electronic communication essay

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Electronic Communication Essay

Essay on electronic communication.

What dangers are there for a society which depends on computer screens rather than face to face contact as its main means of communication? Introduction Communication has been the center of human society since time immemorial. Human beings are social beings. This renders communication a cog in the wheels of daily interactions. Online interaction consists of communication via electronic mail, chatting, blogging and social networking. These keep human beings glued to their mobile phones and computers. Sending text messages is another dimension of electronic communication. These methods are fast and convenient. They have gained fast popularity in the human population. Individuals are hooked on social media sites, chat rooms and e-mail accounts. These modes of communication and interaction are becoming acceptable to the general population. However, this kind of interaction comes with dire consequences.

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This essay endeavors to explain the dangers that dependency on social media and online communication pose to society. Research has been carried out in the area of social media and online communication. The effects of electronic communication and social media on human interactions have been investigated .The data obtained is the basis upon which reliable conclusions can be drawn. Psychologists postulate that the withdrawal from face to face communication is a danger to the society as a whole. Individuals withdraw from the interactions with each other. This undermines the social nature of human beings.

Thesis statement: A society that depends mainly on electronic communication is likely to disintegrate. This is due to the lack of holistic communication presented by electronic means of communication.

Dependency on social media and electronic communication leads to degeneration of social skills. 75% of the human population in a study carried out in 21 countries uses their cell phones to text. 50% of the population in America is actively involved in social networking (Pew Research 2012) Adults who use electronic communication regularly find themselves unable to deal with one on one communication. Face to face communication needs practice. Human beings need regular interaction with each other in order to develop and polish their communication skills. Electronic communication is one dimensional. This can be attributed to the fact that this mode of communication is solely based on typing and reading. This kind of communication mutes the experience offered by one on one interaction. Communication consists of words, emotions, body language and personal presence (Joinson 2007). Words and smiley faces cannot capture the essence of communication. Authentic communication involves what one is saying and how one is saying it. A good example is a termination message sent via e-mail to an employee. The words alone cannot convey the tone and expressions of the employer. The employee is likely to draw conclusions based on how he or she feels about the termination.

This example illustrates the gap created by electronic communication. This gap creates assumptions which lead to misunderstandings. It is impossible to communicate regret, trust, confidence etc via electronic media. Communications skills are necessary for personal development and growth. Majority of the individuals found online are teenagers. Social media is a meeting point for teenagers. 73% of 18-19 year olds use their cell phones to access internet (Pew 2012) Teenagers are able to meet and relate with friends from all over the world without having to meet them physically. This trend leads to neglect of communication skills. Young people learn to interact superficially. They avoid face to face communication. This means that they will never get a chance to practice actual one on one interaction. This kind of conditioning endangers future relationships. Individuals will find themselves unable to maintain meaningful relationships. An individual who is accustomed to updating his or her status, tweeting, sending short text messages and chatting will find holding a conversation difficult and cumbersome.

Communication is the backbone of human relationships. Human relationships are the basis of a functional society. A society which does not have functional relationships is a dysfunctional society.

Online communication perpetrates crime. Social structure requires boundaries (Joinson 2007). Without boundaries, chaos is likely to result. Social media lacks human boundaries. Anonymity is a predator of society. Anonymity removes the human face of an individual. Social media and online interaction provide means of masking one’s identity. This leads to a trend dubbed ‘online dis-inhibition effect’. This refers to the phenomena whereby an individual is freed of social norms.

This freedom results in a variety o interesting phenomena. Individuals tend to be more trusting and gullible than they would normally be. It is difficult to judge a person’s character online. Body language is crucial in character discernment. People can pretend to be who they are not. This pretense is easily propagated online. This is one of the reasons as to why online crime thrives. It is easy to commit crime when one’s identity is hidden. Individuals easily divulge personal information online. The boundaries that protect an individual in face to face interactions are absent online. This increases the chance of an individual becoming a victim to cyber crime. Another effect of anonymity on social media is cyber bullying. 32% of teenagers on social media say that bullying occurs online (Lenhart 2007).This mostly affects the teenage population. Cyber bullies are cruel and vicious. Anonymity gives them the courage to carry out atrocities that they would not attempt in broad daylight. A society that chooses online interactions and other forms of electronic media is likely to suffer the ravages of crime. Anonymity is a tool that fuels the dark machinations o perverted human beings.

Social media and electronic communication violates privacy (Austin 2003). Social media sites are the biggest violators of privacy. There is a general presumption of privacy within social media circles. Twitter is a social media site whereby what an individual tweets can be re-tweeted infinitely. 6% of tweets are re-tweets (Sysomos 2010). In this kind of scenario, the original tweeter has no control as to how far and wide his or her tweet will travel. Other social media sites have options for sharing photos. A user may decide to tag private photos to certain friends.

However the chosen friends can decide to share the photos with all sundry. This limits the privacy that an individual can maintain online. Privacy is a personal treasure. It is difficult to deal with violated privacy. It undermines the integrity of the individual. A society with reliance on online communication and socialization is likely to forget the tenets of privacy (Joinson 2007). Everybody’s dirty laundry will be aired online for the whole world to see. This will degrade the moral values of the society.

Conclusion A society that chooses online interaction and electronic communication will disintegrate due to lack of proper communication skills. The members of this society will be prone to crime. Crime and cyber bullying will increase due to anonymity. The society whose members are hooked on to their computer screens will have no respect for privacy and personal space. It is therefore imperative for people to consider stepping out of their comfort zones and indulging in some old fashioned face to face communication.

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Electronic Communication Essays

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Electronic Communication vs Direct Human Interactions Essay

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A commercial featuring celebrity Kristen Bell and Dax Shepard for Samsung tablet show the couple through a day of their life, engaged continually with their gadgets, even when they are sitting in front of one another. They avoid many social events to watch a film in their gadget and connect with one another through the device from different rooms in their house. Though unintentionally, but the advertisement shows how electronic communication impairs face-to-face interaction.

Proponents of electronic communication contend that it has increased connectedness and removed the distance created by time and space, creating an indispensable medium of communication. Nevertheless, its socio-psychological effect on man raises questions concerning its effectiveness as a means of communication. It is like an addiction of the modern age to fight loneliness, thereby, making lonelier souls. I believe direct human interaction is better than electronic communication. In this essay, I argue that electronic communication removes emotional complexities of human interaction, sterilizes human senses essential for man-to-man interaction, and creates island human beings.

What is communication? Is it just an exchange of meaningful words, as is done over emails or SMS? Communication is a meaningful expression of various emotional cues, articulated with or without words or in combination of the two. I believe electronic communication is incomplete as it fails to deliver the emotional quotient of a human interaction. Conversation entails not only the spoken words but also the emotions hidden behind the words.

When we communicate, our senses work together in order to receive signals from the other, generate mirror neurons in response, and reciprocate accordingly (Wagner 115). For example, when one complains of the trouble at work to a face-to-face conversation with a friend, the latter can relate to the former’s anxiety and anger not only because of the words she speaks, but also from her body language. However, if the same message was shared through an SMS, the feelings are foregone, thus producing little or no empathy from the receiver. Thus, the communication remains incomplete.

Electronic communications create a delusional reality. Incessant use of video games, mobile phones, computers, or social media alienates one from the real world. For instance, Facebook is a medium to communicate and interact. Some think that it is a potent means to make new friends. On the contrary, it builds relationships based on falsehoods (Wagner 118). A woman posts a picture that shows her as a slim, beautiful woman but actually, she proves to be an overweight person.

