Informatics Interchange
Informatics Interchange Analysis of pharmacists’ use of Twitter
T
he use of online social networks has grown rapidly in the past decade, as social media have become a vital interaction venue in our personal and professional lives.1 Despite Facebook’s ascension to the most popular social medium, Twitter has gained a niche for subject-specific communications.2,3 From detecting influenza outbreaks to exploring the misuse of antibiotics, Twitter has been used to gain insight into health information dissemination and communication.4,5 Twitter (www.twitter.com) is a microblogging online platform with which users can post messages (“tweets”) no longer than 140 characters that are accessible by any Twitter user as well as users who specifically “follow” them. Followers can “retweet” messages that they believe are noteworthy (similar to forwarding an e-mail) or reply (“@user”) to tweets, creating a relatively public online conversation. Users can also exchange private messages. Lists can be created to gather a “tweet feed” of users sharing common interests or characteristics. Unlike Facebook, privacy in Twitter is an all-or-none option; users elect to make their accounts either totally public or private. Twitter is the second most commonly used social media platform by hospitals in the United States and has been used by organizations to promote health and detect poor-quality health care.6-8 In addition, Twitter has been piloted in pharmacy education as a tool to actively engage students in the learning process.9,10 Although Twitter’s popularity has been growing, adoption has been variable among health care professionals. One study recently found 672 accounts
belonging to emergency physicians; 11 another study found that just 13 pharmacy preceptors acknowledged creating a Twitter account.12 Another study identified 12% of pharmacists from a single state as having a Twitter account.13 More broadly, American Society of HealthSystem Pharmacists (ASHP) surveys suggest that 25% of pharmacy students regularly use Twitter, 22% of new practitioners have an account, and only about 12% of pharmacists who have been in practice keep an active Twitter account,14 compared with 13% of the general population.15
While surveys may provide estimates of pharmacists’ use of Twitter, little is known about the actual number of pharmacists actively using Twitter, their usage characteristics, and their professional connections. A better understanding of the current role of pharmacists on
Twitter may provide guidance on the optimal use of this platform for the profession, benchmark its use by other health professionals, and highlight opportunities for impact. The purpose of this study was to identify the number of pharmacists with Twitter accounts, their usage characteristics, and their professional networking patterns. Methods. Account identification. Pharmacists’ Twitter accounts were identified by searching usernames and biographies for “pharmacist,” “R.Ph.,” and “Pharm.D.” using Twitter’s Web-based search and FollowerWonk service.16 This process identified 7470 accounts. Accounts were excluded if they had fewer than 100 tweets, their tweets were primarily not in English, the pharmacists were outside of the United States, or the account had no activity after 2011 (identification and extraction were initiated in July 2012). Advertising-focused (e.g., sales), industry, student pharmacist, and private accounts were also excluded. In all, 6847 accounts were excluded, leaving 623 remaining. Data extraction. Of the 623 pharmacist Twitter accounts eligible for analysis, 204 were sampled for content evaluation. This sample size, combined with an extraction of 30 tweets from each account, ensured content-analysis saturation and exceeded that used in similar research performed in this area.17 Microsoft Excel (Microsoft Corp., Redmond, WA) was
The Informatics Interchange column gives readers an opportunity to share their experiences with information technology in pharmacy. AJHP readers are invited to submit their experiences and pertinent lessons-learned related to pharmacy informatics. Topics should focus on the use of information technology in the medication-use process, informatics pearls, informatics education and research, and information technology management. Readers are invited to submit their ideas or articles for the column to [email protected] or ASHP, c/o Karl Gumpper at 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-657-3000).
