The challenge of computer-mediated communication in health care
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The challenge of computer-mediated communication in health careby Thore DanielsenCould CMC turn out as a helpful tool for the exchange of information within health care? Could CMC support situations beyond the writing of a note or a short letter to a colleague or a co-operating institution? Could CMC become a tool for bridging the information islands? Islands which are a result of implementation of information systems designed to cover the needs of the individual. Bridging is anyway a repair process through the exchange of data between information systems. In this paper we shall first investigate electronic mail and other CMC applications. This will form a basis for a discussion on the potential and the pitfalls for CMC, computer-mediated communication, in health care. The discussion is partly based on surveys of communicational patterns.Introducing CMCThe concept CMC will be used as a reference to both electronic mail systems (e-mail) and the more juicy groupware or CSCW systems. E-mail systems have been around long enough to have matured into commercial products in daily use by a number of people. Systems for CSCW (computer supported co-operative work), or groupware, are still in its infancy except for the more basic conference systems, i.e. vanilla flavoured groupware.E-mail systems will be used as the basis for the first part of the paper when discussing usage, usability and effects of CMC. Groupware will be considered in the concluding discussion and visions for future use of CMC. E-mail systems provide users with the tools necessary for creating, distributing and deleting messages or "electronic letters". As the name itself indicates, the functionality of such systems may be seen as a computer-based copy of traditional mail systems except for two major differences: speed and methods for handling message contents. These, and more subtle differences, all induce changes in interpersonal relations and inter-organisational behaviour. Early CMC applications included methods for handling communication within groups of users, often based on the Delphi method. The first of such systems to be used was EMISARI way back in the early seventies (Hiltz 1977). Later followed systems like EIES, CONFER, COM etc. They differ from the distribution lists by two main aspects:
CMC - spreading the messageExact figures concerning the use of CMC are hard to find. An estimation done in the mid-eighties (Quarterman & Hoskins 1986) show above 200,000 users, i.e. mailboxes on the UUCP (unix-to-unix copy) mail network alone. These users of UUCP were served by some 7,000 hosts. The total number of mail hosts listed in the same survey is close to 30,000. One third of the hosts did however belong to the corporate network of Dec. IBM would supposedly also support a vast number of mailboxes, though their number of hosts was less than a quarter of what Dec had at that time. Most hosts in these networks did also support remote login and file transfer. In addition some 2,500 hosts gave more than 50,000 users access to USENET news, a distributed distribution list service (see below). And these numbers does not include any of the dial-up bulletin-boards systems. An estimate for today would show some million users on a world basis accessing USENET News through some hundred thousand hosts.A forecast made in 1988 (Clausen 1991) indicates that the total number of public and private mailboxes throughout Northern America, Europe and Pacific Asia should exceed 50 million by 1993. The increase over the 5-year period from 1988 was then indicated as approximately 40 % per year. Electronic mail is in a unique position as it "is currently the only organisational computing tool in widespread use by many kinds of people in many kinds of organisations" (Sproull & Kiesler, 1991). The success of any tool for communication relies on the sheer number of peers you may reach through the system. The 50 million mailboxes are by no means interconnected. Most mailboxes reside within private or corporate networks with lacking or no gateways to public systems. Currently close to 70 e-mail services which are listed in the monthly EEMA Briefing1) show a disappointing state-of-the-art for interconnections. Electronic mail is therefore no universal tool for interpersonal communication which is the one major deficiency when compared to telephony and ordinary mail. The power of the simplicity of new services did prove right when the telefax was introduced. Unlike electronic mail, telefax may be used with cheap and functional equipment on an existing network. CMC have although reached a high level of acceptance and usage in academic environments. Most university and research institute employees in technology-oriented sciences and a few others have access to CMC-services. But again, the use of CMC seems to depend more on the tradition of the institution and the interpersonal network of the individual than of the ease of access to CMC. And matters does not necessarily get better when we move on from the interpersonal e-mail to the group-oriented conference tools. CMC - efficiency gained or efficiency lost?Speed is often described as the main advantage with electronic communication. Next, we often find