CHEST
Topics in Practice Management
The Intelligent Use of Digital Tools and Social Media in Practice Management Christopher L. Carroll, MD, FCCP; and Pradeep Ramachandran, MBBS
The Internet has fundamentally transformed the way patients and health-care providers communicate and interact. The use of digital tools and social media platforms, such as blogs, Facebook, Instagram, and Twitter, have empowered patients to expand their health-care knowledge and have provided practitioners with new ways to gain knowledge, lead discussions, promote causes, and build relationships with patients and other providers. In this article, we discuss the difference between digital communication, static one-way digital presence, and two-way social media connections. We also describe ways to establish and foster your digital profile, review the benefits and risks of engaging professionally in social media, and describe ways in which digital and social media tools may prove useful in both reimbursement and practice management. CHEST 2014; 145(4):896–902
has fundamentally transformed the way TheweInternet communicate and interact. More of us spend
significant amounts of time immersed online through tools such as blogs, Facebook, Instagram, and Twitter.1-3 According to a recent Nielsen survey, . 8 billion h/y are spent online just in the United States, an increase of 21% from July 2011 to July 2012.1 Both patients and practitioners have increasingly adopted digital communication and social media in their interactions.3,4 Health-care social media usage is increasing independent of education, race, ethnicity, or access to health care.3 Consumers are using social media to inform their health-care decisions, to network with other patients, and to find information about providers.3 More than one-half of all consumers will look into a provider online prior to engaging in person,1 and in a survey of 1,000 patients regarding social media and health care, . 70% want the opportunity to use social media as a tool to manage their health.5 Eightyfive percent of patients in the United States believe
Manuscript received February 1, 2013; revision accepted August 7, 2013. Affiliations: From the Connecticut Children’s Medical Center (Dr Carroll), University of Connecticut, Hartford, CT; and Genesys Regional Medical Center (Dr Ramachandran), Grand Blanc, MI. Correspondence to: Christopher L. Carroll, MD, FCCP, 282 Washington St, Hartford, CT 06106; e-mail: ccarrol@ connecticutchildrens.org © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-0251 896
that digital communication, such as e-mail, text messages, and voicemails, are as helpful, if not more helpful, than in-person or phone conversations with their health-care provider.6 Health-care practitioners have also begun to cautiously adopt these tools in their practice. Practitioners are using social media to open new ways to interact with patients and to provide additional opportunities for customer service and support. For example, Boston Children’s Hospital refers prospective patients to disease-specific support groups to learn firsthand from other families how they treat chronic disease.5 There are other sites, such as PatientsLikeMe.com, which connects . 140,000 patients with others who share chronic diseases, improving engagement and patient education.5 At Texas Health Resources, a network of 25 hospitals has adopted a social media strategy that engages patients through education and development of affinity groups, and taps into the expertise of staff and patients to solve problems within the hospital system.5 Digital tools also have the potential to improve practice efficiency and reduce administrative costs and to improve a health-care practitioner’s communication with other providers, with a level of speed and convenience that has the potential to transform how providers coordinate complex medical care.1,2,5,6 There are several types of online platforms and digital tools. Frequently there is overlap between these terms, but some categories can still be defined. First, there are digital communication tools, such as e-mail Topics in Practice Management
and text messaging, which are used to speed direct communication between known individuals. Digital communication tools are most well known and widely adopted. Second, there are digital profiles that are used to provide a source of information on a particular issue, service, or provider. Examples of digital profiles include a practice webpage or a physician online profile. Digital profiles typically are used for one-way communication (practitioner to patient), although interactive tools can be added. The third type of platform is social media tools. These tools, such as blogs, Facebook, Instagram, and Twitter, have a more open-ended audience that can provide bidirectional exchange of information (Figs 1, 2). Initially these were popularized for their social purposes (hence, the term “social media”), but they are being increasingly used for professional and advocacy purposes as well as for more serious forms of digital communication. In this article, we review the concepts of digital profiles and social media and the benefits and risks of these platforms and provide readers with a basic understanding of how to incorporate these tools into their practice. We also discuss changes in reimbursement and how the changes may affect or facilitate communications between patients and providers.
