boundary negotiation for patient-provider communication...

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Boundary Negotiation for Patient-Provider Communicationvia WeChat in China

XIANGHUA DING, Shanghai Key Laboratory of Data Science, School of Computer Science, Fudan Univer-sity, Shanghai, ChinaYUNAN CHEN, School of Information and Computer Science, University of California Irvine, Irvine,California, United StatesZHAOFEI DING, School of Computer Science, Fudan University, Shanghai, ChinaYIWEN XU, School of Computer Science, Fudan University, Shanghai, China

Patient-Provider Communication (PPC) is crucial to the quality and outcome of healthcare practices. Withthe development of Information and Communication Technologies (ICTs), ICT mediated PPC has becomeincreasingly commonplace, and has been extensively studied. However, prior research has primarily focusedon the institutional use of ICTs for PPC, with institutional support and regulation, while the personal use ofICTs for this purpose has been mostly under-explored. This paper presents a qualitative study of the use ofWeChat, a general mobile social application, that has been personally appropriated for PPC in China. Sixteenpatients and seven physicians, who had experience using WeChat for PPC, were recruited and interviewed togain an understanding from both perspectives on how WeChat was utilized for the communication purposesbetween them. We found that the use of WeChat helped to strengthen the relationship between patientsand providers, and provided a psychological reassurance that the structure of the current Chinese healthsystem doesn’t provide. Most importantly, we found that the use of WeChat was dependent on the negotiationand management of boundaries that address various concerns associated with the use of ICTs for PPC, suchas workload and safety. In this paper, we will highlight the boundary negotiation practices and discussimplications based on the findings.CCS Concepts: • Human-centered computing → Empirical studies in collaborative and social com-puting.

Additional Key Words and Phrases: Patient-Provider Communication; WeChat; Boundary NegotiationACM Reference Format:Xianghua Ding, Yunan Chen, Zhaofei Ding, and Yiwen Xu. 2019. Boundary Negotiation for Patient-ProviderCommunication viaWeChat in China. Proc. ACMHum.-Comput. Interact. 3, CSCW, Article 157 (November 2019),24 pages. https://doi.org/10.1145/3359259

1 INTRODUCTIONPatient-Provider Communication (PPC) has long been considered a critical component of healthcareservices and has been increasingly shaped by the use of Information and Communication Technolo-gies (ICTs). From telephones, emails, and text messages to messages on web portals, ICT mediatedAuthors’ addresses: Xianghua Ding, Shanghai Key Laboratory of Data Science, School of Computer Science, Fudan University,Shanghai, China, [email protected]; Yunan Chen, School of Information and Computer Science, University of CaliforniaIrvine, Irvine, California, United States, [email protected]; Zhaofei Ding, School of Computer Science, Fudan University,Shanghai, China, [email protected]; Yiwen Xu, School of Computer Science, Fudan University, Shanghai, China,[email protected].

Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without feeprovided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice andthe full citation on the first page. Copyrights for components of this work owned by others than ACM must be honored.Abstracting with credit is permitted. To copy otherwise, or republish, to post on servers or to redistribute to lists, requiresprior specific permission and/or a fee. Request permissions from [email protected].© 2019 Association for Computing Machinery.2573-0142/2019/11-ART157 $15.00https://doi.org/10.1145/3359259

Proc. ACM Hum.-Comput. Interact., Vol. 3, No. CSCW, Article 157. Publication date: November 2019.

https://doi.org/10.1145/3359259

https://doi.org/10.1145/3359259

157:2 Xianghua Ding et al.

PPC has been found to provide a variety of benefits for healthcare practices, such as increasedaccess to care (with a special value for people with disabilities) [23], lower healthcare costs [8],and timely intervention [40]; it has been especially valuable for the care of chronic diseases [55]and non-urgent issues [19]. In addition, ICT mediated PPC has been seen as offering promise forcollaborative care [59], patient participation [43, 61] and self-management [20].

In prior studies of ICT-mediated PPC, there was often a formal relationship between patients andproviders, conjoined with sufficient institutional support or regulation. The existence of an officialor contractual patient-provider relationship, such as in family physician or primary care physiciansystems, means that healthcare providers have more explicit responsibility for their patients. Thisexplicit responsibility, as well as institutional support (e.g., financial support, clinical staff mediation)and regulation [3, 25, 33, 49] have become ways to address various concerns associated with theuse of ICTs for PPC, such as the provider’s workload [3, 55], privacy [18, 53], and safety [3, 22].The more recent web portals [73], usually found with the integration of multifunctional electronicpersonal health records and secure messaging support, were developed particularly for and arerun by healthcare institutions, making it possible to better address some of these concerns at theinstitutional level.What remains unclear is how ICTs might be used for PPC in a healthcare context where there

is no contractual relationship between patients and providers, or institutional infrastructure forPPC. For instance, quite different from the U.S. and other countries, in China, healthcare servicesare primarily carried out in either privately or publicly owned hospitals, since small and personalclinics are still rare, and most people don’t have a primary care or a family physician. Instead ofmaintaining a long-term relationship with one particular doctor, the system has a walk-in modelwhere patients visit a hospital when they need healthcare services. While today, online registrationservices are provided for some Chinese hospitals, there is still no contractual relationship betweenproviders and patients in the system. In such a context, providers may not hold the same level ofresponsibility for their patients as those in the family physician or primary care physician systems,and institutional support for ICT- mediated PPC is generally not available.

Recently, however, we have noticed an emergence in the use of WeChat, a popular mobile socialapplication, for PPC in China. WeChat is similar to other mobile social applications that havebeen widely adopted in western countries (e.g., Whatsapp and Facebook messenger), and allowsindividuals to friend and communicate through short text, audio and video messages, as well as seeothers’ posts on a timeline similar to Facebook’s. Unlike Facebook, however, WeChat is a closedplatform, as only people on one’s contact list can see posts on one’s timeline, and respond to theposts with likes or comments. As a closed communication medium, it is considered more personalthan phone calls, emails, or other social media. WeChat has been pervasively adopted in Chinafor both personal and work communications, and is now also being leveraged for PPC, a type ofcommunication between healthcare professionals and individual health consumers. This raisesthe question of how such a personal channel can be used in a healthcare context where thereis no formal relationship or institutional infrastructure to support it. More specifically, how dohealthcare providers and patients adopt WeChat for communication between them? How doesthe use of WeChat shape their relationship? What do they use WeChat for, and how do providersaddress the concerns mentioned above associated with the use of ICTs for PPC without institutionalinfrastructure, e.g. deal with the communication load?

To answer these questions and gain a better understanding of ICT-mediated PPC, we conducteda qualitative study of the use of WeChat for PPC in China. We recruited and interviewed 16patients and 7 physicians who had experience using WeChat for PPC in order to learn aboutthe WeChat use from both perspectives. In our study, we found the use of WeChat, in additionto the previously mentioned general benefits, enhanced the relationship between patients and


Boundary Negotiation for Patient-Provider Communication via WeChat in China 157:3

providers, and compensated for the lack of an official relationship between them；this, in turn, ledto psychological reassurance for the patients. More importantly, we found that the effective useof WeChat for PPC depended on the construction and management of various boundaries, whichwere established and then constantly renegotiated between the patients and providers to address anumber of the abovementioned concerns, such as workload and safety.

In this paper, we present an overview of the use of WeChat for PPC in China and highlight howthe boundary negotiating work, carried out between healthcare professionals and their patients,ensures the effective use of WeChat for PPC. The notion of boundary is commonly drawn upon,implicitly or explicitly, in CSCW and related fields to understand social practices and the impactof related technologies [30, 36, 44, 63]. It generally refers either to looking at social boundariesbetween different communities of practice to analyze how technologies may support collaborationsbetween them [63], or the temporal/spatial boundaries between work and life to examine theimpact of ICTs. [7, 44]. It is usually pointed out that boundaries, instead of being stable, are rich anddynamic [7, 36]. In this paper, based on the definition of boundaries as "something that indicates orfixes a limit or extent" [46], we use it broadly to refer to structures that condition or regulate theuse of technologies. We extend a similar thinking of boundaries as dynamic and being continuouslyworked on, and highlight the nuanced ways doctors and their patients negotiate and manage newboundaries in order to appropriate ICTs - WeChat in our case - into their healthcare practices,which is quite different from the institutional approach.

