And just try to get regular people to use email encryption. Yes, it could be signed to show that it hasn't been altered, but then most users can't even figure out where a file has been saved.
So they use faxes.
Here (not US) they've tried implementing a dedicated "secure email platform" for medical professionals so that they can exchange patient data. It's both progress and kind of idiotic, but it's not very widely used (because now, they have yet another email address to manage, on top of the six they already have to use).
It certainly isn't common.
Most of the "small towns" would be villages everywhere else, but it feels like it's shameful in the US. Maybe some places decided to roll with it.