Abstract
Since the beginning of the millennium, there has been a remarkable change in how people access and share information. Much of this information is user-generated content found on social media sites. As digital technologies and social media continue to expand, health care providers must adapt their professional communication to meet the expectations and needs of consumers. This adaptation may include communication on social media sites. However, many health care providers express concerns that professional social media use, particularly interactions with patients, is ethically problematic. Social media engagement does not create ethical dissonance if best practices are observed and online communication adheres to terms of service, professional standards, and organizational policy. A well-executed social media presence provides health care providers, including physical therapists, the opportunity—and perhaps a professional obligation—to use social media sites to share or create credible health care information, filling a consumer void for high-quality online information on fitness, wellness, and rehabilitation. This perspective article provides a broad review of the emergence of social media in society and health care, explores policy implications of organizational adoption of health care social media, and proposes individual opportunities and guidelines for social media use by the physical therapy professional.
According to data frequently updated by the Pew Research Center (www.pewinternet.org), the vast majority of US adults are Internet users, have a smartphone, and use social media sites to access and share information.1–3 Health care—including physical therapist practice—is not immune from this influence.4 However, many health care providers, usually citing privacy and liability concerns, have been slow to adopt social media. As digital technologies and social media continue to expand, health care providers must adapt their professional communication to meet the expectations and needs of consumers. Physical therapy professionals have the opportunity—and perhaps a professional obligation—to use social media sites to share or create credible health care information, filling a consumer void for high-quality online information on fitness, wellness, and rehabilitation.5 This perspective article provides a broad review of the emergence of social media in society and health care, explores policy implications of organizational adoption of health care social media, and proposes individual opportunities and guidelines for social media use by the physical therapy professional.
Social Media
Also referred to as Web 2.0 or the read-write web, social media are Internet sites and applications that allow users to create, share, edit, and interact with online content. In other words, social media sites contain information generated by users for users, a departure from institutionally created, read-only Web 1.0 content. The most popular social media are social networking sites such as Facebook and LinkedIn.6 However, there is a vast, dynamic social media landscape that includes dozens of sites for publishing, sharing, discussing, and networking (Fig. 1). The emergence of social media has shifted information-seeking behavior in society, whether that information informs buying decisions, determines news exposure, or becomes the basis for health care decisions. Consumers have moved from consulting their local telephone book to using online directories to find a physical therapist and may now choose a provider based on their Facebook page, blog, or user-created ratings on sites such as yelp.com. The explosion of social media and the ability to access the Internet almost anywhere, anytime using wireless Internet and mobile devices presents exciting opportunities and new considerations for health care organizations and professionals.
Depiction of the social media landscape in 2014. Google, Twitter, and Facebook are featured in the center, surrounded by social media sites in the categories of discussing, sharing, publishing, and networking. Major media, commerce, and technology companies are investing in social media platforms. Social Media Landscape 2014 image from Fred Cavazza.net. Available at http://www.fredcavazza.net/2014/05/22/social-media-landscape-2014/. Creative Commons License.
The Reach of Social Media in Health Care
The spread of social media use can widely be understood as a bottom-up, consumer-driven phenomenon that is changing demand for and access to health information. The vast majority of Internet users look for health care information online, with many seeking online sources for self-diagnosis or to diagnose someone else.7,8 People living with chronic disease are particularly likely to seek peer-to-peer social media sites for support.9 Technology and social media affect health behaviors and decision making. A growing number of Internet users use technology aids such as mobile health tracking apps to monitor and share individual health information.10 Internet users consult online reviews and rankings when selecting a health care provider or seeking access to treatments,8 and many consumers say that information found on social media sites influences decisions to seek a second opinion, choose a specific provider or facility, cope with a chronic condition, or manage diet, exercise, and stress.11 The reliance on online information for health care decision making may be worrisome to health care professionals who are concerned about information accuracy. However, although online social media review sites may be vulnerable to bias, there does seem to be some validity in using a provider's or organization's social media presence as a measure of quality. A recent study in the American Journal of Medical Quality showed that, for a group of New York hospitals, there was a one percentage point decrease in 30-day mortality rate for every 93 “Likes” on the hospitals' Facebook pages. Facebook “Likes” were more closely related to mortality than patient satisfaction surveys.12
Health care providers and organizations have recognized and responded to the reality that consumers rely on Internet sources and social media for health information and in making their health care decisions. Social media use among health care providers has risen sharply over the past several years.13 Nearly every US hospital has a website, and many support interactive social media features. As of early 2014, the Mayo Clinic reported that more than 1,500 US hospitals managed 6,500 social media accounts on sites such as YouTube, LinkedIn, Facebook, Twitter, 4square, and blogs.14 Health care social media sites such as the Mayo Clinic Social Media Health Network and KevinMD.com use social media to provide a platform for health care organizations and providers to interact with one another as well as with patients and consumers. The American Physical Therapy Association (APTA) has a strong social media presence. In addition to the APTA Online Communities, the organization maintains 8 active Twitter accounts (3 event-specific accounts, 3 Facebook pages, 2 YouTube channels, and 1 LinkedIn group).15 Each of these social media sites provides specific, unique opportunities for information sharing among members, nonmembers, students, event attendees, other health care professionals, and consumers.