She fantasizes herself as that online avatar and engages in a relationship with others through the social medium. Clearly, this woman is unsatisfied with her body image, and it may have damaged her relationships in the real world. When she gets a new medium that gives her the freedom to create a new self, a new identity, she eagerly embraces it. Thus, she creates her own unrealities and communicates them to others. This communication is basically false. Therefore, social media actually manipulates our fears and anxieties to push us to accept and project lies.

Electronic communication has the potential to control and manipulate the worst fears and anxieties of man. Loneliness is endemic in the modern world. People, who are introverted, often lack social skills to engage in communication with others (Kang and Munoz 205). Electronic communication is an easy medium for those who lack social skills to participate and engage in online conversations.

This is so because real life communication has a lot of pressure on the people who lack social skills and they constantly make efforts to meet those demands. They are aware of their shortcomings and fear connecting in real life. Such people are usually loners as inadequate social skills ostracize them from society. However, electronic communication obliterates these incompetencies. It provides a medium for such people to communicate without fear of being judged (“Does Facebook make you lonely?” par. 6). This induces such people to engage more in online social media as it gives them a new platform to remove their social anxieties.

Thus, social media removes fear from people who were otherwise loners. Apparently, electronic media helped a person to overcome his fear of communication. However, did this makeover transpose to the real life or was it confined to the virtual world? Ideally, when an introvert person gains confidence in his communication skills in the virtual world, it should also show in the real world. However, in reality this does not occur. A loner becomes lonelier as his detachment with the real life, due to his growing online engagements, increases (“Does Facebook make you lonely?” par. 15).

Electronic communication is an ineffective medium of interaction as it fails to deliver the whole message as essential emotions are discarded. Electronic communications are just words. There are no emotions, no senses, no compassion attached to it. In addition, it preys on the loneliness of people and entices them into a fantastic world of lies and deceit. In the end, it completely strips a man’s social communication skills and draws him into the quagmire of loneliness, making him an island.

Works Cited

“ Does Facebook make you lonely? ” 2014. University of Wisconsin-Milwaukee . Web.

Kang, Sun-Mee and Martha J. Munoz. “Preference for Online Communication and Its Association with Perceived Social Skills.” Individual Differences Research 12.4 (2014): 198-208. Print.

Wagner, Lori Ann. “When Your Smartphone Is Too Smart for Your Own Good: How Social Media Alters Human Relationships.” The Journal of Individual Psychology 71.2 (2015): 114-121. Print.

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100 Electronics Engineering Essay Topic Ideas & Examples

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Electronics engineering is a fascinating field that involves the design and development of electronic devices and systems. If you are a student in this field, you may be required to write essays on various topics related to electronics engineering. To help you get started, we have compiled a list of 100 essay topic ideas and examples that you can use for your assignments.

The impact of artificial intelligence on electronics engineering

The role of electronics in the healthcare industry

The future of wearable electronics

The importance of signal processing in electronics engineering

The challenges of designing power electronics systems

The evolution of electronic communication

The use of electronics in renewable energy systems

The impact of IoT on electronics engineering

The role of electronics in autonomous vehicles

The future of quantum computing in electronics engineering

The challenges of designing electronic devices for harsh environments

The role of electronics in space exploration

The importance of cybersecurity in electronics engineering

The impact of 5G technology on electronics engineering

The role of electronics in the defense industry

The challenges of designing low-power electronics

The future of robotics in electronics engineering

The role of electronics in the entertainment industry

The impact of electronics on the environment

The challenges of designing flexible electronics

The role of electronics in the education sector

The importance of nanotechnology in electronics engineering

The impact of biometrics on electronics engineering

The challenges of designing electronic devices for the elderly

The future of brain-computer interfaces in electronics engineering

The role of electronics in telemedicine

The importance of MEMS technology in electronics engineering

The impact of blockchain technology on electronics engineering

The challenges of designing electronics for smart homes

The role of electronics in agriculture

The future of 3D printing in electronics engineering

The importance of robotics in electronics manufacturing

The impact of virtual reality on electronics engineering

The challenges of designing electronics for the automotive industry

The role of electronics in disaster management

The importance of machine learning in electronics engineering

The impact of big data on electronics engineering

The challenges of designing electronics for the aerospace industry

The future of bioelectronics

The role of electronics in the music industry

The importance of analog electronics in modern devices

The impact of smart grids on electronics engineering

The challenges of designing electronics for smart cities

The role of electronics in sports technology

The future of quantum electronics

The importance of optical communication in electronics engineering

The impact of augmented reality on electronics engineering

The challenges of designing electronics for the Internet of Things

The role of electronics in environmental monitoring

The future of bioinformatics in electronics engineering

The importance of sensors in electronics engineering

The impact of power electronics in renewable energy systems

The challenges of designing electronics for medical implants

The role of electronics in the fashion industry

The future of energy harvesting in electronics engineering

The importance of cybersecurity in the design of electronic devices

The impact of edge computing on electronics engineering

The challenges of designing electronics for smart agriculture

The role of electronics in disaster recovery

The future of artificial intelligence in electronics engineering

The importance of haptics in electronics engineering

The impact of cognitive radio on electronics engineering

The challenges of designing electronics for smart transportation systems

The role of electronics in the gaming industry

The future of neuromorphic computing in electronics engineering

The importance of quantum cryptography in electronics engineering

The impact of neuromarketing on electronics engineering

The challenges of designing electronics for the mining industry

The role of electronics in wildlife conservation

The future of electronic voting systems

The importance of wearable electronics in healthcare

The impact of electronic waste on the environment

The challenges of designing electronics for underwater applications

The role of electronics in disaster response

The future of electronic skin

The importance of energy-efficient electronics

The impact of electronics on the job market

The challenges of designing electronics for space exploration

The role of electronics in the music production industry

The future of electronic textiles

The importance of sensors in autonomous vehicles

The impact of electronics in the fashion industry

The challenges of designing electronics for smart buildings

The role of electronics in wildlife monitoring

The future of electronic warfare

The importance of flexible electronics in wearable technology

The impact of artificial intelligence in electronic

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Home — Essay Samples — Science — Electronics — Types of Electronic Communication

Types of Electronic Communication

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Published: Dec 18, 2018

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The Role Of Technology In The Evolution Of Communication

For as long as humans have been on this planet, we’ve invented forms of communication—from smoke signals and messenger pigeons to the telephone and email—that have constantly evolved how we interact with each other. 

One of the biggest developments in communication came in 1831 when the electric telegraph was invented. While post existed as a form of communication before this date, it was electrical engineering in the 19th century which had a revolutionary impact. 

Now, digital methods have superseded almost all other forms of communication, especially in business. I can’t remember the last time I hand wrote a letter, rather than an email at work, even my signature is digital these days. Picking up the phone is a rare occurrence too—instead, I FaceTime, Zoom, or join a Google Hangout. 

When I look back at how communication has advanced over the years, it really is quite incredible…

The Telephone 

In 1849, the telephone was invented and within 50 years it was an essential item for homes and offices, but tethering impacted the flexibility and privacy of the device. Then, came the mobile phone. In 1973, Motorola created a mobile phone which kick-started a chain of developments that transformed communication forever. 