Establishing a Digital Profile As a health-care practitioner, an online presence is crucial for your professional reputation and for pre-
senting yourself to patients. One-third of US consumers are using social media to find medical information, research and share their symptoms, and offer opinions about doctors and treatments.5 Now, more than at any other time, patients have access, literally at their fingertips, to a much wider source of information, not only regarding diseases, treatments, and outcomes but also regarding health-care providers. If practitioners do not take an active role digitally, they are missing the opportunity to shape their online presence and reputation. This digital presence or “footprint” is increasingly the face that practitioners present to the outside world, and it provides an opportunity to change how we interact with both patients and other practitioners, potentially transforming how health care is provided and coordinated. A central part of a practitioner’s digital profile is the practice website. A website provides practitioners an opportunity to provide direct information about themselves and their practice. It is, therefore, important that they consider incorporating their practice website into a larger digital strategy. A website also provides a platform for physicians to provide reliable sources of information to patients and provide links to trusted information sites. Just as importantly, it can serve to repudiate biased, slanted, or false information. The Internet is filled with inaccurate information, and without leadership from health-care providers, charlatans and snake oil cures can flourish more easily. A website with up-to-date, carefully curated content can help better educate your patients and your community.
Figure 1. Twitter homepage of one of the authors accessed through mobile app. journal.publications.chestnet.org
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Figure 2. Facebook home profile page of the American College of Chest Physicians.
Before launching a digital profile, practitioners should consider how they would like to interact online. A good place to start is with a self-audit of your online presence by entering your name (or that of your organization) into a search engine. This process, also referred to as “googling,” can provide an overview of the depth and reach of one’s online presence as well as potential problem areas, such as negative reviews or inaccurate information.7 This information, in turn, can guide your digital strategy and help determine what kind of tools you may want to use, including whether to use one-way or two-way forms of communication. Websites, physician profiles, and blogs can either be a oneway communication tool, where practitioners post and do not receive feedback, or a bidirectional exchange of ideas. Both have advantages and disadvantages. A oneway platform is easier to maintain and can still provide a significant amount of information and exposure. However, two-way communication can be established through inclusion of a comment section or through linking to social media. This has the benefit of providing greater interaction.
Using Social Media to Compliment Your Digital Profile Social media has also become an important tool for online communication. Practitioners can keep abreast 898
of the latest research, learn from the knowledge and experience of other providers, advocate for causes, provide customer service, and potentially improve the care we give to patients by building on the practitionerpatient relationship. Social media tools are being increasingly used by consumers to communicate with the services they use. Almost one-half of all US consumers have reached out directly to businesses to express satisfaction or complaints with service.1 It would be reasonable to conclude that health-care services will also be subject to this phenomenon. The use of online reviews has become an important medium for customers to provide feedback and voice complaints. Consumers currently use online reviews to make choices about all manner of services, including physicians. It is, therefore, important for practitioners to foster their online identities by encouraging patients to provide online reviews to mitigate the effect that a lone negative review could render. Although encouraging patients to provide online reviews may raise concerns about generating negative content, a study by Lagu et al7 actually found that 88% of online physician ratings were positive. Additionally, by referring patients to the rating websites that are in the first page of a Google search, practitioners can effectively exert some degree of control over their digital footprint. The first step in establishing a social media presence is to choose a format for your online profile. To determine this, practitioners need to consider their Topics in Practice Management
goals prior to participating in social media. Examples might include promoting their practice or themselves or advocating for a particular cause or issue. Providers should never use their personal accounts for these pursuits, as this may blur provider-patient boundaries. The identity, which will typically be a practitioner’s name or organization, can then be registered at various social media outlets, such as Twitter, Facebook, and LinkedIn. However, different platforms are better suited for different types of goals. For example, advocating for a cause is best done through Twitter or a blog, but promoting a practice is done most effectively using Twitter, Facebook, or a website. In any case, this online identity should be dedicated toward the promotion of the entity or person for which it was created, and not used for personal purposes. A provider should initially try to pick a single platform with which to become comfortable posting professionally and as an engagement tool. Then consider using sharing or cross-posting applications, such as Tweetdeck or Buffer, to expand posting to other social media platforms. Additionally, budgeting time is also important, since like any tool, social media can be used incorrectly and in a way that reduces overall efficiency. Once a practitioner’s professional social media identity is established, he or she should post regular, focused posts that current and future patients might find useful, being mindful to stay within the boundaries of professionalism. Blogging is another social media format that practitioners can use to communicate and enhance their digital profile. A blog (web log) is a site where individuals post original articles on related topics to a dedicated webpage. Although the discussion of establishing and maintaining a blog are beyond the scope of this article, there are a few caveats practitioners need to consider before establishing a blog. First, an individual should have an interest in writing, to create content that is compelling to readers. Second, to keep readers engaged, a blog should have regular posts. This requires a significant commitment of time that needs to be set aside, which many in the medical field may not have. Third, as with other aspects of social media, practitioners should remember to maintain standards of professionalism when posting online. Once practitioners have determined their digital strategy and have become comfortable with using social media tools for professional purposes, they should consider connecting these sites with their practice website. Social media sites such as Facebook and Twitter have tools that allow users to easily incorporate them into a practice website. These can take various different forms; from a Facebook “like” icon to a running feed showing the practitioner’s most recent posts at a connected social media site (Fig 3). The inclusion of these social media tools into the practitioner’s practice website generates opportunity for greater patient educajournal.publications.chestnet.org
tion as well as greater patient engagement with the practitioner. In addition to enhancing one’s digital profile, social media also has the potential to expand and improve communication between health-care providers. The global nature of digital media enables a provider to have access to a significantly wider world of knowledge and experience. This broader scope enables a provider to better collaborate and connect with others. Additionally, the diversity of experiences online allows practitioners to solve problems and acquire knowledge through “crowdsourcing” (ie, distributed problem solving). An example would be the use of social media to keep abreast of the latest scientific innovations and publications by following thought leaders and medical journals on social media platforms. There are also relatively protected forums, such as Sermo or the American College of Chest Physicians’ e-community portal, where members of a community can discuss medical controversies and the current literature more freely. Using these strategies, social media can potentially improve a health-care practitioner’s efficiency and also potentially improve effectiveness in the delivery of patient care.