In the sections below, we first review the related work on PPC as well as on boundaries andboundary work, and then provide background information on the healthcare system in China andon WeChat. We then present our study and its findings, and discuss boundary construction andnegotiation for appropriating ICTs into healthcare communication.

2 RELATEDWORK2.1 Patient-Provider CommunicationPatient-provider communication has long been a key area of research in health. Studies have shownthat the effectiveness of PPC is important to patient satisfaction [34, 72], treatment compliance[39] and health outcomes [29]. Numerous studies have examined PPC during clinical consultations,focusing on issues such as providers’ communication skills (e.g., gesture, respect) [12], patients’health literacy [54] and values [4] as well as the impact of ICTs, such as the electronic health record[65], computer devices [60] and different computing technologies on the effectiveness of in-clinicPPC [47, 50].

In recent years, ICTs have also been increasingly adopted to support patients and providers forremote communication over the Internet. Generally speaking, ICT- mediated PPC is carried out intwo ways. The first is through independent online healthcare services outside of the conventionalhealthcare system. For instance, the online Ask the Doctor service is for patients to seek answersfrom unknown doctors over the Internet [5, 41, 67, 69]. Some of these services are free of charge(e.g.[69]), and others are commercialized pay-fee systems (e.g.[41]). Moreover, there are telemedicinesystems that offer remote medical consultations that are largely PPC in nature, e.g., eVisit [45].Studies suggest that these online healthcare services are able to meet the needs that regularhealthcare services have not been able [67].

More relevant to our study, the use of ICTs offer additional channels for PPC to complement regu-lar clinical consultations. These ICTs, such as emails and the more recent online web portals, supportasynchronous communication between patients and healthcare providers, and allow patients toask questions beyond their clinical visits. When email became popular, studies were conducted tounderstand how email could be used for PPC [3, 26, 42, 55, 70]. Later, portal systems dedicated to



healthcare were developed to make secure messaging an integral component of healthcare servicesand a part of the Electronic Health Records implementation in many institutions [1, 27, 32, 62].In general, the findings of different studies on the use of ICTs for PPC, especially those on

asynchronous communication such as emails or web portals, are consistent. There appears tobe an agreement that ICTs are mainly used for uncomplicated, transactional, administrative, ornon-urgent issues, such as appointments, medication refills, test results, and other non-urgenthealth concerns [19]. It has also been reported that the use of these communication mechanismshave improved the continuity of care, facilitated chronic-disease management, and increased theflexibility of providers to respond to non-urgent issues [55].

Several studies suggest that while emails and online web portals are supplementary to telephonemessages, they are often preferred over phone calls [16]. For example, while patients tend to use thetelephone for urgent issues, email was preferred for non-urgent and transactional issues [19]. Somestudies found that physical separation and computer-mediation help patients disclose psychologicalor intimate issues [26], and ameliorate the unequal access of medical services [57]. In addition, it issuggested that using asynchronous communication in healthcare may be an important instrumentfor increasing patient participation leading to better self-management [19].

However, it has also been found that there is a gap between what patients desire from ICTs andwhat physicians can currently provide [37]. For the majority of the scenarios described, patientstended to favor ICT use more than the physicians [16]. Patients and doctors often have differentexpectations of the use of these channels; for example, while patients often wanted to consult forcomplex health issues that require long answers, practitioners often preferred giving uncomplicatedand short answers [26]. In a study, almost half of the patients indicated that email communicationwas a suitable medium for the consultation of an urgent medical matter [42]. Physicians also appearto be selective in choosing which patients they will communicate with via email, although thecriteria for the selection is unclear [55]. As Andersen et al. point out, patients and clinicians havedifferent concerns, and an appropriate alignment of their concerns is needed when we designeHealth systems to support collaborations between them [2].

While the use of ICTs for PPC appears promising and is likely to expand in the near future [68],a significant area of concern is how to integrate these communication mechanisms into the dailyworkflow of practitioners [32, 55]. Currently, this is often addressed at the institutional level, wherethe mediation of office personnel is a commonly adopted practice for their integration, and onlinemedical communication is reimbursed [55]. However, response time [27], differing expectations ofthe physicians and patients [26], and communication with clinical staff rather than the doctor, haveall directly impacted the experience and satisfaction levels of the patients [8]. Studies also suggestthat secure messaging is not being fully taken advantage of: not all messages are responded to, theresponse time is varied, and the message content is concentrated on transactional issues or thosewithout urgency [66].

Overall, there has been growing interests in PPC and PPC systems within the past decade, and thepotential effects and complexities of PPC systems have been widely explored in medical and CSCWliterature. However, the majority of this research has been within the institutional boundaries ofhospitals and healthcare systems. How patients and healthcare providers may adopt and appropriategeneral social applications that are not designed for PPC and lack institutional buy-in has not beenexplored in prior literature, although we have seen some work on how WhatsApp can supportmedical education [58] or communication between physicians [24, 71].

2.2 Boundaries and Boundary WorkBoundaries are a critical concept with regards to ICT use in social practices. In CSCW, boundariesare often used to refer to social boundaries, or boundaries between different social worlds or



communities of practices [63], where the attention is on how to support collaborations across thesedifferent communities. In addition, the notion of boundaries is also commonly used to analyze andunderstand the impact of technology in our lives, mainly between work and life [7].With the increased connectivity and access to information, there is a common concern that

ICTs has blurred or even destroyed the previously well-established boundaries in everyday life –the boundary between work and non-work hours, or the work boundaries that were previouslyconfined either spatially or temporarily, such as the workplace and home [28, 35, 44]. Many studieshave been conducted to understand boundary work – the various strategies individuals deployedto manage the boundaries with the use ICTs, such as using separate applications for personaland work emails, or removing a work email from their phone during time off [9, 48]. In terms ofdesigning technology, rather than merely focusing on "seamless design" which allows users toaccess information and computing anytime and anywhere, "seamful design" has been recommendedas a strategic design choice to present seams as resources from which users can draw and betterappropriate technologies into their lives [10].While similarly acknowledging the importance of boundaries, more scholars have started to

question the presumption of the stability of boundaries and consequently begin to rethink theroles of ICTs. Lee, based on a study of a newly-formed, interdisciplinary design group, points outthat the presumption of a standardization of boundaries is "inherently problematic for theorizingincipient, non-routine, and novel collaborations" between social worlds [36]. Building on the notionof boundary objects [63], she proposes the notion of boundary negotiating artifacts to betterunderstand how this dynamic boundary works and to push past the assumptions of standardizationand stable boundaries between communities [36]. Bødker, upon reflecting on various projectsand literature, also questions the idea of stability, emphasizing the dynamic nature of boundaries[7]:"In human activity, boundaries are dynamic and change over time. They are drawn, challengedand negotiated, and worked on(originally emphasized), all the time".While the notion of boundaries are commonly employed in CSCW and related fields, either

in terms of social boundaries between different collaborative communities, or temporal/spatialboundaries between work and home, we use boundaries here in a broader sense - in terms ofstructures that condition or regulate the use of a new technology into a practice. Although concernsand strategies for boundary management with ICTs have been commonly reported [9, 28], howvarious boundaries, beyond those between work and life, are negotiated and renegotiated byhealthcare professionals and their patients have not been studied previously, partly due to the stricthierarchy of medical practices. By focusing on the volunteer adoption of a general social applicationin China’s healthcare system as the site of study, we uncover nuanced boundary negotiationpractices for ICT-mediated PPC and offer new insights into boundary work for future CSCWresearch.

3 BACKGROUND3.1 Healthcare Practices in ChinaIn China, small and personal clinics are still uncommon, and so are family and primary carephysicians [75]. Most healthcare services are carried out in publicly or privately owned hospitals.When patients find that they need to visit a doctor, rather than making an appointment, they justwalk into the hospital and register with a department, based on their symptoms. Often, hospitals arepacked, especially big ones and those that are highly ranked, and each step, including registration,clinic consultation, payment, lab testing, and medication pick up, requires a long wait. The clinictime for each patient is also usually very limited - sometimes maybe only a few minutes, as onedoctor may need to see 60 patients, even more, a day [74]. Today, while some applications have



shown certain doctors’ clinic hours or have provided online registration services, allowing patientsto find an appropriate time or to register online to see a particular doctor, there is still no contractualrelationship between healthcare providers and patients. While healthcare practices are mainly basedon western medicine, Traditional Chinese Medicine (TCM) also exists in China. Many hospitalshave TCM departments, and there are relatively more small clinics for TCM than those for westernmedicine.

