Social Media in Health Care: Benefits,Concerns,and Guidelines for Use

Abstract

The use of social media and other electronic communication has exploded as the number of social media outlets and applications continue to increase. These are exciting and valuable tools when used wisely, but pose risks when inappropriately used. The purpose of this article is to consider what comprises social media, its benefits and concerns, and guidelines for use that protect patients, employees, and organizations.

Social media and other forms of electronic communication are exciting and valuable tools when used wisely, as demonstrated by the communication among the public, health care workers, and patients during the recent Boston Marathon bombing. Because social media is largely technology-driven and given to buzzwords, the terminology used to describe it can be confusing. The following terms and definitions will help us to understand its value.

The use of social media has expanded networking to nurture personal and professional relationships; allowed for more rapid exchange of knowledge; created forums for collegial interactions; and provided for dissemination of information and discussion of nursing and health-related education, research, and best practices.

Social technologies refer to any technology that facilitates social interactions and is enabled by a communications capability, such as the Internet or a mobile device. Examples are social software (e.g., wikis, blogs, and social networks) and communication capabilities (e.g., web conferencing) that are targeted at and enable social interactions (Gartner, 2012).

Social media are broadly described as forms of electronic communication (e.g., websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content such as videos (Merriam-Webster, 2012).

Social networking refers to systems that allow members of a specific site to learn about other members’ skills, talents, knowledge, or preferences. Commercial examples include Facebook and LinkedIn. Some companies use these systems internally to help identify experts (Gartner, 2012).

Other social technology terms include the following in alphabetical order:

Blogs (short for web logs) are websites designed to facilitate users’ entries in chronological order. The entries are then displayed in reverse chronological order and are usually archived on a periodic basis. Blogs are mostly used to express opinions on topical events such as sports or politics, but in the past few years they have emerged as established communication channels for businesses as well as individuals. Blogs are often distributed to other sites or readers using Really Simple Syndication (RSS; Gartner, 2012).

Bring your own device (BYOD) is a strategy allowing employees, business partners, and other users to employ personally selected and purchased client devices such as cell phones, tablets, and laptop computers to execute enterprise applications and access data (Gartner, 2012).

Collaborative/peer editing allows groups of people to edit the same document simultaneously. This can be done face-to-face or remotely using collaborative tools such as instant messaging (IM), breakout rooms, application sharing, and whiteboards. Collaborative editing can also be accomplished asynchronously via tools such as discussion boards, change-tracking, and e-mail. Collaborative/peer editing assignments can include projects, papers, presentations, and wikis (Collaborative/Peer Editing, 2012).

Mashups are web-based aggregations of content from different online sources that leverage consumer-oriented sites to create a new service. Mashups rely partly on data and services from public websites, such as Google Maps, Craigslist, eBay, Amazon.com, and others. An example is a program that pulls job listings from one site and displays them on a Google map to show job locations (Gartner, 2012).

Microblogging is a form of multimedia blogging (such as Twitter) that allows users to send and publish brief text updates of up to 140 characters or micromedia such as photos or audio clips, either to be viewed by anyone or by a restricted group chosen by the user. Authors and journalists can use microblogs to drive awareness of new posts, articles, announcements, and so forth (Gartner, 2012).

Predictions or predictive markets are mechanisms that can forecast outcomes of ongoing issues of contention based on analysis of content or actions taken by the collective. They include information markets, decision markets, idea futures, event derivatives, and virtual markets. Prediction markets are websites that use polling mechanisms to forecast events by aggregating opinions across a wide base of users (Gartner, 2012). For example, predicting a shortage of nurses and physicians in a geographic area may suggest limited access to medical care as a reason not to live there.

Podcasts are audio (or audio and video) content specifically designed for synchronizing and playback on mobile audio players and playback-enabled mobile phones. Much of this content is derived from radio or TV broadcasts, and is often free. Podcasts are an example of “sticky” content: listeners are encouraged to subscribe to a podcast “channel” that typically is updated with new content daily or weekly (Gartner, 2012).

Rating tools are mechanisms for users to provide a numerical quality rating for pieces of content through a website (Merriam-Webster, 2012). When ratings are aggregated across a large pool of users, the company gains valuable insights into customer preferences.

Really Simple Syndication (RSS) is an application that allows people to subscribe to online distributions of news, blogs, podcasts, or other online information (Gartner, 2012).