Early smartphones were primarily aimed towards the enterprise market, bridging the gap between telephones and personal digital assistants (PDAs), but they were bulky and had short battery lives. By 1996, Nokia was releasing phones with QWERTY keyboards and by 2010, the majority of Android phones were touchscreen-only. 

In 2007, Steve Jobs revealed the first iPhone to the world and Apple paved the way for the aesthetics of modern smartphones. Before the iPhone, “flip phones”, and phones with a split keyboard and screen were the norm. A year later, a central application store with an initial 500 downloadable ‘apps’ was launched. Currently, there are over two million apps available in the Apple App Store. 

The Internet 

Since the mid-1990s, the Internet has had a revolutionary impact on communication, including the rise of near-instant communication by electronic mail, instant messaging, voice over Internet Protocol (VoIP) telephone calls, two-way interactive video calls, discussion forums, blogs, and social networking. 

The internet has made communication easier and faster, it’s allowed us to stay in contact with people regardless of time and location. It’s accelerated the pace of business and widened the possibilities within the enterprise space. It’s allowed people to find their voice and express themselves through social media, YouTube and memes. The internet has connected and divided us like nothing before. 

As a byproduct of the World Wide Web, email was introduced to the world in 1991 (although it had been operating years before) and it has vastly changed our lives—whether for better or worse depends on your viewpoint. The first users of the messaging platform were educational systems and the military who used email to exchange information. In 2018, there were more than 3.8 billion email users —that’s more than half the planet. By 2022, it’s expected that we will be sending 333 billion personal and business emails each day. 

While email is invaluable and we can’t imagine a world without it, there are tools that are springing up that are giving email a run for its money. Take Slack (an acronym for “Searchable Log of All Communication and Knowledge”) for example, the company which launched in 2014 has often been described as an email killer . However, while Slack has become the most popular chat and productivity tool in the world used by 10 million people every day, email is still going strong. In recognition of this, Slack’s upgrades have ensured that people who still rely heavily on email are not excluded from collaboratory work. 

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Wearable Technology 

The first instance of wearable technology was a handsfree mobile headset launched in 1999 , which became a piece of tech synonymous with city workers. It gave businesspeople the ability to answer calls on the go, most importantly, while driving.

Ten years ago, the idea that you could make a video call from an item other than a phone would have been a sci-fi dream. Now, with smartwatches, audio sunglasses, and other emerging wearable technology, these capabilities are a part of our daily lives. 

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Virtual Reality (VR) 

The next generation of VR has only been around since 2016, but it’s already shaking up communications. The beauty of VR— presence —means you can connect to someone in the same space at the same time, without the time sink and cost of travel, even if participants are on different continents. 

VR also helps to facilitate better communication. In a typical discussion, a lot of information is non-verbal communication which can be transcribed in VR. Voice tone, hesitations, head and hand movements greatly improve the understanding of the participants' emotions and intents. Plus in VR, all distractions are removed and people can be fully focused on what is happening around them. In fact, MeetinVR claims that there is a 25% increase in attention span when meeting in virtual reality compared to video conferencing. 

In addition, research suggests we retain more information and can better apply what we have learned after participating in virtual reality. 3D is a natural communication language overcoming linguistic barriers as well as technical jargon. 

5G, the 5th generation of mobile network, promises much faster data download and upload speeds, wider coverage, and more stable connections. These benefits will bring about significant improvements in communication. Instantaneous communication will be possible and those patchy frustrating video calls will be a thing of the past. 

The average 4G transmission speed currently available for our smartphones is around the 21 Mbps mark. 5G will be 100 to 1000 times faster. The Consumer Technology Association notes that at this speed, you could download a two-hour movie in just 3.6 seconds, versus 6 minutes on 4G or 26 hours on 3G. The impact of 5G will go far beyond our smartphones as it will allow millions of devices to be connected simultaneously. 

Looking ahead, there is already buzz about 6G . Although it’s still in basic research and around 15-20 years away, it’s interesting from an innovation point of view. 6G will form the framework of the connected utopia we aspire towards, and with it will come untold improvements in the speed and consistency of our communication. 

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• Writing, Technology and Teens
• Electronic Communication

Table of Contents

• Acknowledgments and Methodology
• Introduction
• The Lives of Teens and Their Technology
• Teens and Their Writing Habits
• The Relationship between Writing, Communication and Technology Ownership
• Parental Attitudes toward Writing and Technology
• The Way Teens See Their Writing and What Would Improve It
• What Teens Tell Us Encourages Them to Write

Previous work by the Pew Internet Project suggests that the communicative functions of the internet and cell phones are the main reason why teens use these technologies. 17 , 18 Since many of these technologies are text-based, they constitute another potential space for writing under a broadly constructed definition of the term. Yet despite the ubiquitous use of these tools, our research suggests that teens see an important distinction between the “writing” that they do for school and for personal reasons, and the “communication” they engage in electronically using instant messaging, text messaging, email and social networking sites.

However these tools are defined, many educators and observers have expressed concern that the abbreviated language styles of text messaging, email and wall posts are filtering inappropriately into formal school writing. Young adults generally do not believe that technology negatively influences the quality of their writing, but they do acknowledge that the informal styles of writing that mark the use of these text-based technologies for many teens do occasionally bleed into their school work.

Communication with friends and family is frequently conducted through the prism of technology, particularly among girls and older teens.

Despite the range of online communication tools available to them, teens continue to rely primarily on telephone or face-to-face interactions to communicate daily with their friends. More than one-third of teens say they talk with their friends in person outside of school (39%), talk on a cell phone or landline phone (35%), or send text messages (36%) on a daily basis.

While verbal modes of communication such as talking on the phone or meeting face-to-face dominate the daily lives of teens, a great deal of social interaction occurs in a text-based setting. The most popular of these interactions is text messaging—36% of teens text message their friends daily. As one of our focus group participants noted, text messaging can be both time-consuming and integrated in daily tasks.

I put in 20 hours [per week] plus [texting].  I can’t even count because I mean it’s not like you’re spending a continuous hour writing/texting.  It’s just like text, text, text while you’re doing other stuff. – 10/12 th Grade Girl, Southwestern City.

Of course, computer-based communication is popular as well. Nearly three in ten teens (29%) send instant messages to their friends daily, and close to one quarter (23%) send messages through social network sites. As in previous Pew Internet Project research, 19 email remains the least popular choice for daily communication: just 16% of teens send email to their friends on a daily basis.

Teens choose different methods for communicating with friends based on personal preference, the availability of friends or potential romantic partners in a particular media space, and the costs and logistics involved:

I actually wrote a long message to my friend yesterday . . . . like 5 paragraphs . . . [sent] . . . just to him because sometimes I don’t like saying stuff to people in person.  I just feel more comfortable when I say it on the computer.  I can get more feelings out so I just went on and on and on.  I was explaining a situation to my friend and that was probably the longest thing I’ve ever written on My Space. – 9/11 th Grade Girl, Southwestern City.

I instant message . . . I don’t text because texting costs, so I IM. – 10/12 th Grade Girl, Southwestern City.

Well I don’t really do text messaging on my own phone.  But sometimes I’ll borrow a friend’s phone and like a lot of it is just kind of screwing around with your phone.  You’ll leave like hi, what are you doing? – 9/11 th Grade Girl, Southwestern City.

