The buzz on social media is fast and furious, and the popular spin is that social media will revolutionize clinician-patient relationships and transform the delivery of healthcare. Is there any there, there? Let’s look at what social media is, how it is being used in health care, and what this could mean for health centers.
First, what is social media? Wikipedia, the definition source for all things technical, defines social media as the set of capabilities provided by “web-based and mobile technologies used to turn communication into interactive dialog”1. This is only one definition of many, but all generally incorporate the use of shared, primarily user-generated, content, through accessible technologies. These include: web (computer) and phone-based applications that provide short-form texting and messaging capability to defined users, location sharing, photo and media (video, music) sharing, facilitation of various types of virtual communities (dining, shopping, gaming etc.) and a myriad of others. Most of us are familiar with, and possibly use, Twitter, Facebook, Foursquare, Yelp and many other social applications. Of interest is if, and how, these applications are used in health care.
First, let’s look at what health-related social media is being used for, and by whom. A primary category of users is health care consumers, or patients and their families/caregivers. According to a report by the accounting firm PwC’s Health Research Institute, one-third of the U.S. consumers surveyed. (N=1,000), and 50% of those under 35 years of age, have used social media applications for healthcare purposes2. Consumers use these applications and sites to gather health care information, connect for support and information with other patients who may have a similar condition or diagnosis, and research and share experiences with providers and healthcare organizations. The PwC report found that approximately 40% of these consumers used one of four social sites: Facebook (18%), YouTube (12%), Google+ (8%), and Twitter (6%); with another 4% using specialized sites such as WebMD and PatientsLikeMe. Information-gathering and interaction with other patients are the most important current uses of health-related social media. Patient-focused sites that offer general physician generated content, or physician response to general questions, are also gaining traction. A secondary but important way in which social media is being used by consumers is to aid in the selection of providers, hospitals and in some cases, treatments.
Doctors and other healthcare professionals are another group of users. Providers are using social media to connect with their patients, to provide specific information related to the patients’ conditions or plan of care, and in some cases, to obtain patient-reported information. They are also connecting with other providers for consultation, referrals and to make transitions smoother. PwC cites a finding by Manhattan Research (Pharma & Social Media – Practical Social Media Strategies for the Pharmaceutical Industry, 2009) indicating that 60% of U.S. physicians already use or are interested in using on-line physician communities, such as Sermo, to collaborate and share information3. Many providers and healthcare organizations now use Twitter, YouTube or other general sites informally to facilitate communication between and amongst providers. Notwithstanding the potential issues associated with this practice, provider communications may include sharing clinical notes, as well as discussing specific, but unidentified patients4. The current focus on meaningful use and patient-centered medical homes emphasizes increased interconnection between patients and their providers or care team members to improve transparency in both the treatment process and clinical outcome. The conventional applications used to support administrative and clinical functions, such as practice management and electronic health record systems, do not have much capability to facilitate this type of increased interaction, so social media is being used to effectively bridge the gap.
PwC sites that nationally, 1,200 hospitals currently participate in nearly over 4,000 social networking sites, including Facebook, Twitter, YouTube, LinkedIn, foursquare, and blogs6. Increasingly, healthcare organizations such as the Palo Alto (CA) Medical Foundation (1,000 providers, 700,000 patients) use provider and patient blogs to provide information, Twitter and email messaging to connect and inform providers and other staff, and interactive web applications to make available chronic care and self-monitoring capabilities. This allows a very broad range of interaction between patients and providers that has the possibility of improving not only communication, but ultimately, patient care.
Social media is also being used by patients to directly report to their clinicians data from home-based, patient-controlled monitoring devices (blood pressure, blood glucose etc.) or to document or report on medication use. Patients are also sending information from their personal health records (PHRs) to providers. A 2010 study by the California HealthCare Foundation found only 7% of more than 1,800 adults surveyed used a PHR7 , with PHR use most geographically concentrated in the west8, but the number is growing; and of those who do not have a PHR, 40% express interest in using one9. Of note is that among those who expressed interest, 58% expressed a preference for using a PHR from a hospital or provider, while 50% said they would use a PHR sponsored by their insurer10. So while PHRs are not yet widely used, their increasing acceptance suggests uses incorporating social media that were not previously considered or feasible.
In addition to being used directly by providers and direct consumers, the different types of provider- and patient-facing social media vehicles are being deployed by organizations that deliver, organize and monitor care. Some large insurers have begun to make patient portals, blogs and other information and feedback sources available to their members. Public health agencies are also beginning to use blogs, portals and other technologies for announcements, informal data gathering and feedback. These are, in effect, new tools being applied in traditional organizations and systems of care as they transition to new models of care and delivery.