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originally used to stratify accounts by level of activity for accurate representation of the variety of users and to conduct the stratified random-sampling process. FollowerWonk16 was used to extract the full name, biography, location, Web address of the profile, number of followers, number of friends, date of account creation, date of last tweet, and total number of tweets. The SEOTools Excel plugin was used to extract the 30 most recent tweets from each account.18 Investigators initially predicted an average of 1–2 tweets per pharmacist account per day, so the extraction of 30 tweets would represent about two weeks’ to one month’s activity per account. SEOTools provided the date, text, and source of each tweet as well as the retweet count for every extracted tweet. Quantitative analysis. Two blinded investigators evaluated the content of extracted tweets (n = 6120) and classified each account as (1) exclusively professional, (2) predominantly professional, (3) exclusively social, or (4) predominantly social. Accounts were defined as exclusive if all of the extracted tweets (30 of 30, 100%) were either social or professional in nature. Accounts were put in a “predominant” category when more than 50% but less than 100% of tweets were social or professional. Accounts containing tweets with language inconsistent with the “Oath of a Pharmacist”19 or “Code of Ethics” were also noted. Violations mainly consisted of profane language, criticism of patients’ behavior, narcissistic criticism of the employer, and similar content. Cohen’s kappa (k) was used to assess interrater concordance. Descriptive statistics were used to characterize results. Qualitative analysis. Qualitative data were analyzed using both phenomenological and narrative frameworks,20,21 which allowed for patterns, themes, and categories to emerge. These categories involved a hierarchical set of constructs that accounted for the phenomena in the data. Once themes were created by investigators (i.e., professional, social), successive levels of qualitative analyses were conducted. First, descriptive analyses
616
focused on developing an understanding of participants’ messages and the reasons they were posted. A thematic analysis focused on elaborating the structures of the basic study. Additional constructs were added to the constructs that arose in the early phases of analysis. Data were reviewed and relevant ideas identified. Next, concepts were divided into the various subcomponents of the themes. This stage of the analysis consisted of reexamining the data for consistency within each concept. A comparative analysis was also conducted to clarify differences in the use of Twitter among pharmacists (i.e., social or professional). After understanding concepts as presented by individuals, the analyses were then extended across similar individuals, and comparisons were made across groups of people who shared potentially significant characteristics. Once the conceptual scheme was suitably differentiated, the quantitative and qualitative data were integrated to lay the foundation for constructing a report of the findings. This process involved reexamining the results of all the preceding analyses to create conceptual understandings of the Twitter communication experiences of pharmacists in the sample. Visualization and social network analysis. Unlike other social media, Twitter’s social network relationships are directional. The connection between accounts is unidirectional when one pharmacist only follows another pharmacist’s tweets. This connection becomes bidirectional when two pharmacists mutually follow each other’s tweets. The NodeXL Excel plugin was used to extract the connections from pharmacists’ Twitter accounts, calculate pharmacists’ Twitter network metrics, and visually represent pharmacists’ connections to other pharmacists and centrality (reflecting popularity and leadership among other pharmacists) on Twitter. Results. Pharmacists’ characteristics and Twitter activity. A total of 623 pharmacists were identified, representing a sixfold increase from the 102 pharmacists identified in a previous analysis of 2009 data.22 The peak registration time of accounts for new pharmacists on
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Twitter (n = 52) was observed in March 2009 (Figure 1). Since the creation of the first pharmacist account in March 2007, identified pharmacists had collectively generated 1.3 million tweets. The mean ± S.D. frequency of status updates (i.e., tweets) per pharmacist was 3 ± 7 times per day, reaching a mean ± S.D. of 399 ± 1163 Twitter users who subscribed to receive their tweets (i.e., followers). Content analysis. Of the 204 pharmacist Twitter accounts identified, one third were randomly sampled for content evaluation: 57% (n = 115) were classified as exclusively social, 33% (n = 68) as predominantly social, 9% (n = 18) as predominantly professional, and 1% (n = 3) as exclusively professional. In addition, 54 accounts (26%) contained tweets inconsistent with the “Oath of a Pharmacist” or pharmacy’s “Code of Ethics” (i.e., unprofessional content). The recorded interrater reliability demonstrated good agreement (k, 0.67; 95% confidence interval, 0.59–0.75). Major themes that emerged from the qualitative analysis for the aggregated professional category (i.e., exclusively and predominantly professional) were the exchange of health information, insurance coverage, and job concerns. The primary theme that emerged from the aggregated social category (i.e., exclusively and predominantly social) was entertainment. Interconnections among pharmacists. The characteristics and interconnections of the identified pharmacist accounts are visualized in Figure 2. Most accounts had no incoming or outgoing connections with other pharmacists and therefore mainly shared day-to-day socially related tweets with their social circle. Some accounts had numerous connections (>50) to other pharmacists on Twitter and may represent the most influential and interconnected users in the pharmacist Twitter network. Influential pharmacist accounts were distributed in a bimodal nature between early adopters advocating the use of Twitter as a social and professional network and other pharmacists “venting” about daily job concerns that appear to resonate with pharmacy practitioners in the community setting.
