Evolving Pediatrician Perceptions of a Telemedicine Program

Authors

  • Eve-Lynn Nelson,

    1. Currently completing her clinical residency at University of Miami's Jackson Memorial Hospital and will earn her Ph.D. in Clinical Psychology from the University of Kansas in 2002. She has worked at the Center for TeleMedicine and TeleHealth at Kansas University Medical Center since 1998. Most recently, she coordinated the Healthy Steps over Telemedicine project. The program offers parent education and extended well child visits, all through videoconferencing technology at a local high school and a daycare. She has participated in other telemedicine projects including TeleKidcare® telemental health research, and telemedicine in the jail setting. She has presented on telemedicine topics at TeleMed 2001, ATA conferences, and other local and national venues. Her dissertation concerns a randomized controlled trial of therapy for childhood depression over telemedicine versus the same therapy face-to-face
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  • David Cook,

    1. Center for TeleMedicine and TeleHealth, University of Kansas Medical Center
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  • Pamela Shaw,

    1. Department of Pediatrics, University of Kansas Medical Center
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  • Georgina Peacock,

    1. Department of Pediatrics, University of Kansas Medical Center
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  • Gary Doolittle

    1. Center for TeleMedicine and TeleHealth, University of Kansas Medical Center
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Abstract

This study addresses pediatrician perceptions of a telemedicine program as it developed from 1998 to 2000. The researchers completed structured interviews with ten pediatricians who provided telemedicine services between a university medical center and an urban school district. The results describe how pediatricians understood the telemedicine program, including technology, consult process, and relationships. This understanding of how pediatricians “make sense” of telemedicine allows optimal planning for the program's future and may inform other telemedicine initiatives about challenges in the pediatric setting.

Evolving Pediatrician Perceptions of a Telemedicine

Telemedicine may be defined as the “…use of telecommunications technologies to provide medical services and information” (Perednia & Allen, 1995, p. 483). Telemedicine has roots from the 1950's, but the last decade has seen a rapid increase in telemedicine programs. Telemedicine research often focuses on telecommunications technologies - equipment, software, connectivity, and so forth. As Whitten, Sypher, & Patterson (2000) put it, “…we know a good deal about bandwidths and resolutions, but little about the human dimensions that make practice possible”(p.112).

Social constructivism provides a useful theory to explore these human dimensions that not only create the technology, but also create and recreate the contexts in which it is used. As Fulk (1993) explains: “…communication technologies…link disparate entities in a seamless web that engages joint sensemaking in the process of mediated interaction” (p. 922). In the telemedicine world, this joint sensemaking often begins with a needs assessment (Doolittle & Cook, 1999). A telemedicine needs assessment is initiated around a perceived deficiency in the current healthcare delivery process. The needs assessment process brings together healthcare providers, local agencies, and community members. This is a social constructive process - a decision is made based on how group members “make sense” of telemedicine's role in healthcare.

Whitten, Cook, Shaw, Ermer, & Goodwin (1998) describe such a needs assessment for TeleKidcare®. This project is a collaboration among the Kansas University Medical Center's Departments of Pediatrics and Child Psychiatry, a large school district, the Center for TeleMedicine and TeleHealth, and community organizations. The collaborators sought to overcome healthcare barriers in an urban setting. For example, one-third of the district's children live in poverty, double the state average for Kansas, and many are without insurance. Following a two-year needs assessment, the group defined a vision of school-based telemedicine services. TeleKidcare® was conceptualized as linking the physician, the parent, and the school nurse using videoconferencing technology. The purpose, as summarized in TeleKidcare® outreach materials, is: “…to help kids get healthy faster, so they can be in school doing what they should be doing…LEARNING!” (University of Kansas Center for TeleMedicine and TeleHealth, 1998).

TeleKidcare® utilizes PC-based technology using ISDN lines at 128 kilobytes per second and PictureTel software. This technology was chosen based on affordability, ease of use, and minimal space requirements. The system connects the physician at the Medical Center with school nurses' offices at ten schools. The parties communicate in “real-time.” Electronic stethoscopes allow the pediatrician to hear lung and heart sounds. Examination of the ears, nose, and throat may be performed using a telemedicine otoscope. The school nurse directs the camera, otoscope, and stethoscope in collaboration with the pediatrician. TeleKidcare® physicians examined almost nine-hundred children (881 consults) from February 1998 to June 2000. TeleKidcare® consultation evolved into a 15-step process as identified by Whitten, Kingsley, Cook, Swirczynski and Doolittle (2000).