Some people they text – somebody could be sitting right here and I could be texting somebody and they’d be standing right there.  I mean what is the point? – 11/12 th Grade Boy, Northeastern City.

I used my cell phone, maybe an hour a day.  Secondary would be instant messaging on the computer . . . . It is just easier to communicate using instant messenger instead of using the phone. – 9/10 th Grade Boy, Pacific Northwest City.

If it wasn’t for girls, we wouldn’t be talking on the phone or using IM or anything else like that. Or I guess not using it as much. – 11/12 th Grade Boy, Northeastern City.

Girls and older teens are more likely than boys and younger teens to engage in a variety of daily communications activities. Girls are significantly more likely than boys to socialize or engage with friends daily via a home or landline telephone, cell phone, text messaging, instant messaging, email, and through private messages within a social networking site. Girls and boys are equally likely to meet with friends in person outside of school on a daily basis.

While older and younger teens are equally likely to socialize daily with friends in person or on a landline phone, older teens are more likely to communicate daily with friends via text messaging (50% for older teens vs. 22% for younger teens), instant messaging (34% vs. 24%), cell phone (47% vs. 24%) and messages on social network sites (34% vs. 13%). This is at least partly because older teens are more likely to own the technologies (such as cell phones or computers) that make these communications possible.

Socio-economic status is correlated with the daily communication choices made by teens, although not strongly so. Teens living in households with an annual income under $50,000 per year and those with annual incomes of $50,000 or more are equally likely to participate daily in text messaging, talking on a cell phone, sending instant messages and email, and sending messages within social networking sites. However, teens in higher-income households are more likely to meet face-to-face with friends (43% do this daily, vs. 32% for lower-income teens) while teens in lower-income households are more likely to talk to their friends on a landline or home phone (42% do this daily, vs. 33% for those with higher incomes). This more frequent in-person contact among higher-income teens may be due in part to their increased exposure to friends during extracurricular or out-of-school activities—fully 34% of higher-income teens participate daily in a school club, sports program or other school/community activity, compared with just 22% of lower-income teens.

Despite its ubiquity in their lives, teens have divergent views on whether these personal electronic communications constitute “writing.”

Fully 85% of all teens engage at least occasionally in some form of electronic personal communication, which includes text messaging, sending email or instant messages, or posting comments on social networking sites. Although participation in these activities is widespread, a majority (60%) of teens who send these communications do not consider them to be “writing.” Just over one third (38%) of teens think of these communications as writing, and an additional 2% don’t know whether they consider them to be writing or not.

Although an overall majority of teens do not consider themselves to be writing when they send personal electronic communications to their friends, this view is not universally held among all subgroups. Black and lower-income teens in particular stand out in this regard. More than half (55%) of black teens who engage in personal electronic communications with friends view these communications as writing, compared with just 33% of white teens. Similarly, 47% of teens living in households with an annual income under $50,000 per year view their personal electronic communications as writing, while just 34% of higher-income teens share this view. There are no significant differences on this issue relating to age, gender, cell phone ownership, computer ownership or usage of social networking sites.

Our focus group discussions similarly indicate that most teens do not regard their technologically facilitated text-based communication as “writing,” since writing is considered to occur in more formal settings, usually for school.

I don’t think [Instant Messaging] is [writing].  You’re not writing enough for it to be called writing. Unless you’re, I don’t know, unless you’re like describing something, if you want to tell your whole life story, or your saying what happened … but it’s got to be long for it to be considered writing. – 9/10 th Grade Girl, Midwestern City.

I said [text messaging is not writing] because it differs from writing using a pen or a pencil.  Plus, you have to just press a lot of buttons and I guess I would consider it typing not exactly writing – the action of doing it.  But what it becomes – the result of it – is writing. – 11/12 th Grade Boy, Northeastern City.

MySpace:  That’s different.  It’s just like a conversation. – 9/11 th Grade Girl, Southwestern City.

Blogging and social networking are dominated by girls.

More than half (58%) of all teens maintain a profile on a social networking site such as Facebook or MySpace, 27% have an online journal or blog and 11% maintain a personal website. Girls dominate the teen blogosphere and social networks—66% of girls have an SNS profile compared with 50% of boys, and 34% of girls (versus 20% of boys) keep an online journal or blog.

Older girls are especially enthusiastic adopters of these technologies. Four in ten (41%) girls ages 15-17 have a blog, and fully 86% of 15-17 year old girls have a social networking profile. Boys (particularly younger boys) continue to trail girls in their use of social networking sites and blogs, although social networking in particular is growing in popularity among older boys: nearly seven in ten (69%) boys ages 15-17 have a social networking profile. While teens with broadband at home are more likely to maintain a personal website, there is no “broadband effect” for blogging or social networking. There are no statistically significant differences by race, ethnicity, income or parent education between those with a social networking profile and those without one.

Teens increasingly communicate using social networking sites.

Fully 60% of internet-using teens (58% of all teens) have profiles on social networking sites such as Facebook and MySpace. For those who use them, social networking sites are a hub of teenage communication. Fully 95% of social networking teens use their profile to communicate with their friends in one way or another, with adding comments to a friend’s picture and posting messages on a friend’s wall or profile page being the most popular methods.

As with the general communication tools discussed earlier, girls and older teens are more proficient than boys and younger teens at using social networking sites to interact with their friends.

Among social networking teens, girls are more likely than boys to add comments to a friend’s picture (89% vs. 76% for boys), post messages to a friend’s page or wall (82% vs. 70%) and send a group message or bulletin (61% vs. 46%). Teens ages 15-17 are more likely than younger teens to post public messages on a friend’s page or wall (82% vs. 66%) and to send private messages within the social networking system (79% vs. 56%), although younger teens are more likely to send bulletin or group messages to all of their friends at once—63% of younger teens have done this, compared with 50% of older teens.

Among social networking teens, whites are more likely than blacks to use their social networking profile as a communication tool, whether to post messages to a friend’s wall (78% of whites do this, versus 63% of blacks) or to send private messages within the social networking system (75% v. 55%). Indeed, fifteen percent of black social networking teens do not do any of the six activities listed above, compared with just 4% of white teens. The sample size of social networking Hispanic teens (n=62) is too small to make meaningful inferences about the communication choices of this group.

Teens on opposite ends of the income scale are overall quite similar in how they use social networking sites to communicate with friends, if they use such sites in the first place. The one exception to this rule is the usage of social networking sites to send instant messages or text messages to friends. Fully 63% of teens from households earning under $50,000 per year do this, compared with half (49%) of teens from higher-income households (somewhat lower rates of cell phone ownership among lower-income teens may help explain this phenomenon).

In our focus groups, teens explained some of the allure of social networking websites and how use of them has changed and replaced other online practices.

It sounds stupid and everything but like once you like get into it it’s really like addicting – just like everything. Like you have your song and like you write like all this stuff about yourself and like all my friends basically have it.  So like we always like read each other’s pages and like call each other and like kind of, and like you put like 300 pictures up so . . . people’s pictures and stuff and comments. – 9/10 th Grade Girl, Midwestern City.

[You go on MySpace] when all of your friends have gone to MySpace and they aren’t emailing anymore. – 9/10 th Grade Boy, Pacific Northwest City.

Social networking teens are avid communicators across the board.

While social networking sites are used intensively for communications between friends, these sites supplement rather than replace existing modes of communication. Social networking teens are more likely than non-social networking teens to participate in a wide range of daily communications activities, from in-person interactions with friends to talking on the telephone or sending IMs or text messages.