Potential Risks of Social Media The use of social media, however, is not without risk, and a practitioner needs to be cognizant of these risks prior to joining the online community. First and foremost, a practitioner’s professionalism must be maintained on the Internet.8,9 A positive digital footprint can improve your professional persona and reputation, but, just as easily, actions taken online can negatively impact reputations and medical careers.10 Although there is the illusion of anonymity online, it is rarely possible to stay completely anonymous for long. Practitioners should be aware that what they do on Facebook, Twitter, and other social networking sites should be considered public and that patients, colleagues, and employers can potentially view everything they post. Second, maintaining standards of confidentiality and appropriate boundaries of the physician-patient relationship is critical. In a published survey of 485 health-care providers, 94% of medical students, 79% of residents, and 42% of attending physicians used online social media.2 Of this cohort, almost one-third reported patient-doctor interaction online, including “friend requests” from patients or family members of patients. Practitioners need to be aware of the importance of maintaining these boundaries and limit professional interaction with patients to those accounts that were created for professional interaction. However, it should be stressed that even in one’s professional social media platforms, practitioners are required to CHEST / 145 / 4 / APRIL 2014
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Figure 3. Caduceusblog.com, home page of the blog of one of the authors.
keep health-care information protected. Confidential and protected health information should never be discussed in a potentially public social media setting. Whether such communications take the form of seemingly innocuous “elevator talk” of anecdotal cases, or patient-initiated communications, providers should be aware that the information may be visible to thousands of people, and discussing it in public forums would not be consistent with standards of professionalism. Should a physician have a case that he wishes to discuss with other practitioners, the use of secured forums for practitioner-to-practitioner communication (such as the American College of Chest Physicians e-communities) is recommended. If a patient does initiate a health-related discussion in a public forum, a provider should move that dialogue either off-line or to a more protected digital platform where the discussion can be conducted confidentially. Additionally, wherever digital means are used for patient communication, clear guidelines should be established so that patients, providers, and office staff have similar expectations for how and when this mode of communication is appropriate.11 Within a practice, individual providers may differ in how they communicate digitally with patients; however, some basic statements can help clarify, define, and standardize use (Table 1). Office staff members can also be delegated to help distribute digital communication to the appropriate staff, further streamlining this communication. Practitioners should also be aware that as patients engage with medical practices through social media outlets they will have an expectation of a timely response.5 Therefore, personnel should be designated to respond to comments or questions that come through these forums. 900
Additionally, practitioners should be aware of liability issues when commenting on public forums or offering medical advice online. This is particularly true when commenting on issues directly related to a particular patient or medical case. Many providers include caveats such as “not intended to provide medical advice” in their online profiles to help mitigate this liability. This practice may not provide protection against liability issues, although the inclusion of such warnings may reduce the likelihood that patients interpret any specific comment as advice for their particular medical case. Physicians should be aware that any specific Table 1—Suggestions of Statements to Include in Guidelines for Digital Communication With Patients Suggested Statements Statement that digital communication should not be used for urgent matters List of the types of messages that are accepted (scheduling, prescription refills) Expectation of time to response Statement of who besides physicians will read and respond to messages Description of security and privacy measures taken to protect confidential patient information Statement of specific information that patient should include in subject line so that the message can be routed to the correct staff member Statement that an office visit will be scheduled by the staff if the medical question is too complex or sensitive to discuss electronically Statement that all communication will be included in patient record Statement that overuse of digital communication by a particular patient may result in that patient losing digital communication privileges
Topics in Practice Management