Informatics Interchange
Source of tweets. Mobile devices were the most popular sources of tweets by identified pharmacists on Twitter. iPhone, Android, and Blackberry devices collectively contributed as the sources for 44% of pharmacists’ tweets. Twitter’s website was the second most popular source of tweets (24%), followed by desktop applications and other miscellaneous sources. The iPad alone was the source of only 3% of pharmacists’ tweets compared with 27% of tweets generated from iPhones. The iPhone was the primary source of tweeting by exclusively social and predominantly social accounts, while Twitter’s website was the primary source of publishing for exclusively professional and predominantly professional accounts. Discussion. Based on recent estimates, about 81% of the U.S. adult population uses the Internet and 13% of online adults use Twitter.15,23 In our survey, 623 pharmacists were identified on Twitter with account profiles written in English, a significant increase from the 102 pharmacists reported in 2009.22 This number (623) represents less than 1%
results of a recent survey by Kukreja et al.,12 who found that the majority of pharmacy preceptors were unwilling to use social media in professional practice. The nature of Twitter use in this study also reflected on the content of the tweet feed used by the two groups. Pharmacists using Twitter for social interactions published entertainment- or leisure-focused tweets representing day-to-day social interactions, while pharmacists using Twitter professionally published tweets largely divided into two categories: health information dissemination and job concerns. Health information dissemination tweets consisted of tweets about the latest drugs approved by the Food and Drug Administration as well as useful recent information published in scientific journals or pharmacy-related news. Job concern tweets consisted of criticism of pharmacists’ work conditions, mostly in retail settings, and routine patient insurance coverage issues facing pharmacists in practice. Notably, 26% of the accounts that underwent content analysis had published at least one tweet containing profane language or demonstrating other
of the estimated 282,000 employed U.S. pharmacists in 2012.24 Similar queries have identified about 700 emergency physicians on Twitter, which represented 1.6% of board-certified emergency physicians in the United States. The largest number of pharmacist accounts created on Twitter was in March 2009, a similar finding to the peak sign up of emergency physicians to Twitter in April 2009.11 This similarity can be related to the peak in Twitter popularity and growth noted in early 2009. In fact, despite launching in 2006, an estimated 73% of all Twitter users joined this social network in the first five months of 2009, but this percentage strikingly dropped thereafter.25,26 Based on these figures, pharmacists’ adoption of this social network seems to have followed a similar trend compared with the global Twitter user base. Ninety percent of the pharmacists whose accounts were randomly sampled used Twitter exclusively or predominantly for social interaction, with the remaining 10% using it exclusively or predominantly for professional interactions. This finding corresponds to the
Figure 1. Number of Twitter accounts created by pharmacists per month, March 2007–April 2012 (n = 623). 60
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unprofessional conduct (e.g., “Pt on cell phone at the counter picking up Xanax,” “I need a ride cuz I need to sell this ****,” “#drugdealsinthepharmacy”). The phenomenon of blog posting using critical language and the generation of negative impressions by pharmacists online was also detected by Cain and Dillon27 and Clauson et al.28 This is a common finding across blogging and microblogging platforms. This may also suggest that
pharmacists who previously maintained traditional blogs are adopting new social media to preserve or expand their follower base. While ASHP recently published a statement on the use of social media by pharmacists, advocating professional judgment and adherence to legal requirements and professional standards,29 it is vital to reiterate the significance of e-professionalism in the regulated practice environment.30
The predominance of Twitter use in the professional or social setting also reflected on the social network analysis of pharmacists’ accounts on Twitter. The majority of accounts (90%) that used Twitter for social interactions had no connections to other pharmacists and represented the outermost boundaries of the social network analysis. This group mainly connected with families, friends, and other users who may share similar
Figure 2. Representation of the nature of pharmacist Twitter accounts. Each sphere represents one pharmacist or account, with the color denoting the number of followers of the account (black = 0 followers, bright red = 48 followers). A green line connecting two spheres indicates that two pharmacists were following each other’s tweets, and a dark blue line indicates that the connection was unidirectional (i.e., only one user was following the other). Most of the accounts on the outer boundaries of the diagram represent those that had no incoming or outgoing connections with other pharmacists and therefore mainly shared day-to-day socially related tweets with their social circle. Accounts in the middle of the figure represented by red spheres had numerous connections (>50) to other pharmacists on Twitter.
Legend Pharmacist
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social interests. The second group consisted of highly influential pharmacist accounts, a virtual equivalent of key opinion leaders. This group had many followers among pharmacists and other less influential pharmacists with an intermediary role in this online social network. This group was the figurative and literal inner circle in Figure 2. The identification of pharmacists on Twitter was challenging, and numerous searching techniques were tested (e.g., Twitter search, snowball sampling combined with known lists of pharmacists on Twitter). Ultimately, the FollowerWonk tool provided the largest number of reliably consistent results; however, the use of this tool was dependent on descriptors in Twitter account biographies. Thus, some pharmacists using Twitter may not have been captured by the search strategies used; this is also complicated by the lack of a means to verify whether the accounts were actually pharmacist authored. Furthermore, since accounts with non-English tweets were excluded, results cannot be extrapolated to pharmacists using Twitter globally or pharmacists in the United States tweeting in more than one language. Further, only the latest 30 tweets of each account were extracted, which limited the pharmacist content extracted from Twitter solely in this cross-sectional time frame. Pharmacists may shift their use of Twitter based on environmental changes, including impact from surrounding colleagues as well as employer policies. Conclusion. Pharmacists’ use of Twitter was mainly socially driven to interact with other nonpharmacist users and share entertainment tweets. A small group of pharmacists used Twitter to create strong mutual connections, post profession-focused updates, share health-related information, or informally critique conditions of practice in the retail setting. 1. Madden M, Zickuhr K. 65% of online adults use social networking sites. http:// pewinternet.org/Reports/2011/SocialNetworking-Sites.aspx (accessed 2013 Aug 20). 2. Brenner J. Pew internet: social networ king . htt p://p ew inter ne t.org/
3.
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11. 12. 13. 14.
15.
16. 17.
18. 19.