3.2 WeChatWeChat is a popular mobile social application that was first launched in January 2011 by TencentCompany in China. Its instant messenger window can support text messaging, voice messaging,voice and video calls, location sharing, and more, similar to other mobile social applications, e.g.,WhatsApp. In addition, users can update their statuses through Moments by sharing text-basedposts, photos, videos, and links, which can then be viewed, liked, or commented on by theircontacts, similar to the functions of the Facebook timeline. WeChat originally started out as aninstant messaging application but has integrated more functions to support people’s daily lives,including audio/video conferencing, subscribed official accounts that provide articles, a paymentfeature, and step counting. It has become the "stickiest" application in Chinese people’s daily lives[11] - with around 30% of mobile internet time spent on WeChat [31], which translated to almosta whole hour of use per day on average by the year 2017 [51]. WeChat has had over one billionactive monthly users since January 2018 [13].Unlike other popular social media platforms, such as Twitter, Weibo, or Facebook, WeChat is a

rather closed platform. It relies on a two-way communication mechanism. That is, one needs tosend a friend request, which is colloquially called "adding WeChat," and only after that request isaccepted and one becomes part of another’s WeChat contact list, can the two chat and see eachother’s posts on Moments. There are multiple ways for WeChat users to send WeChat contactrequests, such as searching by WeChat ID, scanning a WeChat QR code, or through shared namecards sent by other contacts. WeChat provides additional privacy settings for users to control whocan access their Moments, even within their contacts. In contrast, on Weibo and Twitter, peoplecan freely follow others, see their posts and initiate communication; on Facebook, people beyondone’s contact list can often access one’s posts.

4 THE STUDYTo understand WeChat use for PPC, we attempted to recruit both patients and healthcare providersfrom a wide range of healthcare practices, including both western medicine and Traditional ChineseMedicine, since they co-exist in China. While it was relatively easier to find patients, we made aspecial effort to recruit doctors. For the rest of the paper, we will designate participants by P(atient)| D(octor) to distinguish whether it is a patient participant or a doctor participant.

4.1 Participant RecruitmentWe designed a recruitment flyer which described the purpose of the study, the study procedure, theneeded qualifications (experience using WeChat for PPC) and compensation (50RMB/person) forparticipation, as well as our contact information. We posted it on our own WeChat Moments, andsome of our friends reposted it. Through this approach, eight patient participants were recruited,including a few of our friends and relatives. we also joined a TCM QQ group1 and a WeChat groupto post the flyer there, and recruited eight more eligible patient participants after some screening.Eventually, 16 patient participants were recruited in total.

1QQ is an instant messaging software also developed by Tencent.



Table 1. Demographics of Patients

Participants Gender Age Type of Disease Occupation LocationP1 M 40s Coldness of body worker ShanghaiP2 M 20s Anxiety disorder,Whelk worker ShanxiP3 F 20s Eczema postgraduate ZhejiangP4 F 20s Eczema,Stomachache,Hemorrhoids postgraduate ShanxiP5 M 20s Gastrointestinal disease,HFMD postgraduate BeijingP6 F 40s Advanced lung cancer salesman AnhuiP7 F 20s Lumbar disc herniation,Knee disease postgraduate AnhuiP8 M 20s Uvula inflammation postgraduate ShanghaiP9 M 40s Asdthenic splenonephro-yang worker FujianP10 M 20s Oral surgery postgraduate ShanghaiP11 F 20s Tooth loss undergraduate JilinP12 F 50s Cerebral infarction,Glaucoma self-employed JiangsuP13 F 20s Asthma undergraduate ShanghaiP14 M 40s Pediatrics doctor JiangsuP15 M 20s Angiocardiopathy undergraduate ShanghaiP16 F 20s Safe-au-lait-spots undergraduate Shanghai

We tried the flyer approach to recruit doctor participants. After having posted it on WeChat,and in multiple other online forums, we had only recruited one doctor (D5 from a doctor’s onlineforum called Ding Xiang Garden). We then turned to our own social network and personally askedthe people around us to introduce us doctors who had experience using WeChat to communicatewith patients. We recruited five doctors this way. During an interview, we learned that P13’s father(D4) was a doctor and had communicated with patients using WeChat. We recruited him to ourstudy, which, in the end, had seven doctor participants total.Table 1 shows the profiles of the 16 patient participants. They range in age between 20 and 50,

but most are in their 20s. Our patients and doctors were connected via WeChat for the consultationof a variety of illnesses including Eczema, HFMD, Lumbar Disc herniation, Asthma, and Glaucoma.Some participants were connected with more than a doctor for different diseases (e.g., P4 wasconnected with different doctors for Eczema, stomach pains, and Hemorrhoids, among others).Some participants also used WeChat to consult doctors for their family members, who were tooold or too young to use WeChat for communication (e.g., P6, P7, P12 and P15 for their parents orgrandparents; P14 for his newborn child, and P5 for his nephew).Table 2 shows the basic information of the 7 doctor participants, aged between 20 and 50.

Except for D7 who worked in his own clinic, the rest were from public hospitals, and workedin various departments, including TCM departments. They also had WeChat connections withmultiple patients.

4.2 Data Collection and AnalysisThe interviews were semi-structured and conducted through face-to-face communication, telephonecalls, WeChat voice calls, and WeChat text chat (only P10 who was reserved and asked for thismethod), based on the participants’ preferences. The interview duration ranged from half an hour toan hour and a half. During interviews, we asked participants about their experiences of connectingwith doctors or patients over WeChat, when they chatted and what they chatted about, theirinteractions on Moments, and their opinion of using WeChat for healthcare consultation. When



Table 2. Demographics of Doctors

Participants Gender Age Specialty/Organization LocationD1 F 20s TCM/hospital ShanghaiD2 M 20s Ultrasound Diagnosis/hospital ZhejiangD3 F 20s TCM/acupuncture and tuina/hospital ShanghaiD4 F 50s ECG Function/hospital ZhejiangD5 M 40s Internal medicine/hospital JiangsuD6 F 20s TCM/hospital ShanghaiD7 M 30s TCM/private clinic Jiangsu

interesting information came up, we followed up for more details and specific examples. Mostof our participants were friendly, supportive, and open to sharing their experiences with us. Inparticular, some participants indicated that this was a very meaningful and interesting study thatthey would have been willing to participate without compensation. Except for two who could onlyspeak dialects, our interviews were conducted mainly in Mandarin. All voice-based interviewswere audio-recorded and then transcribed into text.

We used the grounded theory approach [64] for data analysis. The first author conducted opencoding on the transcript and then axial coding to sort the various codes. Through rounds ofdiscussions among the authors, some prominent themes emerged, and we identified boundariesas an overarching theme to consolidate our codes. Then different codes were sorted, and all therelated data was collated within the identified theme. Representative quotes were translated intoEnglish and applied for illustration purposes to this paper.

5 FINDINGSWe found that the WeChat connections between doctors and patients were primarily established intwo ways. The first was in a more personal manner, in which the patient asked to add the doctoron WeChat (or the other way around) usually during offline clinical visits, or through friends’recommendation, e.g., by sharing name cards between contacts. In this model, the use of WeChatwas complementary to regular healthcare practices. In the second model, WeChat was employedas a business tactic of actively leveraging the Internet for healthcare services, so that the doctor’sWeChat contact (often in the form of a QR code) or other contact information was posted online forpotential clients. For example, some of our patient participants reported that they searched onlineusing key words, and got connected with their doctor by scanning the QR code that came up inthe search. In this paper, our focus is on the use of the first model of WeChat for PPC; we will notdiscuss the second model.

5.1 An Overview of WeChat Use for PPCWhile WeChat has been commonly used in China for work and personal communication, its use forthe interaction between patients and doctors is still an emerging and new phenomenon. Our studyrevealed some of the reasons why WeChat hadn’t been more widely used for PPC, including thebusy schedule of doctors, the lack of a formed habit of doing so, as well as a general understandingthat WeChat is more personal than other communication channels such as phone calls and emails.In general, we found that doctors who were relatively less occupied (e.g. younger doctors or doctorsin relatively small hospitals, less busy departments, or in small towns) were more likely to adoptWeChat for PPC.