advice given online to an individual may be construed as constituting a patient-doctor relationship and may carry additional responsibility. Another risk of social media is not being online to protect and defend your own reputation and interests. Fortunately, or unfortunately, the social media movement is not going away and is significantly affecting the practice and business of medicine. More people are using these digital tools, and there is a risk to your business and your brand to not participating. The relative anonymity of the internet can encourage negativity, particularly in those who feel that they have not had appropriate customer service. Not participating can also put a practitioner’s reputation at risk by not being there to defend issues or concerns that arise. Roles of Digital Communication and Social Media in Practice Management Beyond some of the more intangible benefits to social media involvement, there are significant tangible benefits to the increased use of digital communication in practice management, revolving around the coordination of care of patients with complex medical illnesses. Several factors, including increasing subspecialization, increasing illness complexity, and an aging population, have contributed to the development of a patient population that requires increased amounts of coordination of care and communication, both with patients and with practitioners of other medical specialties. Better coordination and transitioning of care provided to these medically complex patients have the potential to improve outcomes and reduce costs. Changes in the health-care landscape will likely create a much larger role for digital communication in the management of such patients. Novel systems of care, such as accountable care organizations and patientcentered medical homes, are being developed that place greater emphasis on communication, coordination, and quality outcomes and less emphasis on the current feefor-service model.12 Such systems would naturally encourage practitioners to develop systems of communication that harness interaction via digital means, which would be less time consuming (and less expensive) than telephonic or face-to-face interactions. Beginning this year, new Current Procedural Terminology codes have been developed that encourage non-face-to-face coordination of care. Specifically, Medicare will now reimburse physicians involved in primary care, reporting codes 99495 or 99496, for non-face-to-face time spent in transitioning patients from the inpatient to outpatient settings.13 Among the requirements for reimbursement of the transitional care management code is that telephonic, in-person, or digital communication be established within 2 busijournal.publications.chestnet.org
ness days of discharge. A face-to-face visit is also required within 7 to 14 days of discharge, which is bundled into the transitional care management code. Current Procedural Terminology codes have also been created for complex care coordination, although Medicare is not yet separately reimbursing for this service. These codes show that payers understand that cognitive time spent in managing and coordinating care is often as important as face-to-face time. This is a revolutionary step forward in the practice of medicine and could potentially spur significant changes in how patient care is managed and coordinated. The movement away from fee-for-service would encourage medical systems to increase efficiencies in coordination and management of care among providers and communication with patients. Risk sharing capitated models such accountable care organizations inherently encourage medical systems to reduce cost by increasing efficiency and reducing unnecessary procedures and office visits. One can imagine that digital communication would be a centerpiece of such an effort. From video conference patient-provider visits, to delivering results via protected digital platforms, to smartphone apps that allow practitioners and patients to exchange information, the possible applications of secure systems of communication would be limited only by the imagination and creativity of the involved medical systems. Conclusions In this article, we have endeavored to provide practitioners an introduction to using and integrating social media tools in their practice. Social media and digital communication are dramatically changing the way patients and health-care providers communicate and interact. These tools have empowered patients to expand their health-care knowledge and have provided practitioners with new ways to gain knowledge, lead discussions, promote causes, and build relationships with patients and other providers. However, there are risks to being involved in this digital forum, and practitioners should be aware of basic rules of professionalism prior to going online. However, practitioners should be aware that even if they are not active online, they may be discussed without their knowledge, and by being online they can protect their digital and real-world reputations. Additionally, digital tools have the potential to improve office administrative efficiency and reduce costs. Changes in reimbursement for non-face-to-face services may further spur these changes. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any CHEST / 145 / 4 / APRIL 2014
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companies/organizations whose products or services may be discussed in this article. 7.
References 1. State of the media: the social media report 2012. The Nielson Company website. http://www.nielsen.com/us/en/insights/ reports-downloads/2012/state-of-the-media-the-social-mediareport-2012.html. Accessed April 2013. 2. Bosslet GT, Torke AM, Hickman SE, Terry CL, Helft PR. The patient-doctor relationship and online social networks: results of a national survey. J Gen Intern Med. 2011;26(10): 1168-1174. 3. Chou WY, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social media use in the United States: implications for health communication. J Med Internet Res. 2009;11(4):e48. 4. Hawn C. Take two aspirin and tweet me in the morning: how Twitter, Facebook, and other social media are reshaping health care. Health Aff (Millwood). 2009;28(2):361-368. 5. Health Research Institute. HRI social media consumer survey, 2012. PricewaterhouseCoopers LLP website. http://www. pwc.com/us/en/health-industries/publications/health-caresocial-media.jhtml. Accessed April 2013. 6. Televox. Technology beyond the exam room: how digital media is helping doctors deliver the highest level of care. Jones Public Relations website. http://www.jonespr.net/TeleVox/
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8.
9. 10.
11.
12. 13.