Commentary/2012/March/Pew-InternetSocial-Networking-full-detail.aspx (accessed 2013 Nov 2). Visualscope. What is the difference b e twe en Tw itter and Fa ce b o ok? www.v isualscop e.com/tw itfb.ht ml (accessed 2013 Nov 2). Signorini A, Segre AM, Polgreen PM. The use of Twitter to track levels of disease activity and public concern in the U.S. during the influenza A H1N1 pandemic. PLoS One. 2011; 6:e19467. Scanfeld D, Scanfeld V, Larson EL. Dissemination of health information through social networks: Twitter and antibiotics. Am J Infect Control. 2010; 38:182-8. Greaves F, Ramirez-Cano D, Millett C et al. Harnessing the cloud of patient experience: using social media to detect poor quality healthcare. BMJ Qual Saf. 2013; 22:251-5. Neiger BL, Thackeray R, Burton SH et al. Evaluating social media’s capacity to develop engaged audiences in health promotion settings: use of Twitter as a case study. Health Promot Pract. 2012; 14:157-62. Bennett E. Health care social media list. http://network.socialmedia.mayo clinic.org/hcsml-grid (accessed 2013 Feb 5). Fox BI, Varadarajan R. Use of Twitter to encourage interaction in a multi-campus pharmacy management course. Am J Pharm Educ. 2011; 75:88. Bussières JF, Métras MÉ, Leclerc G. Use of Moodle, ExamSoft, and Twitter in a firstyear pharmacy course. Am J Pharm Educ. 2012; 76:94. Lulic I, Kovic I. Analysis of emergency physicians’ Twitter accounts. Emerg Med J. 2013; 30:371-6. Kukreja P, Heck Sheehan A, Riggins J. Use of social media by pharmacy preceptors. Am J Pharm Educ. 2011; 75:176. Alkhateeb FM, Clauson KA, Latif DA. Pharmacist use of social media. Int J Pharm Pract. 2011; 19:140-2. Shaw G. Pharmacists a-Twitter: is it time to ride this social media wave? www.phar ma cy pr a c t icenews.com/ PrintArticle.aspx?A_Id=22517&D_ Id=53&D=Operations+ (accessed 2013 Sep 30). Smith A. 13% of online adults use Twitter. www.pewinternet.org/~/media//Files/ Reports/2011/Twitter%20Update%20 2011.pdf (accessed 2013 Aug 20). SEOmoz. Twitter analytics: find, analyze, and optimize for social growth. http:// followerwonk.com (accessed 2013 Dec 2). Robillard JM, Johnson TW, Hennessey C et al. Aging 2.0: health information about dementia on Twitter. PLoS One. 2013; 8:e69861. Nielsbosma. SEOTools for Excel: real SEOs work in Excel! http://nielsbosma.se/ projects/seotools (accessed 2013 Dec 2). American Pharmacists Assosciation. Oath of a pharmacist. www.pharmacist.com/ oath-pharmacist (accessed 2013 Aug 20).
20. Creswell JW. Research design: qualitative, quantitative and mixed methods approaches. 2nd ed. Thousand Oaks, CA: Sage; 2003. 21. Patton MQ. Qualitative research and evaluation methods. 3rd ed. Newbury Park, CA: Sage; 1990. 22. Clauson KA, Ramos Y, Morejon Y, Hawker MD. Analysis of a national sample of pharmacist generated Twitter content. Poster presented at ASHP Midyear Clinical Meeting. Anaheim, CA; 2010 Dec 6. 23. Fox S. Pew internet: health. http://pew internet.org/Commentar y/2011/ November/Pew-Internet-Health.aspx (accessed 2013 Jan 4). 24. Bureau of Labor Statistics. Occupational employment statistics. 2012. www.bls.gov/ oes/current/oes291051.htm (accessed 2013 Aug 20). 25. Cheng A, Evans M. An in-depth look inside the Twitter world. www.sysomos.com/ insidetwitter (accessed 2013 Feb 4). 26. Seiple P. HubSpot releases third state of the Twittersphere report. www.hubspot.com/ blog/bid/5503/HubSp ot-ReleasesThird-State-of-the-Tw ittersphereReport-SOTwitter (accessed 2013 Feb 4). 27. Cain J, Dillon G. Analysis of pharmacycentric blogs: types, discourse themes, and issues. J Am Pharm Assoc. 2013; 50: 714-9. 28. Clauson KA, Ekins J, Goncz CE. Use of blogs by pharmacists. Am J Health-Syst Pharm. 2010; 67:2043-8. 29. American Society of Health-System Pharmacists. ASHP statement on use of social media by pharmacy professionals. www.ashp.org/DocLibrary/BestPractices/ AutoITStSocialMedia.aspx (accessed 2013 Aug 20). 30. Childs LM, Martin CY. Social media profiles: striking the right balance. Am J Health-Syst Pharm. 2012; 69:2044-7.
Zaher Hajar, Pharm.D., Fellow, Consumer Health Informatics College of Pharmacy [email protected] Kevin A. Clauson, Pharm.D., Associate Professor College of Pharmacy Robin J. Jacobs, Ph.D., M.S.W., Associate Professor College of Osteopathic Medicine Nova Southeastern University Fort Lauderdale, FL Adam Mitrani, Sandy Truong, Ivan Vila, and Yekatrina Melomed are acknowledged for their valuable efforts in data analysis.