TeleKidcare® has offered school-based telemedicine services over the last two and a half years. In the spring of 1998, two pediatricians conducted over 90% of the ITV consults. These pediatricians were leaders in the needs assessment that established TeleKidcare®. In the 1999–2000 school year, 21 physicians provided at least one TeleKidcare® consultation. Of these, 12 pediatricians remained with the TeleKidcare® service over a period of time and completed at least six consultations. In the 1999–2000 school year, 399 consults occurred using the TeleKidcare® system at ten different schools. The consults were mostly with elementary age children, across gender and ethnicity. Approximately one-third of the children did not have insurance. Ear, nose, and throat (ENT) concerns were the most common pediatric presenting concern, followed by skin disorders. Behavioral health concerns were largely followed by child psychiatry rather than pediatrics.

Social constructivists hold that the meaning of telemedicine will evolve as telemedicine users interact with the technology, with each other, and with their larger environment. New meanings emerge about why telemedicine is done, about what is done, and about what can be done in the future as the program progresses. Research has not addressed this iterative meaning-making process and its effect on telemedicine programs over time. This is an important question as interest in telemedicine continues to grow in numerous settings, including schools. It also has unique implications for TeleKidcare®. Current pediatrician perceptions influence how physicians, school officials, community members, and telemedicine staff plan for TeleKidcare®'s future, including expansion to new schools and to new services.

In the current study, researchers assessed the perceptions of active TeleKidcare® providers over the 1999–2000 school year. A similar interview process was conducted with teachers, nurses, and administrators involved with TeleKidcare® (Whitten, Cook, et al., 2000). This study addressed the following research questions:

  • Research Question 1: What is the pediatrician perception of telemedicine in an urban setting and how does it relate to the original TeleKidcare® rationale?

  • Research Question 2: What is the pediatrician perception of the TeleKidcare® technology?

  • Research Question 3: What is the pediatrician perception of diagnosis and treatment via telemedicine?

  • Research Question 4: What is the pediatrician perception of relationships using TeleKidcare®?

Methodology

Ten pediatricians who conducted at least six TeleKidcare® consultations during the 1999–2000 school year completed the structured interview. The number of consults ranged from 6 to 99 (see Table 1).

Table 1.  Pediatrician and Number of Consults.
Pediatrician# of Consults
18
210
399
46
520
629
78
836
97
1054

The range is broad because pediatricians were assigned to the TeleKidcare® clinic for varying lengths of time. Two additional pediatricians were unavailable for interview due to moving and vacation. The child psychiatrist who conducted most behavioral consults was not included in this pediatric interview study.

The interviewer took notes during the meetings and transcribed additional information from the audio-taped interview. A focused, open-ended interview guide was used to encourage the pediatricians to express their unique perspectives concerning telemedicine (Whitten, Sypher, & Patterson, 2000). The ten interviews were face-to-face and took approximately 40 minutes each. Six of the pediatricians interviewed had conducted TeleKidcare® consults prior to the 1999–2000 school year. None of these pediatricians provided telemedicine services in other contexts. Seven female pediatricians and three male pediatricians were included. Their mean age was 38.7 years. Seven pediatricians were residents and three were staff physicians.

Results

The interviews were analyzed to address the research questions.

RQ1: What is the pediatrician's perception of telemedicine in an urban setting and how does it relate to the original TeleKidcare® rationale?

