Six years ago, a man pulled off a highway in rural Washington because his chest hurt. The ER physician called Gautam, the cardiologist on call, 120 miles away. Nearly twenty minutes passed before he had the ECG. In rural Washington in 2019, you send an ECG by fax. By the time Gautam reviewed it and called back, the patient was coding. He died.
That story is about a fax machine. It is also about something harder to fix: two physicians on either end of that phone call who had no secure, reliable way to coordinate care across organizations in real time. The fax machine was the symptom. The communication gap was the disease.
The fax machine is not a metaphor. It is the actual infrastructure connecting most rural hospitals today. When a critically ill patient needs a specialist 200 miles away, someone dials a paging operator, waits on hold, and eventually gets a document that arrives blurry, sideways, or not at all. The EHR was supposed to solve this. It didn’t. EHR systems were built for documentation and billing, not for the conversation that drives clinical decisions. We have never heard a colleague say the EHR helped them coordinate care.
Texting is better than a paging operator on hold. But it isn’t HIPAA compliant, it leaves no audit trail, and when a case goes wrong, there is no record of who knew what and when. Every physician who has ever texted a patient’s name and lab result to a colleague knows exactly what that feels like. You do it because it works. You do it knowing you probably shouldn’t. When something goes wrong, that text thread becomes a malpractice record nobody intended to create.
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We are a cardiothoracic surgeon and a cardiologist, friends since medical school, who spent the years after that case building what didn’t exist. Not because we are engineers, but because we were tired of watching the problem go unsolved. The result is Coltrain: a free, HIPAA-compliant, EHR-independent platform that lets any clinician coordinate care with any colleague around a shared patient, regardless of location or health system. Within three years, almost 1,900 clinicians across Washington and Kansas are using it. ECMO teams activated across institutions at 2 a.m. Tumor boards running across multiple hospital systems. Community health workers reaching specialists their patients had never been able to see.
In the health systems where clinical and IT leadership looked at it together and asked the right questions, the process moved in weeks. The technology worked. The clinical case was clear. Approval came.
But that is not the common experience.
More often, this is what happens. A physician brings a solution to their health system. Clinical leadership sees the value immediately. The CMO understands the coordination problem. The CEO sees the physician retention argument. And then it goes to IT. Reviews begin. Months pass. The conclusion, when it comes, is almost always the same: not approved, no alternative offered, because none exists. Health systems cannot afford to lose another doctor to frustration but pick the fax machine anyway.
This is not a criticism of health IT leaders. The people responsible for information security are doing exactly what their institutions trained them to do, inside guardrails that were built for a specific purpose. Every new platform is a potential security exposure. Every vendor relationship carries compliance risk. Those guardrails are right for a $10 million Epic integration. They are the wrong tool for evaluating a free, HIPAA-compliant platform already in use by nearly two thousand clinicians. The problem is not the people following the process. The problem is that no institution has built a separate process for this category of solution. In the absence of that process, the default is no. Not because anyone decided the solution was bad. Because nobody built a pathway to find out if it was good.
Eighty-six percent of rural counties in the United States have no cardiologist. Rural Americans die of cardiovascular disease at measurably higher rates than their urban counterparts. These are not statistics about technology. They are statistics about whether a patient can reach the right physician, with the right information, at the right moment. The tools to close that gap exist. What most health systems are missing is a pathway for evaluating clinician-built solutions that are already HIPAA-compliant, already in clinical use, and already producing measurable outcomes.
If you are a clinician reading this, you do not need to wait for that process to be built. There is no IT ticket to file, no procurement process to survive, no administrator to convince. You find your colleague and you start. A surgeon connects with a cardiologist at a different hospital. An oncologist runs a tumor board across three systems. A community health worker reaches a specialist her patient has never been able to see. You do not need your health system’s permission to coordinate with a colleague. You need a colleague. Start there.
If you lead a health system or a health IT department, you are not the obstacle. The process is. And you are the ones who can fix it. Build a separate evaluation pathway for clinician-built innovation. Separate security review from vendor procurement. Create criteria specifically for solutions that are free, HIPAA-compliant, and already in clinical use. The institutions that build this pathway will retain more physicians, improve care coordination, and find that the people closest to the problem are often closest to the solution.
The man who died in rural Washington six years ago deserved a better system than the one we had. So do the millions of Americans with no specialist nearby. The tools exist. The physicians are ready. The next thing worth building is the process that lets both of those things matter.
We took an oath. It didn’t come with a sign-off requirement.
Sanjay Khicha and Gautam Nayak are physician executives.