Nonetheless, the participants who had already adopted WeChat for PPC, both patients anddoctors, were very positive about it. In addition to logistical issues, such as confirming the doctor’sclinic hours, it was fairly common for patients to use WeChat to consult their doctors directlyabout their healthcare problems, e.g., what to do for a minor health issue, or how to take theirmedicines. As reported elsewhere [41], our patient participants appreciated that this use of WeChathelped them avoid extra travel and allowed them to get help in a more timely manner. Our doctorparticipants liked it too, as it allowed them to more easily oversee patient progress and makemore timely adjustments. For example, D5 said: "If there were no WeChat communication, in specialcircumstances, we couldn’t give (patients) guidance at the earliest time possible. With the help ofWeChat, we can give (them) guidance as soon as possible for small problems and solve them. Then thesesmall problems won’t develop into bigger problems; this brings convenience for the follow-up treatment."D4 also described why he liked to use WeChat: "There isn’t any economic benefit associated withit (the use of WeChat for PPC). It is nothing but responsibility for us. However, since we are doctors,we should try our best to help others within our capacity, right?” As we can see here, WeChat wasadopted by our doctors for PPC primarily in the interest of better healthcare outcomes for theirpatients.In particular, we found the use of WeChat positively enhanced the relationship between the

patients and providers. All participants commented that having more communication led to moreunderstanding, and thus a closer relationship. For instance, P14 described :"It certainly brings uscloser. With more communication due to its convenience, we can know each other better." Other patientsalso commented on how WeChat Moments reinforced their connection; as P13 put it:"Probably itwas because of the Wechat Moments, which gives a more comprehensive understanding of a person.Phone calls and text messages feel more formal and distant, but WeChat communication feels more like(communication between) friends." P12 echoed this assessment:"You may have not contacted him onWeChat for a long time; however, when you see the doctor’s Moments, you regain this impression, whichenhances the relationship, right?" Interestingly, D4 pointed out how the involvement of picturesafforded by WeChat provided a sense of emotional bond: "With this approach (WeChat), there maybe pictures, or they may send photos, which certainly enhances our understanding of each other. Well,it may not be understanding. It is more like an emotional bond." To D5, it was the better healthcareoutcome with the use of WeChat that ultimately improved the patient-provider relationship:"Thatdefinitely brings us closer. On one hand, we can communicate more, and on the other hand, themore important thing is that we give them effective guidance, which keeps their conditions fromgetting worse." As such, its convenience for additional interactions, seeing contacts’ updates onMoments, the involvement of pictures, as well as better healthcare outcomes afforded byWeChat allhelped enhance the patient-provider relationship. Interestingly, D3 emphasized how the enhancedrelationship was especially meaningful for a young doctor in China’s healthcare system:“As a doctor,everyday you will see patients, like on an assembly line. Because each patient has very limited timefor consultation, and he may not want to come back to see you again, especially when you are still ayoung doctor. When I answer them on WeChat, even if I don’t contact them on my own initiative, itmakes me different from other doctors. To the ordinary people, having a doctor answer your everydayhealth questions is very nice.”Having a WeChat connection with doctors then reassured the patients and made them worry

less. As P2 explained:"The reason why you consult your doctor on WeChat is because you feel helplessor panic over your problem, as it can’t be solved by yourself. With the doctor’s replies, you find thatthe problem is not so serious, and you know what to do next, which makes you feel more relieved."P8 reported having a similar experience after consulting the doctor on Wechat: "At least this kindof doubt or tension has been relieved, which means that the problem can actually be controlled, or iswithin a controllable range." P3 further noted that WeChat communication with the doctor filled the



information gap between clinic visits: "It may have closed this gap — the lack of information whenyou only have a few face-to-face communication sessions. Only after you have more communicationwith your doctors can you know what you’re doing. Then you don’t have to worry too much about yourconditions." As shown in these quotes, patients found that WeChat communication with doctorsmade them understand their health conditions better and feel more in control; as such, they worriedless, which was considered by some to be the main value of using WeChat for PPC.

Our data reveals why the various features of WeChat often made it a preferable choice for PPC.First, WeChat is very pervasive in China, which eliminates the need to download and install newapplications. D2 put it this way:"WeChat’s penetration rate is the highest...We do not have to say, let’sdownload an App for this." Second, WeChat’s use is free, as long as there is an Internet connection.P2 explained: "You need to pay for making a phone call or sending a short text message. With WeChat,it doesn’t cost you much for a data package, right?” Third, WeChat is less disruptive (than phonecalls), and feels more informal. P7 explained: "But with WeChat, I can send a message to him wheneverI am free, and he can reply whenever he has time. I think it is more convenient. It does not have to be sovery clear: if he does not understand it (the question), he can ask, and I can reply when I see it. Its useis not as formal as using short text message.” Lastly, WeChat comes with rich media support, suchas photo, audio, and even video. Almost all our participants reported using pictures and videos tocommunicate more effectively, an important reason why WeChat was highly favored. All of thesefeatures contributed to better communication experiences and healthcare outcomes with lowercosts.

However, our data also suggests that these positive effects were conditional upon the constructionand management of various boundaries, which were repeatedly negotiated by the providers andthe patients; at the same time, the delineation of these boundaries varied from provider to provider.In the sections below, we elaborate on how these boundaries were negotiated and managed inorder for the doctors and patients to effectively use WeChat.

5.2 Social Boundaries: With Whom to ConnectThis paper focuses on WeChat patient-provider connections that were personally established, inwhich no mandatory requirements or institutional regulations were involved. In other words, theseare connections in which the doctor decides whether or not to adopt WeChat and how to use it. Asmentioned, many doctors were still not open to the idea of having WeChat connections with theirpatients. P5 reported his own experience: "Actually, I only added one doctor on WeChat when I wasin Beijing because many of them were unwilling to do so." P14, both as a patient and a healthcareprovider in our study, had aWeChat connection with the pediatrician for his newborn baby througha friend’s recommendation, and spoke from the doctor’s perspective: "Doctors don’t want to addpatients on WeChat, unless they have been recommended by a friend...One reason is the lack of habit... Idon’t think it’s necessary. If every patient added the doctor on WeChat, the doctor would not have timeto see patients in person. It could be very annoying." However, none of the doctors we interviewedin the study complained about the use of WeChat for PPC, although they all reported that theyused their personal time to answer questions on WeChat. This indicates that to them the valueassociated with the use of WeChat for PPC outweighed the corresponding costs, such as sacrificingpersonal time. We now look at how these social boundaries were negotiated through the patients’consideration of the doctors’ needs and the doctors’ selectivity.

5.2.1 The Considerate Patient. In our study, it was usually the patient who initiated the WeChatconnection process, and often this step involved some considerations on the part of the patient.That is, the patient needed to think about various factors before making such a move, and therewere many hesitations in doing so.



One primary hesitation came from an awareness of the doctor’s workload. P7 expressed suchconcerns shaped her asking forWeChat connections:"In fact, it is quite stressful forme to communicatewith doctors. Because, on the one hand, they don’t have free time, and on the other hand, they arealso people with certain social status. There is a stress for me when communicating with them. I thinkit’s enough to just add one doctor from each department that my mother went to for treatment." Ourpatient participants commonly expressed concerns that their messaging would add to the doctors’workload, which might not be acceptable to the doctors. Their concerns were recognized by thedoctors as well, as D3 told us:"In fact, patients generally think that doctors are not willing to add themon WeChat, especially doctors in big hospitals like us. Patients think that doctors are very busy and donot want to communicate with them on WeChat." As suggested by D3, factors such as whether thehospital is big or popular, and the seniority or fame of the doctor all potentially make the doctor’stime an even more precious resource, which could limit how much ICT mediated PPC might beaffordable. As such, while P3 considered WeChat to be a valuable channel for her as a patient,she did not think that it could be used widely:"As I mentioned before, I think this is a very goodmechanism. But due to doctors’ work hours, the extent of how busy they are, they are not able to spenda lot of time on WeChat. Because, just imagine, the doctor needs to see so many patients in the hospital.After work, does he still need to spend his private time answering questions from patients?" This is tosay that the particular healthcare system in China (e.g. there is no official relationship betweenthe patient and one particular doctor), and the knowledge that doctors use their personal time toanswer questions caused the considerate patient to hesitate to ask for a WeChat connection in thefirst place.