TVX-TechnologyBeyondExam(Screen).pdf. October 2012. Accessed April 2013. Lagu T, Hannon NS, Rothberg MB, Lindenauer PK. Patients’ evaluations of health care providers in the era of social networking: an analysis of physician-rating websites. J Gen Intern Med. 2010;25(9):942-946. Professionalism in the use of social media. American Medical Association website. http://www.ama-assn.org/ama/pub/physicianresources/medical-ethics/code-medical-ethics/opinion9124. page. Accessed April 2013. Greysen SR, Johnson D, Kind T, et al. Online professionalism investigations by state medical boards: first, do no harm. Ann Intern Med. 2013;158(2):124-130. Bruno, Kristi (@kristibruno). Every employee is an #ambassador for the #brand- whether positive or negative, online or IRL. http://twitter.com/kristibruno. Posted January 22, 2013. Communicating with patients electronically. American College of Physicians website. http://www.acponline.org/running_ practice/technology/comm_electronic.pdf. August 2008. Accessed April 2013. Lansey D. Transitional care management services change in 2013. ACP Internist. January 2013. http://www.acpinternist. org/archives/2013/01/coding.htm. Accessed April 2013. Payments to primary care physicians increase in 2013. Centers for Medicare & Medicaid Services website. http://go.cms. gov/UlKaJY. November 1, 2012. Accessed April 2013.
Topics in Practice Management
Topics in Practice Management
The Intelligent Use of Digital Tools and Social Media in Practice Management Christopher L. Carroll, MD, FCCP; and Pradeep Ramachandran, MBBS
The Internet has fundamentally transformed the way patients and health-care providers communicate and interact. The use of digital tools and social media platforms, such as blogs, Facebook, Instagram, and Twitter, have empowered patients to expand their health-care knowledge and have provided practitioners with new ways to gain knowledge, lead discussions, promote causes, and build relationships with patients and other providers. In this article, we discuss the difference between digital communication, static one-way digital presence, and two-way social media connections. We also describe ways to establish and foster your digital profile, review the benefits and risks of engaging professionally in social media, and describe ways in which digital and social media tools may prove useful in both reimbursement and practice management. CHEST 2014; 145(4):896–902
has fundamentally transformed the way TheweInternet communicate and interact. More of us spend
significant amounts of time immersed online through tools such as blogs, Facebook, Instagram, and Twitter.1-3 According to a recent Nielsen survey, . 8 billion h/y are spent online just in the United States, an increase of 21% from July 2011 to July 2012.1 Both patients and practitioners have increasingly adopted digital communication and social media in their interactions.3,4 Health-care social media usage is increasing independent of education, race, ethnicity, or access to health care.3 Consumers are using social media to inform their health-care decisions, to network with other patients, and to find information about providers.3 More than one-half of all consumers will look into a provider online prior to engaging in person,1 and in a survey of 1,000 patients regarding social media and health care, . 70% want the opportunity to use social media as a tool to manage their health.5 Eightyfive percent of patients in the United States believe
Manuscript received February 1, 2013; revision accepted August 7, 2013. Affiliations: From the Connecticut Children’s Medical Center (Dr Carroll), University of Connecticut, Hartford, CT; and Genesys Regional Medical Center (Dr Ramachandran), Grand Blanc, MI. Correspondence to: Christopher L. Carroll, MD, FCCP, 282 Washington St, Hartford, CT 06106; e-mail: ccarrol@ connecticutchildrens.org © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-0251 896
that digital communication, such as e-mail, text messages, and voicemails, are as helpful, if not more helpful, than in-person or phone conversations with their health-care provider.6 Health-care practitioners have also begun to cautiously adopt these tools in their practice. Practitioners are using social media to open new ways to interact with patients and to provide additional opportunities for customer service and support. For example, Boston Children’s Hospital refers prospective patients to disease-specific support groups to learn firsthand from other families how they treat chronic disease.5 There are other sites, such as PatientsLikeMe.com, which connects . 140,000 patients with others who share chronic diseases, improving engagement and patient education.5 At Texas Health Resources, a network of 25 hospitals has adopted a social media strategy that engages patients through education and development of affinity groups, and taps into the expertise of staff and patients to solve problems within the hospital system.5 Digital tools also have the potential to improve practice efficiency and reduce administrative costs and to improve a health-care practitioner’s communication with other providers, with a level of speed and convenience that has the potential to transform how providers coordinate complex medical care.1,2,5,6 There are several types of online platforms and digital tools. Frequently there is overlap between these terms, but some categories can still be defined. First, there are digital communication tools, such as e-mail Topics in Practice Management
and text messaging, which are used to speed direct communication between known individuals. Digital communication tools are most well known and widely adopted. Second, there are digital profiles that are used to provide a source of information on a particular issue, service, or provider. Examples of digital profiles include a practice webpage or a physician online profile. Digital profiles typically are used for one-way communication (practitioner to patient), although interactive tools can be added. The third type of platform is social media tools. These tools, such as blogs, Facebook, Instagram, and Twitter, have a more open-ended audience that can provide bidirectional exchange of information (Figs 1, 2). Initially these were popularized for their social purposes (hence, the term “social media”), but they are being increasingly used for professional and advocacy purposes as well as for more serious forms of digital communication. In this article, we review the concepts of digital profiles and social media and the benefits and risks of these platforms and provide readers with a basic understanding of how to incorporate these tools into their practice. We also discuss changes in reimbursement and how the changes may affect or facilitate communications between patients and providers.