What about near-future uses and the evolution of social media in health care? Dr. Ted Eytan, a Medical Director at the Permanente Foundation, has written that use of all types of social media in healthcare will increase both the quantity and quality of communication – patient to provider as well as provider to provider – and that this can only help to improve the quality of care and the pace of innovation11. The federal Agency for Healthcare Quality and Research (AHRQ) is focusing on the use of social media primarily for health maintenance and wellness activities12. In Florida, Nova Southeastern University’s College of Pharmacy recently announced the launch of the Center for Consumer Health Informatics, which is dedicated to using consumer health informatics (integration of patient preferences, behaviors, and technology) to improve health13.
Of course, there are many issues and challenges that must be addressed for social media to be more broadly used in health care. Privacy is a primary concern. Provider-patient communications must comply with HIPAA regulations with respect to consent as well as logging, tracking and auditing. Any information used to make patient-specific medical decisions, including social media interactions, must be archived. This is true even if public media such as Facebook or Twitter are used as the communication tool. These additional requirements are not currently accommodated by public forms of social media. There are also important issues related to the reliability and accuracy of the available content. How much medical ‘advice’ can a provider give over a social media channel to someone who is not his or her regular patient? What information can be exchanged and what liability does the provider have? There may also be issues of licensure. Can a provider who is not licensed to practice in a particular location give medical advice to patients via social media in that location? The current answer may be no, but it is a good question. All of these issues require further research, review, guidance and potentially, legislation.
Finally, there is the issue of real and perceived costs. The immediate and direct cost of social media is primarily in the time it takes to participate, but many providers appear to believe that there are substantial costs associated with the use of social networks, including those related to changing workflow and practice style.
Clearly, the extent to which social media is being used is framed by the uncertainties about potential use, applications, and cost. In this context, how might community health centers begin to think about social media?14. A panel at the November 2011 NACHC FOM-IT conference provided some general context for CHCs : The speakers advised that CHCs develop a policy regarding social media, determine what information is to shared, and use Facebook and Twitter to share news and other information with the media and public sector officials. These are good points, but let’s get a bit more specific. One of the advantages of social media for health centers is that the costs are primarily in time rather than capital, that is in the time it takes for providers and staff to participate rather than in systems investment, unless a private portal or media systems is developed or bought. Even then, the direct costs may be minimal and offset by other efficiencies or improved outcomes. Health centers can use social media for conveying information to the media and to patients. Potentially more effective approaches include patient-to-provider health maintenance and wellness programs, provider-to-provider or care team communication to support care management and transitions, and patient-to-patient community building, experience sharing and information gathering. All of this could be achieved through a set of private portals or considered and guided use of public social media (Twitter, Facebook, YouTube).
There are, however, issues other than cost to be considered, several of which were discussed at the AHRQ Innovations Exchange. The Exchange, via electronic chat, included a number of health center patients, who raised the issue of access to social media in diverse communities. This question was not specifically addressed during the Exchange, but one answer is that social media is available on many different devices, including many types of phones. The types of media used can be targeted to specific devices that may be in use by health center patients. Today, mobile phone use is widespread, with current statistics suggesting that in the U.S., the number of phones exceeds the population, with 322.9 million subscribers (102.4 percent of population) in June 2011 and about 50% associated with smart phones that are social media capable (although even a standard mobile can send and receive texts)15.
Another issue brought up at the Exchange was use of social media among and with populations that are not English speaking. NACHC reports that the number of CHC patients who best communicate in a language other than English rose 64% between 2000 and 200716 and 30% of patients are now best served in a language other than English. This issue can be partially addressed by providing patient-directed social media content in several languages, although many health centers serve communities where multiple languages are spoken. By way of illustration, the Kaiser system lists 131 spoken and 119 written languages in their EHR guidelines. It is much more expensive to provide interactive media in many languages, as compared with static translation. Health centers could choose to provide static content, such as information on chronic conditions or care transitions, in multiple languages, as that content would only change periodically. Providing interactive content requires either the use of an intermediary (program or person) to facilitate bi-directional translation in both directions, or sufficient language proficiency amongst the staff to provide concurrent networked interaction. This is possible in a very small number of languages, but gets expensive for any number larger than about three, and this is a barrier to be addressed
In spite of the limitations and concerns, the use of social media has many potential advantages for health centers. Among these – and perhaps the of the most immediate use and benefit – are greatly improved communication across patient communities that can help improve the dispersion of information and compliance with care plans; streamlined provider and patient interaction, and enhanced transparency. Each of these changes can benefit the health center as it develops care teams, moves toward medical home qualification, and addresses the increasingly complex needs of an expanded patient population. So the limitations notwithstanding, on the whole this is a direction health centers will want to move in. Our patients already use social media for a very wide range of personal and social interactions. Facilitating real-time, media enhanced patient interaction with the health center and care team and guiding consumers toward practical and attainable health-related uses of social media, can be beneficial to the patient as well as the provider.
David Hartzband, D.Sc. is the Director for Technology Research at the RCHN Community Health Foundation.