Tagging is done by software that enables individual users to attach descriptive words and identifiers to discrete pieces of web content (audio, video, blog postings, etc.; Gartner, 2012).

Videoconferencing is a service that allows communication by individuals or groups using systems that support image, voice, and data transfer over digital networks or telephone circuits. Videoconferencing systems can take the form of large, dedicated units for group meetings or can be integrated with desktop personal computers (Gartner, 2012).

A 2011 Pew Internet Project Report calls the Internet “the de facto second opinion” for health-related information.

Wikis are collaborative authoring systems for creating and maintaining linked collections of web pages that can be added or changed by users. Wikis enable mass authorship in which potentially millions of people can collaborate to generate new content (Gartner, 2012).

Benefits and Value

The benefits of social media and social technologies in health care have increased because emerging tools have extended the capacity of individuals and businesses to increase communication with peers, family, friends, colleagues, and customers. The use of social media has expanded networking to nurture personal and professional relationships; allowed for more rapid exchange of knowledge; created forums for collegial interactions; and provided for dissemination of information and discussion of nursing and health-related education, research, and best practices.

Organizations have begun to use social media in ways that attempt to meet the demands of their patients, employees, subcontractors, insurers, and the general public. A 2011 Pew Internet Project Report calls the Internet “the de facto second opinion” for health-related information (ECRI Institute, 2011). Social media are a significant factor in how patients use the Internet for health care, with 94% of 23,000 respondents in the Pew Report identifying Facebook™ as their primary source for health-related information, followed by YouTube™. Almost one-third of survey respondents reported their trust for social media as “high” or “very high” and one-quarter of respondents reported that the information they find on social media was “likely” or “very likely” to influence their decisions (ECRI Institute, 2011).

Health care organizations are using social media to raise awareness about themselves by sharing organizational news and services, community events, and general news from local or national media such as major studies, legislation, or health-related stories of interest to the hospital's patients and employees. Success stories highlighting staffs', physicians', or patients’ achievements, awards or struggles, and customer outreach and engagement drive traffic to the organization's website.

The recent Boston Marathon tragedy demonstrates the increasing use of social media. Each of the hospitals communicated with patients, family, and staff via Facebook, providing information on blood donation and statistics on victims being treated (e.g., number of patients in each condition level), sharing expert advice on coping with the event (e.g., how to talk with children), and updating staff on scheduling issues. Three hospitals receiving the majority of casualties (Massachusetts General Hospital, Brigham and Women's Hospital, and Beth Israel Deaconess Medical Center) used status updates to notify the community of changes in their security status, operating procedures, and appointment cancellations throughout the week after the bombing. Finally, Boston hospitals used their social networks to thank their supporters and share acts of kindness happening in their facilities. The use of social media is helping to solidify it as a crisis communication tool (HealthLeaders Media Intelligence, 2013).

Potential uses of social media by hospitals include disaster management, recruiting blood donations, weight management and support, epidemiological tracking, arranging outpatient appointments, “ask a nurse” services with referrals to support and treatment services, arranging outpatient care, real-time satisfaction surveys, and food and product safety alerts (ECRI Institute, 2011).

Concerns

Labor efficiency

Although labor is the largest single expense in most hospitals, layoffs and workforce reductions are not an attractive cost-cutting strategy. Nearly 20% of respondents in an October 2012 cost containment survey reported that they expect to eliminate administrative staff at the executive (vice president and higher) level, and 51% expect to reduce numbers of other nonclinical personnel. The hoped-for efficiencies from the reduction in support personnel can only be attained through enhanced technology automation if bedside nursing positions are to be maintained and quality preserved in patient care (HealthLeaders Media Intelligence, 2012).

Risks

The health care industry's reluctance to adopt social media has been driven largely by concern for potential risks of privacy violations, inaccurate information becoming “fact,” loss of public trust, and undermining of individual careers.

Protecting Patient Privacy

Patient privacy in the social media age is an evolving issue requiring hospitals to be proactive. Social media distributes information instantaneously to a wide audience and, unlike verbal conversations, it creates a permanent electronic record that cannot be fully deleted and may be used in discovery in court proceedings. Consider the following real life examples.

Two nurses from a Wisconsin hospital photographed a patient's X-ray and one posted it on her personal Facebook profile. An anonymous caller alerted local police to the photo's presence and related online discussion among the nurses. The nurses were both fired from the hospital and faced action from the state licensing board. The hospital reduced its liability because it had a well-documented Health Insurance Portability and Accountability Act (HIPAA) policy employee training program and took swift action on the matter (ECRI Institute, 2011).