The shortcuts and casual conventions teens use in their daily communications frequently bleed into their school writing.

Despite their best intentions, teens in our survey do admit to using conventions from their electronic communications in their school writing. Half (50%) of teens say they sometimes use informal writing styles in the writing they perform in school, 38% have used shortcuts from instant messaging or email, and 25% have used emoticons in their school writing. Overall, nearly two-thirds of teens (64%) incorporate some informal styles from their text-based communications into their writing at school.

Since much of the writing teens do at school (such as writing in a journal, taking notes in class, or crafting creative fiction) is relatively informal in nature, it is not necessarily surprising to find teens adopting the conventions from texting, email or other online speech into their writing for school. With that said, certain groups of teens are more likely to utilize these conventions in their school writing than others.

While teen bloggers and social network users are prolific writers, they also have a tendency to use text shortcuts, emoticons and informal writing styles in their school writing. Similarly, teen cell phone owners are significantly more likely to use text shortcuts in school (42% do this) compared with non-cell phone owners (30%).

Teens who communicate regularly with their friends through a wide range of communications channels are more likely than less “communicative” teens to incorporate informal or technology-related elements into their school writing. The more types of personal daily communications teens engage in with friends, the more likely they are to incorporate these conventions into the writing they do at school.

Usage of different communications methods outside of school is not the only factor correlated with usage of technology-based writing conventions in school—attitudinal factors play a role as well. In particular, teens who view their electronic communications with friends as “writing” are significantly more likely than teens who do not view these communications as writing to use informal writing styles (59% vs. 47%), text shortcuts (56% vs. 34%) and emoticons (39% vs. 19%) in a school environment.

Among demographic groups, girls are more likely than boys to use text shortcuts from IM or email (45% vs. 33%) and emoticons (35% vs. 17%). Black teens (48%) are more likely than whites (35%) to use text shortcuts in school, although there are no racial or ethnic differences with respect to usage of informal writing styles or emoticons. Finally, among children of college graduates, just over half (54%) use at least one of these elements in their writing for school; this is a significantly lower rate than for children of parents with some college education (67% of whom use at least one of these techniques), or for children of parents with no college experience (71%).

Teens in our focus groups acknowledged the movement of text-based slang into their school work, but also suggested that learning not to use the slang is a part of the maturation process. They also took this issue one step further by pointing out that not only had text message slang and informal language crept into their formal school work, but it had also infiltrated spoken language for some teens.

. . . [S]ince I was a sophomore in high school I have seen some changes.  I saw some under classman in the hallway saying OMG where is my classroom or LOL and you know I was like, “OK, they are going to have to work through that.” – 11/12 th Grade Girl, Pacific Northwest City.

As you get older you develop and you learn that publicly it isn’t a good idea to use text message slang.  It may influence people to think things about you.  It will give the wrong impression of you. – 11/12 th Grade Girl, Pacific Northwest City.

I can speak very well, but there are also times that I have been laughing and actually said LOL.  So it all depends on how much you text and who you are around at the time. – 11/12 th Grade Girl, Pacific Northwest City.

. . . [I]f people are going to think that the way we type on the internet is going to corrupt the way we write like for school, it’s just because those people don’t want to write normally and they’re not going to if they don’t want to. – 9/11 th Grade Girl, Southwestern City.

• Analysis of daily communications choices is based on all teens, regardless of technology ownership. ↩
• Lenhart, Amanda, Madden, Mary & Hitlin, Paul. (2005) “Teens and Technology: Youth are Leading the Transition to a Fully Wired and Mobile Nation,” Pew Internet & American Life Project, Washington, DC, July 27, 2005. ↩
• Lenhart et al. (2007) Teens and Social Media , Pew Internet & American Life Project, Washington, DC, December 19, 2007. ↩

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telecommunication , science and practice of transmitting information by electromagnetic means. Modern telecommunication centres on the problems involved in transmitting large volumes of information over long distances without damaging loss due to noise and interference. The basic components of a modern digital telecommunications system must be capable of transmitting voice, data, radio, and television signals. Digital transmission is employed in order to achieve high reliability and because the cost of digital switching systems is much lower than the cost of analog systems. In order to use digital transmission, however, the analog signals that make up most voice, radio, and television communication must be subjected to a process of analog-to-digital conversion. (In data transmission this step is bypassed because the signals are already in digital form; most television, radio, and voice communication, however, use the analog system and must be digitized.) In many cases, the digitized signal is passed through a source encoder, which employs a number of formulas to reduce redundant binary information. After source encoding, the digitized signal is processed in a channel encoder, which introduces redundant information that allows errors to be detected and corrected. The encoded signal is made suitable for transmission by modulation onto a carrier wave and may be made part of a larger signal in a process known as multiplexing . The multiplexed signal is then sent into a multiple-access transmission channel. After transmission, the above process is reversed at the receiving end, and the information is extracted.

This article describes the components of a digital telecommunications system as outlined above. For details on specific applications that utilize telecommunications systems, see the articles telephone , telegraph , fax , radio , and television . Transmission over electric wire , radio wave , and optical fibre is discussed in telecommunications media . For an overview of the types of networks used in information transmission, see telecommunications network .

Analog-to-digital conversion

In transmission of speech , audio, or video information, the object is high fidelity—that is, the best possible reproduction of the original message without the degradations imposed by signal distortion and noise . The basis of relatively noise-free and distortion-free telecommunication is the binary signal. The simplest possible signal of any kind that can be employed to transmit messages, the binary signal consists of only two possible values. These values are represented by the binary digits, or bits , 1 and 0. Unless the noise and distortion picked up during transmission are great enough to change the binary signal from one value to another, the correct value can be determined by the receiver so that perfect reception can occur.

If the information to be transmitted is already in binary form (as in data communication), there is no need for the signal to be digitally encoded. But ordinary voice communications taking place by way of a telephone are not in binary form; neither is much of the information gathered for transmission from a space probe, nor are the television or radio signals gathered for transmission through a satellite link. Such signals, which continually vary among a range of values, are said to be analog, and in digital communications systems analog signals must be converted to digital form. The process of making this signal conversion is called analog-to-digital (A/D) conversion.

Analog-to-digital conversion begins with sampling, or measuring the amplitude of the analog waveform at equally spaced discrete instants of time. The fact that samples of a continually varying wave may be used to represent that wave relies on the assumption that the wave is constrained in its rate of variation. Because a communications signal is actually a complex wave—essentially the sum of a number of component sine waves, all of which have their own precise amplitudes and phases—the rate of variation of the complex wave can be measured by the frequencies of oscillation of all its components. The difference between the maximum rate of oscillation (or highest frequency) and the minimum rate of oscillation (or lowest frequency) of the sine waves making up the signal is known as the bandwidth ( B ) of the signal. Bandwidth thus represents the maximum frequency range occupied by a signal. In the case of a voice signal having a minimum frequency of 300 hertz and a maximum frequency of 3,300 hertz, the bandwidth is 3,000 hertz, or 3 kilohertz. Audio signals generally occupy about 20 kilohertz of bandwidth, and standard video signals occupy approximately 6 million hertz, or 6 megahertz.