The pediatricians reported receipt of little formal training or formal rationale when they first began to provide TeleKidcare® services. For example, the residents were assigned to the clinic “just like any other rotation,” although some pediatricians believed they were chosen because of being close to finishing residency and proficiency in Spanish. The staff pediatricians reported using the system because of interest in telemedicine and in meeting families unable to come to the Medical Center. The pediatricians identified healthcare barriers similar to the original needs assessment (Whitten et al., 1998). Pediatricians generated a list of concerns including: lack of transportation (9 of 10 pediatricians), difficulty for the parent to get off work (6 of 10), lack of insurance (4 of 10), cost of traditional clinic visits (4 of 10), language/cultural barriers (3 of 10), lack of available community providers (1 of 10), and limited childcare for other children in the household (1 of 10). Pediatricians generated few alternative solutions to increase healthcare access. Different pediatricians listed: giving the families monetary assistance to attend clinic visits; giving them passes to assist with transportation to the hospital; picking up the patients directly; informing patients' families about current transportation options already available with Medicaid; and using midlevel providers at the school. All pediatricians viewed TeleKidcare® as a solution within the context of other community outreach programs. One pediatrician concluded: “Educate people to realize they don't go to the doctor only when sick, like well-child visits. Identify a primary care provider that they have confidence in and trust. Access Medicaid, Healthwave [the Kansas Federal Children's Health Initiative Program], and the free clinic. It takes a lot. I know, I'm a working mom of three. With telemedicine, you don't even need the parent to be there. You can get the history on the phone even if mom's at work.”

RQ2: What is the pediatrician's perception of the TeleKidcare® technology?

Pediatricians rated technology-related concerns on a seven-point Likert scale (see Table 2).

Table 2.  Mean Pediatrician Ratings to Technology Questions.
Technology QuestionMean Rating
Comfort level using the TKC equipment (1=very comfortable; 7=very uncomfortable)2.6
Ease of using the TKC equipment (1=very easy; 7=very difficult)2.4
Reliability of the TKC equipment (1=very reliable; 7=very unreliable)2.8
Overall audio quality (1=very clear; 7=very hard to hear)2.4
Overall video quality (1=very clear; 7=very hard to see)3.0

Pediatricians reported moderate comfort with the technology. They attributed some of the ease in using the equipment to the availability of immediate technical support and to school nurses experienced with the system. Pediatricians rated the TeleKidcare® equipment as reliable. The pediatricians reported rebooting the computer on either the pediatrician's or the nurse's side as the most common technical troubleshooting task. Overall, pediatricians reported audio quality was better than video quality.

RQ3: What is the pediatrician's perception of diagnosis and treatment over telemedicine?

All of the pediatricians agreed the diagnoses most amenable to TeleKidcare® were those based largely on history taking and less on physical exam (see Table 3).

Table 3.  Pediatrician Perceptions of Diagnoses over TeleKidcare®.
More easily diagnosedMore difficult to diagnose
1. Diagnoses based more on history, including nausea, diarrhea, sore throat, ear pain, runny nose, and fever1. Diagnoses based more on physical exam and assessment based on abdominal or rectal exam
2. Technology enhanced some images such as the ear membrane2. Assessment based on seeing color/texture, such as redness or rash
3. Diagnoses around assessment tools available to the school nurse, such as the rapid strep test3. Diagnoses around hearing lung sounds, particularly Reactive Airway Disease and asthma

The pediatricians also emphasized the importance of the school nurse in gathering history from the family. Nine pediatricians reported satisfaction with the otoscopic exam because the image is larger on the computer screen, explaining: “…the ear membrane is magnified on the screen and you can see the [middle ear] landmarks better.” Limitations of the otoscopic exam included school nurse placement of the otoscope and inability to remove ear wax before the exam. Six pediatricians were less comfortable diagnosing causes of diarrhea and constipation because they wanted a more extensive physical exam, including abdominal and rectal exam.

Most pediatricians reported some concern diagnosing rashes based on a remote view of skin color and texture. They again emphasized the importance of collaboration with the school nurse for such diagnoses. Seven pediatricians described difficulty “seeing the red” on the screen and two pediatricians elaborated, saying that this relates to “looking white on screen due to glare.” Finally, five pediatricians reported concern using the stethoscope for lung sounds, as with asthma, and reported the necessity of having the child come to the Medical Center if there were any diagnostic concerns.

Nine pediatricians reported success in diagnosing strep based on the school nurse's access to rapid strep tests. Pediatricians mentioned limitations based on fewer assessment options over TeleKidcare®. They gave examples of laboratory tests and procedures not available at school, such as an EEG as a diagnostic test secondary to dizziness.

Pediatricians expressed overall confidence in TeleKidcare® but described limitations. One limitation was the school entrance physical; the pediatricians agreed that this needed to be done face-to-face. One pediatrician summed up: “I usually do a more complete physical in acute care. I see the reflexes and the Tanner staging. I see more of the patient. It's not as thorough over TeleKidcare®. Sometimes I see things no one else has seen, like an undescended testicle that you wouldn't view over telemedicine. There's a risk of missing something because you may not see it.”

