Efax vs Fax Server in Healthcare: Which to Choose

In the efax vs fax server in healthcare decision, a cloud efax service suits most clinics: no hardware, per-page billing and pages delivered to email or a portal. An on-site fax server suits organizations with high volume, their own IT staff and a need to keep faxing when the internet fails. Cost, PHI controls and automation hooks decide the rest.

Efax services and fax servers, defined

An efax service is a hosted product that sends and receives faxes for you over the internet, so the clinic owns no fax hardware or phone lines. A fax server is software, often on a hardware appliance, that the clinic or hospital runs itself, connected to its own phone lines or a voice provider. Both produce digital files.

The difference is where the pages land and who runs the machinery. With an efax service, an incoming fax arrives at the provider's data center, is converted to a file and is delivered to the clinic. The FCC's 2019 Amerifactors declaratory ruling on online fax services (DA 19-1247) describes users reaching those faxes the way they reach email: by logging into a server over the internet or by receiving a PDF attachment in an email. The clinic never touches the phone side.

With a fax server, the incoming call ends on equipment the organization controls. The server writes each fax to a file, then drops it into a shared folder, a print queue, an email inbox or an application. The organization manages the server, its storage, its backups and its connection to the phone network.

Both models still receive the same thing: an image of a page. Neither one reads the page for you. A referral, a lab result and a prior authorization reply all arrive as pictures until something or someone turns them into data.

A third arrangement sits between them. Some electronic health record (EHR) systems include a fax feature that sends and receives through a hosted service in the background, so staff work from the EHR screen. The ONC data brief on interoperability and methods of exchange among hospitals in 2021 lists "eFax using EHR" as its own method, used by 67% of hospitals to send summary of care records often or sometimes. For this comparison, an EHR fax feature behaves like an efax service with a different front end.

Efax vs fax server costs over three years

Efax and fax server costs differ in shape more than in total. An efax service is mostly an operating cost: a monthly fee, a page allowance and charges per extra page. A fax server is mostly an upfront cost: hardware or licenses, phone lines or a voice service, and IT hours to install, patch and support it.

A three-year view is fair because a fax server's purchase is spread over its working life, while an efax bill starts the first month. Build the comparison from your own quotes and your own page counts. The table below shows the cost lines to fill in, with example figures that are invented for illustration and are not market prices.

Plug in your real numbers and add them up for 36 months. In the invented example above, the efax side comes to about $3,240 in fees plus overages and a little IT time. The server side comes to $6,000 at the start, $4,320 in voice service, $3,600 in support and far more IT time. The example is only arithmetic; your quotes may reverse it.

Three costs get left out of most comparisons. The first is page growth: per-page pricing grows with volume, while a server's cost stays mostly flat until it needs more lines. The second is staff time spent on missing faxes, busy signals and reprints, which is real but rarely counted. The third is the cost of whatever happens after the page arrives. If staff key every referral and lab result by hand, that labor will dwarf both fax bills, and it is the same for both models.

What to ask for in a quote

Ask each efax provider for the price per page above the allowance, whether inbound and outbound pages count the same, and the fee to move numbers out later. Ask each fax server seller for the license model, the support term, the number of simultaneous calls each line or channel supports, and what the voice connection costs per month.

Which is easier to secure for PHI: efax or a fax server?

Neither an efax service nor a fax server is secure by default. An efax provider handles protected health information (PHI) on the clinic's behalf, so a business associate agreement (BAA) is needed and the provider runs most of the controls. A fax server keeps PHI on the organization's own systems, so its own IT team carries every control.

The HIPAA Security Rule at 45 CFR 164.312 on the eCFR sets the technical safeguards for electronic PHI. It requires access controls that allow access only to people or software granted rights. It requires transmission security that guards against unauthorized access to electronic PHI sent over a network. It lists encryption and decryption as an "addressable" specification.