Spheres of Social Media Use in Professional Health Care Communication
Social media communication is not new. However, social media for health care communication is a more recent development that requires institutions and providers to acknowledge and assess multiple societal, organizational, professional, and individual considerations and implications. Figure 2 illustrates the spheres of use that guide social media participation for the health care provider. These nested spheres include social media sites' terms of service, professional standards, organizational policy, and individual best practices. This framework illustrates the overlap among societal, organizational, and individual considerations in professional health care social media, appreciating that as a health care provider, an individual's social media presence does not exist in isolation.
Spheres of social media use in professional health care communication.
Terms of Service Within Social Media Platforms
When an individual uses a social media site, he or she is entering into a legal agreement with that site to adhere to the “terms of service.” Items covered in terms of service often include, but are not limited to, privacy and security, safety, intellectual property rights, content limitations, user identity, and age requirements. Users are often tempted to quickly agree to the terms that are presented when registering a social media account. However, it is the responsibility of all users to understand these terms and to be aware that terms are variable and dynamic within social media platforms. Violation of a social media sites' terms of service may result in removal of content, account suspension, or, in extreme situations, prosecution.
Professional Standards for Health Care Providers' Use of Social Media
Health care professionals are obligated to adhere to their profession's standards of ethical and professional conduct in all interactions, including those that occur on social media sites. In 2010, the American Medical Association (AMA) became the first health care professional body to adopt social media guidelines with the AMA policy: Professionalism in the Use of Social Media.16,17 The AMA's adoption of a specific social media policy acknowledged that the reach of social media introduced new ethical and legal considerations for physicians. However, the policy did not introduce novel standards but stated the relevance of existing standards during online interactions. For example, it referenced the established standards regarding physician-patient boundaries but articulated the implications of Internet contact: “If they interact with patients on the Internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just, as they would in any other context.”
In 2011, the American Nurses Association (ANA) adopted Principles for Social Networking and the Nurse,18 and the National Council of State Boards of Nursing (NCSBN) released White Paper: A Nurse's Guide to the Use of Social Media.19 The following year, the American Society of Health System Pharmacists (ASHP) adopted the ASHP Statement on the Use of Social Media by Pharmacy Professionals.20 Similar to the AMA policy, the policies adopted by the ANA, NCSBN, and ASHP largely restated the importance of adhering to existing ethical and legal standards, with an emphasis on protecting patient privacy and confidentiality within online forums.
The physical therapy profession addressed the topic of social media by adopting the Standards of Conduct in the Use of Social Media21 during the 2012 session of the APTA House of Delegates (Fig. 3). Like the policies adopted by other health care organizations, the Standards of Conduct in the Use of Social Media did not change existing standards or introduce new legal and ethical standards. It acknowledged that changing modes of communication may require physical therapists to reconceptualize how existing standards apply to online communication. The Standards of Conduct in the Use of Social Media ultimately requires that physical therapists, physical therapist assistants, and physical therapy students use social media in accordance with the Code of Ethics for the Physical Therapist22 and Standards of Ethical Conduct for the Physical Therapist Assistant.23
Standards of Conduct in the Use of Social Media.21 Adopted by the American Physical Therapy Association House of Delegates in 2012. Reprinted with permission from the American Physical Therapy Association. Copyright © 2014.