All pediatricians reported that conditions easiest to diagnose via telemedicine (i.e., diagnoses based on history) were also most effectively treated via telemedicine. One pediatrician summarized: “It's ideal for ear pain, fever, anything you can diagnose quickly and treat quickly.” They reported some concerns about treatment via the new medium (see Table 4). One concern was treatment availability. For example, a patient with asthma may not have access to the same breathing treatment at school as at the Medical Center.

Table 4.  Pediatrician Treatment Concerns about TeleKidcare®.
Treatment Concerns
1. Treatment availability
2. Treatment adherence
3. Patients receiving samples and prescriptions
4. Patient privacy

A second concern was treatment adherence. Pediatricians consistently reported that treatments were as effective as traditional clinical visits if followed as prescribed. Four pediatricians gave the example of a patient receiving antibiotic pills via telemedicine as opposed to an antibiotic injection at the Medical Center. They suggested compliance increased with the injection because it is a one-time event monitored by the physician, rather than daily pills administered by the parent.

Another issue related to adherence was concern with patients' being able to afford prescriptions. Pediatricians described provision of samples when available. Three pediatricians reported less control over patient education about the illness and its treatments. This ranged from providing written brochures about illnesses (e.g., asthma) to explaining how to use medication and medical devices (e.g., inhalers).

A third concern was follow-up. Because the TeleKidcare® pediatrician may vary between visits, depending upon who is staffing TeleKidcare® on a particular day, five pediatricians expressed concern with establishing long-term relationships and with accurate assessment on follow-up. Some pediatricians wanted families to attend both face-to-face and telemedicine sessions in order to build the physician-patient relationship. Nine pediatricians credited nurses with assistance with follow-up and contacting the pediatrician concerning the child's progress.

A final concern was patient privacy. Three pediatricians reported less ability to provide anticipatory guidance over telemedicine on topics ranging from safety to sexuality. One pediatrician described: “…these are private issues and TeleKidcare® is not a private medium. The nurse and people may come in and out. People may not be as comfortable.”

RQ4: What is the pediatrician's perception of relationships using TeleKidcare®?

All pediatricians underscored the importance of the relationship between the school nurse and themselves in the success of TeleKidcare®. All described the crucial role the nurse plays in identifying children in need of TeleKidcare® services and working as a liaison with the parent. One pediatrician summarized: “The nurse does an initial evaluation. [She decides:] Is it important enough for a doctor to see it or is it just a common cold and the child will get better?”

Pediatricians viewed the nurses as essential to history taking as well as their “eyes, ears, and hands” on site. They valued nurse descriptions during the interaction, explaining that diagnostic ability: “…depends on the nurse and how good she is at describing the raised area and how it feels. Is it bumpy or not? Some explained it well and some didn't. Some said it was scaly feeling and it looked like this while others just said it was a rash.” They described the school nurse as having a role similar to a clinical nurse – making the family feel at ease and educating the patient. They reported additional responsibilities for the school nurse compared to a clinical nurse, including: initiating the appointment, gathering school personnel as needed for the appointment, reminding the parent of appointment times, elaborating on the psychosocial context affecting the child's current illness, monitoring progress and scheduling immediate follow-up if needed. Half of the pediatricians attributed nurse proficiency in the TeleKidcare® consult (both with equipment and history taking) to their amount of experience with the telemedicine system. Nine pediatricians reported limited experiences working with school nurses outside TeleKidcare®. One pediatrician summarized it: “The TeleKidcare® nurse is much more active, with the examination and the whole process, from the diagnosis, plan, and education. The other nurses I've worked with are more pill dispensers and send the kid home. The role is more involved in the care of children. The nurse is empowered. She is more likely to be proactive and call you if you really need to see the patient.”

Pediatricians also credit nurses for simplifying the healthcare process for families and increasing access to diverse community members. As one pediatrician described: “It's a day-to-day fight for survival and other things may take priority. They [the families] have chaotic lives and can't schedule ahead. So many things are going on. The school nurse calls and tells the parent: ‘The doctor can see your child at this time.’ This simplifies the process.”