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130307
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Informatics Interchange Analysis of pharmacists’ use of Twitter
T
he use of online social networks has grown rapidly in the past decade, as social media have become a vital interaction venue in our personal and professional lives.1 Despite Facebook’s ascension to the most popular social medium, Twitter has gained a niche for subject-specific communications.2,3 From detecting influenza outbreaks to exploring the misuse of antibiotics, Twitter has been used to gain insight into health information dissemination and communication.4,5 Twitter (www.twitter.com) is a microblogging online platform with which users can post messages (“tweets”) no longer than 140 characters that are accessible by any Twitter user as well as users who specifically “follow” them. Followers can “retweet” messages that they believe are noteworthy (similar to forwarding an e-mail) or reply (“@user”) to tweets, creating a relatively public online conversation. Users can also exchange private messages. Lists can be created to gather a “tweet feed” of users sharing common interests or characteristics. Unlike Facebook, privacy in Twitter is an all-or-none option; users elect to make their accounts either totally public or private. Twitter is the second most commonly used social media platform by hospitals in the United States and has been used by organizations to promote health and detect poor-quality health care.6-8 In addition, Twitter has been piloted in pharmacy education as a tool to actively engage students in the learning process.9,10 Although Twitter’s popularity has been growing, adoption has been variable among health care professionals. One study recently found 672 accounts
belonging to emergency physicians; 11 another study found that just 13 pharmacy preceptors acknowledged creating a Twitter account.12 Another study identified 12% of pharmacists from a single state as having a Twitter account.13 More broadly, American Society of HealthSystem Pharmacists (ASHP) surveys suggest that 25% of pharmacy students regularly use Twitter, 22% of new practitioners have an account, and only about 12% of pharmacists who have been in practice keep an active Twitter account,14 compared with 13% of the general population.15
While surveys may provide estimates of pharmacists’ use of Twitter, little is known about the actual number of pharmacists actively using Twitter, their usage characteristics, and their professional connections. A better understanding of the current role of pharmacists on
Twitter may provide guidance on the optimal use of this platform for the profession, benchmark its use by other health professionals, and highlight opportunities for impact. The purpose of this study was to identify the number of pharmacists with Twitter accounts, their usage characteristics, and their professional networking patterns. Methods. Account identification. Pharmacists’ Twitter accounts were identified by searching usernames and biographies for “pharmacist,” “R.Ph.,” and “Pharm.D.” using Twitter’s Web-based search and FollowerWonk service.16 This process identified 7470 accounts. Accounts were excluded if they had fewer than 100 tweets, their tweets were primarily not in English, the pharmacists were outside of the United States, or the account had no activity after 2011 (identification and extraction were initiated in July 2012). Advertising-focused (e.g., sales), industry, student pharmacist, and private accounts were also excluded. In all, 6847 accounts were excluded, leaving 623 remaining. Data extraction. Of the 623 pharmacist Twitter accounts eligible for analysis, 204 were sampled for content evaluation. This sample size, combined with an extraction of 30 tweets from each account, ensured content-analysis saturation and exceeded that used in similar research performed in this area.17 Microsoft Excel (Microsoft Corp., Redmond, WA) was
The Informatics Interchange column gives readers an opportunity to share their experiences with information technology in pharmacy. AJHP readers are invited to submit their experiences and pertinent lessons-learned related to pharmacy informatics. Topics should focus on the use of information technology in the medication-use process, informatics pearls, informatics education and research, and information technology management. Readers are invited to submit their ideas or articles for the column to [email protected] or ASHP, c/o Karl Gumpper at 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-657-3000).