Patient privacy in the social media age is an evolving issue requiring hospitals to be proactive. Social media distributes information instantaneously to a wide audience and creates a permanent electronic record that cannot be fully deleted and may be used in discovery in court proceedings.

A Rhode Island hospital's media relations department found YouTube footage of a trauma center patient's videotape of another patient who was drunk. Although the trauma center's staff members were portrayed in a positive way in caring for the intoxicated man, his embarrassing event was made public. The hospital contacted police, who were unable to intervene. YouTube's parent company refused to remove the video because it did not violate the user agreement. The video lives online (Cawley Jean, 2012).

In the second scenario, taking and posting the video was not a HIPAA or Health Information Technology for Economic and Clinical Health (HITECH) breach because the activity was not carried out by a hospital employee (U.S. Department of Health Services, 2009). However, depending on the specific circumstances, the hospital and the person who took the video could be held liable under state law for emotional distress, invasion of privacy, and negligence. That hospital is now developing new privacy policies specific to patients and visitors using smartphones to take pictures and videos, and is planning signage about the inappropriate use of personal devices for recording. Staff are being asked to be more aware of what patients and visitors are doing and are empowered to ask people to turn off their cell phones and not to take pictures and videos (Cawley Jean, 2012).

When used inappropriately, accessing social media sites and reading and responding to personal e-mail and text messages causes distraction that puts patients at risk.

Presenteeism and Loss of Productivity

Never has the phrase “Time is money” been truer for hospitals than now. Leadership is being held accountable daily for everything from patient volumes to staffing to cash flow. Presenteeism occurs when employees are at work but are not performing at their peak because of working while sick or other distractions from home, family, or work. Productivity lost because of presenteeism is almost 7.5 times greater than that lost to absenteeism (American Psychological Association Practice Organization, 2010).

Requests for additional staff are being scrutinized, and unit leadership is increasingly aware of the double-edged sword of staff use of social media technologies. When the technology is used positively and productively, employees can access authorized resources in support of patient care, such as reactions to medications or symptoms of complications. When used inappropriately, accessing social media sites and reading and responding to personal e-mail and text messages causes distraction that puts patients at risk. Unit managers and service line directors have shared anecdotal experiences of disciplining employees for work delays involving personal phone calls, text messages, and social media sites; these behaviors led to delayed medication administration or treatments contributing to coworker and patient dissatisfaction and unnecessary overtime. Less anecdotal are cases based on events reported to boards of nursing that depicted inappropriate uses of social and electronic media (National Council of State Boards of Nursing [NCSBN], 2011).

A study by Deloitte LLP (2009) found that companies that allowed their employees access to Facebook at work lost an average of 1.5% in employee productivity. The study found that 77% of workers who have a Facebook account use it at work. Of those using Facebook at work, 87% said they had no clear business reason for using the site (Deloitte LLP, 2009).

Social technology tools designed to increase productivity may actually contribute to lost productivity and dollars. This is supported by a survey conducted by harmon.ie (2011), which found that

Nearly 60% of work interruptions now involve either using tools like email, social networks, text messaging and IM, or switching windows among disparate standalone tools and applications and 53% of employees waste at least one hour a day due to all types of distractions. (harmon.ie, 2011)

Using this percentage to calculate dollars lost to work interruptions from social media technologies, for a full-time employee at an average salary of $30/hr, the lost productivity will cost the company $7,800 a year. For organizations with 1000 employees, these interruptions cost more than $7 million annually.

Former Employees or Volunteer Groups

Former employees or volunteer groups may use social media to talk about the organization and in so doing, may talk about former patients. HIPAA obligations only address current employees and volunteers, so a hospital may not be sanctioned for violating HIPAA obligations. However, if the employee no longer works there, the hospital could be at risk if it is shown that it did not provide HIPAA education and obtain a signed acknowledgment from all employees and volunteers.

Reputation Management

When using social media, managing the organization's reputation is one of the most significant risks it faces, second only to privacy protection. The organization must be aware of and respond to criticism and complaints that originate outside the organization, and must ensure that social media content accurately reflects the organization's message and does not harm its reputation. Reputation management practices include having employees engaged in social media being aware of what is being said about them and the organization, providing timely responses, responding honestly to outsiders in creating new content, and being respectful in all communications.