the reduced need for paper and printed versions of the communication as reasons for reduced costs in interpersonal communication. The use of electronic group mail - groupware - may, as pointed out by Sproull and Kiesler (1991), lead to a reduction in the costs of co-ordinating groups of communicators. The asynchrony provided by the CMC system eases the task of scheduling and co-ordinating participants. But asynchrony does also determine communicational processes for which CMC is not suited. As shown by Whittaker (Whittaker, 1991), there are "a number of underlying media factors which determine that asynchronous interaction can never be incremental". Hence, "asynchronous communication is inappropriate for various types of activity that rely on negotiation or shared meaning because these require incremental communication." (ibid). Asynchrony may also delay decision making. An evaluation of two face-to-face and computer conferencing techniques (Archer 1990) showed that "the elapsed time spent in arriving at a decision was generally much longer for CMC than for face-to-face". Such results should not be too unexpected from in-house experiments. But the same experiment did also show that the quality of the decision-making "did not depend on whether or not group interactions were computer-mediated" or not. (ibid.) Thus, CMC may, if it is applied to the "right" communicational processes, result in an increased efficiency due to speed and asynchrony.The integration of CMC into the users' environments may however turn out to be crucial if the gained efficiency shall not be lost. So far, most CMC systems have been given minimal functionality and little or no integration with other information systems. The result is CMC systems suited for exchanging short messages and memoranda and less suited for exchanging documents given in users' electronic file. A few approaches have although been made at designing CMC agents capable of supporting links between electronic mail and the stored information, cfr. (Motiwalla & Nunamaker 1992). At the heart of these agents we find processing mechanisms known as knowledge-based (Motiwalla & Nunamaker 1992, Richardsen & Danielsen 1989). Another approach could be to look at the integration of all communication tools into one single environment. This is for instance found in the Ratatosk environment (Danielsen et al 1991, Finnset 1992, Hartvigsen 1992). Efficiency is more than increased speed. New technology may prove to have effects beyond what is measured in traditional analyses. It may well be that "the most important effects of a new technology may be, not to let people do old things more efficiently, but rather to do new things that simply were not possible or feasible with the old technology" (Sproull and Kiesler 1991). These "second-level effects come about when a new technology connects people with new information and new people". (ibid.) Once users experience this to be "true", CMC will have proven its unique power compared to other communication means. CMC - joining the crowdA critical factor for CMC to be regarded as useful and usable is a well-balanced relation between the complexity of the system, i.e. the number of functions and procedures supported, and the "ability" of the user interface to level with the user and his expectations. Introducing CMC to a new user society will always demand a lengthy and well-coached period of training. Advanced on-line assistance may help out in these matters (Wasson & Akselsen 1992).Studying why people fail to use CMC - why they don't join the crowd - might be interesting. Even more interesting are studies on why people quit using CMC - why the drop out of the crowd. It turns out that implementation of CMC systems, maybe more than any other computer-based system, should be need-driven. The implementation should not start "with a technology in search of an application, but with a collaborative group which has an important and enjoyable task" (Hiltz 1989). They should find CMC as a most appropriate way of communicating regularly, and they should all have easy access to the system, i.e. have their own terminal at their work-place. Minimalising the requested user-effort should be one of the main goals of the design of the CMC and its environment. CMC - getting used to talking electronicallyExactly what is the nature of CMC, and how may CMC prove useful? And with its speed, does CMC end up as a means of increasing the information overload? Surely, the speed and power of CMC might remind us of McLuhans global village: "Ours is a brand-new world of allatonceness. "Time" has ceased, "space" has vanished. We now live in a global village ... a simultaneous happening. () At the high speeds of electronic communication, purely visual means of apprehending the world are no longer possible; they are just too slow to be relevant or effective. () As soon as information is acquired, it is very rapidly replaced by still newer information." (McLuhan & Fiore, 1967).2) CMC and electronic communication has too often been presented with a most promising future, as e.g. by Tesler (1991): "In five or six years' time it will be as natural to collaborate through a network as it is to prepare a holiday feast with friends in a common kitchen".CMC has been subject to studies of usage and effects of use ever since