Am J Health-Syst Pharm—Vol 71 Apr 15, 2014
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originally used to stratify accounts by level of activity for accurate representation of the variety of users and to conduct the stratified random-sampling process. FollowerWonk16 was used to extract the full name, biography, location, Web address of the profile, number of followers, number of friends, date of account creation, date of last tweet, and total number of tweets. The SEOTools Excel plugin was used to extract the 30 most recent tweets from each account.18 Investigators initially predicted an average of 1–2 tweets per pharmacist account per day, so the extraction of 30 tweets would represent about two weeks’ to one month’s activity per account. SEOTools provided the date, text, and source of each tweet as well as the retweet count for every extracted tweet. Quantitative analysis. Two blinded investigators evaluated the content of extracted tweets (n = 6120) and classified each account as (1) exclusively professional, (2) predominantly professional, (3) exclusively social, or (4) predominantly social. Accounts were defined as exclusive if all of the extracted tweets (30 of 30, 100%) were either social or professional in nature. Accounts were put in a “predominant” category when more than 50% but less than 100% of tweets were social or professional. Accounts containing tweets with language inconsistent with the “Oath of a Pharmacist”19 or “Code of Ethics” were also noted. Violations mainly consisted of profane language, criticism of patients’ behavior, narcissistic criticism of the employer, and similar content. Cohen’s kappa (k) was used to assess interrater concordance. Descriptive statistics were used to characterize results. Qualitative analysis. Qualitative data were analyzed using both phenomenological and narrative frameworks,20,21 which allowed for patterns, themes, and categories to emerge. These categories involved a hierarchical set of constructs that accounted for the phenomena in the data. Once themes were created by investigators (i.e., professional, social), successive levels of qualitative analyses were conducted. First, descriptive analyses
616
focused on developing an understanding of participants’ messages and the reasons they were posted. A thematic analysis focused on elaborating the structures of the basic study. Additional constructs were added to the constructs that arose in the early phases of analysis. Data were reviewed and relevant ideas identified. Next, concepts were divided into the various subcomponents of the themes. This stage of the analysis consisted of reexamining the data for consistency within each concept. A comparative analysis was also conducted to clarify differences in the use of Twitter among pharmacists (i.e., social or professional). After understanding concepts as presented by individuals, the analyses were then extended across similar individuals, and comparisons were made across groups of people who shared potentially significant characteristics. Once the conceptual scheme was suitably differentiated, the quantitative and qualitative data were integrated to lay the foundation for constructing a report of the findings. This process involved reexamining the results of all the preceding analyses to create conceptual understandings of the Twitter communication experiences of pharmacists in the sample. Visualization and social network analysis. Unlike other social media, Twitter’s social network relationships are directional. The connection between accounts is unidirectional when one pharmacist only follows another pharmacist’s tweets. This connection becomes bidirectional when two pharmacists mutually follow each other’s tweets. The NodeXL Excel plugin was used to extract the connections from pharmacists’ Twitter accounts, calculate pharmacists’ Twitter network metrics, and visually represent pharmacists’ connections to other pharmacists and centrality (reflecting popularity and leadership among other pharmacists) on Twitter. Results. Pharmacists’ characteristics and Twitter activity. A total of 623 pharmacists were identified, representing a sixfold increase from the 102 pharmacists identified in a previous analysis of 2009 data.22 The peak registration time of accounts for new pharmacists on
Am J Health-Syst Pharm—Vol 71 Apr 15, 2014
Twitter (n = 52) was observed in March 2009 (Figure 1). Since the creation of the first pharmacist account in March 2007, identified pharmacists had collectively generated 1.3 million tweets. The mean ± S.D. frequency of status updates (i.e., tweets) per pharmacist was 3 ± 7 times per day, reaching a mean ± S.D. of 399 ± 1163 Twitter users who subscribed to receive their tweets (i.e., followers). Content analysis. Of the 204 pharmacist Twitter accounts identified, one third were randomly sampled for content evaluation: 57% (n = 115) were classified as exclusively social, 33% (n = 68) as predominantly social, 9% (n = 18) as predominantly professional, and 1% (n = 3) as exclusively professional. In addition, 54 accounts (26%) contained tweets inconsistent with the “Oath of a Pharmacist” or pharmacy’s “Code of Ethics” (i.e., unprofessional content). The recorded interrater reliability demonstrated good agreement (k, 0.67; 95% confidence interval, 0.59–0.75). Major themes that emerged from the qualitative analysis for the aggregated professional category (i.e., exclusively and predominantly professional) were the exchange of health information, insurance coverage, and job concerns. The primary theme that emerged from the aggregated social category (i.e., exclusively and predominantly social) was entertainment. Interconnections among pharmacists. The characteristics and interconnections of the identified pharmacist accounts are visualized in Figure 2. Most accounts had no incoming or outgoing connections with other pharmacists and therefore mainly shared day-to-day socially related tweets with their social circle. Some accounts had numerous connections (>50) to other pharmacists on Twitter and may represent the most influential and interconnected users in the pharmacist Twitter network. Influential pharmacist accounts were distributed in a bimodal nature between early adopters advocating the use of Twitter as a social and professional network and other pharmacists “venting” about daily job concerns that appear to resonate with pharmacy practitioners in the community setting.