The concept of bandwidth is central to all telecommunication. In analog-to-digital conversion, there is a fundamental theorem that the analog signal may be uniquely represented by discrete samples spaced no more than one over twice the bandwidth (1/2 B ) apart. This theorem is commonly referred to as the sampling theorem , and the sampling interval (1/2 B seconds) is referred to as the Nyquist interval (after the Swedish-born American electrical engineer Harry Nyquist ). As an example of the Nyquist interval, in past telephone practice the bandwidth, commonly fixed at 3,000 hertz, was sampled at least every 1/6,000 second. In current practice 8,000 samples are taken per second, in order to increase the frequency range and the fidelity of the speech representation.

In order for a sampled signal to be stored or transmitted in digital form, each sampled amplitude must be converted to one of a finite number of possible values, or levels. For ease in conversion to binary form, the number of levels is usually a power of 2—that is, 8, 16, 32, 64, 128, 256, and so on, depending on the degree of precision required. In digital transmission of voice, 256 levels are commonly used because tests have shown that this provides adequate fidelity for the average telephone listener.

The input to the quantizer is a sequence of sampled amplitudes for which there are an infinite number of possible values. The output of the quantizer, on the other hand, must be restricted to a finite number of levels. Assigning infinitely variable amplitudes to a limited number of levels inevitably introduces inaccuracy, and inaccuracy results in a corresponding amount of signal distortion. (For this reason quantization is often called a “lossy” system.) The degree of inaccuracy depends on the number of output levels used by the quantizer. More quantization levels increase the accuracy of the representation, but they also increase the storage capacity or transmission speed required. Better performance with the same number of output levels can be achieved by judicious placement of the output levels and the amplitude thresholds needed for assigning those levels. This placement in turn depends on the nature of the waveform that is being quantized. Generally, an optimal quantizer places more levels in amplitude ranges where the signal is more likely to occur and fewer levels where the signal is less likely. This technique is known as nonlinear quantization. Nonlinear quantization can also be accomplished by passing the signal through a compressor circuit, which amplifies the signal’s weak components and attenuates its strong components. The compressed signal, now occupying a narrower dynamic range, can be quantized with a uniform, or linear, spacing of thresholds and output levels. In the case of the telephone signal, the compressed signal is uniformly quantized at 256 levels, each level being represented by a sequence of eight bits. At the receiving end, the reconstituted signal is expanded to its original range of amplitudes. This sequence of compression and expansion, known as companding, can yield an effective dynamic range equivalent to 13 bits.

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Electronic communication improves access, but barriers to its widespread adoption remain

Tara f. bishop.

1 Division of Outcomes and Effectiveness, Department of Public Health, Weill Cornell Medical College, New York, NY

2 Department of Medicine, Weill Cornell Medical College, New York, NY

Matthew J. Press

Jayme l. mendelsohn, lawrence p. casalino.

Principles of patient-centered care imply that physicians should use electronic communication with patients more extensively, including as a substitute for office visits when clinically appropriate. We interviewed leaders of 21 medical groups that use electronic communication with patients extensively and also interviewed staff in six of these groups. Electronic communication was widely perceived to be a safe, effective and efficient means of communication that improves patient satisfaction and saves patients time, but increases the volume of physician work unless office visits are reduced. Practice redesign and new payment methods are likely necessary for electronic communication to be used more extensively.

Electronic communication (e.g., email, messaging through an electronic health record [EHR]) between patients and physicians potentially has advantages over office visits and telephone communication. 12 Because it is asynchronous (i.e., the patient and the physician do not have to communicate with each other at the same time), it may be used at times and from locations that are convenient for both patients and physicians. It gives patients a record of their interaction with their physician. In cases where electronic communication is used through an EHR, conversations can be documented automatically in the medical record.

In 2001, the Institute of Medicine recommended changing from care provided solely through office visits to care provided through alternative mechanisms such as telephone and electronic communication to improve quality of care. 1 Principles of new primary care models such as the Patient Centered Medical Home (PCMH) and the Chronic Care Model (CCM) imply that practices should use electronic communication more with patients and that this form of communication could sometimes substitute for office visits when clinically appropriate. 2 – 10 , 11

Despite the potential benefits of electronic communication and its potentially important role in improving quality of care, in 2008 less than 7% of physicians reported regularly communicating electronically with patients. 13

Several medical groups, however, have described using electronic communication not only to communicate clinical information to patients (e.g., test results) but also to manage clinical conditions (e.g., simple acute problems) instead of having patients come into the office for face-to-face visits. Little is known about how such electronic communications programs function, what barriers medical groups face when starting electronic communication programs, and the effect of electronic communication on patients and provider. This knowledge may be useful for other medical groups that are looking to increase electronic communication and for payers and policymakers who may want to encourage more electronic communication between patients and their providers.

In this qualitative study of medical groups that use electronic communication extensively, we aimed to answer three research questions: 1) how can primary care practices use electronic communication to manage clinical issues that traditionally are managed during office visits, 2) what are the perceived advantages and disadvantages of these programs for patients, physicians, and practices, and 3) what are the barriers to and facilitators of implementation of electronic communication programs?

Design and sample

We identified 78 medical groups that we believed were using electronic communication through literature review, personal knowledge of organizations, and discussions with nine key informants, including informants knowledgeable about PCMH demonstration projects. Leaders responded from 35 groups. We asked each leader if they were using electronic communication systematically to deliver primary care. In the 21 groups in which the reply was “yes,” we requested an interview with that person or another leader.

We chose six of these groups (“case study medical groups”) for additional interviews because they used electronic communication extensively and varied in type, size, location, and the way they were paid by health plans. In these six groups, we conducted additional interviews with frontline providers (i.e., providers who spent the majority of their time doing direct clinical care) and non-provider staff who were identified by the leaders we had interviewed.

The six medical groups were: 1) Colorado Permanente Medical Group, a multispecialty group practice that cares for Kaiser Health Plan patients 2) Eisenhower Primary Care 365, a small group practice within an academic medical center that charges an annual retainer fee for all of its patients, 3) Fairview Health Services, a large group practice that uses a fee-for-service model but is reimbursed by private health plans for specified e-visits, 4) Group Health Cooperative, an integrated health care delivery and insurance system, 5) Palo Alto Medical Foundation, a large medical group that is paid via a fee-for-service model, and 6) Southcentral Foundation, a non-profit medical group that cares for an underserved population and is paid via a fee-for-service model with government supplementation.

We also interviewed a convenience sample of 6 leaders from national and regional health plans to learn whether their plan paid for electronic communication or had intentions to pay for electronic communication.

Data collection

We developed an interview guide to use in semi-structured telephone interviews with group leaders. The instrument focused on 1) demographic characteristics of each medical group, 2) details of each group’s electronic communication program, 3) perceived advantages and disadvantages of electronic communication between physicians and patients, and 4) perceived barriers to and facilitators of implementation of electronic communication programs. For the six case study medical groups, we used a similar interview tool with frontline providers and non-provider staff but focused more on their day-to-day experience with electronic communication and their perceptions of the advantages and disadvantages of this communication medium.

One of three investigators (T.F.B, M.J.P, or L.P.C) conducted each interview and one investigator recorded notes (J.L.M.). Interviews lasted between 30 and 60 minutes. We conducted interviews from February, 2012 to June, 2012.

Two investigators (T.F.B. and J.L.M) coded the interview notes in Atlas.ti (Version 6.2 Scientific Software Development) using the constant comparative method. 23 , 24 We identified a priori domains and themes and iteratively refined them until no new domains or themes emerged. In the results section, we report the number of respondents who mentioned each advantage, disadvantage, barrier, and facilitator.

