COVID-19 testing backlog caused by schedulers waiting on one fax at a time

For at least six days, a school-age boy had to stay in a room by himself,as he waited for an appointment to get a COVID-19 test.

On the sixth day, his mother learned her son's test request had been lost. She burst into tears at the thought of starting the process all over again, back at the end of the line.

"We've been patient and we've followed the rules and the system has absolutely let us down," the mother wrote in an email to Education Minister Dominic Cardy on Nov. 26, 2020.

On that same day, New Brunswick logged 12 new cases of COVID-19, primarily in the Saint John region. Demand for testing was high.

A backlog in the "ability to test and screen symptomatic patients in a timely manner" was cited as one of the reasonsthe province briefly moved the Fredericton health region into the more restrictive orange phase of recovery on Nov. 27.

That backlog, and the boy's lost test request, were caused by a glitch involving technology that most people have probably long forgotten about: fax machines.

New records obtained by CBC News through access to information show how Department of Health and Horizon Health Network officials were dealing with a bottleneck of around 1,500 faxes.

It left assessment centres unable to schedule patients for COVID-19 tests, leaving those with symptoms inlimbo. New testing queues in the Fredericton and Saint John health regions had to be opened to try to clear the backlog.

The documents show the problem appears to have begun on the morning of Nov. 24, when none of the province's COVID-19 assessment centres could receive testing referrals by fax, according to a Horizon Health memo.

A backlog

The fax system, which is managed by Service New Brunswick, was experiencing a system outage.

Part of the problem was that fax machines can only receive one message at a time and took about 130 seconds to spit out one page. One fax must be successfully sent and received before another message can be received, and a backlog quickly started to build.

Compounding the issue was "the limited number of fax machines" that were receiving testing referrals, the memo said.

"Realizing the delays this was causing, Horizon acted quickly to ensure electronic referral lists were supplied to the assessment centres in the meantime so that appointments could continue to be booked," Tim Calvert, Horizon Health's regional director of information technology/information security officer, wrote in an emailed statement to CBC News.

Two days after the backlog began to grow, Horizon rolled out a new system that relies on email, instead of fax machines, to print COVID-19 test referrals. Using email meant pages could be printed in less than two seconds per page, with no busy signals, records show.

"This new secure system has eliminated the potential for bottlenecks in the distribution of referrals to the assessment centres," Calvert wrote to CBC News.

'Having a kid isolated in a room for six days is terrible'

But on Nov. 27 the same day the frustrated parent emailed Cardy for help the province acknowledged that some testing requests sent during the glitch had gotten lost in the fax machine ether.

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"I'm dumbfounded, dismayed, at an absolute loss," the mother wrote to Cardy, after describing the prospect of having to submit a new request. The mother's name was redacted from the information provided to CBC.

Cardy forwarded the mother's email to Health Minister Dorothy Shephard.

"Another sad case. I was going to suggest that she go to the hospital with her son unless there's another way to get him back to his rightful place in the queue," Cardy wrote to Shephard.

"Having a kid isolated in a room for six days is terrible."

Shephard sent the email to deputy minister Grald Richard, who sent the request down the line to a member of the province's COVID response team.

"I need this kid to be called in for a test," Richard wrote.

The email chain doesn't indicate when the boy was finally able to get tested.

Vitalit still using fax machines to send test requests

While most people under 40 likely haven't used a fax machine in their lifetime, the technology is still quite common in health care.

"The health care system has long used faxes as a secure method of transferring confidential or sensitive documents, particularly in cases where agility, cost, and also any limitations posed by legacy systems are a factor," Calvert wrote.

"With faxing, the information is transferred directly from one fax to a receiving fax with a confirmation that the transmission was received, thus limiting the risk of unauthorized access."

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Department of Health spokesperson Bruce Macfarlane said in November that fax machines were used because of their "ease of mobility and for confidentiality," with assessment centres being set up and taken down throughout the province as needed.

"The malfunction took place due to an increase in demand, beyond the reliable transmission rate the fax machines were able to process," Macfarlane said in a statement sent this week. "Capacity has been since rectified in order to prevent backlog from taking place again in the future."

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Even though Horizon has now moved to a more advanced system that relies on email, Vitalit Health Network confirmed it's still using fax machines to receive COVID-19 testing requests.

"We work in cooperation with Service New Brunswick to ensure that all fax machines are in good working order and meet current standards," Vitalit spokesperson Thomas Lizotte wrote in an emailed statement.

Fax is an old system, but it's secure in the sense that it can't be hacked, according to public health researcher Sajjad Fazel.

Still, Fazel would like to see health care agencies move on to something more modern.

"I think now we need to look at a better system such as email or even electronic medical records systems that do exist, although they exist in ad hoc ways instead of a more broad and connected system within a province," said Fazel, who is a postdoctoral associate at the University of Calgary.

Fax might not be the right solutionwhen urgency is needed, Fazel added.

"We know that at the end of the day, getting those results out quickly and having people either isolate and stay away from others is effective."

Atleast one province has decided to ditch fax machines for more modern technology. Ontario's finance minister says he is directing the province's public service to phase out 1,500 telephone fax lines by the end of 2021.

• Ontario to (finally) pull the plug on fax machines in public service

"Nothing saysThe Flintstoneslike a fax machine," Ontario Finance Minister PeterBethlenfalvytold CBC News.

Technology not always to blame

Like Fazel, Kathryn Brohman wasn't surprised to hear that New Brunswick was relying on fax machines, which she described as "quite a reliable technology," even if it's not exactly new and modern.

"Whereas a lot of these email systems, I think for good reason, some people within the health care system would suggest that they're just not reliable enough," said Brohman, who is an associate professor of digital technology and faculty fellow at Smith School of Business at Queen's University.

"And so I think it really comes down to different parts of the health care system. Although we see them as one big system, they are really motivated by different vulnerabilities."

Brohman questioned whether anyone had tested the system to see if the fax machines could handle a situation like the one that happened. She said it probably wouldn't have taken someone long to determine fax machines weren't the right tool for the job.

Brohman said leaders should always think twice before they blame technology, rather than strategy, for a problem.

"Technology glitches, even 10 years ago, was a safer bet," Brohman said.

"But today's technology is pretty robust, and especially when you're talking about a fax machine, where it's probably one of the most reliable out there."