By Bob Watson, CEO, Health Gorilla
LinkedIn: Robert (Bob) W.
LinkedIn: Health Gorilla
One of the clearest tests of the federal government’s $50 billion Rural Health Transformation Program (RHTP) will be whether rural patients’ health information can move with them across the healthcare system.
To ensure continuity of care, it’s essential that when patients travel long distances for specialty care, emergency treatment, or hospital procedures, their records are readily available to their local clinicians to continue their care upon their return home. With the goal of addressing longstanding rural healthcare gaps, in December 2025 the Centers for Medicare & Medicaid Services announced Rural Health Transformation Program awards for all 50 states, with funding distributed in $10 billion installments through 2030. Yet whether that investment produces better outcomes may depend on a basic capability that received little attention in state applications: ensuring that rural patients’ clinical information follows them wherever they receive care.
The fax machine is infrastructure, not a relic
Fax and mail remain widely used to exchange clinical documents between healthcare organizations, and many incoming records still require manual review, routing, or data entry. In 2025, 40% of hospitals reported that they “often” use mail or fax to send patient records to outside sources, identical to the number in 2018, according to the Office of the National Coordinator for Health Information Technology (ONC). Rural providers face an even steeper interoperability challenge because they are less likely than urban providers to have the systems and connectivity needed for seamless electronic exchange. The reason is not nostalgia. Exchange networks only work when both ends are connected, and a lot of rural providers are not.
For example, picture a patient who drives 90 minutes to an out-of-market center of excellence for a procedure, then returns home with a stack of printouts that a front desk staffer has to scan in by hand. That handoff produces duplicated testing, broken follow-ups, and administrative burden on clinics that are already stretched thin.
CMS has set a 2028 goal to phase fax machines out of data exchange, an ambitious timeline for providers still working through it. Consider the urban versus rural contrast: A large, urban academic medical center sees patients from a defined referral area with established relationships. Conversely, a rural provider is sometimes the only provider in the county, the last line of defense, seeing a patient who may have been in an emergency room two counties over last week and a specialist’s office last month.
Rural patients also carry a higher chronic disease burden and more complex social needs, which raises the cost of every data gap. When a critical access hospital transfers a patient to a regional trauma center, what happens – or doesn’t happen – to that record matters as much as the transfer itself.
Why rural providers face a steep climb
Large health systems typically have chief information officers, an integration teams, and the leverage to negotiate connections with their biggest partners. A 25-bed critical access hospital generally has none of that. Many rural providers still run on smaller, legacy, or niche electronic health record systems that were never built for FHIR-based exchange, and most regional health information exchanges grew up around the urban systems that held the most data first, leaving rural providers outside those networks almost by design. Thin IT staffing and patchy broadband compound the problem. For rural hospitals, many of which operate at a loss, there is little room to invest in the infrastructure they are already years behind on.
This is where TEFCA and the Qualified Health Information Network framework matter most, and why they matter differently for rural providers than for large systems. TEFCA has already processed more than a billion records, up from roughly ten million a year earlier, and new QHINs keep joining. For a rural clinic with close to zero existing connections, “join once, connect to everyone” is likely its only realistic path to interoperability. However, that only holds if states treat connectivity as core infrastructure rather than an afterthought.
What the money should buy
The $50 billion splits into two branches, half distributed equally across states and half weighted by workload and results. States have real discretion over the next 12 to 18 months, and legal groundwork matters as much as technical groundwork. Without clear legal frameworks spelling out who can access records, under what consent, and who bears liability when data crosses organizational or state lines, even a fully connected network can stall in practice or expose states to compliance risk.
Data sharing agreements, privacy compliance, and governance structures need to be built alongside the technology, not after, according to the Network for Public Health Law.
States will also be tempted by vendors pitching the next shiny tool. The sturdier foundation treats telehealth, interoperability, and cybersecurity as the non-negotiable floor beneath everything else, not optional add-ons layered on top, according to EY. Skipping that floor risks a connectivity cliff once the five-year funding window closes.
Fifty billion dollars is enough to build something durable, or enough to paper over the same structural gaps for another decade. The difference comes down to whether data infrastructure gets funded as the foundation the rest of the program stands on. The continued dependence on fax machines was never really the problem. It represents the symptom of rural health never getting the connective tissue the rest of the system takes for granted. Allocating RHTP funding wisely represents the best opportunity to reduce this long-running imbalance.