Limitations

Our study has some limitations. First, we used key informants to identify practices that communicate electronically with patients and possibly missed small practices, which are less visible. However, national surveys suggest that most small practices do not use electronic communication extensively. 13 Second, we interviewed a limited number of frontline providers and non-provider staff who were not randomly selected, but rather suggested to us by leaders of the groups. It is possible that these respondents had a more positive view of electronic communication than others in their organizations. Third, we used an iterative process for interviews, changing our interview instrument slightly as new information emerged. These factors, plus time constraints on the length of the interviews, meant that not every respondent was asked about every possible advantage, disadvantage, barrier, and facilitator. Therefore the numbers we report should be interpreted as frequencies not as percentages (ie, numerators over a denominator of twenty-six). Finally, we did not interview leaders or physicians in medical groups that had not instituted extensive electronic communication programs. Thus, the barriers we cite are ones that successful groups overcame. Medical groups that are not successful at implementing electronic communication programs or choose not to try may experience different barriers than those cited in our study.

Case study medical groups

Group characteristics.

Five of the groups were large (four with over 500 physicians, one with 115 physicians); the sixth was a smaller group (15 physicians) within a large academic medical center. Two groups (Group Health and Colorado Permanente) were tightly linked to their respective health plans and were paid via a negotiated budget, rather than by fee-for-service. The other four groups contracted with multiple health plans and were paid via fee-for-service. One group (Eisenhower 365) charged an annual retainer fee of approximately $500 per patient and one (Southcentral) received government funds to help support its operations.

Electronic communication programs

Motivation to start initiative.

Leaders said that they started electronic communication programs to improve access to care and communication with patients. “There’s no way you can have a person-centered delivery system without having email communication with patients,” said a leader at Group Health. A leader at Fairview said, “We want to provide better access to primary care so [patients] don’t end up in the Emergency Department.”

For two groups (Group Health and Colorado Permanente) that were paid via capitation (i.e. paid a set amount for each patient), their payment model was a motivator for shifting face-to-face visits to electronic communication. Face-to-face visits generate revenue for groups being paid fee-for-service but represent a cost to groups paid via capitation.

Content, management, and volume of electronic communications

All six groups used electronic communication to communicate test results to patients and to allow patients to request medication refills, request appointments, and ask questions. At all the groups, providers decided whether they wanted to manage acute and chronic clinical issues electronically.

Fairview was the only group that had a formal e-visit program, which they differentiated from the informal electronic communication of test results, medication requests, and appointment scheduling. Patients initiated e-visits and providers delivered care that required a clinical decision and might normally be done in the office: the management of simple acute issues (e.g., urinary tract infections, upper respiratory infections) and the management of chronic clinical conditions (e.g., blood pressure management).

At three groups (Group Health, Colorado Permanente, Southcentral) nurses, medical assistants or case managers triaged all the messages from patients. At the other three groups (Eisenhower 365, Fairview, Palo Alto Medical Foundation), patients could send messages to different pools (e.g., nursing pool for refills, front desk pool for appointments) but could also send messages directly to their providers. Providers could decide whether to manage all these messages themselves or have one of their staff triage them. In Fairview’s e-visit program, all messages went to a pool of registered nurses who could either manage a limited set of clinical issues using internally-developed protocols, forward visits to providers, or ask patients to come in for an office visit if the issue could not be addressed electronically.

Based on our conversations with frontline providers, the volume of electronic messages that reached the provider (after triage in some cases) varied from 5 to 10 per provider per day at Colorado Permanente to 20 to 50 per provider per day at Eisenhower 365 and Fairview. The volume of formal e-visits at Fairview was about 3 to 4 per provider per week.

Payment for electronic communication

Fairview was the only group that charged patients for e-visits. Fairview had negotiated reimbursement for e-visits with some private insurers. E-visits required some level of clinical decision-making. Reimbursement for e-visits was typically less than for face-to-face visits, and patients paid a copay. Medicare and Medicaid did not reimburse for e-visits. Fairview did not charge for other forms of electronic communication (e.g., test results).

Palo Alto Medical Foundation initially charged patients a $60 annual fee for unlimited electronic communication, but removed that fee in 2011 because competitors were providing the service for free.

Fairview assigned e-visits and electronic messages relative value units (RVUs) at lower values than for office visits and gave credit for these when calculating physicians’ pay. Group Health initially paid its physicians an incentive ($5 per secure message) but eliminated it because physicians were dissatisfied with the incentive amount.

Provider schedules and workday

Two medical groups added desktop medicine time to providers’ schedules. Colorado Permanente changed the primary care schedule such that each hour included two 20 minute face-to-face appointments followed by 20 minutes for telephone or electronic management of clinical issues. Group Health incorporated an hour of desktop medicine to the daily primary care schedule.

Eisenhower 365 did not carve out specific time for electronic communication, but providers could decide how many patients to see each day, with some choosing as few as 10 face-to-face visits and spending the remainder of their time on electronic communication and, to some extent, telephone communication with patients.

At Fairview, Group Health, and Southcentral, staff assessed provider schedules either the day before or the morning of each clinical session, determined whether any scheduled visits could be managed electronically or by telephone, and contacted these patients to offer management by telephone or electronically. This eliminated unnecessary visits and opened space for same-day appointments. This not only saved patients time but eliminated unnecessary out-of-pocket expenses (e.g., copays and deductibles).

Perceived advantages of electronic communication

Convenient access that saved patients time.

Fourteen respondents said that electronic communication provided convenient access to care that saved patients time. “Patients feel like they have direct access and a better line of communication even than a doctor’s personal cell phone,” said one leader at Eisenhower 365. A frontline physician at that same group described a patient who unexpectedly lost her spouse and benefited from direct access to her physician: “at 3 am when she couldn’t sleep she would email me. That was something I would never have dreamt would be a good thing [but it was].”

Southcentral’s patients often travel long distances for care. “If a woman knows that she’s had UTIs before and has the same symptoms, she is really appreciative of not coming in,” said one provider.

Patient satisfaction

Eighteen respondents said that patients were more satisfied after the initiation of electronic communication programs. “Patients love this model,” said a leader whose group’s Press-Ganey patient satisfaction scores were consistently in the 99 th percentile. A frontline physician at Colorado Permanente said, “It’s a real customer service satisfier. People are really satisfied to be able to access their provider by email.”

Leaders and frontline providers cited efficiency as an advantage. “[An email] takes 1 minute or less of my time,” said a frontline physician at Eisenhower 365. A leader at Palo Alto Medical Foundation reiterated this point, stating that electronic messages take on average 70 seconds to send.

A physician at Group Health sends his patients a secure message several days before their appointment asking for their concerns. This improves the efficiency of office visits: “half the time they’ve written the history of present illness. I just copy and paste it into the EMR.”

Safe, high quality care

We asked specifically whether respondents were aware of cases in which electronic communication led to poor outcomes; no respondents were able to think of such a case. Some respondents argued that care delivered electronically was safer than other modes of care. “Almost everything you say on the phone, they forget immediately. It’s good to have a paper trail,” said one physician.

Nevertheless, most medical groups had safeguards in place such as warnings that secure messaging should not be used for emergencies.

Perceived disadvantages of electronic communication

More work for providers.