Moreover, WeChat was also considered a more personal and less official channel than emails orphone calls, which also kept patients from freely asking for a connection as they perceived doingso to be impolite. For example, P14 told us how he felt it was impolite to ask for a doctor’s WeChatconnection, even with his friend’s introduction:"I have a friend who is very familiar with him, andhelped introduce us...It was the doctor who sent the friend request, because I felt uncomfortable doing iton my own. Usually, doctors won’t add patients on WeChat, and neither will the patient add the doctor.If patients really want to add the doctor, they’ll add the hospital’s official WeChat account. But, usuallythey won’t add doctors’ private WeChat accounts, unless it is through friends’ recommendations."P7 was also more careful about asking for his doctor’s WeChat than asking for other contactinformation:"I didn’t ask him for his WeChat contact directly. At first, I told my mother to ask forthe doctor’s email address because I thought it was impolite to ask for the doctor’s personal contactinformation, or he would mind it." The connotation of WeChat as more personal and private limitedhow people asked for WeChat connections in the first place. In other words, most patients didn’tdare to ask for a WeChat connection, even when they wanted to.It usually took social capital, in terms of a social network, social trust, or some other features

of a social organization [56] for a patient to ask for a WeChat connection. Many patient-doctorWeChat connections were established through social recommendations or a social network, whichthen provided a foundation or social capital for "favors" from the doctor. D5 put it this way: "Someof them are relatives or friends. It is not a big deal doing them a favor." For WeChat connections notestablished through a social network, repeated visits to the same doctor or hospitalization wasusually required, after which point, the doctor and patient were not strangers anymore. Severalpatient participants used the Chinese saying “strangers the first time,friends the second” to describesuch a process. Connections not established through a social network were mostly establishedat the second visit at the earlier. For example, P13 described his case this way:"I didn’t add himthe first time. I just went there to visit him. Then it was quite serious the second time, with aerosoltherapy for Asthma or something. That time I asked the doctor a lot of questions. As I thought he hadhelped me twice, he was familiar with my condition anyway, so we got connected via WeChat then.”



P5 reported a similar situation: "Because it was the second time I saw the doctor... it was the secondtime I saw him that I added his Wechat. He saw the (health) record from the last time - because thereare records in our school’s health system (it is a school hospital). He said that he’s seen me before, andthen I said, well, let’s add WeChat, and he agreed.” As such, while there was no formal relationshipbetween patients and doctors, as in the US primary care system, repeated visits to the same doctorbecame a way for patients and doctors to get to know each other and form a relationship, uponwhich WeChat connections could then be established. In a healthcare system like this, seeing thesame doctor again also showed some intention on the part of the patient (if not by chance), sinces/he needed to find out the particular doctor’s clinic hours.

Patients were also cautious regarding whether a WeChat connection was acceptable to the doctoror not. P7 described the process of how she negotiated contact with his doctor and gradually gotmore personal: "I asked him for an email address, so he could reply when he saw the message, as I wasnot in a hurry anyway. Later, the doctor gave us a phone number directly, so I got his phone number.At that time, I didn’t bother him often. If there was an emergency and I really wanted an answer, Iwould ask him. Then I talked to him over the phone as well as text messaged. I found that he was quitenice, so I tried to use his phone number to search for his WeChat ID and got it. I then sent the request,and he accepted.". P3 offered another example which shows how she assessed whether a WeChatconnection was possible: "He then showed me a male patient’s photos on WeChat, comparing photosbefore and after the treatment. He told me that the guy added his WeChat contact, talked to him everyweek, sent pictures to him, and asked whether he was getting better. Then I asked the doctor if I couldadd his WeChat, so I could contact him when needed. He agreed. He could have actually just given mea business card, but with the business card, you can only use the phone number to contact him." Asshown in these cases, WeChat connections were handled in a more careful and considerate manner,compared to sharing phone numbers and emails which were still more commonly used.

5.2.2 The Selective Doctor. While our doctor participants were generally positive about the use ofWeChat for PPC, we found that they were also selective in terms of who they would connect withthrough WeChat. This selectivity had been reported in previous work, but it was unclear what theparticular standards were for selection [55]. Our study was revealing in this respect. First, theirselection was based on the disease of the patient and what kind of care was needed, which wasthen used to justify the workload associated with the WeChat connection. Consistent with previousfindings, it was usually patients with chronic conditions who were thought to benefit more fromsuch a channel [19, 55]. D3 made this point: "Usually if the patient is in a chronic condition andneeds time to recuperate, I will add them on WeChat. Those who come and go, I will not." D5 alsoemphasized the role of chronic conditions in the selection process:"Because it was a chronic disease,and he wanted to treat it. Then he asked to add my WeChat." D2 noted that WeChat was usuallyadded when on-site treatment was insufficient:"Most of these cases are those that cannot be diagnosedon site and require long-term follow-up care." As such, WeChat provided a complementary channelwhen in-clinic visits were not enough.

Second, the doctors needed to make sure that a patient was a excellent communicator and trust-worthy enough for a Wechat connection. In-person communication and social recommendationswere ways for them to make such a judgment. For example, D5 reported how some patients cameto her and were always quite communicable, so she was willing to have WeChat connections withthem:"Like these two patients, it was nice to talk to them, and they have come to me for long-termtreatment. I think I shall give them guidance and advice via WeChat." In contrast, she revealedhow she denied a WeChat request from a patient who did not give her a sense of security duringin-person contact. D4 confirmed it was important to have a basic understanding of who the patientwas, and a social network (social recommendation) could be helpful with that:"I need to know who



they are. I don’t add the WeChat of strangers. Basically, I just add people who I know... know who theyare. Then, I add those who come to me at other patients’ recommendations." These quotes also explainwhy, from a doctor’s perspective, repeated in-person visits were important for establishing WeChatconnections with the patient; they were a way to get to know the patient, address safety concerns,and ensure effective communication.

Our data also suggest that if a patient demonstrated that he himself took his healthcare seriously,the doctor would be more likely to form a connection with him. For example, D1 listed patients’feelings towards their own health as one of the conditions for such a connection:"I’ll add them onlywhen needed...those who are concerned with their own health." D6 reported that for those who tooktheir own health seriously, he would even initiate the connection process:"Generally, it is they whoactively add me. If they care about their own health, I will also actively add them." Here, the WeChatconnection was formed as encouragement of patients’ active participation in the healthcare process,consistent with the spirit of collaborative care [59] or participatory care [61], a model of healthcareincreasingly emphasized in recent years.In summary, what is illustrated here is the thoughts and considerations people put into the

process as well as the mechanisms and nuanced ways employed for the establishment of a WeChatconnection between patients and providers in the first place. As we can see here, the doctors werequite selective and the patients were considerate, and we believe these are the necessary conditionsfor the effective voluntary use of WeChat for PPC. In other words, PPC over WeChat could onlywork well between selective doctors and considerate patients, by taking the reality of the particularhealthcare context, and the social norms of what is considered to be appropriate and polite intoaccount.

5.3 Temporal Boundaries: When to MessageIn addition to social boundaries, when to send and respond to messages was also a key concern forthe effective integration of WeChat into the doctor’s everyday life, and it was a key area whereboundaries were negotiated between patients and doctors.

5.3.1 Timing. Our data suggest that compared to phone calls, emails or other web messagingservices, the portable, instant and asynchronous nature of WeChat made it possible for the doctorsto use fragmented time, and more smoothly integrate it into their daily workflow. For example,D4 said:"Usually, I’ll reply whenever I have time. Sometimes we are busy, and my cell phone may notalways be with me. Anyway, generally, I will reply to them as soon as possible, at least I’ll reply ‘Got it’or something like that." D5 described a similar strategy: "When I see it ,if I have time during work, I’llanswer, otherwise, I’ll answer after work." P11 provided an example from the patient’s perspective ofhow a doctor handled WeChat messaging and phone calls differently:"I still remember once he wasperforming an operation on a patient (dental surgery), and he actually saw a message coming on hisphone. He looked at it and then went onto the surgery. A couple of times, people called, one time he justhung up, and another time he answered and said that he was busy." As shown in this case, rather thanhaving to hang up or accept the phone call and then explain why he can’t engage, with WeChat, asimple glance was enough for the doctor to decide whether or not to engage at that moment.