Establishing a Digital Profile As a health-care practitioner, an online presence is crucial for your professional reputation and for pre-
senting yourself to patients. One-third of US consumers are using social media to find medical information, research and share their symptoms, and offer opinions about doctors and treatments.5 Now, more than at any other time, patients have access, literally at their fingertips, to a much wider source of information, not only regarding diseases, treatments, and outcomes but also regarding health-care providers. If practitioners do not take an active role digitally, they are missing the opportunity to shape their online presence and reputation. This digital presence or “footprint” is increasingly the face that practitioners present to the outside world, and it provides an opportunity to change how we interact with both patients and other practitioners, potentially transforming how health care is provided and coordinated. A central part of a practitioner’s digital profile is the practice website. A website provides practitioners an opportunity to provide direct information about themselves and their practice. It is, therefore, important that they consider incorporating their practice website into a larger digital strategy. A website also provides a platform for physicians to provide reliable sources of information to patients and provide links to trusted information sites. Just as importantly, it can serve to repudiate biased, slanted, or false information. The Internet is filled with inaccurate information, and without leadership from health-care providers, charlatans and snake oil cures can flourish more easily. A website with up-to-date, carefully curated content can help better educate your patients and your community.
Figure 1. Twitter homepage of one of the authors accessed through mobile app. journal.publications.chestnet.org
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Figure 2. Facebook home profile page of the American College of Chest Physicians.
Before launching a digital profile, practitioners should consider how they would like to interact online. A good place to start is with a self-audit of your online presence by entering your name (or that of your organization) into a search engine. This process, also referred to as “googling,” can provide an overview of the depth and reach of one’s online presence as well as potential problem areas, such as negative reviews or inaccurate information.7 This information, in turn, can guide your digital strategy and help determine what kind of tools you may want to use, including whether to use one-way or two-way forms of communication. Websites, physician profiles, and blogs can either be a oneway communication tool, where practitioners post and do not receive feedback, or a bidirectional exchange of ideas. Both have advantages and disadvantages. A oneway platform is easier to maintain and can still provide a significant amount of information and exposure. However, two-way communication can be established through inclusion of a comment section or through linking to social media. This has the benefit of providing greater interaction.
Using Social Media to Compliment Your Digital Profile Social media has also become an important tool for online communication. Practitioners can keep abreast 898
of the latest research, learn from the knowledge and experience of other providers, advocate for causes, provide customer service, and potentially improve the care we give to patients by building on the practitionerpatient relationship. Social media tools are being increasingly used by consumers to communicate with the services they use. Almost one-half of all US consumers have reached out directly to businesses to express satisfaction or complaints with service.1 It would be reasonable to conclude that health-care services will also be subject to this phenomenon. The use of online reviews has become an important medium for customers to provide feedback and voice complaints. Consumers currently use online reviews to make choices about all manner of services, including physicians. It is, therefore, important for practitioners to foster their online identities by encouraging patients to provide online reviews to mitigate the effect that a lone negative review could render. Although encouraging patients to provide online reviews may raise concerns about generating negative content, a study by Lagu et al7 actually found that 88% of online physician ratings were positive. Additionally, by referring patients to the rating websites that are in the first page of a Google search, practitioners can effectively exert some degree of control over their digital footprint. The first step in establishing a social media presence is to choose a format for your online profile. To determine this, practitioners need to consider their Topics in Practice Management