Informatics Interchange
Source of tweets. Mobile devices were the most popular sources of tweets by identified pharmacists on Twitter. iPhone, Android, and Blackberry devices collectively contributed as the sources for 44% of pharmacists’ tweets. Twitter’s website was the second most popular source of tweets (24%), followed by desktop applications and other miscellaneous sources. The iPad alone was the source of only 3% of pharmacists’ tweets compared with 27% of tweets generated from iPhones. The iPhone was the primary source of tweeting by exclusively social and predominantly social accounts, while Twitter’s website was the primary source of publishing for exclusively professional and predominantly professional accounts. Discussion. Based on recent estimates, about 81% of the U.S. adult population uses the Internet and 13% of online adults use Twitter.15,23 In our survey, 623 pharmacists were identified on Twitter with account profiles written in English, a significant increase from the 102 pharmacists reported in 2009.22 This number (623) represents less than 1%
results of a recent survey by Kukreja et al.,12 who found that the majority of pharmacy preceptors were unwilling to use social media in professional practice. The nature of Twitter use in this study also reflected on the content of the tweet feed used by the two groups. Pharmacists using Twitter for social interactions published entertainment- or leisure-focused tweets representing day-to-day social interactions, while pharmacists using Twitter professionally published tweets largely divided into two categories: health information dissemination and job concerns. Health information dissemination tweets consisted of tweets about the latest drugs approved by the Food and Drug Administration as well as useful recent information published in scientific journals or pharmacy-related news. Job concern tweets consisted of criticism of pharmacists’ work conditions, mostly in retail settings, and routine patient insurance coverage issues facing pharmacists in practice. Notably, 26% of the accounts that underwent content analysis had published at least one tweet containing profane language or demonstrating other
of the estimated 282,000 employed U.S. pharmacists in 2012.24 Similar queries have identified about 700 emergency physicians on Twitter, which represented 1.6% of board-certified emergency physicians in the United States. The largest number of pharmacist accounts created on Twitter was in March 2009, a similar finding to the peak sign up of emergency physicians to Twitter in April 2009.11 This similarity can be related to the peak in Twitter popularity and growth noted in early 2009. In fact, despite launching in 2006, an estimated 73% of all Twitter users joined this social network in the first five months of 2009, but this percentage strikingly dropped thereafter.25,26 Based on these figures, pharmacists’ adoption of this social network seems to have followed a similar trend compared with the global Twitter user base. Ninety percent of the pharmacists whose accounts were randomly sampled used Twitter exclusively or predominantly for social interaction, with the remaining 10% using it exclusively or predominantly for professional interactions. This finding corresponds to the
Figure 1. Number of Twitter accounts created by pharmacists per month, March 2007–April 2012 (n = 623). 60
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unprofessional conduct (e.g., “Pt on cell phone at the counter picking up Xanax,” “I need a ride cuz I need to sell this ****,” “#drugdealsinthepharmacy”). The phenomenon of blog posting using critical language and the generation of negative impressions by pharmacists online was also detected by Cain and Dillon27 and Clauson et al.28 This is a common finding across blogging and microblogging platforms. This may also suggest that
pharmacists who previously maintained traditional blogs are adopting new social media to preserve or expand their follower base. While ASHP recently published a statement on the use of social media by pharmacists, advocating professional judgment and adherence to legal requirements and professional standards,29 it is vital to reiterate the significance of e-professionalism in the regulated practice environment.30
The predominance of Twitter use in the professional or social setting also reflected on the social network analysis of pharmacists’ accounts on Twitter. The majority of accounts (90%) that used Twitter for social interactions had no connections to other pharmacists and represented the outermost boundaries of the social network analysis. This group mainly connected with families, friends, and other users who may share similar
Figure 2. Representation of the nature of pharmacist Twitter accounts. Each sphere represents one pharmacist or account, with the color denoting the number of followers of the account (black = 0 followers, bright red = 48 followers). A green line connecting two spheres indicates that two pharmacists were following each other’s tweets, and a dark blue line indicates that the connection was unidirectional (i.e., only one user was following the other). Most of the accounts on the outer boundaries of the diagram represent those that had no incoming or outgoing connections with other pharmacists and therefore mainly shared day-to-day socially related tweets with their social circle. Accounts in the middle of the figure represented by red spheres had numerous connections (>50) to other pharmacists on Twitter.
