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Practical Use of Social Media and Electronic Communications

By Tracy Denninger

Quality of care, patient privacy, and liability concerns dictate the appropriate uses of social media and electronic communications to interface with patients.

Trying to escape social media and other forms of electronic communication is almost like trying not to breathe—it’s nearly impossible. From online social media platforms such as Facebook, Twitter, and LinkedIn to e-mails and text messages, people of all ages and from a variety of backgrounds use these services.

The strong presence of electronic communication requires geriatricians, primary care physicians, and related health care professionals to examine how they’ll use such tools in their practices for their patients’ and their own benefit. And just as important, they must protect patients’ personal health information and avoid violating laws such as HIPAA.

To help address such concerns in the medical community, a recent report from the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB), “Online Medical Professionalism: Patient and Public Relationships,” provides some general guidance on best practices for utilizing technology and social media in medical practice.

Enhancing Patient Relationships
The ACP/FSMB position paper covers an array of social media and electronic communications, from e-mail to blogs to Facebook. According to the paper, “The initial decision about whether to extend the patient-physician relationship to the online setting includes the following factors: the intended purpose of the exchange and content of conversation; the immediacy of electronic media and expectations, including response time; how communications will take place (for example, through social networking sites, microblogging, or professional e-mail on a protected server) while maintaining confidentiality; and how emergency or urgent situations will be managed.”

Online media offer a variety of benefits but come with drawbacks as well. For instance, the position paper notes that text messaging can be used successfully in a public health realm, as studies have shown that sending patients information or reminders can positively impact their health. However, directly text messaging with a patient, against which the paper expressly advises, creates problems “because of its abbreviated format and the greater possibility of missed messages.”

E-mailing patients, when done in a “systematic and thoughtful way,” can improve patient care and outcomes, the paper notes. Patients with chronic medical conditions, for example, may find that regular e-mail communication with their physician acts as a “booster” to physician advice and even can improve treatment outcomes. Patients also may feel a stronger sense of satisfaction regarding the physician-patient relationship stemming from this additional care.

“Some patients want to contact me by e-mail. They do so directly and are informed it should not be used for emergencies,” explains Gretchen Orosz, MD, a geriatrician at Sparks Senior Health Center in Fort Smith, Arkansas.

“I do communicate regularly on e-mail with patients and, in some cases, their designated proxy,” says Peter H. Cheng, MD, AGSF, CMD, a geriatrician with the Palo Alto Medical Foundation in northern California. “I am fortunate to have access through a secure online messaging system that is built into our health care system’s electronic health records. Our office staff do ‘first touch’ with all online messages from patients before the messages get to me.

“Messages that may work well on e-mail include [prescription] refill requests; preclinic tests and orders; discussions involving nonemergent test results; reporting of self-monitoring data, such as blood pressure readings and a dietary diary; and nonemergent conversation exchanges with family members of geriatric patients,” he notes.

“I use a separate clinic e-mail address that is checked daily by an administrative assistant first. Then she forwards the messages as appropriate,” says Rosemary Laird, MD, MHSA, AGSF, medical director of the Health First Aging Institute, past president of the Florida Geriatrics Society, and the 2013 Clinician of the Year for the American Geriatrics Society (AGS). “We generally ask for questions related to upcoming appointments or clarification of issues discussed at appointments, for example. Out-of-town family members will often send information ahead of time, and we’ll get requests for letters from our social workers, forms completion, etc.

“When we provide our e-mail, it comes with a written notice to use only for nonurgent matters,” Laird continues. “Just in case, we have an automatic return reply message that reminds senders of the nonemergent nature of our e-mail system and instructs [patients] to call 911 or go to the emergency department if it is an emergency or they are unsure.”

However, physicians must maintain patient confidentiality not only to protect a positive physician-patient relationship but also to avoid potential repercussions, such as HIPAA violations that could result in financial ramifications. According to the position paper, physicians should use only technology that includes the proper safety protocols to ensure safe communications between physicians and their patients, including using secure e-mail or messaging services. Additionally, any e-mail communication should be conducted only with patients with whom the physician has already engaged in face-to-face encounters and with the patients’ consent to such communication. Copies of e-mail conversations also should be included as part of patient medical records.

Additionally, answering e-mails cuts into physicians’ already largely divided time. “There is currently no uniform recognition of the impact of electronic communication on physician work burden,” Cheng says. “Enough time needs to be allocated for timely completion of this important task. Proper compensation from health plans is also needed to sustain this crucial way of caring for our patients.”

