks, or require substantial improvements to be considered viable. Buyers should consider alternative options if available.

A Score of Three: Average – Meets Similar Requirements as Other Fax Methods

A score of three indicates that the fax technology meets the standard requirements for the category. It performs adequately and is comparable to other fax methods. While it may not offer exceptional features or benefits, it is a reliable and functional option that can meet the basic needs of most healthcare organizations.

A Score of Four: Above Average – Meets More Requirements than Other Fax Methods

A score of four signifies above-average performance. The fax technology exceeds standard requirements and offers additional benefits or features that enhance its value. It is a strong choice for healthcare organizations looking for advanced capabilities, better security, or improved efficiency. This score suggests that buyers should consider this technology as a high-quality option.

A Score of Five: Best in Class – Buyers Should Consider First

A score of five represents best-in-class performance. The fax technology excels in the category, providing exceptional functionality, security, and efficiency. It meets or exceeds all requirements and offers significant advantages over other fax methods. Buyers are encouraged to prioritize this technology as it is likely to deliver the best results and support for interoperability and other critical needs in healthcare.