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social interests. The second group consisted of highly influential pharmacist accounts, a virtual equivalent of key opinion leaders. This group had many followers among pharmacists and other less influential pharmacists with an intermediary role in this online social network. This group was the figurative and literal inner circle in Figure 2. The identification of pharmacists on Twitter was challenging, and numerous searching techniques were tested (e.g., Twitter search, snowball sampling combined with known lists of pharmacists on Twitter). Ultimately, the FollowerWonk tool provided the largest number of reliably consistent results; however, the use of this tool was dependent on descriptors in Twitter account biographies. Thus, some pharmacists using Twitter may not have been captured by the search strategies used; this is also complicated by the lack of a means to verify whether the accounts were actually pharmacist authored. Furthermore, since accounts with non-English tweets were excluded, results cannot be extrapolated to pharmacists using Twitter globally or pharmacists in the United States tweeting in more than one language. Further, only the latest 30 tweets of each account were extracted, which limited the pharmacist content extracted from Twitter solely in this cross-sectional time frame. Pharmacists may shift their use of Twitter based on environmental changes, including impact from surrounding colleagues as well as employer policies. Conclusion. Pharmacists’ use of Twitter was mainly socially driven to interact with other nonpharmacist users and share entertainment tweets. A small group of pharmacists used Twitter to create strong mutual connections, post profession-focused updates, share health-related information, or informally critique conditions of practice in the retail setting. 1. Madden M, Zickuhr K. 65% of online adults use social networking sites. http:// pewinternet.org/Reports/2011/SocialNetworking-Sites.aspx (accessed 2013 Aug 20). 2. Brenner J. Pew internet: social networ king . htt p://p ew inter ne t.org/
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Commentary/2012/March/Pew-InternetSocial-Networking-full-detail.aspx (accessed 2013 Nov 2). Visualscope. What is the difference b e twe en Tw itter and Fa ce b o ok? www.v isualscop e.com/tw itfb.ht ml (accessed 2013 Nov 2). Signorini A, Segre AM, Polgreen PM. The use of Twitter to track levels of disease activity and public concern in the U.S. during the influenza A H1N1 pandemic. PLoS One. 2011; 6:e19467. Scanfeld D, Scanfeld V, Larson EL. Dissemination of health information through social networks: Twitter and antibiotics. Am J Infect Control. 2010; 38:182-8. Greaves F, Ramirez-Cano D, Millett C et al. Harnessing the cloud of patient experience: using social media to detect poor quality healthcare. BMJ Qual Saf. 2013; 22:251-5. Neiger BL, Thackeray R, Burton SH et al. Evaluating social media’s capacity to develop engaged audiences in health promotion settings: use of Twitter as a case study. Health Promot Pract. 2012; 14:157-62. Bennett E. Health care social media list. http://network.socialmedia.mayo clinic.org/hcsml-grid (accessed 2013 Feb 5). Fox BI, Varadarajan R. Use of Twitter to encourage interaction in a multi-campus pharmacy management course. Am J Pharm Educ. 2011; 75:88. Bussières JF, Métras MÉ, Leclerc G. Use of Moodle, ExamSoft, and Twitter in a firstyear pharmacy course. Am J Pharm Educ. 2012; 76:94. Lulic I, Kovic I. Analysis of emergency physicians’ Twitter accounts. Emerg Med J. 2013; 30:371-6. Kukreja P, Heck Sheehan A, Riggins J. Use of social media by pharmacy preceptors. Am J Pharm Educ. 2011; 75:176. Alkhateeb FM, Clauson KA, Latif DA. Pharmacist use of social media. Int J Pharm Pract. 2011; 19:140-2. Shaw G. Pharmacists a-Twitter: is it time to ride this social media wave? www.phar ma cy pr a c t icenews.com/ PrintArticle.aspx?A_Id=22517&D_ Id=53&D=Operations+ (accessed 2013 Sep 30). Smith A. 13% of online adults use Twitter. www.pewinternet.org/~/media//Files/ Reports/2011/Twitter%20Update%20 2011.pdf (accessed 2013 Aug 20). SEOmoz. Twitter analytics: find, analyze, and optimize for social growth. http:// followerwonk.com (accessed 2013 Dec 2). Robillard JM, Johnson TW, Hennessey C et al. Aging 2.0: health information about dementia on Twitter. PLoS One. 2013; 8:e69861. Nielsbosma. SEOTools for Excel: real SEOs work in Excel! http://nielsbosma.se/ projects/seotools (accessed 2013 Dec 2). American Pharmacists Assosciation. Oath of a pharmacist. www.pharmacist.com/ oath-pharmacist (accessed 2013 Aug 20).
20. Creswell JW. Research design: qualitative, quantitative and mixed methods approaches. 2nd ed. Thousand Oaks, CA: Sage; 2003. 21. Patton MQ. Qualitative research and evaluation methods. 3rd ed. Newbury Park, CA: Sage; 1990. 22. Clauson KA, Ramos Y, Morejon Y, Hawker MD. Analysis of a national sample of pharmacist generated Twitter content. Poster presented at ASHP Midyear Clinical Meeting. Anaheim, CA; 2010 Dec 6. 23. Fox S. Pew internet: health. http://pew internet.org/Commentar y/2011/ November/Pew-Internet-Health.aspx (accessed 2013 Jan 4). 24. Bureau of Labor Statistics. Occupational employment statistics. 2012. www.bls.gov/ oes/current/oes291051.htm (accessed 2013 Aug 20). 25. Cheng A, Evans M. An in-depth look inside the Twitter world. www.sysomos.com/ insidetwitter (accessed 2013 Feb 4). 26. Seiple P. HubSpot releases third state of the Twittersphere report. www.hubspot.com/ blog/bid/5503/HubSp ot-ReleasesThird-State-of-the-Tw ittersphereReport-SOTwitter (accessed 2013 Feb 4). 27. Cain J, Dillon G. Analysis of pharmacycentric blogs: types, discourse themes, and issues. J Am Pharm Assoc. 2013; 50: 714-9. 28. Clauson KA, Ekins J, Goncz CE. Use of blogs by pharmacists. Am J Health-Syst Pharm. 2010; 67:2043-8. 29. American Society of Health-System Pharmacists. ASHP statement on use of social media by pharmacy professionals. www.ashp.org/DocLibrary/BestPractices/ AutoITStSocialMedia.aspx (accessed 2013 Aug 20). 30. Childs LM, Martin CY. Social media profiles: striking the right balance. Am J Health-Syst Pharm. 2012; 69:2044-7.
Zaher Hajar, Pharm.D., Fellow, Consumer Health Informatics College of Pharmacy [email protected] Kevin A. Clauson, Pharm.D., Associate Professor College of Pharmacy Robin J. Jacobs, Ph.D., M.S.W., Associate Professor College of Osteopathic Medicine Nova Southeastern University Fort Lauderdale, FL Adam Mitrani, Sandy Truong, Ivan Vila, and Yekatrina Melomed are acknowledged for their valuable efforts in data analysis.
The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp130307
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