As such, dependant on their availability, doctors could potentially be very responsive on WeChat.We found that WeChat was used to address urgent issues in several cases, not merely non-urgentones as is commonly reported with the use of asynchronous communication [19, 21]. P12 providedan example. Once, when it was in the middle of the night, she felt uncomfortable bothering thedoctor and chose to use WeChat rather than making a phone call. Luckily, the doctor respondedand helped address the issue right away:"My mother suffered from Glaucoma, and it broke out once.It was at two o’clock in the morning and it was very serious, with tears, a headache and sore nose. My



mother couldn’t hang on to the morning, and we needed to take her to the hospital right away. I wouldhave felt very uncomfortable giving him a call, so I sent a WeChat message to him and he actuallyreplied. He was having a rest at home, but he gave me a call and told me how to deal with it." Portableand asynchronous, WeChat was a small ambient display that leveraged the doctor’s peripheralawareness in order to help the doctor decide whether to engage or not based on the urgency of theissue as well as the availability of their attention.In order to manage the boundary between online and offline patient attention, several doctors

allocated a specific time during the day to answer WeChat questions, which was usually duringtheir personal time. Almost all of them reported using the lunch break or time after work to answerquestions on WeChat. D3 put it this way:"I’m still a clinic doctor, so surely I can’t and don’t havetime to answer these questions during work. I have to wait until after work, and then I will answerquestions when I see messages. In fact, the use of WeChat increased the workload for us, since westill help patients answer questions when we are on break." D2’s case was more unique, for as anultrasound physician, his messages were of a more sensitive nature, and replying during off-workhours could indicate serious results; consequently, he picked his response time carefully:"I usuallycan not answer these questions quickly during work. After all, I don’t have a whole lot of time then.We try to avoid answering these kinds of questions (about their diagnoses and results) after work toobecause they are sensitive to this kind of information. I might answer these questions when I’m aboutto get off work, or during the intervals, which means it is usually around 10am to 11am or around 3pmto 5pm."Over time, some patients gradually developed an understanding of their doctor’s work habits,

and then found the most appropriate time to message. P10 described the responsiveness of differentdoctors and illustrated an understanding of their different work rhythms:"(Whenever I messaged),Doctor Zhuang’s response was a little bit slow on Wechat. I guess maybe he was making his roundsat the hospital or having a meeting or something. He would usually reply after an hour or two.Doctor Rong replied more quickly. After I sent messages to her, she would reply almost immediately.Perhaps ophthalmologists have fewer patients, while neurologists are more busy, right?" P1 notedthat doctors were more responsive after work: "Doctors don’t respond during work hours, but theyrespond promptly after work." After figuring out their doctors’ schedules, some patients consciouslyleveraged that information. P7 told us that he would wait until the doctor was off work to sendmessages:"Because I know he gets off work around six o’clock, I always asked him after he got off work.If he is at work, I think maybe he is making rounds or doing surgery, so I won’t bother him at thattime. When I asked him after work on WeChat, he replied quickly." D7 explained, from the doctor’sperspective, how the timing of messages was carefully managed by patients over time:"It seemslike they know when I am busy and when I am not. They tend to send messages to me when I amnot busy, such as at noon when I am having lunch, or in the evening when I am having dinner. I amusually not busy at that time." As we can see here, through the messaging process, the patients andtheir doctors gradually negotiated the temporal boundaries of their WeChat communication; theseboundaries differed based on each doctor’s individual schedule and minimized both the responsetime and the disruption to the doctor’s life.

5.3.2 Period and Frequency of Messages. From the data, we found that the duration during whichpatients sent WeChat messages to their doctors usually matched up with the period of treatment.Patients only used WeChat to ask questions when they came to the doctor for medical treatment,and when the patient stopped seeing the doctor, the WeChat messaging stopped as well. To someextent, the medical treatment, either through sustained in-person visits or the taking of medicineprescribed by the doctor (mainly TCM) justified their free WeChat consultations with the doctor.The example given by P6 was typical in our data:"Then I took it (the medicine) for about a month



and a half, and stopped taking it afterward. After that I didn’t talk much to him anymore." P3 had asimilar case:" (I used WeChat with him for) over a year, during the time I went him for treatment. Overa year." Sometimes, patients could feel the effects of this boundary when they tried to go beyondit. As P6 explained:"He was good and responsible. But when we stopped going there to see him, hebecame not as good as before. I felt his attitude was different from when we first saw him. He becamenot as enthusiastic." P9 reported on a very similar situation: “When I was taking his prescription, wehad a higher frequency of communication. However, when the medication period was over, he was alittle less patient when I talked to him.” These cases suggest that while the free WeChat connectionremained in place, other primary care services were needed to sustain its effectiveness.Our data also shows that the volume or frequency of patients’ messages to their doctors was

highly related to the progress of their disease or treatment. This quote provided by P2 describes howthe frequency of messages changed over the recovery process:"For the dermatologist, I communicatedwith him frequently in the early stage, and contacted him every 3 to 4 days on WeChat. This situationlasted for about a month. After my skin condition got better, I seldom messaged him.” P12 also reportedon how the frequency of messages aligned with the frequency of disease outbreaks:"It was Doctor Yu,director of neurology. When my mother had an outbreak sometimes, I would contact him via WeChator make phone calls to arrange a bed or something. Such contact is not very often because my motherhas been taking medicine he prescribed to us since she got out of the hospital, and she has felt goodon this medicine. Doctor Rong treated Glaucoma for my mother, and my mother’s Glaucoma breaksout often and sometimes comes with tears or headaches. Then I will contact Doctor Rong. I contactdoctor Rong from the ophthalmology department more often." D7 confirmed this from a doctor’sperspective:"Communication is not as frequent as before, because it is closer to the end stage of thetreatment now, and the effect has been very good. It is the stage of strengthening, and everything willbe better with an appropriate diet everyday; now we just let the body gradually recover and improve."As D6 explained, no message was a right message: "And then later on, there is no message. I don’thave time to ask them how it turns out, but basically if there is no response, it is the best response." Assuch, while we didn’t quantitatively collect or analyze the WeChat message data, the interviewdata seem to suggest that we could read quite a lot about disease progression and treatment effectsfrom the frequency of messages between patients and their providers.Taken together, we can see how various temporal boundaries or patterns emerged, in terms of

responsiveness, the valid period for a free consultation, and frequency of communication, for theintegration of WeChat into providers’ healthcare work. These boundaries and patterns were shapedby the portable, instant, and asynchronous nature of WeChat, providers’ work nature and rhythm,related care services, as well as disease or treatment progresses.

5.4 Negotiating Boundaries through Content: What to MessageIn addition to social and temporal boundaries, theWeChat messages between patients and providersalso had boundaries related to content in terms of what was considered acceptable, relevant, andappropriate.The first boundary was that it needed to be maintained within what was essentially a free

service. As mentioned, our primary focus in this paper is on WeChat consultations used in personal,not commercial ways. That is, WeChat communications were provided for free to complementthe primary care taking place at a hospital, where treatment is paid for and partly covered bysocial security. This is quite different from the use of commercial software designed explicitly forhealthcare where patient-provider communication is supported but charged. We found that manyof our patients only messaged their doctors to ask questions about small problems; as such, the freeservice boundary was maintained. For example, P2, who asked questions about his cough, said:"Itwas all for free because I don’t think that this was a big problem." P1, who asked questions about



small skin problems, similarly said:"They were all small problems, and were addressed for free." P9,on the other hand, intruded on the free service boundary since he inquired a lot about TCM:"Thedoctor was a bit grumpy. I am interested in Traditional Chinese Medicine, and I may have known alittle bit. So I asked him questions just like a primary school student asking a college student, andthey may have sounded naive to him. Sometimes, he was kind of angry. He would sometimes say:‘Paytuition!’" When the primary care was expensive, and the patient was the one responsible for thebill, the patient often felt more comfortable using WeChat to ask questions for free. For example,P3 said:"(Using WeChat is) free! Seeing the doctor for this kind of skin disease was actually quiteexpensive, and the treatment was at my own expense (not covered by social security), so the doctor alsofelt like helping me to recuperate." In general, how the WeChat consultation or how the primarycare was charged shaped what questions were appropriate to ask.