Although pediatricians were generally positive about the TeleKidcare® system, seven expressed concern with “losing the Gestalt of the situation” or being unable to interact with families as directly. One pediatrician explained: “They're mostly one-time visits; this decreases our relationship. It's less personal. I can't shake their hand or pat their head. You lose the personal quality. I like the interaction better in the clinic. I would never choose telemedicine unless it's the only way to see the patient.” Most (8 of 10) pediatricians interviewed, however, saw few other healthcare options for these patients. One pediatrician elaborated: “[There are] no other means; no health insurance, no transportation, language barriers, parent schedules with two to three jobs. It's difficult to get to a physician. Both parents may work or it may be a single-parent household. They may have multiple kids and have to prioritize.”

All pediatricians endorsed bringing the child to the Medical Center if the pediatrician had any unease about diagnosis. One pediatrician summarized: “I think that where there's no access, no physician or just family practice docs, it's helpful. Here its helpful but you lose the same relationship. It's a more direct relationship when they're in front of you. You don't get as used to the patient when they're not. They don't recognize you as their pediatrician.” Most reported that children and parents responded well to the technology but two of ten reported the concern that: “…for younger kids, it's an unreal experience. It's a face talking on the screen.” Pediatricians also reported parent appreciation for the opportunity to interact with a Spanish-speaking physician.

Discussion

When TeleKidcare® began in 1998, the telemedicine system was perceived as a means for children to obtain the same healthcare services as in face-to-face outpatient pediatric clinics. The two pediatricians, child psychiatrist, and nurses involved at the beginning of the program, “…viewed the technology as having very little impact on the nature of the consults.” (Whitten et al., 1998, p. 342–343). The current study addressed how pediatrician perceptions of TeleKidcare® have changed as both the project and the number of pediatricians providing services have grown. Pediatrician perceptions are important because of the physician's role in the telemedicine consult. Pediatricians not only diagnose and treat, but also set the tone for communication and relationship building during the consult.

Just as in the program's beginning, the ten current pediatricians viewed telemedicine as a reasonable way to practice medicine. They viewed the telemedicine technology as reliable and moderately easy to use. This fits with TeleKidcare® data suggesting only nine equipment-related cancellations out of 399 consults.

A limited number of practitioners were involved with this one program. Their range of experience with the telemedicine system also influenced the results, although the purpose of this study was to explore perceptions across the spectrum of users. The results must be viewed within the context of pediatricians willing to practice via telemedicine. Future research may address what characteristics and attitudes toward technology and healthcare encourage such success.

The group was also an older group of residents and predominantly female. These demographic factors and life experiences may have lead the group to be more amenable to alternative healthcare options. The study also interviewed university-based pediatricians in one geographic region. Pediatricians at other venues, such as private practice, or in other locations, such as rural sites, might express different perspectives. The study is also limited to a particular type of telemedicine-a moderate speed, PC-based system with otoscope and stethoscope. The results may at best be interpreted as providing an understanding of how perceptions of a telemedicine program may change over time and of what questions are important to ask practitioners about their experience with telemedicine.

Although the pediatricians generally rated the technology positively, they did not view telemedicine as the same as in-clinic care. Telemedicine was not constructed as a separate type of practice, but rather as a type of delivery system to be compared to face-to-face visits. They described some similarities in diagnosis and treatment as compared to face-to-face clinics, but also highlighted differences. These differences related both to technology and communication.

Pediatricians identified diagnoses based on history as the best fit for TeleKidcare®. This is more specific than the original TeleKidcare® uses, which included a wider range of presenting concerns including the school's mandatory physical examinations (Whitten et al., 1998). There was a range of opinion about what symptoms were based on history. The most commonly listed were nausea, diarrhea, sore throat, ear pain, runny nose, and fever. Most pediatricians generated otitis media as an exemplary referral for TeleKidcare®, in part because the diagnosis is based on history and in part because the telemedicine otoscope enlarges the image. They also supported use of TeleKidcare® to complement screening by the school nurse, such as the rapid strep screen. This is instructive for future TeleKidcare® uses and considering other possible presenting concerns based largely on history.