Organizational Policy on Social Media Use
Health care organizations run thousands of social media accounts on various platforms.14 Many have adopted social media policies to provide guidance for official organizational accounts as well as employees' personal and professional use. In 2011, Cain outlined the need for health care organizations to address these new questions by developing social media policies and described organizational concerns about social media as falling into 3 primary categories: (1) reputation, (2) privacy, and (3) productivity.24 Health care organizations typically have existing policies addressing these 3 themes and often direct employees back to these existing policies when using social media.
The Mayo Clinic, considered by many to be the “gold standard” for health care social media, begins its social media policy by directing employees to, “Follow all applicable Mayo Clinic policies. For example, you must not share confidential or proprietary information about Mayo Clinic and you must maintain patient privacy. Among the policies most pertinent to this discussion are those concerning patient confidentiality, government affairs, mutual respect, political activity, Computer, E-mail & Internet Use, the Mayo Clinic Integrity Program, photography and video, and release of patient information to media.”25
In section 5.1.1 of its social media policy, Kaiser Permanente, one of the nation's largest not-for-profit health plans, states, “Employees are expected to adhere to Kaiser Permanente compliance requirements and the Kaiser Permanente Principles of Responsibility when using or participating in social media. All the rules that apply to other Kaiser Permanente communications apply here, specifically: respecting members, patients, customers and one another; protecting confidentiality, privacy and security; and safeguarding and proper use of Kaiser Permanente assets.”26
Vanderbilt University Medical Center's (VUMC's) social media policy, adopted in 2013, parallels social media policies of other academic medical centers by advising individuals to “Follow the same VUMC Credo behavior, HIPAA [Health Insurance Portability and Accountability Act], Conflict of Interest policy, Privacy and general civil behavior guidelines cited above including respecting copyrights and disclosures, and not revealing proprietary financial, intellectual property, patient care, or similar sensitive or private content.”27 These policies address reputation, privacy, and productivity issues primarily by directing users back to existing legal and ethical guidelines, with particular sensitivity to HIPAA compliance and protection of proprietary information.
Individual Best Practices
Given the ubiquity of social media in society, it is likely that a large proportion of health care providers use social media, at least for personal purposes. Professional standards and organizational policies often warn health care providers of the negative consequences of social media use, emphasizing avoidance of undesired behaviors. Many health care providers have ethical concerns surrounding patient-provider interactions on social media.28 However, the reach of social media for health and wellness presents exciting opportunities for the health care professional with a well-executed social media presence. Social media give health care providers a far-reaching platform on which to contribute high-quality online content and amplify positive and accurate health care information and messages. It also provides a forum for correcting misinformation and addressing misconceptions.
Because of this potential, practical approaches and guidelines for social media use by individual health care professionals should be more than a set of “do's and don'ts” and must articulate more than avoidance of negative behaviors. Rather, guidelines should provide recommendations for a thoughtful, effective social media presence that adheres to platform-specific terms of service, professional standards, and organizational policies. There is very little research related to health care social media, and much of the available literature is expert commentary similar to this perspective article. However, a broad review of the health care social media literature reveals that consensus is building around a number of principles that may help guide informed, appropriate professional health care social media use.29–32 Using the Spheres of Use in Health Care Social Media as a guiding framework, the social media guidelines for health care providers (Fig. 4) were developed. These guidelines may be useful for all health care providers and may provide a frramework for social media use across the 5 roles of the physical therapist: the clinician or consultant who wants to expand client outreach, the administrator who is involved in organizational policy, the educator who mentors and models use to students, and the researcher who is building networks with collaborators.
Proposed social media guidelines for health care providers. HIPAA=Health Insurance Portability and Accountability Act.
Define your goals and objectives.
Social media is a vast landscape consisting of platforms that may be used for various purposes, including gathering information, connecting with other professionals, marketing, sharing ideas, and developing a personal brand. A well-executed social media presence requires a defined audience and a clear purpose.
Protect patient privacy and confidentiality.
In any context, HIPAA prevents health care providers from sharing any patient-specific information that is not essential for delivery of care.33 This role extends to all forms of communication, including written, verbal, e-mail, listserves, online discussion boards, and social media. Social media platforms—even within private accounts, small circles, or closed groups—cannot be assumed to provide the level of security that would support any patient-specific discussions.