The second boundary was safety. For safe healthcare, the WeChat channel itself was not consid-ered appropriate for diagnosis or prescriptions, for which clinic visits were often suggested instead.For example, D5 said:"His blood sugar level was high, and then there were symptoms of a Urinary-tract infection. He then asked me: ‘For my situation, may I just take some antibiotics?’ I suggestedhe come to see me for a diagnosis and then see how to address it. These kinds of questions can’t beanswered on WeChat, and can only be addressed after an actual examination and lab tests." This wasalso true for TCM, as described by D7:"There are too many kinds of questions (that we can’t answeron WeChat). For example, for prescriptions, one can say what symptoms, conditions, and feelings hehas, but if we do not take his pulse or do a face diagnosis, we can’t give prescriptions...They can consultme as the first step, and I can answer their questions and then ask them to come over for a face-to-facediagnosis. If they want treatment, a face-to-face diagnosis is an inevitable step." To maintain the safetyof healthcare, WeChat was only used as a complementary channel, not as a replacement of clinicvisits.

It was also important to protect their liability. For example, D2 told us how he would not answersome of the questions he was asked, in order to protect his peers: "The kind of questions we cananswer...We offer guidance for patients’ follow-up treatment or examination...For example, if he hasan abdominal ache after the examination, I would suggest he do a colonoscopy or a lower abdominalenhanced CT. We will give guidance on this kind of things. But if he comes to me, say, to look at thediagnosis or the pathology results from another hospital, and asks me if his condition is normal or hisdiagnosis is correct or something like that, we won’t answer. Based on the peer protection principle,such questions will not be answered. So surely we give more guidance than solutions, and we thinkmore carefully if asked to give solutions."

The third and final boundary was professionalism. With the use of such general social media forPPC as Facebook and WeChat, there has always been a concern for an intrusion into the personalspace of the provider [17]. In our study, we found that much of the time, the professional boundarywas maintained through concise answers or only health-related replies. For example, P7 told of adoctor who would only provide very succinct answers to questions:"Yes, his answers were brief andto the point. Sometimes when I asked him if anything was needed, he just answered yes or no." Thisdoctor would also not respond to more personal messages, such as holiday greetings:"When it wasthe National Day, I sent a greeting message to this doctor. I think he used his own time to answer myquestions, so I was very grateful to him and sent a greeting message to him, but there was no response.He only responds when you really have a health-related question." After this, P7 decided not to sendgreetings to the doctor anymore. Similarly, P11 described the WeChat communication with herdoctor as shallow, consistent with their offline communication:"I feel my communication with himon WeChat was quite shallow. When offline, I felt that he also focused more on direct treatment, anddid not say much nonsense."



However, what constituted a professional boundary varied according to the individual. Forexample, P7 felt that one doctor was more personal and friendly:"I sent him a message, ‘HappyHolidays’. I wrote ‘thank you very much for taking care of us when my mother and I were in thehospital’. He replied quite sincerely. He said ‘you are welcome’. I forgot what else he said. I felt his replyshowed some of his feelings. And then I asked whether he had National Day or Mid-Autumn festival off.He said yes, seven days off." A similar variety was also found in the doctors’ use of WeChat Moments.Some doctors did not share their posts at all or only shared professional posts. For example, P14said that all he could see was his doctor’s work related posts:"There are many activities going on inhis hospital, such as volunteer activities. And there are things about his studies overseas and some otherthings. These are what I have seen." P12 had a similar observation:"Many are medical care related.Mainly medical care related. All kinds of TCM and Yang Sheng (Life Maintenance) information. DoctorRong is an ophthalmologist, and his Moments are all about ophthalmics." P11 confirmed:"He almostnever posted about his everyday life." However, other doctors showed more personal Moments totheir patients, such as photos of their families. Indeed, with WeChat, the relationship boundarybetween patient and provider was a bit blurred. D6 described the relationship as sort of beingin between friends and the official doctor-patient relationship:"We can call it ‘friendship’, but weseldom chat at other times. We can call it a formal patient-doctor relationship, but it is not that formal.If we really wanted to name it, it’s more like a relationship in which you happen to be in need, and Ihappen to be able to help."

To sum up, we found various boundaries were also maintained through the content of messaging,in terms of what messages to respond and how to craft the messages, to ensure affordance, safety,and sometimes professionalism of using WeChat for PPC.

6 DISCUSSIONS AND IMPLICATIONSOur findings show that the use of WeChat contributed positively to the healthcare experiences andoutcomes. At first glance, the adaptation of WeChat, a rather personal communication channel, forthe professional nature of PPC, might seem a little strange. However, after the study, we found thatthe particular context of China made the use of WeChat especially meaningful, as it filled a needthat is mostly missing in the current Chinese healthcare system – that is, an official patient-providerrelationship and a formal communication channel between them. The use of WeChat in our studynot only provided logistical benefits and answers to many healthcare-related questions patients mayhave but more importantly, it provided psychological assurance which was particularly appreciatedby our patient participants. As such, WeChat’s use was initiated because it brought benefits, similarto the early stages of email for PPC [3]. Moreover, we highlighted the boundary negotiation workcarried out by patients and providers for the appropriation of an originally personal communicationtool for PPC, including the social boundary between those connected or not connected, temporalboundaries in terms of when to message, as well as professional and other boundaries managedthrough message content. In this section, drawing on our study of the use of WeChat for PPC inChina, we will unpack boundaries and boundary work with ICT for PPC in more detail.

6.1 Boundary Negotiation Work for ICT-mediated Patient-Provider CommunicationAs indicated in the literature review, recent research emphasizes the dynamic nature of boundarywork and different role boundaries could play. For example, Lee draws attention to how boundariesare negotiated continuously and in a dialectical manner, especially in non-routine projects [36].Clement Wagner note that boundaries are drawn to support more efficient communications withinboundaries [15]. Star focused on the formalization of the boundaries and sees boundary objectsas a kind of interim objects [38]. Bødker, drawing on several case studies, argues for a richer and



more dynamic understanding of boundaries, which technology could mediate, dissolve, enforce,change, negotiate and maintain [7].By the same token, our study shows that boundaries are not stable but dynamic, and ICTs are

not just destructive but also constructive. For example, as suggested by our study participants,the relationship that WeChat helped to construct did not fit into an existing type of relationship,for it was neither strictly a professional authoritative-customer relationship restricted by legalresponsibilities, nor a personal relationship such as family or friends; it was a new relationshipcaught in between, not so formal, but also not that personal. As such, WeChat messaging is not asfree as personal communication nor as restricted as professional communication. Through temporalboundary negotiation, patients were able to identify the appropriate time to message their doctors.The emergence of this new boundary creates a space for online PPC to fit into traditional offlinehealthcare practices. That is, with the use of ICTs, some old boundaries became blurry (e.g., theinteractions between doctors and patients were not confined to the clinical setting anymore) andsome new boundaries emerged or were constructed through the use of ICTs (e.g., when appropriateonline interactions took place). In that respect, the use of ICTs is both destructive and constructiveto dynamic boundary work.It is also worth noting here that, when we talk about boundaries, we are not talking about

boundaries between different social worlds as in [36], or between patients and providers as in [14];but rather, we are talking about the broader structures or regulations that condition the adoptionof a new technology into a practice, making its use affordable and appropriate. Still, we foundLee and others’ thinking about dynamic and continuously negotiated boundaries when lackingstandardization quite useful here to understand the broader notion of boundary work involved inpatient-provider communication, especially when outside of institutional regulations. As shownin our findings, various boundaries, including social, temporal, and professional, are carefullynegotiated and collaboratively managed by the patients and providers to make it possible for theWeChat channel to work. This is very different from the previous institutionalized model of PPCregulation, as commonly found in the primary care or family physician system, where it mainlyrelies on institutional systems and policies to ensure the effective use of PPC systems, e.g., policieson when and how to respond to messages. While previous work has discussed similar boundarywork with the use of ICTs in different situations, including with professionals in various serviceindustries [44], boundary work for PPC has not been studied much, partly due to the strict hierarchyof medical practices. Focusing on a particular healthcare site with such a general social application,then, it opens a box and allows us to see how people find and maintain these boundaries beforethings become formalized or institutionalized for PPC.