Although respondents cited many fewer disadvantages than advantages, one commonly cited disadvantage was that electronic communication created more work for providers. One leader said that one of the problems with electronic communication is that the work never ends: “it takes a psychological toll on some people - the feeling of never being done.”

Frontline providers in all six groups reiterated this point: “each email takes little time but the emails add up. In one day, I’ve been in touch with 60 of my patients - 10 in person and 50 through email.” Another physician said, “There’s no end to it. This has allowed us to work all the time.” One physician found electronic communication a nuisance: “initially I thought it would be helpful. The way my day is set up right now, I am scheduled to see patients; I really have no time to respond to emails. If I had time allotted in my schedule [for email] every day I think it would help.”

Barriers to implementation of electronic communication programs

Patient and physician resistance to change.

Several respondents cited patient resistance to change and inexperience with computers/email as barriers to the use of electronic communication. For some patients, electronic communication is a “whole new way of communication – it’s a different world,” said one physician. Others stated that patients are used to the “old-fashioned model” and “the biggest obstacle to get people to buy in is educating [patients].”

Physician resistance to change was also cited as a barrier. One leader from Fairview said that physicians initially did not want to use secure messaging but their opinions changed after they realized it made it easier to reach patients. This sentiment was reiterated by a leader at Group Health.

Lack of payment for electronic communication

Palo Alto Medical Foundation - the only fee-for-service group that did not charge a retainer fee, did not receive payment for e-visits from health plans, and did not receive supplemental government funding - cited lack of payment for electronic communication by health plans as a barrier. “The health plans say ‘the physicians are already doing it for free, why would we pay for it?” said one leader.

Facilitators of implementation of electronic communication programs

Management support.

Management support was the most frequently cited facilitator for the implementation of electronic communication programs. Management educated providers on the benefits of electronic communication, allotted time in the workday for virtual care, and, in some cases, added RVUs for virtual care.

Patient demand

Frontline providers and staff cited patient demand as a facilitator. “People are used to being able to access anything and now they realize they can access their physicians,” said a physician at Colorado Permanente. Another stated that patients, both young and old, feel comfortable using computers and smart phones.

Summary of information from the non-case study medical groups

Our interviews with leaders in 15 additional medical groups yielded information that was consistent with the themes from the case studies, but a few additional details emerged.

First, four groups charged patients a fee for e-visits that ranged from $20 to $45. None of these groups charged annual fees or were paid via capitation. Patients could submit their bill to their health plan; some private payers reimbursed for these e-visits.

Second, all of our case study groups and most of the other groups used non-structured input in which the patient entered text like an ordinary email. However, two groups used Instant Medical History, a structured input system where patients go through a set of questions that varies based on symptoms. 25

Summary of information from health plan leaders

From our interviews with six leaders from national and regional health plans we learned that to their knowledge very few health plans reimbursed for electronic communication.

Some leaders were exploring ways to help providers become more efficient, including incentives for e-visits. “It’s important to understand that [our] policy is not to reimburse for visits that are not face-to-face. However, in the telehealth arena we do have several exceptions to our policy. We have a rigorous process through which we will allow those exceptions [and pay for email],” said one health plan executive.

Second, some health plans consider new reimbursement models such as monthly per-member PCMH reimbursements as a mechanism to pay for any services that fell outside office visits, including e-visits and do not pay anything additional for electronic communication.

Finally, one executive stated that there was little demand by patients and physicians for electronic communication: “Other than seeing an occasional article in the press, I’m not sure how much it’s getting traction. It seems like it should, and I can certainly see the ACOs [Accountable Care Organizations] in particular having a keen interest in this. I could see it becoming important in a few years. But right now, we’re not hearing or seeing demand coming from the provider side.”

Electronic communication with patients is not common in the U.S., and extensive use of electronic communication to replace office visits appears to be rare. Nonetheless, we were able to identify several medical groups that extensively use electronic communication in clinical care. The interviewees in these groups reported many more advantages of electronic communication than disadvantages.

These interviewees stated that electronic communication improved access to care for patients, saved patients time, and improved patient satisfaction. Physicians reported that it was an efficient form of communication for them as well - each individual e-mail or secure message took little time. Given these findings, electronic communication should help groups meet PCMH goals such as improved access to care and better communication with patients.

The biggest disadvantage that these medical groups experienced and others could experience in the future is added work from electronic communication - providers lamented that electronic communication made the workday longer. As the number of electronic communications with patients increased, several groups tried to cut down on the number of office visits but, in most cases, the number of office visits did not decrease very much. Electronic communication therefore was often added work to a full day of office visits.

One possible way to circumvent this disadvantage is to implement team-based care, in which non-provider staff can help triage and manage electronic communications. Several groups described using nurses to electronically manage simple clinical issues using protocols and teams to triage and co-manage electronic communication. This may be a key feature to avoid overburdening providers. But even with teams in place, providers and groups probably need more of a cultural shift. Not only do they need to realize what clinical care can be delivered electronically but also need to figure out who on a team should deliver electronic care.

A key challenge to broader use of electronic communication for clinical care is the traditional fee-for-service payment model. Since few health plans pay for electronic communication, it is not surprising that most of the medical groups we identified were paid in ways other than traditional fee-for-service (e.g., capitation, annual membership fees). For example, a capitated group working within a fixed budget can reduce its expenses and increase its net revenue if electronic communication replaces office visits.

The Palo Alto Medical Foundation was an exception. This group was paid via traditional fee-for-service and payers did not reimburse it for electronic communication. Competition with other medical groups was the main motivator in their extensive use of electronic communication. It was unclear from our interviews whether this group lost revenue because of a shift to clinical care that was delivered via electronic communication.

Fairview, was another exception. It was paid via traditional fee-for-service but was able to negotiate payment from some health plans for e-visits, that were defined as electronic communications initiated by patients in which clinical decision-making occurred (by a physician, non-physician provider, or nurse).

Fairview’s reimbursement mechanism is one way that payers and policymakers can promote the use of electronic communication particularly for clinical care. But paying for this type of electronic communication is not the only reimbursement mechanism. If ACOs and PCMHs are given sufficient financial incentives, they may find it financially viable to shift away from the current model of providing as many office visits as possible to a model with fewer office visits and more care delivered electronically. It also remains to be seen whether competition for patients will eventually result in large numbers of practices using electronic communication extensively, even without compensation.

In summary, we identified a number of organizations that extensively use electronic communication for clinical care. Their experiences with electronic communication were, on the whole, very positive. Electronic communication allowed them give patients better access to care and allowed them to provide more patient-centered care. Unfortunately, traditional payment models are not equipped for a shift from care provided predominantly in the office to one provided electronically. As a result, extensive electronic communication may not be widely viable, and goals of better access and more patient-centered care may not be attainable.

Acknowledgements

Funding: This project was funded by a grant from the Commonwealth Fund. Dr. Bishop and Dr. Press are supported in part by funds provided to them as Nanette Laitman Clinical Scholars in Public Health at Weill Cornell Medical College. Dr. Bishop is supported by a National Institute On Aging Career Development Award (K23AG043499).

We thank Melinda Chen, M.D., M.S. for her insight and expertise that greatly assisted the early phases of this research. We also thank the many people who consented to be interviewed, especially the organizations that consented to be case studies for this research.

Disclaimers: None

The authors have no conflicts of interest to report.