Two-way texting and fax are the two communication channels a clinic cannot opt out of. Patients text, and the rest of medicine still faxes. Most EHRs handle both through a separate vendor: a texting app that syncs back to the chart, an e-fax service with its own login. Moonshot EHR sends and receives texts and faxes itself, from numbers registered to your clinic, and shows texts, portal messages and faxes in one inbox inside the chart. The difference shows up in subscriptions, in logins, and most of all in where a patient's reply lands.
This came up on a call with a customer last week. He had chosen Moonshot partly because texting is built in, and he pointed out that our own website barely mentions it. He was right. Two-way SMS and fax sit in one line of a feature list, as if every EHR had them. Most do not, and the ones that say they do usually mean something narrower than it sounds. So this guide spells it out.
"Integrated" is doing a lot of work
When an EHR vendor says it offers texting, it means one of three things, and the brochure rarely says which.
Native. The EHR owns the phone number, sends the message, receives the reply, and stores the whole conversation in the chart. Staff never leave the EHR. There is one vendor, one login, one bill.
Marketplace integration. A separate company (Curogram, OhMD, Emitrr, BloomText and others sell exactly this) provides the texting. It pulls your patient list from the EHR through an API, your staff text from the vendor's app or browser tab, and some version of the conversation is pushed back into the chart. Sometimes that is a live sync. Often it is a PDF of the thread attached to the record after the fact. You pay the texting vendor separately, usually per user or per location.
Connector. A workflow tool (Zapier, Keragon, Tabflows) wires the EHR to a communication platform such as Spruce. Nothing is really integrated; two products exchange events through a third. This is the version most likely to break quietly.
All three get described as "two-way texting" on a features page. The questions that separate them are simple:
- Who owns the phone number patients text? If the texting vendor does, the number leaves with the vendor.
- Where does a patient's reply appear first? In the chart, or in another app that later copies it over?
- Is there a per-user or per-location fee for texting on top of the EHR?
- When a patient texts STOP, which system enforces it, and does the other one know?
- If you cancel the texting vendor, what happens to three years of conversations?
Why texting, and why the portal alone is not enough
Cash-pay patients at TRT, GLP-1, longevity and performance clinics are mostly working adults. They do not answer calls from unknown numbers and they do not check a patient-portal inbox unless something prompts them. They text. A "your labs are ready" message that arrives as a text gets read in minutes; the same message as a portal notification gets read when the patient happens to log in, which can be never.
The portal still matters, because SMS is not an encrypted channel. Results, dosing conversations and anything else with clinical detail should travel through the secure portal, with the text used to nudge the patient to look. That means a clinic needs both channels, and the failure mode of most setups is that the two live in different places: texts in a texting app, portal messages in the EHR, and no single view of what the patient has been told. The design that works is one thread per patient that carries both, with the staff member choosing the channel for each reply.
Fax is still how medicine moves paper
Nobody likes it, and it is not going anywhere soon. Records requests from a patient's prior clinic arrive by fax. Imaging centers want the order by fax. Specialists want the referral packet by fax. Pharmacies that do not take an electronic order want a fax. A clinic that treats fax as optional ends up with a staff member's personal e-fax account, a shared inbox nobody owns, and PDFs that never make it into the chart.
Native fax means the fax goes out from the thing being faxed: a records release from the chart, an imaging order from the order itself, a referral packet assembled from the visit. Each send has a delivered or failed state you can see later, not just a "sent" toast at click time. Inbound faxes land in a fax inbox inside the EHR where staff file each one to the right patient. The clinic has its own fax number, and there is no separate e-fax bill. Several EHRs do include fax, and credit where due: Cerbo, Jane and Practice Better all list it as a built-in feature. Fewer include texting, and almost none put the two in the same inbox as portal messages.
Where texting and fax actually live, by EHR
The table below is based on each vendor's published feature pages, help centers and announcements, checked on October 14, 2026, with sources at the end. Features change often. Treat this as a map of what to ask, not a verdict.
Scroll horizontally to compare all columns. Keyboard: focus the table region, then use the arrow keys.