Organizations need policies to manage content originating both outside and within the organization. There are numerous examples of individuals and celebrities doing lasting harm while working on behalf of an organization when they post crude, inappropriate, or otherwise unprofessional content on social media. “Self-twimmolation” is the term that has been used to describe actions that lead to “firing over a quick, ill-advised tweet” (ECRI Institute, 2011).

Organizations need to develop, enforce, and/or update policies to address appropriate and inappropriate use of social media technologies, including employee confidentiality agreements, training for employee orientation and other mandatory education, employee handbooks, and performance appraisals.

Social Media Background Checks (SMBC)

A 2011 ruling by the Federal Trade Commission allows companies to keep an archive of individuals’ public social media activities for seven years, even if it has been deleted from an account. Four types of content are flagged when conducting background checks:

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Racially insensitive remarks

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Sexually explicit material

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Flagrant displays of weaponry

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Other demonstrations of clearly illegal activity

There are limits to what a future employer can do with the information provided by SMBC companies. The employer must comply with the Fair Credit Reporting Act (FCRA) by informing candidates that they are performing a background check, obtaining permission before doing so, and telling the applicant about any damaging information they uncover. Since the FCRA only requires new reports to be run on each applicant, it is important that job seekers keep their files updated and remove damaging information that is brought to their attention (Hill, 2011).

BYOD problems can occur when physicians, staff, and/or patients bring their personal cell phones, tablets, and laptop computers into the hospital. These devices create problems with data protection, security, data management, and privacy. Managing successful BYOD programs requires organizations to set clear ground rules, create sensible security policies, enforce those policies, and devise strategies for navigating privacy protections.

We are beginning to learn that the greater the critical mass of the social network, the greater the opportunity to extend the hallway conversation to new dimensions making teamwork and care collaboration a seamless effort to engage our clinical teams for answers that saves lives.

Guidelines for Use that Protect Patients, Employees, and Organizations

The American Nurses Association (ANA) and the NCSBN have collaborated on guidelines for the professional use of social media. The NCSBN (2011) developed guidelines for nurses on how to use social media responsibly and minimize risks. The ANA's Principles for Social Networking (ANA, 2011) include the following:

Nurses must not transmit or place online individually identifiable patient information.

Nurses must observe ethically prescribed professional patient-nurse boundaries.

Nurses should understand that patients, colleagues, institutions, and employers may view postings and professional information online.

Nurses should bring content that could harm a patient's privacy, rights, or welfare to the attention of appropriate authorities.

Nurses should participate in developing institutional policies governing online conduct.

Organizations must develop social technologies management programs. Decision makers must consider the following factors in their social media management.

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Identify the benefits and risks of using social media in the organization, and the best ways to manage those risks.

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Develop, enforce, and/or update policies to address appropriate and inappropriate use of social media technologies, including employee confidentiality agreements, training for employee orientation, other mandatory education, employee handbooks, and performance appraisals.

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Manage social media technologies appropriately. This is often a shared responsibility between information technology, human resources, and media relations.

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Consider business intelligence analytics to understand how social media is being used both positively and negatively within the organization, and modify policies and programs accordingly.

Conclusion

Social media has great potential for providing information to nurses, other health care professionals, and health care consumers. When nurses are confronted by challenges in practice, it has always been easier to ask someone who may have the answer. However, the challenge is that the person with the best answer may not always be available to help. We are beginning to learn that the broader the social network, the greater the opportunity to extend the hallway conversation to new dimensions, making teamwork and care collaboration a seamless effort to engage our clinical teams for answers that saves lives. The use of social media and the possibilities of social learning networks can improve the care we provide. By being careful of the potential ramifications of misusing social media, nurses may enjoy the personal and professional benefits of social media without violating patient privacy and confidentiality.

Footnotes

ChrysMarie Suby, MS, RN, is an international health care consultant specializing in the areas of clinical operations, labor management, scheduling and staffing systems, and productivity management. She is owner and co-founder of the Labor Management Institute (LMI), editor of the newsletter Perspectives of Staffing and Scheduling© (PSS™), and publisher of LMI's PSS™ Annual Survey of Hours Report©.

References

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Hill

(2011, June 20). Social media background check company ensures that job threatening Facebook photos are part of your application. Forbes| Tech. Retrieved from http://www.forbes.com/sites/kashmirhill/2011/06/20/now-your-embarrassingjob-threateningfacebook-photos-will-haunt-you-for-seven-years/.

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