The Medium as a System

In Understanding Media: The Extensions of Man, Marshal McLuhan most aptly summarized this contagious, all-encompassing effect of a new technology through an analogy about medicine:

The new media and technologies by which we amplify and extend ourselves constitute huge collective surgery carried out on the social body with complete disregard for antiseptics. If the operations are needed, the inevitability of infecting the whole system during the operation has to be considered. For in operating on society with a new technology, it is not the incised area that is most affected. The area of impact and incision is numb. It is the entire system that is changed. (1964, p. 64)

Indeed the HITECH Act with its requirement of the secured portals through which the EHR is accessed and electronic messaging takes place, has become a significant systemic change for medicine affecting all related systems throughout the United States. In fact, once the Stages of Meaningful Use are fully implemented, potentially everyone who engages in the healthcare system (which is basically every U.S. citizen), will have been affected by the use of this system in one way or another.

McLuhan further argues that how the message is transferred (i.e., the medium through which it is sent) can have as much influence on the effectiveness and interpretation of that shared message as the words themselves. His often quoted statement, “The medium is the message,” infers that the message cannot be interpreted without consideration of the effect of the medium, in this case the electronic message sent through the secured portal.72 The message could be read

on a piece of paper, spoken out loud, or written in an email; but which medium is used affects the interpretation and perceived meaning of that message.

An example may clarify. When a patient says, “I am feeling a bit blue,” out loud, in person, the physician interprets that message based upon the context in which it is said, past history, the tone of voice, eye contact, facial expression, and body positioning. When a patient says the same in a letter written in a journal, this message is again interpreted based upon the context of the message, past history of written messages, style of hand writing as compared to previous messages, and assumed privacy level of that message (intended or not intended for someone else to read). When those same words are written in an electronic message to the physician within a secured portal that guarantees a response within 48 hours, it might be interpreted based upon the exact time of day the message was written, the surrounding information given, the assumption that someone else who has access to the patient user name and password might see this message, the fact that it cannot ever be erased (or lost as with paper or denied as with oral communication), and the knowledge that a nurse might obtain this note before the physician (as opposed to an office visit when only the patient and physician are present). Interpreted messages through various mediums may be relatively equivalent or totally different from each other. It all depends upon which factors are attended to when receiving and interpreting the message. The message is the same, but the delivery system or medium may affect the interpretation of that message.

Further, to complicate this issue, patients’ and physicians’ perceptions of using the medium to deliver messages also affects how they transmit and interpret those messages. For instance, if patients or physicians perceive the medium of the online messaging service to be burdensome, confusing, time-consuming, or artificial, they may be less likely to produce an

effective message and/or interpret a message in a favorable manner. If the senders perceive the medium as time efficient, money saving, convenient, and accessible, they may be more inclined to use the medium more frequently themselves and respond more favorably to incoming messages as well. The perception of the medium is directly related to how the message within that medium is perceived.

Finally the medium is the message, as McLuhan would argue. That is, when physicians or patients choose to use the electronic service, it says something about themselves as users: their attitude towards the medium, their overall disposition towards patients, their willingness to change, their level of media literacy, and even their basic willingness to communicate at a level most accommodating for the other party. If older physicians, for instance, implement a new EHR system and actively use electronic messages with their patients, this action itself conveys something about them as users. Perhaps younger patients might perceive these physicians as being up-to-date, open minded, or willing to meet them at their level. If physicians complain about the use of the medium to their patients and say they are only using it because they “have to,” then their patients might perceive their physicians as not really interested in receiving the online messages or not wanting to be bothered by something that is being forced upon them. This also can be said from the patient point of view. How physicians perceive their patients has an effect on whether or not they feel the patients will want to use the online portal. If the physicians feel their patients are too old, technologically challenged, not interested, or too poor to afford the Internet, the physicians may not feel the effort in transitioning into the secured portal system is even worth it. Or, they may decline to offer the service to patients based upon their perceived assumptions about their patients’ overall desire and willingness to use online messaging. Perceptions, therefore, affect how successfully the implementation of the secured

portals will be and how much the form of interaction will be a part of the evolving relationship between the physician and patient. The medium transmits the messages between users, affects how those messages are interpreted, says something about the users’ attitude towards the medium itself, and finally, conveys information about the medium’s overall effectiveness, usefulness, and relationship-developing nature. The point is that much more than the words exchanged is being “said” when and how physicians and patients communicate online.

Therefore, to study the medium of electronic messaging as an information system even beyond the content of the messages is just as valid and edifying as studying the message itself; and perhaps McLuhan would say the medium is even more edifying than the content of the message itself. The electronic message as transmitted through the secured portals of the newly mandated EHR systems has become a “new” medium through which physician/patient interactions can share in the process of improved health through online dialogue that now not only is available to and expected by patients but is mandated for physicians to use as part of the requirements of Stage Two Meaningful Use.

McLuhan’s notion of a systemic change seems particularly apropos as indeed the entire system of how physicians now are and will be communicating affects the laws, the economy, the healthcare industry, the technological transmission systems, and the relationship between the physicians and patients. Indeed this transformation marks a period in which the face-to-face, in- office visit becomes not replaced but re-envisioned as a field of options for how patients engage in their own health through a multitude of communication mechanisms. The medium of electronic messaging forever alters the potential patterns of communication within the evolving physician/patient relationship.