its introduction. The introduction of the EIES system was for instance accompanied by field experiment for assessment of the new technology (Hiltz 1978). Such field experiments may have methodological disadvantages, but they have given valuable insight into the nature of CMC and mediated communication as such. The nature of communication through CMC differs more from the nature of other written communication than what was first expected by e-mail designers. Although being a medium for the written communication, some studies show that users of e-mail soon adopt a more verbal and informal writing style than in both traditional mail and in use of telefax. The differences may be due to the fact that typing something on a computer screen is regarded as less work, and thus as less formal, than putting some message on a sheet of paper. Or as Sproull and Kiesler (1991) puts it, social posturing and sycophancy are reduced which may be regarded advantageous. Also, a study on the comparative use of different communication media cited by Motiwalla et. al. (1992) indicated that users found face-to-face communication and telephone more appropriate for exchanging rich information. A more in-depth study by Lea (1991) shows that users themselves find CMC most like note-writing and letter-writing and least like face-to-face communication. Leas users did also rate CMC as just as asynchronous as letter-writing even though electronic transfer is that much faster. This is an interesting, if not unexpected, result. Further, "E-mailing was construed to be equally spontaneous as face-to-face and telephone conversation" (Lea 1991). Worth noting are also a set of results from a study on computer support for work groups consisting of retired employees and employees at work but eligible to retire (Eveland & Bikson 1988, Hahm & Bikson 1989). The electronically supported groups in this experiment developed structures taking advantage of the electronic media in terms of breadth of access and opportunity to participate and asynchrony increased the ability of non-collocated retired members to take an active role. More interestingly, the electronic groups maintained significantly higher degree of contact and they had considerably less communication isolation. Electronic groups did also experience significantly more involvement. Last, but not least, electronic communication did not turn out as a substitute for traditional media. The electronic groups did instead maintain higher levels of communication through all channels. Other effects, the reduction of politeness and concern for others, are the main disadvantages with electronic communication. "In adding the memory and processing power of computers to communication technology, electronic communication does much more than speed up information flow. It loosens constraints of space, time, numbers of people, social or organisational boundaries, and information ownership on communication" (Sproull and Kiesler 1991). Not surprisingly we thus find a category called "Threats and put-downs" in McCormick and McCormicks (1992) study of the contents of undergraduates' e-mail. During a six month period more than 3 % of the messages exchanged fell into this category. Although the users in this case were a youthful, small sample of undergraduates, "flaming" is found in most e-mail environments. Regarding "emotional quality" Leas users rate e-mail slightly towards the poor end of the dimension, whereas face-to-face communication and telephoning were seen as activities providing a "facility to express emotions" (Lea 1991). Leas users were using e-mail in their business and inter-organisational communication, therefore one would expect them to do less socialising across the network. McCormick and McCormicks users were young students, and more than half of the replies to why they used electronic mail was that they did it to socialise. For these users, CMC "enhanced intimacy instead of stifling it" but CMC was not seen as a substitute for a face-to-face support network. Conversely, of those students that did not use e-mail, less than one fifth of the answers gave "Prefer private conversations" as the reason of non-use of CMC (McCormick and McCormick 1992). Most studies of CMC-usage show that heavy users of e-mail report having more face-to-face communication than the light users. The low emotional quality of CMC have however given rise to a whole set of new grammatical constructs like e.g. :-) showing a smile (mostly used to indicate that a specific phrase is to be taken as a joke), :-0 showing that the writer is shouting at you; ;-) showing that the writer is winking at you, etc. CMC have thus proven to establish new ways of interpersonal behaviour. And CMC have been looked at as a tool which might enhance present working situations. Electronic mail is the general-purpose CMC tool which leaves the user more in control of the situation than some of the more advanced groupware tools which forces the users to behave according to specified patterns. Which is the better, the former or the latter, is all dependent upon the context in which the communication takes place. Learning through the networkCMC have given a new dimension to the world of distance learning. With CMC available it turns out that students in distance learning may more easily establish