In proposing boundary negotiating artifacts, Lee suggests that, "Or perhaps, even more intriguingly,future work may find that boundary negotiating is an alternative form of collaborative work thatis advantageous for certain types of circumstances (e.g., short term or highly innovative projects)"[36]. Reflecting on our findings, we do find that, compared to the institutional model, the personalboundary negotiation and the emergence of these new boundaries in the use of ICTs are in manyaspects more advantageous when the domain of healthcare and PPC are concerned. First, the morepersonal approach allows direct communication between patients and doctors and for possibleresponsiveness to urgent issues. Previous research discusses the potentially negative impacts ofmobile communication technologies in maintaining the boundary between work and life; however,when healthcare is concerned, maintaining a strict work boundary, e.g. 9 to 5 or weekday/weekend[9], for professionals, might not be ideal as the 9-5 or workday/weekend boundary is not compatiblewith the nature of illness, which progresses anytime and anywhere. With the deployment of ICTs,the new emerging boundaries and the associated practices of managing such boundaries is crucialto support the patients’ need to communicate with their healthcare providers when illness occurs.



More so, as shown in the study, the asynchronous, instant, and portable nature of WeChat facilitatedthe negotiation and construction of these boundaries (e.g., the selection process put the controlin the hands of the doctor, the considerate patient only sent messages at times when doctorswere less occupied, the portable nature leveraged segmented time throughout the day for quickinteractions). As such, while WeChat allowed the request or the inquiry to be sent over the distancerather than being confined within the spatial boundary of the hospital, it also helped to establishnew boundaries to make it better integrated into the doctors’ daily workflow. In addition, it takeslocal specifics into account when constructing these boundaries, allowing more flexible use of thetechnology for healthcare purposes. For example, as shown in our findings, a young healthcareprovider may voluntarily leverage WeChat or other ICT mechanisms for PPC, for recognition orreputation and for career development, which in turn is also helpful for the patients.

We shall emphasize here that the boundary negotiation work described in this paper was mainlyenabled by the voluntary nature of WeChat use. PPC through WeChat, in our study, was neithermandated by the healthcare institutions where the health providers were employed nor expectedby the patients who sought medical advice from these providers. The voluntary nature of suchcommunication creates an opportunity for the dynamic negotiating process and the emergence ofthe new form of relationship between patients and healthcare providers. If such PPC is mandated,e.g., patients have to pay to receive replies, and healthcare providers are in agreement to providesuch service, either personally or through their institutions, the personal negotiation process willlikely be replaced by other formal policies [55], e.g., organizational rules on when the messagesshall be replied. This institutional or standardized approach can better address issues such asdata security or the lack of full documentation of interactions between patients and providers.However, it may not accommodate local specifics such as doctor’s work rhythms and patients’situations into account. Bjørn et al. argue when design hospital information systems (HIS), it isimportant to articulate and identify which aspects to be standardized and which aspects to belocally reconfigurable [6]. We found a similar concern could also apply here for the design ofICT-based PPC that offers localized flexibility and functionality to suit a particular work context.Based on the personal boundary negotiation work we uncovered in this study, we suggest

these are potential directions to look into to better support ICT-mediated PPC: to better serve theinternal interest of the doctors in healthcare outcomes besides financial incentives (e.g. to alloweasy overseeing treatment effects or progress); to better support boundary negotiation practices(e.g. making doctors’ work rhythms more visible, or signaling the level of urgency of the healthconditions); to leverage AI and other technologies to increase benefits and minimize costs for thedoctors in answering questions.

6.2 Boundary Structuring with ICTsTo better understand the role of technology in the boundary construction and negotiation process,we find it helpful to draw on Orlikowiski’s structurational model of technology [52]. Orlikowskiemphasizes that information technology is neither an external objective force that determinesthe impact on the social structure nor merely an outcome of strategic choice and social action.Rather it is both subjective and objective: it is physically and socially constructed in certain socialcontexts, with different meanings attached to it during its design, production and use; at the sametime, it also assumes objective properties once it is well developed and deployed in a stable manner.Orlikowski uses the term "interpretative flexibility" to describe how much users engage in theconstitution of technology during its development or use and how the technology is influenced bythe characteristics of human agents, context, as well as material artifacts (software and hardware).This is exactly what we found with the use of WeChat in our case, where new boundaries wereconstructed by the considerate patients as well as the responsible doctors, and shaped by the



particular healthcare context and general social norms of China, and the properties of WeChatafforded by its underlying social-technical infrastructure.That there was no institutional support or regulation does not mean that WeChat was used in

a vacuum; rather, the patient and doctor agents drew on general social and moral norms whichthen played a role in structuring its use and shaping the various boundaries. For example, insteadof directly asking to connect on WeChat, our study shows that it usually took repeated visitsor a social network to establish this digital connection, which is considered more appropriatein the social system. The availability of the communication channel also didn’t mean that thepatients could ask questions anytime freely, but rather, it takes the regular healthcare service tosustain its effectiveness, and our patients would take the doctor’s workload and work rhythms intoconsideration and carefully choose a time for consultation. While doctors could use WeChat withall their patients, they did so selectively, choosing those who were in need, who were trustworthyor seemed considerate, and those who took their health seriously, in order to ensure an effective useof WeChat for healthcare. When some boundaries were intruded upon, such as when patients sentmessages not related to their illness (e.g., some holiday greetings, for learning TCM knowledge), thedoctors in our study chose to manage the boundary of communication by ignoring such messagesor showing impatience. The unequal relationship between doctors and patients in the healthcareconsultation (i.e., one is in need of help, and the other provides help), also means that the doctorlikely has more power to determine where the boundaries are for PPC, although this could varyfrom doctor to doctor.In addition to social norms and the considerations of the doctors and patients, the properties

of WeChat also shaped how the boundaries were constructed. As mentioned before, WeChatis a closed two-way communication channel, and its connection verification procedure helpedmanage the social boundaries. This procedure made it possible for the doctors to be selective withwhom they communicated. Additionally, the verification procedure addressed not only the doctors’workload issues but also the safety and quality communication concerns that frequently come upin discussions about using ICTs for PPC. Moreover, the portability and asynchronous nature ofWeChat allowed for the renegotiation of temporal boundaries for healthcare services.

In other words, what we reveal is not just what and where these boundaries are, but also thethoughts, considerations, and work people put into constructing, negotiation, and maintainingthese boundaries, which in turn are shaped by local specifics such as the doctor’s work rhythms,broader social norms as well as technology properties.

7 CONCLUSIONIn this paper, we present a study of WeChat, a mobile social application, that is repurposed tomediate patient-provider interaction in China. In the study, we showed how this personal commu-nication channel positively contributed to healthcare experiences and outcomes, strengthened therelationship between patients and doctors, and provided patients with psychological assurance.Our study suggests that the use of WeChat filled a gap in the particular healthcare system of Chinawhere the relationship and the formal communication channels between patients and providers arelacking. To do so, various boundaries were negotiated and constructed by patients and doctors basedon their personal interests, social norms, and technological affordance. This personal approachof boundary maintenance is quite different from what was revealed in previous work where PPCwas a mandatory institutional behavior and required formal organizational support. Moreover, thispersonal approach also provides advantages that the institutional approach does not, such as directcommunication between doctors and patients, and potential responsiveness to urgent issues.

While previous studies have noted the potential negative consequences of mobile technologieson work and life boundaries, our study suggests the use of ICTs does not simply blur or destroy old



boundaries, but also create space in constructing new boundaries with the active agents within aparticular social context – in this case, the patients and care providers within the Chinese healthcaresystem. With this study, we argue that to understand the role technologies may play in healthcarepractices, we should pay more attention to the structurational process with the use of ICTs, andto the emergence of new structures or boundaries, rather than simply seeing things within oldstructural frames.

ACKNOWLEDGMENTSThe work is supported by the National Key Research and Development Plan under Grant No.2016YFB1001200, theNational Natural Science Foundation of China (NSFC) under Grant No.61672167.

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Received April 2019; revised June 2019; accepted August 2019


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