goals prior to participating in social media. Examples might include promoting their practice or themselves or advocating for a particular cause or issue. Providers should never use their personal accounts for these pursuits, as this may blur provider-patient boundaries. The identity, which will typically be a practitioner’s name or organization, can then be registered at various social media outlets, such as Twitter, Facebook, and LinkedIn. However, different platforms are better suited for different types of goals. For example, advocating for a cause is best done through Twitter or a blog, but promoting a practice is done most effectively using Twitter, Facebook, or a website. In any case, this online identity should be dedicated toward the promotion of the entity or person for which it was created, and not used for personal purposes. A provider should initially try to pick a single platform with which to become comfortable posting professionally and as an engagement tool. Then consider using sharing or cross-posting applications, such as Tweetdeck or Buffer, to expand posting to other social media platforms. Additionally, budgeting time is also important, since like any tool, social media can be used incorrectly and in a way that reduces overall efficiency. Once a practitioner’s professional social media identity is established, he or she should post regular, focused posts that current and future patients might find useful, being mindful to stay within the boundaries of professionalism. Blogging is another social media format that practitioners can use to communicate and enhance their digital profile. A blog (web log) is a site where individuals post original articles on related topics to a dedicated webpage. Although the discussion of establishing and maintaining a blog are beyond the scope of this article, there are a few caveats practitioners need to consider before establishing a blog. First, an individual should have an interest in writing, to create content that is compelling to readers. Second, to keep readers engaged, a blog should have regular posts. This requires a significant commitment of time that needs to be set aside, which many in the medical field may not have. Third, as with other aspects of social media, practitioners should remember to maintain standards of professionalism when posting online. Once practitioners have determined their digital strategy and have become comfortable with using social media tools for professional purposes, they should consider connecting these sites with their practice website. Social media sites such as Facebook and Twitter have tools that allow users to easily incorporate them into a practice website. These can take various different forms; from a Facebook “like” icon to a running feed showing the practitioner’s most recent posts at a connected social media site (Fig 3). The inclusion of these social media tools into the practitioner’s practice website generates opportunity for greater patient educajournal.publications.chestnet.org
tion as well as greater patient engagement with the practitioner. In addition to enhancing one’s digital profile, social media also has the potential to expand and improve communication between health-care providers. The global nature of digital media enables a provider to have access to a significantly wider world of knowledge and experience. This broader scope enables a provider to better collaborate and connect with others. Additionally, the diversity of experiences online allows practitioners to solve problems and acquire knowledge through “crowdsourcing” (ie, distributed problem solving). An example would be the use of social media to keep abreast of the latest scientific innovations and publications by following thought leaders and medical journals on social media platforms. There are also relatively protected forums, such as Sermo or the American College of Chest Physicians’ e-community portal, where members of a community can discuss medical controversies and the current literature more freely. Using these strategies, social media can potentially improve a health-care practitioner’s efficiency and also potentially improve effectiveness in the delivery of patient care.
Potential Risks of Social Media The use of social media, however, is not without risk, and a practitioner needs to be cognizant of these risks prior to joining the online community. First and foremost, a practitioner’s professionalism must be maintained on the Internet.8,9 A positive digital footprint can improve your professional persona and reputation, but, just as easily, actions taken online can negatively impact reputations and medical careers.10 Although there is the illusion of anonymity online, it is rarely possible to stay completely anonymous for long. Practitioners should be aware that what they do on Facebook, Twitter, and other social networking sites should be considered public and that patients, colleagues, and employers can potentially view everything they post. Second, maintaining standards of confidentiality and appropriate boundaries of the physician-patient relationship is critical. In a published survey of 485 health-care providers, 94% of medical students, 79% of residents, and 42% of attending physicians used online social media.2 Of this cohort, almost one-third reported patient-doctor interaction online, including “friend requests” from patients or family members of patients. Practitioners need to be aware of the importance of maintaining these boundaries and limit professional interaction with patients to those accounts that were created for professional interaction. However, it should be stressed that even in one’s professional social media platforms, practitioners are required to CHEST / 145 / 4 / APRIL 2014
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Figure 3. Caduceusblog.com, home page of the blog of one of the authors.