and maintain interpersonal networks and they are given easier and more convenient "access" to their tutors (Fjuk & Jenssen 1989, Castro 1991, Rasmussen et al 1993). It seems that CMC fills the need for a way of exchanging questions and answers, problems and suggested ways of dealing with those in an asynchronous manner. And, taking into account the situation of the distance learner who holds down a job or has a family to look after, CMC is particularly suited (Castro 1991). In this manner, CMC turns out to be a powerful addition to the pre-packaged instruction material.CMC has been used for constructing virtual classrooms (Hsu & Hiltz 1991) and has proven to be extremely helpful in teaching collaborative skills to students. Through the virtual classroom, a set of software in combination with the EIES CMC system, students were grouped into teams carrying out role playing, event-oriented scenario games. A control group was given the same tasks to perform, but were not given access to the virtual classroom. Not only did the students with access to the virtual classroom gain better results in the games, but they did also establish a closer social network and "camaraderie" (Hsu & Hiltz 1991). Confer also the results of the field experiment with the retirees cited above (Eveland & Bikson 1988, Hahm & Bikson 1989). In another study (Harasim 1991) it was found that "delivery of education through computer communication alters the relationship of the instructor, the students, and the course content" - students engaged in collaborative learning. The same study does however point to the importance of the interface of the CMC and the integration with other computer-based tools for handling information, including the information exchanged through CMC. Integration, and the structuring of information, may further strengthen the position of CMC in distance education. One such system is based on the use hyper-structures as means for communicating in a local area network (Romiszowski 1990). This experiment came about after some initial experiments with plain CMC in distance learning. The integration of CMC with access to databases have also proven as a powerful means of gathering information in the process of learning. CMC and the health care environmentSurviving in the information society is more a question of gaining access to the most relevant information for the situation at hand than a question concerning the existence of the information. In other words, it is not that much a question of "is the information somewhere to be found?" than a question of "how do we go about finding what we want?" "Communication systems can provide a way to assess the need for medical help and avoid unnecessary visits to doctors, as well as encourage necessary ones." (Greenberger & Puffer 1989).Most works concerning computing in health care which touch upon the concept of communication translates this into the networking of information systems (databases). The basis of these stories are always the same: the vast amount of medical information which may be relevant for problem solving, and the large number of sources of relevant information. This is true for e.g. Rennels and Shortliffe (1987) in their work on advanced computing for medicine: "The need for communication systems arises in part because it is increasingly difficult for a physician (or a biomedical investigator) to read, memorise and remember all the information needed to solve a particular problem. () Physicians have accordingly started to use literature data bases, or bibliographic retrieval systems." The same is true for O'Desky et. al. (1990) when they try to identify evolving computer technologies and further try to anticipate what effect they will have by the year 2000. Also, we seldom find CMC considered as relevant in works on medical informatics and education (e.g. the special issue of the Methods of information in medicine, vol. 28, 1989). From this we could have concluded that CMC has no future neither in the daily work in health care, nor in the education of health care workers. A counterexample is found in the book by Ellis (1987) where he looks at computing and applications in medical environments where a few passages briefly touches the concept of CMC and its potential: "A particular growth area is in the computer technology analogue of the postal service: electronic mail. () Whether this is between individual doctors or health centres and hospital departments, electronic mail offers much scope for breaking the tyranny of the paper-based health service. Furthermore, such facilities as bulletin boards allow doctors and other health care professionals to exchange views and information in a more immediate and informal fashion than the traditional letter in a journal." (Ellis 1987, page 28). This gives hope for CMC as a method of establishing and maintaining professional interpersonal networks. Further, Ellis finds applications for CMC in relation to the general practitioners information systems: "... what the doctor could do with is: a) more efficient channels of communication between his or her clinical environment and the outside; b) assistance in sorting the informational wheat from the chaff; and c) practical strategies for handling knowledge in a more positive manner. () Obvious applications of electronic mail