Overall, pediatricians believed treatments prescribed over TeleKidcare® were as effective as those face-to-face. Their overriding concern was whether families adhered to treatment recommendations following the telemedicine consult. They reported a number of barriers to adherence, including cost of medication, family understanding of the treatment rationale/recommendations, and language barriers to following instructions. These barriers are not unique to the telemedicine context, but were more pronounced due to the socio-economic factors in the urban setting. Pediatricians, school nurses, and telemedicine staff have collaborated to address these worries. Steps taken include obtaining samples from pharmaceutical companies and providing faxed and on-site educational materials. Pediatricians were also concerned about treatment availability, such as breathing devices for asthma. They described working with schools to have some options available on-site as well as having the child come to the Medical Center as needed. Finally, future researchers may address pediatricians' beliefs that families may be less likely to discuss personal issues via telemedicine.

Communication was viewed as both the greatest strength and the greatest weakness of TeleKidcare®. The pediatricians were very positive about communication with the school nurses. This is consistent with previous research and the belief that TeleKidcare® would enhance the role of the school nurse (Whitten et al., 1998). The pediatricians identified the nurse as crucial in initiating the visit, gathering history, managing the visit and equipment, and implementing treatment plans. This fits with the nurse's description of her expanded duties (Whitten, Cook, et al., 2000). To encourage such skills, TeleKidcare® organized the continuing education course: “Pediatric Assessment for the School Nurse.” Pediatricians reported limited experience with school nurses outside the TeleKidcare® context. The traditional clinic may also gain lessons from the telemedicine clinic, such as using the school nurse as a healthcare ally, over and above dispensing medication.

Doctor-patient communication was viewed as a challenge. The differences between face-to-face communication and telemedicine communication were difficult for the pediatricians to define. They pointed to differences in getting a complete picture of the family's situation (“losing the Gestalt of the meeting”) and in nonverbal communication (such as “patting the patient on the head or giving the parent a handshake”). Future research may address the best ways to build relationships in the telemedicine context. For example, some pediatricians suggested alternating telemedicine and face-to-face visits to increase rapport with families. Pediatricians also reported concern with different providers at intake and follow-up and suggested having the same pediatrician follow a child over time.

Pediatricians identified many barriers to healthcare. They overwhelmingly viewed TeleKidcare® as a part of the solution along with other community initiatives. They viewed it as effective as face-to-face care for some presenting concerns but less effective for other presenting concerns. Their solutions centered on helping families visit the Medical Center in some instances and improving the technology. Pediatricians emphasized the physician's role not only in providing healthcare, but also in leading the community toward healthcare solutions. Many conceptualized healthcare “as the right of every child” and viewed telemedicine as one means of achieving this goal.

This study has implications for face-to-face, clinic-based consultation. There is little research on provider perceptions of traditional clinical visits, yet they are considered to be the gold standard. Future research may elaborate on these same questions in face-to-face settings - perceptions of diagnostic accuracy, treatment effectiveness, relationships with nursing staff, and barriers to care. The TeleKidcare® process may also offer something new to traditional clinics, such as collaboration with school nurses in accessing healthcare and in treating illness. The study underscores that needs assessment is an ongoing process rather than a one-time event. Future assessments need to address the specific problems each group encounters from the technical side, the relationships side, and the treatment- planning side. It would also be informative to follow these pediatricians over time to see if satisfaction levels change as TeleKidcare® evolves and what factors influence this satisfaction.

When asked where TeleKidcare® will be in five years, pediatricians generally believed that it will expand to more sites, particularly in rural areas. If TeleKidcare® expands to other schools, it would be important to include the continual needs assessment discussed above. This will assist projects such as TeleKidcare® to build on strengths and remediate difficulties in technology and communication. For example, pediatricians expressed concern with dermatology consults although this was tied for second as the most common TeleKidcare® presenting complaint. They reported video quality affected ability to see the color and texture of skin. This encourages problem solving across the TeleKidcare® team, including much collaboration with nurses for descriptive information and consideration of technology alternatives such as the dermascope.

The importance of relationship building between all parties cannot be overemphasized. Faster and more accessible technologies may make TeleKidcare® and similar programs feasible in every school, but needs assessment must address whether it is advantageous in every context. Even with advances in technology, the study highlights the continued importance of fundamental skills such as thorough history taking.

Telemedicine, as broadly defined in the introduction, will have many pediatric applications over the next five years and beyond, providing services and information to families. Pediatrician perceptions of these technologies and their effects on the therapeutic context will influence telemedicine's success. From interactive televideo to the Internet, from direct services to distance education, pediatricians will continue to play a vital role in healthcare over the new media.

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