Laird notes that it can be difficult to learn the full details of a patient’s complex medical situation from e-mail correspondence alone. And Orosz notes that “it’s a convenience for patients that use that form of communication but is yet another place I have to check for messages.”

However, Wen Dombrowski, MD, MBA, a geriatrician familiar with social media and technology consulting, notes that some studies and anecdotal reports have shown that e-mail can save time because physicians aren’t interrupted by pages or calls throughout the day when they are trying to meet with patients, and it’s easier for physicians to forward requests to the office staff or nurses if they can handle them.

Education for Both Parties
The position paper notes that the Internet can be a powerful educational tool, with a variety of media and websites available for both patient and physician education. However, when physicians recommend online resources to their patients, they must make sure the resources are of good quality, namely peer-reviewed media or websites where information can be controlled for quality. For themselves, physicians can use the Internet to learn about new care delivery models, utilize online decision aids, and access continuing education and faculty development materials.

Physicians must maintain separation between their personal online presence and their professional one if they choose to use social media in both spheres. This includes refusing to accept (or initiate) friend requests from patients on sites such as Facebook. In fact, according to the position paper, “The FSMB specifically discourages physicians from ‘interacting with current or past patients on personal social networking sites such as Facebook.’”

Dombrowski challenges this suggestion, though, noting that physicians may want to use Facebook to reach out to patients, for example, by posting health education articles or marketing information for the physicians’ practices. She says physicians need to consider their goals in using a social media site such as Facebook and proceed appropriately when it comes to “friending” patients.

For physicians who maintain a personal blog or microblog, the position paper encourages them to “pause before posting.” While clinical vignettes can prove useful for other members of the profession, as long as all identifying information has been removed from a case and, ideally, patient consent has been obtained, venting personal frustrations could prove detrimental. Such posts could cast a poor light on the medical profession or create confidentiality issues.

Expanding Applications
“Professionally, most health providers use social media to network with each other, stay informed on current events, and learn about funding opportunities, job opportunities, and public education materials that they can share with their patients—for example, tip sheets on better health or better living,” says Jillian Lubarsky, communications manager for the AGS.

“I know lots of geriatricians who use social media, mostly Twitter,” says Louise Aronson, MD, MFA, an associate professor in the University of California, San Francisco division of geriatrics. “We use it as a platform to inform each other [as well as others outside the medical profession] of key developments, research, interesting articles, etc, but I know of no one who uses it clinically.”

“Over the last few years, I truly feel social media has played an important part in making me a better geriatrician,” says Cheng, who has incorporated social media into his practice in two ways. “First, social media has opened up new ways for me to keep up with evolving trends in medicine,” he explains. “There are lots of terrific Internet forums that offer health care professionals high-quality opportunities for ‘on-the-spot’ learning and reflecting.

“Second, I am increasingly prescribing social media sites and forums to some patients and their caregivers,” he continues. “I feel that there are many quite thoughtful and well-designed forums out there. Their content often will enhance the messages that I deliver in the office. Some blogs potentially also offer a sanctuary for ‘venting,’ which can be truly therapeutic for some of our geriatric patients and caregivers.”

“The best advice for health providers who want to use social media is to start off slow,” Lubarsky says. “Join Facebook or Twitter and start to follow a few people. The AGS has a list of people to follow on its website. Next, see what other people are saying to get a feel for the type of content to post about.”

Bridging the Gap
Since neither all geriatricians nor all patients are tech savvy, how should physicians go about bridging the gap in order to provide the best care?

Dombrowski has actively used Twitter since 2011, hoping to address the lack of public awareness regarding the need for improving health care and elder services. She offers the following suggestions for helping physicians cautiously but effectively use social media:

• Start by using social media as a listening tool. See what content others are sharing and note whose messages are helpful.

• As you or your patients become more comfortable with how the social media service works, start resharing posts that you find interesting. “The best articles and information will rise to the surface for you to find and then pass along,” she says.

• Create your own content and information to share based on your comfort level, interests, target audience, and goals of using social media.

“Geriatricians should focus on the needs of their patients and caregivers,” Lubarsky says. “If the patient or caregiver is computer savvy, a health provider may want to encourage these people to ‘like’ Facebook pages that are geared toward providing health information.” These patients and caregivers also may be more open to communicating via e-mail.

“However, if a health professional is caring for a frail older adult who is not computer literate, it’s OK, too,” she continues. “Many websites have ‘printer-friendly’ materials that can be printed out by health providers” or with assistance from staff at a local library or senior center.

— Tracy Denninger is the senior production editor for Today’s Geriatric Medicine.