keep health-care information protected. Confidential and protected health information should never be discussed in a potentially public social media setting. Whether such communications take the form of seemingly innocuous “elevator talk” of anecdotal cases, or patient-initiated communications, providers should be aware that the information may be visible to thousands of people, and discussing it in public forums would not be consistent with standards of professionalism. Should a physician have a case that he wishes to discuss with other practitioners, the use of secured forums for practitioner-to-practitioner communication (such as the American College of Chest Physicians e-communities) is recommended. If a patient does initiate a health-related discussion in a public forum, a provider should move that dialogue either off-line or to a more protected digital platform where the discussion can be conducted confidentially. Additionally, wherever digital means are used for patient communication, clear guidelines should be established so that patients, providers, and office staff have similar expectations for how and when this mode of communication is appropriate.11 Within a practice, individual providers may differ in how they communicate digitally with patients; however, some basic statements can help clarify, define, and standardize use (Table 1). Office staff members can also be delegated to help distribute digital communication to the appropriate staff, further streamlining this communication. Practitioners should also be aware that as patients engage with medical practices through social media outlets they will have an expectation of a timely response.5 Therefore, personnel should be designated to respond to comments or questions that come through these forums. 900
Additionally, practitioners should be aware of liability issues when commenting on public forums or offering medical advice online. This is particularly true when commenting on issues directly related to a particular patient or medical case. Many providers include caveats such as “not intended to provide medical advice” in their online profiles to help mitigate this liability. This practice may not provide protection against liability issues, although the inclusion of such warnings may reduce the likelihood that patients interpret any specific comment as advice for their particular medical case. Physicians should be aware that any specific Table 1—Suggestions of Statements to Include in Guidelines for Digital Communication With Patients Suggested Statements Statement that digital communication should not be used for urgent matters List of the types of messages that are accepted (scheduling, prescription refills) Expectation of time to response Statement of who besides physicians will read and respond to messages Description of security and privacy measures taken to protect confidential patient information Statement of specific information that patient should include in subject line so that the message can be routed to the correct staff member Statement that an office visit will be scheduled by the staff if the medical question is too complex or sensitive to discuss electronically Statement that all communication will be included in patient record Statement that overuse of digital communication by a particular patient may result in that patient losing digital communication privileges
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advice given online to an individual may be construed as constituting a patient-doctor relationship and may carry additional responsibility. Another risk of social media is not being online to protect and defend your own reputation and interests. Fortunately, or unfortunately, the social media movement is not going away and is significantly affecting the practice and business of medicine. More people are using these digital tools, and there is a risk to your business and your brand to not participating. The relative anonymity of the internet can encourage negativity, particularly in those who feel that they have not had appropriate customer service. Not participating can also put a practitioner’s reputation at risk by not being there to defend issues or concerns that arise. Roles of Digital Communication and Social Media in Practice Management Beyond some of the more intangible benefits to social media involvement, there are significant tangible benefits to the increased use of digital communication in practice management, revolving around the coordination of care of patients with complex medical illnesses. Several factors, including increasing subspecialization, increasing illness complexity, and an aging population, have contributed to the development of a patient population that requires increased amounts of coordination of care and communication, both with patients and with practitioners of other medical specialties. Better coordination and transitioning of care provided to these medically complex patients have the potential to improve outcomes and reduce costs. Changes in the health-care landscape will likely create a much larger role for digital communication in the management of such patients. Novel systems of care, such as accountable care organizations and patientcentered medical homes, are being developed that place greater emphasis on communication, coordination, and quality outcomes and less emphasis on the current feefor-service model.12 Such systems would naturally encourage practitioners to develop systems of communication that harness interaction via digital means, which would be less time consuming (and less expensive) than telephonic or face-to-face interactions. Beginning this year, new Current Procedural Terminology codes have been developed that encourage non-face-to-face coordination of care. Specifically, Medicare will now reimburse physicians involved in primary care, reporting codes 99495 or 99496, for non-face-to-face time spent in transitioning patients from the inpatient to outpatient settings.13 Among the requirements for reimbursement of the transitional care management code is that telephonic, in-person, or digital communication be established within 2 busijournal.publications.chestnet.org
ness days of discharge. A face-to-face visit is also required within 7 to 14 days of discharge, which is bundled into the transitional care management code. Current Procedural Terminology codes have also been created for complex care coordination, although Medicare is not yet separately reimbursing for this service. These codes show that payers understand that cognitive time spent in managing and coordinating care is often as important as face-to-face time. This is a revolutionary step forward in the practice of medicine and could potentially spur significant changes in how patient care is managed and coordinated. The movement away from fee-for-service would encourage medical systems to increase efficiencies in coordination and management of care among providers and communication with patients. Risk sharing capitated models such accountable care organizations inherently encourage medical systems to reduce cost by increasing efficiency and reducing unnecessary procedures and office visits. One can imagine that digital communication would be a centerpiece of such an effort. From video conference patient-provider visits, to delivering results via protected digital platforms, to smartphone apps that allow practitioners and patients to exchange information, the possible applications of secure systems of communication would be limited only by the imagination and creativity of the involved medical systems. Conclusions In this article, we have endeavored to provide practitioners an introduction to using and integrating social media tools in their practice. Social media and digital communication are dramatically changing the way patients and health-care providers communicate and interact. These tools have empowered patients to expand their health-care knowledge and have provided practitioners with new ways to gain knowledge, lead discussions, promote causes, and build relationships with patients and other providers. However, there are risks to being involved in this digital forum, and practitioners should be aware of basic rules of professionalism prior to going online. However, practitioners should be aware that even if they are not active online, they may be discussed without their knowledge, and by being online they can protect their digital and real-world reputations. Additionally, digital tools have the potential to improve office administrative efficiency and reduce costs. Changes in reimbursement for non-face-to-face services may further spur these changes. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any CHEST / 145 / 4 / APRIL 2014
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companies/organizations whose products or services may be discussed in this article. 7.
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