Educate yourself on the policies of your employer and adhere to them.
It is the responsibility of the health care provider to understand and adhere to organizational policies. In some situations, an individual may need to explicitly state that all opinions are his or her own, not those of his or her employer or professional organization.
Take ownership of your views and responsibility for what you post.
Creation of an alias for a social media account may seem to be a practical solution for a user who wants to separate posted views from his or her public and professional identity. However, most social media guidelines recommend that users do not engage anonymously in social media. Anonymity should not be expected to make social media commentary untraceable. Social media users are better served by acknowledging the highly public and identifiable nature of all posted content and should not confuse social media forums with private correspondence. Although most platforms allow social media content to be deleted, content can never be completely eradicated. “Deleted” content may be retained through screen shots or screen captures, downloading, e-mail notifications, archiving, and cache storage.
Think carefully before practicing “dual citizenship.”
Even if a provider uses social media for connecting with friends and family, he or she may feel uncomfortable using social media in his or her professional life. Some sources, including the APTA Standards of Conduct in the Use of Social Media, propose that users consider creating separate personal and professional identities on social media platforms; this is commonly referred to as “dual citizenship.”34 Although this strategy may be the preferred approach for some users, professionals should consider that the increasing accessibility and “searchability” of the Internet limit the ability to compartmentalize a person's public and personal online presence. One never truly steps out of his or her professional identity in his or her community or personal life, and even information posted to a “personal” profile or page may be viewed in the context of the user's professional training and background. Users may choose the dual citizenship option to stratify content and messaging to particular audiences but should be cautioned that separate accounts will not guarantee privacy or separation of the user's personal and professional images. Users also should be warned that creating multiple profiles violates the terms of use of many social media sites, such as Facebook. Thus, an alternative strategy for those with privacy concerns may be to use different social networks for different purposes, such as using LinkedIn for professional networking and a Facebook profile for connecting with family and close friends.
Practice digital professionalism.
Health care providers who use social media should practice professionalism online as they would offline. Professionals on social media sites should be honest, share good health care information and refute the bad information, correct misinformation, be respectful of others, and correctly attribute shared content. When considering the potential for professional misconduct and liability on social media sites, the health care professional may be guided by the 12-word social media policy described by the Mayo Clinic Social Media Health Network: Don't Lie, Don't Pry; Don't Cheat, Can't Delete; Don't Steal, Don't Reveal.35
Control information sharing.
Professionals who use social media can use privacy settings and grouping features to help create boundaries between personal and professional online interactions and customize information sharing. Health care providers who use social media sites for professional or personal purposes should understand how to use these settings to make their profile and individual posts public or private, create lists, block or hide users, and utilize features such as Facebook and LinkedIn Groups and Twitter hashtags to interact with individuals without friending, connecting, or following.
Take an agnostic approach to social media.
Online communication is evolving. It is certain that currently popular technologies will fall out of favor while new technologies emerge. Health care providers need to be flexible and nimble in their communication methods in response to changing needs of consumers and society. Users should investigate the range of social media technologies available for sharing health care information and may want to consider using multiple platforms to meet a variety of objectives.
Monitor your online identity.
Nearly everyone in US society has an online presence regardless of whether they choose to engage in social media or not. It would be a fallacy to argue that avoidance of social media protects one from a public and online identity, and it is nearly impossible to opt out of all sites that publish publicly available information. Every health care provider—even those who do not participate in social media or other online discussions—should regularly monitor his or her Internet presence. At the minimum, this monitoring should be done by regularly searching for his or her name on common search engines. Users who are active on social media platforms will notice that these user-created profiles will crowd out more obscure listings. Using social media may give users increased control over their Internet search results rather than leaving it to unknown sources and online review sites. In conducting a personal search, the user should consider how his or her professional identity would be perceived by professional peers, potential clients, or students who view results of “googling” him or her. It becomes clear to the professional that the question is not “if” he or she participates in social media, but “how” or perhaps “how well.”
Explore your options for online communication with patients.