| EHR | Two-way patient texting | Fax | Where the patient's reply lands |
|---|---|---|---|
| Moonshot EHR | Built in. Clinic-registered number, send from the chart or inbox, replies thread back automatically | Built in. Send from chart or order; inbound fax inbox files to the chart | One inbox with portal messages, inside the chart |
| Cerbo | Through third-party texting apps (Curogram via Cerbo's API; Spruce via connectors). Not listed as a built-in feature | Built in (outgoing; incoming optional) | In the texting app, then synced to Cerbo depending on the app |
| Jane | SMS reminders only. Two-way texting listed as "in development" (June 2026) | Built in | Secure messages via the Jane client portal or app |
| Practice Better | Client messaging through the portal. No two-way SMS on its feature pages | Built in, with plan page allowances or per-page credits | Client portal |
| Healthie | Through marketplace partners (OhMD). Not listed as a built-in feature | Not listed | In the partner app; conversation pushed back to the chart as a PDF |
| SimplePractice | One-way appointment reminders. Client messaging through the portal | Not listed | Client portal, after an email prompt to log in |
| athenahealth | Native, practice-initiated two-way texting launched in 2026 (Patient Conversations), with secure web chat handoff for PHI | Not evaluated here | Inside athenaOne |
Two things stand out. First, "has texting" and "has two-way texting the patient can reply to" are different claims, and only the second one changes how your front desk works. Second, the EHRs that do include two-way texting natively are mostly enterprise platforms priced for health systems. For a cash-pay clinic the usual path has been a specialty EHR plus a texting vendor on top.
What the bolt-on actually costs
The subscription is the visible part. Published pricing for the common texting add-ons, as of October 2026:
| Add-on | Published price | Notes |
|---|---|---|
| Spruce Health | $24 to $49 per user per month | Plus telecom taxes and fees and a one-time SMS registration fee; e-fax included |
| OhMD | From $300 per month | Per G2 listing |
| Weave | From $249 per location per month | Per G2 listing |
| eFax | $18.99 per month and up | Separate fax-only service; HIPAA tier priced higher |
A five-person clinic on Spruce pays roughly $120 to $245 a month for texting and fax before taxes and fees. That is real but not decisive. The decisive costs are the ones that do not show up on an invoice:
- A second inbox. Someone has to watch the texting app and the EHR. Replies get answered twice or not at all.
- A sync you have to trust. When the push-back fails, the chart is silently incomplete, and nobody finds out until a patient says "I told you that last week."
- Consent in two places. Opt-outs recorded in the texting app do not always reach the EHR's automated reminders, which is how a clinic ends up texting someone who said stop.
- A number you do not own. Leave the vendor and your patients' saved clinic number goes dead.
- Onboarding and offboarding. Every new hire needs another login; every departure is another account to remember to close.
One inbox: texts, portal messages and faxes in the same place
This is the part of Moonshot EHR the website has undersold, so here is exactly how it works.
One row per patient. The Communications inbox shows a single conversation per patient. Their texts and their portal messages are the same thread, color-coded so staff can see which channel each message used. There is no separate "texts" tab to check.
Pick the channel when you reply. The composer has a Text / Portal toggle. It defaults to whatever channel the patient used last, so a texted question gets a texted answer and a portal message gets a portal reply. When the content is clinical, staff flip to Portal and the message goes out securely, in the same thread.
Triage built in. Conversations are Open or Done. Each one can be assigned to a specific staff member or to the team, and the inbox filters to "assigned to me," "unassigned," or a colleague. Staff can leave an internal note on a conversation that patients never see, and turn that note into a task with an owner and a due date without leaving the thread.
Fax in the next tab. Inbound faxes arrive in the Fax tab of the same Communications page. Each one sits as unfiled until a staff member attaches it to a patient's chart or dismisses it. Outbound faxes sent from a chart, an order or a referral packet show delivered or failed in the chart's timeline.
Everything lands on the chart. Texts, portal messages, email, faxes, forms, tasks, encounters and documents all appear on the patient's communication timeline. Conversations started by the clinic's website chat and calls handled by the AI phone receptionist land there too. Reconstructing "what has this patient been told" is one scroll, not four tabs.
What it does not do. SMS is not encrypted, so the system does not pretend otherwise; clinical content belongs in the portal channel. Carriers do not report read receipts for SMS, so a text shows sent or failed, not "read." And Moonshot does not replace the clinic's voice phone line; it owns the written record of the conversation.
Where Moonshot fits, honestly: if you are happy with a specialty EHR plus Spruce or OhMD on top, and your staff have made peace with two inboxes, that stack works and many clinics run on it. Moonshot EHR is for the clinic that wants texting, fax, portal messaging, email and automated reminders to be the EHR's job, with one number the clinic owns and one thread per patient. Clinics already on Spruce can keep it connected as the carrier while the EHR becomes the system of record. See the messaging feature page for the full channel list, or the comparison pages for how it stacks up against specific EHRs.
Sources
Vendor materials checked October 14, 2026: Cerbo features; Jane, "Patient messaging in Jane" (June 23, 2026); Practice Better help center, fax; Healthie features and OhMD Healthie integration; SimplePractice secure messaging; athenahealth, Patient Conversations; Spruce Health plans; G2 pricing listings for OhMD and Weave; Keragon Cerbo and Spruce connector. Competitor descriptions summarize those vendors' own published materials; features and prices change, so confirm current capabilities directly with each vendor before deciding. This guide is general information for clinic operators, not legal or compliance advice. Texting consent rules (TCPA) and HIPAA obligations depend on your program design; confirm them with qualified counsel.