in general practice include sending referral letters to out-patient departments, receiving discharge summaries direct from hospitals, the rapid reporting of pathology results, and so on." (Ellis 1987, page 139). So Ellis points directly to, for instance, the application of CMC in the distribution of information to and from patient record systems. The next step into a CMC-supported health care environment would then have to be based on an investigation into "the channels of communication between a doctors clinical environment and the outside. The challengeThe former is a result of implementation of information systems designed to cover the needs of the individual. The latter is the traditional method of repair through the exchange of data between information systems. For some, CMC is looked upon as a potential bridge between health care institutions. CMC and access to databases are the key applications in the MEDIS package (Engum 1991). This integration was believed to give users, i.e. physicians, a minimum of information services relevant for their needs. A first version of this package has been implemented as part of the telemedicine project and has been introduced to a number of potential users. MEDIS is built to fit with hardware currently available in the health care sector - that is PCs. That means that users should be able to access medical information services from their own workstations. A prototype version of a more advanced integrated package for information services has also been implemented. This package, known as Ratatosk, runs on Unix workstations.In order to gather knowledge on the communicational structures within health care, a number of surveys have been undertaken. These surveys cover general practitioners offices (Danielsen 1991a, Danielsen 1991b), use of external laboratory tests for general practitioners offices (Stenvold & Karlsen 1991) and a radiology department at a specific hospital (Braa et al 1991, Engevik 1991). Some of the results of the survey at GP offices are:
A number of forecasts and "dreams" of a golden age for CMC have been given since the birth of computers. Whether these forecasts were wrong with respect to the number of people using or the frequency with which they use CMC are of less interest. What is of interest to note is that CMC has not turned out to be a key reason for investing in technology for any CMC type of user, i.e. people do not buy computers because they need to or like to use them for communicating with other people. Yet, technology for person-to-person communication is seen as one of the information technologies which will have a significant organisational impact (Straub & Wetherbe 1989). However promising forecasts may be, we should not expect CMC to take over as the one most used general purpose communication medium in health care. CMC may strengthen its position in health care environments if, and only if, it proves to help out in improving productivity. As for CMC and productivity, a study (Hiltz 1988) shows that pre-use expectations correlates the strongest. That means, for CMC to "conquer" the market, potential users should state belief in CMC as the right tool. Further, the study shows that the perceived value of information provided by peers, time spent on-line, perception of problems with this mode of communication and how many users get to know while on-line are process variables playing a role in determining positive productivity outcomes. Lastly, "the social context and software differences will interact to affect the most productive applications of the system". That means that the competitiveness and the co-operation between group members have to be considered carefully. As to the simplicity of the CMC system it turns out that the easier the system is to understand initially, the more are users likely to limit what they will attempt to accomplish. Consequently, CMC should be applied to the non-incremental communicative processes where user expectancies with respect to improved productivity are considered as positive. This would be the case for CMC integrated with computer-based systems for storing patient-oriented information. Furthermore, in the case of group-oriented CMC, e.g. conferencing systems, the emphasis on non-incremental communication should be strengthened. Health care information relevant for such systems are therefore not found in the lengthy discussions between colleagues - even if they are geographically dispersed, but in the processes where data and news are posted for a larger audience which could benefit from commenting or responding to whatever was posted, e.g. a hospital announcing changes in their procedures, etc. The challenge of CMC is to prove itself as the highly context- and problem-specific tool in daily work routines of health care, and not to present itself as merely another general-purpose method for communicating. ReferencesArcher, N P. 1990. A comparison of computer conferences with face-to-face meetings for small group business decisions. Behaviour and information technology, 9, 307-317.Benford, S, Turoff, M, Palme, J. 1992. An ISO standard to support asynchronous group communication. Computer Standards & Interfaces, 14, 363-373. Braa, J, Monteiro, E, Vedel, E. 1991. 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Sist oppdatert 03-09-99.