**2. Theoretical Background**

To understand the key antecedents of poor DPR in the mobile context, we first reviewed the CMC literature to summarize the features of CMC and their potential negative impacts on communication. Then, we narrowed down our discussion on the relationships among CMC, doctor-user communication, and DPR in the mobile context, and proposed a theoretical framework that explains the antecedents of poor DPR in the mobile context.

#### *2.1. Features of Computer-Mediated Communication*

Computer-Mediated-Communication (CMC) refers to communication-based on computers and the internet, such as e-mail, web messaging systems, online forums, and mobile applications [19,20].

Abundant studies have examined the features and differences between traditional face-to-face communication and CMC [21]. Based on an in-depth literature review, we identified four features of CMC, namely connectivity, text-based communication, asynchronism, and anonymity. Connectivity refers to the fact that users can initiate or participate in online interaction regardless of time and space limits [22]. Text-based communication refers to the fact that the majority of communication is delivered through texts, lacking audio or visual clues [20]. The asynchronous nature of the media implies that there is a time delay during the communication [23,24]. Admittedly, as technologies keep upgrading, voice, picture messages and even synchronous video communication are also supported by CMC, but they are still used in relatively low frequency. Finally, anonymity refers to the fact that CMC enables users to hide his or her real identity by using a screen name, which is considered as the most remarkable difference between CMC and traditional offline communication.

CMC brings both positive and negative impacts on the communication process. In Table 1, we draw on extant studies and summarize the potential positive and negative impacts that CMC may have on users' online communication behaviors. In this study, we apply CMC in the mobile medical consultation context and focus on the potential negative impacts.


**Table 1.** The potential positive and negative impacts of each CMC feature on online activities.

#### *2.2. A Computer-Mediated Communication Perspective on Poor DPR*

DPR refers to the collaborative and affective bond between doctors and patients [35]. Satisfaction has been proved to be a critical determinant of DPR [2,36]. For the patient, patient satisfaction significantly increases the likelihood of the patient returning to the doctor for treatment. If the patient's needs are met during the service, there will be fewer complaints and medical disputes, which contributes to positive DPR [4]. For the doctor, doctor satisfaction can increase doctors' work enthusiasm and promote the willingness to establish a friendly relationship with patients [36]. In summary, satisfaction is a key driver for improving DPR for both doctors and patients. Accordingly, unsatisfactory service experience will lead to poor DPR for both doctors and patients [14].

Effective doctor-patient communication is essential to realize satisfactory service and maintain harmonious DPR [5,37]. On the contrary, undesirable doctor-user communication can cause poor DPR [14]. Extant studies consensus on the use of informational and emotional dimensions to depict the communication processes between doctors and patients [1,17,38]. Informational-oriented communication, also termed as task-focused communication [38,39], refers to communication on medical information provision and interpretation. To be more specific, the informational communication can be divided into information providing and information interpreting [14,40]. Emotional-oriented communication, also termed as socio-emotion-focused communication [38,41], refers to communication on the identification and response of emotional cues. Emotional-oriented communication is conducive to meeting both doctors' and users' emotional needs and maintaining a friendly relationship [41]. Both informational-oriented and emotional-oriented communication are two-way communications between doctors and users.

When the medical environment shifts from the traditional face-to-face context to the mobile context, the features of the medium that supports doctor-patient communication have also changed [18,42,43]. While traditional face-to-face medical communication relies on synchronous communication with language tones and facial or body cues, mobile communication relies on text-based asynchronous communication [18]. According to media synchronicity theory, features of media determine the media capabilities in supporting information transmission and information processing and further determine the communication outcomes [40]. Therefore, there are reasons to believe that the features of CMC will impact the doctor-user communication process and further impact DPR in mobile consultation.

Based on the above arguments, we propose a theoretical model (as is shown in Figure 1), aiming at explaining the antecedents of poor DPR in the mobile context. The key arguments of this model are: (1) Features of CMC create barriers for information providing, information interpreting and relationship maintaining for both doctors and users during the two-way communication, and (2) the undesirable doctor-user communication caused by features of CMC leads to poor DPR that is manifested by doctors' and users' dissatisfaction.

While this preliminary framework sheds light upon the logical relationships between CMC features, doctor-patient communication, and DPR, it also reveals several directions for further exploration: 1) it is unclear what representative information providing, information interpreting, and relationship maintaining behaviors of doctors and users lead to poor DPR, and 2) it is unclear how limitations of CMC account for these behaviors. As a result, this preliminary theoretical framework provides initial answers to our research question and guides our data analysis to answer the remaining questions.

**Figure 1.** Theoretical framework.

### **3. Research Method**

To empirically validate and elaborate our proposed theoretical framework, this work employs netnography, or internet-based ethnography, as the qualitative research method [41,44,45]. The study proceeded in three steps: (1) developing a preliminary coding plan based on the CMC literature (as is shown in Figure 1), (2) downloading and coding objective communication records as well as comments that are rated as "dissatisfied" by users in the selected mobile application; and (3) analyzing the data to

identify representative interaction behaviors from users' and doctors' perspectives. The detailed steps of data collection, data analysis, and data interpretation are shown in Figure 2.

**Figure 2.** The methodology roadmap.

### *3.1. Data Collection*

Mobile consultation service allows users to chat with professional and experienced doctors in real-time by sending messages with texts and photos. The electronic medical records of patient-doctor communication during the online consultation process are mainly text-based. Therefore, communication records between doctors and users are valuable materials that worth analyzing. Researchers can analyze these communication records from the perspectives of both users and doctors, and gain an insight into the online patient-doctor communication process.

The communication records used in this study were collected from Chunyu Doctor. We analyzed the communication records that were rated as "dissatisfied" by users on the platform. A Java-based program was developed to automatically download the communication records between doctors and users. On average, consultation records that are labeled "dissatisfied" by users take 10%-11% of the total records. In total, we have downloaded 1923 "dissatisfied" interaction threads between 633 doctors and 1923 users from October 1st, 2018 to December 31st, 2018 in the pediatric department. The period was selected because this quarter of the year is reported to have the highest average monthly user activity in Chunyu Doctor [46]. The pediatric department was selected due to two reasons. On the one hand, pediatrics is the most frequently visited department in mobile consultation due to the shortage of pediatricians in offline hospitals. On the other hand, collecting data from pediatric is conducive to reflecting poor DPR in mobile consultation, because users in the pediatric department are usually the guardians of patients rather than patients themselves. And guardians who have strong feelings for their loved children are more likely to have conflicts with doctors [47]. The "dissatisfied" consultation records represent users' dissatisfactory experience. Additional steps were taken to screen records that reflect doctors' dissatisfactory experience. To be more specific, we used a widely applied Python-based program of Chinese sentiment analysis to obtain the sentiment score of all words generated by the doctor in each dialog. The accuracy of this program is tested as 0.8277 [48]. Through the analysis, results show that the mean value and the variance of doctors' sentiment in 1923 records are -0.0642 and 0.1645 respectively. Records that score in the range of -1 to 0 indicate potential negative emotions

of doctors. Based on this analysis, the research team manually went through all the selected records to ensure accurate identification, resulting in a sample size of 1069 records. Finally, to rule out the possibility that poor DPR is a result of insu fficient communication, we selected communication records with word counts and the number of interactions during the communication above the average. As a result, a total of 592 detailed consultation threads from 358 doctors were collected for analysis. In the final sample, the total Chinese characters amount to 166,985, the average word count is 282.07, an average number of interactions for each communication thread is 33.24.