A common dilemma for health care professionals is: “Is it OK to ‘friend’ a patient?” There is no single answer to this question, which is just beginning to be explored in the medical literature.28,36 The provider must consider a number of factors, including whether the “friend request” was initiated by the provider or patient, the motivation for the “friend” relationship, patient and provider confidentiality, and potential conflict of interest. For some providers, “friending” a patient may not be appropriate or desirable. However, it may be appropriate in other contexts. A provider in a small community may experience a high degree of overlap in personal and professional interactions. A “friend” relationship may have existed prior to the patient-provider relationship. A provider may be highly involved in a health advocacy issue that is supported by social media engagement with patients on “personal” sites. If a provider chooses to open his or her profile by “friending” patients, he or she must accept that the profile is no longer solely personal. Alternatively, a provider may consider using other platforms, such as a professional blog or clinic profile page, for patient interactions. Providers who choose to use social media to interact with patients or potential patients should consider a variety of platforms to suit the needs and objectives of the provider and the patient.
Social Media as a Professional Competency
Policies and guidelines may provide cover for organizations or individuals, but they do not necessarily prevent a problematic event from occurring using social media. It is critical that health care institutions and organizations not only provide policies and guidelines but also offer education, guidance, and support for individuals who want to use social media in their personal and professional lives. Introduction of new tools within a society demands new competencies and knowledge. A systems view of professionalism forces us to consider the impact of external forces on professional behaviors. According to Lesser and colleagues, “external forces need to be harnessed to support—not inhibit— professionalism in practice.”37(p2733) The evolution of new media has necessitated an educational response, as well as a shift in the habits of professional development, toward consideration of social media communication as a professional technical competency. Many practicing physical therapists are new to social media and may not be comfortable with using social media sites to read and disseminate health information or network with colleagues online. Physical therapy professionals in practice should actively seek educational opportunities, including continuing education workshops, informal lunch-and-learn sessions, or webinars, to develop their comfort and knowledge of professional health care social media.
Educators should consider that online behavior can be effectively shaped by explicitly including social media competencies in health care education.38 Many students now entering professional programs have social media accounts that date back to their teen years. Although it may seem excessive or even surprising to a baby boomer or member of generation X, it is not unusual for individuals of the millennial generation to have a social media presence that chronicles minute details of their adolescence, including content that could be viewed as inappropriate in the professional context. Educators have an opportunity to model and support professional social media use to these highly engaged and technology-competent students, thus helping students develop digital citizenship through regular and effective Internet use.39
Educators may be tempted to reduce digital citizenship to proper etiquette, appropriate manners, and norms of engagement in electronic correspondence. For users to realize the benefits of social media and to responsibly engage in social media that benefits society, broader considerations are introduced. In professional education, educators should work not only to teach digital citizenship but also to support students in developing digital professionalism. Technology competencies for online professionalism include—but are not limited to—acknowledging sources of information, clearly delineating personal opinion from organization positions, ensuring security of self and other users, appropriate use of mobile devices and applications, and understanding intellectual property downloading and sharing content. As with other forms of professionalism, digital professionalism should be threaded through the physical therapy curriculum: introduced early in didactic education, modeled by physical therapy academic and clinical faculty, and developed through various social media experiences and assignments. This approach will ensure that technology competencies and digital professionalism become part of the culture of physical therapist education and practice.
Conclusion
Social media will undoubtedly continue to evolve as sites fade in popularity and new platforms emerge, but it is clear that online communication is here to stay. Although social media introduce many legal, ethical, and professional considerations, they provide networks for learning and platforms on which physical therapists may provide the public with credible rehabilitation and wellness information. This perspective article has explored current social media trends in health care and society, presented a framework for organization and individual social media use, and provided proposed guidelines for health care professionals using social media. Together, this information supports the view that health care providers, including physical therapists, physical therapist assistants, and physical therapist students, have not only the opportunity but perhaps also a professional obligation to use social media to create and amplify positive health messages and refute inaccurate online health information.
A major weakness of this perspective article is the lack of empirical evidence on outcomes of using social media in physical therapist education, practice, or research. It is our hope that this perspective article and the information provided will offer a foundation for more work in this area. Future research on social media may help provide further guidance for clinicians and students in using social media for managing their online professional identity, communicating effectively, developing strong digital professionalism, and promoting the physical therapy profession.
Footnotes
All authors provided concept/idea/project design and writing. Dr Gagnon provided project management.
- Received June 4, 2013.
- Accepted May 17, 2014.
- © 2015 American Physical Therapy Association
References
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