Efax: the BAA and the provider's controls

An efax provider that receives, stores or transmits PHI for a clinic is acting as a business associate. Under 45 CFR 164.502 on the eCFR, a covered entity may let a business associate create, receive, maintain or transmit PHI on its behalf only after getting satisfactory assurance that the business associate will safeguard it. In practice that assurance is a signed BAA. What a BAA has to cover is a topic of its own, collected in the HIPAA and PHI category.

With a BAA in place, the clinic still owns its side: who has logins to the portal, whether faxes are forwarded to shared inboxes, how long files are kept in the portal and whether staff download pages to desktops.

Fax server: every control is yours

A fax server keeps pages inside the network, which some security teams prefer. The trade is that the organization must patch the server, restrict folder permissions, encrypt or protect the storage, log access, back it up and retire old files. The general rule at 45 CFR 164.530 on the eCFR asks every covered entity to have appropriate administrative, technical and physical safeguards for PHI, and a fax server sits squarely inside that duty. If the voice service is hosted by an outside company, ask whether it handles the content of the calls and whether it needs a BAA.

The most common failure is the same in both models: faxes landing in a shared email box or folder that too many people can open. Narrow that before choosing a model.

How do efax and fax server outputs feed automation?

Efax services and fax servers both produce page images, and their delivery method decides how easily software can pick those images up. Efax services deliver by email attachment or portal, and some also offer an application programming interface (API). Fax servers typically write files to a network folder or hand them to an application through a connector.

The delivery hooks to look for are these:

• Email delivery. Each fax arrives as an attachment. It is simple, but email is a poor work queue: messages get forwarded, filtered or deleted, and nobody can see who is handling which fax.
• Folder drops. The server writes each fax to a watched folder with a predictable name. Downstream software can pick up new files in order, which suits batch processing.
• API or webhook. The service tells your software when a fax arrives and lets it fetch the file and its metadata, such as sending number, page count and time received.
• File format. Fax pages are stored as image files. The FCC ruling mentions PDF attachments, and products differ in which other image formats, such as TIFF, they can write. Ask which formats you can choose and whether multi-page faxes stay as one file.

Format and resolution matter once software tries to read the pages. How a digital fax file looks to an OCR engine, and why fax resolution causes misreads, is covered in the guide to what a digital fax file looks like to OCR.

After the file is captured, the pages still need sorting and reading. Faxed packets often carry document types that extraction software already handles, such as lab reports, discharge summaries, patient intake forms and pages from medical records. Schema Care reads those listed document types into fields, attaches a confidence score to each one and holds the doubtful fields for a person to check against the page, which the human review section shows step by step.

When an on-site fax server still makes sense

An on-site fax server still makes sense for high-volume senders, for sites that must fax during an internet outage, and for hospital networks that already run their own voice and document systems. In those cases the fixed cost spreads over many pages, and the IT team already exists. A small clinic rarely fits any of these.

The side-by-side view

Volume is the first test. Per-page pricing that looks cheap at a few thousand pages a month can overtake a server's fixed costs at much higher volume. Run the three-year sum from the cost section at your real page count and at double it.

Downtime is the second test. An efax service depends on the clinic's internet connection. A fax server on its own phone lines keeps working if the internet drops, as long as the server and the lines are up. Sites that receive time-sensitive orders around the clock, such as an emergency department or a pharmacy serving inpatients, often weigh this heavily.

Existing systems are the third test. A hospital that already runs a document management system, its own voice network and a staffed IT team may find a server easier to connect than another outside service.

Mistakes in either direction

Moving to efax and keeping the same shared inbox only moves the mess. Keeping a server nobody patches is worse than either option. Choosing on monthly price alone ignores the larger cost of reading and keying pages by hand.

Fax is also only one channel. Before buying for the next five years, weigh how much of your inbound volume could move to other routes. The comparison of Direct messaging vs fax for provider hand-offs and the cost breakdown of fax vs electronic referrals cover the two routes most likely to absorb fax traffic.