Social media has had a dramatic impact on the way the medical community communicates among its members and to the outside world. While it may be appropriate and safe to share deidentified cases or aggregate information with peers to ascertain the legitimacy of specific clinical approaches, research findings, policy issues, and professional needs or support, there are uses that pose potentially serious legal risks and consequences. These include the dissemination of information on specific patients, resulting in HIPAA violations, boundary breaches for “befriending” patients, and practicing medicine in jurisdictions where the clinician is not licensed. When using social media, physicians should ensure that they act responsibly and respect physician-patient confidentiality.

— John A. Fromson, MD*

As usage grows among doctors, benefits, challenges, and liability concerns are emerging.
By Bonnie Darves, a Seattle-based freelance health care writer

The burgeoning social media scene has clearly captured the attention of physicians. It began with blogs a decade ago but has grown exponentially in recent years with the advent of Facebook, MySpace, and Twitter. Doctors are not only blogging about their views on health care or political issues; they’re also creating Facebook pages and jumping into the fray of Twitter. Veteran physician blogger and internist Kevin Pho, MD, who pens the popular KevinMD blog, describes Twitter as “instant messaging to the masses.”

“Social media has really spread in the last two years, and we’re now seeing not just doctors but also hospitals and health systems using social media to communicate with colleagues and patients,” observed Dr. Pho, who practices in Nashua, New Hampshire. His popular blog and sometimes contrarian views have catapulted him into the national limelight and spawned a number of other media opportunities, including a monthly column in USA Today.

“The blog gives me a great way to not only keep up with changes in health care but also to communicate my views to consumers and patients who may wonder how the news applies to them,” he said. “Especially with medical studies, using media like Facebook and Twitter enables me to give a physician context to medical information, which I think is important.”

Dr. Pho, who spends up to three hours a day in social media activities, is surely in a minority of physicians who devote considerable time to blogging, Twittering, or engaging in Facebook updates. But physicians generally — especially young doctors — are moving steadily, if somewhat cautiously, toward using social media for personal and professional purposes. A Manhattan Research survey published in early 2009 reported that 60 percent of U.S. physicians are either actively using social media networks or are interested in doing so. In the ensuing year, during which health care reform and pressing public health issues such as H1N1 containment took center stage, physician participation in blogs and on the popular networking communities Facebook, MySpace, and Twitter has likely grown significantly.

The last two years have also spawned several new networking sites devoted to physicians, and social media has made its way into virtually every aspect of the health care delivery realm. Hospitals are developing Facebook pages and establishing Twitter presences, and physicians in training have even “Tweeted” from the operating room to share their experiences with other physicians. Patients have done the same, albeit after procedures. On a more formal level, the collaborative MedHelp is bringing together medical experts from leading institutions such as Johns Hopkins, Cleveland Clinic, and Cornell University in “Ask-a-Doctor” forums and discussion groups.

Val Jones, MD, CEO of the year-old startup Better Health, and a former Medscape editor who later became medical director of Revolution Health, has been involved in the online health movement almost since its inception. She views MedHelp as “brilliant use of social media and communities” and physician social media participation generally as a win for both doctors and patients, from the standpoint of rapid information sharing and dissemination.

“A lot of the magic in these things is in how you use them,” said Dr. Jones. “Social media is a great way to build relationships with your peers that you might not have time to build otherwise and to keep up with the latest news in your specialty.” She sees Twitter primarily as a valuable means of filtering information. “If you get enough followers and follow enough people, it’s a powerful way to immediately bring to your attention the things you’re most interested in.” Dr. Jones now follows a few hundred physicians on Twitter and has a growing cohort of followers herself.

She is predicting the widespread appeal of her new venture — a syndication of 70 leading medical blogs — in part based on the notion that physicians are not only interested in what their colleagues have to say but are also increasingly engaging in the social media scene.

I figured out that no one had organized the medical blogosphere, and that’s what I’ve done with Better Health — bring together the highly qualified doctors and nurses [who are blogging] to see if I can create a new business model,” she explained. Dr. Jones, who is a family and rehabilitation medicine physician in Washington, DC, said Better Health selects and publishes one post a week from each participating blogger to create a collection of posts that “fit logically” with one another. “In the end, you get a pretty interesting weekly overview of what’s going on in the top bloggers’ sites,” she said.

The business idea is that the individual blogger who has 10,000 readers a month gains, potentially, thousands of new readers. Her near-term objective is to create a modest income source for the bloggers, who typically receive little, if any, revenues.

Augusta, Georgia, physician blogger Rob Lamberts, MD, admits that his popular Musings of a Distractible Mind blog brings in a mere pittance in compensation but pays off mightily personally. He sees social media participation as a means of “humanizing” physicians and giving them a way to offer readers a realistic view into the everyday lives of doctors. “It gives me a voice for the needs and concerns of being a primary care doctor. I use it as a tool to communicate something that I think isn’t being discussed, but I also use it to talk about what it’s like to be me,” said Dr. Lamberts, who is board certified in both internal medicine and pediatrics. Even though his readership is primarily physicians, Dr. Lamberts, who spends about four hours a week in social media activities, intentionally uses no medical jargon so that he doesn’t exclude nonphysician readers.

Like Dr. Pho’s experience with KevinMD, Dr. Lamberts’ blog has become a springboard to more media opportunities. He was interviewed for a recent segment of National Public Radio’s “This American Life” program and an article in The New York Times. He has been tapped for an “expert” slot on Macmillan Publishing’s popular content-aggregating website Quick and Dirty Tips. He also serves as the “House Call Doctor” and produces a humorous companion podcast that has garnered a top ranking in iTunes and recently topped 50,000 downloads a month. Last fall, because of his pointed blog posts on the health care sector’s and physicians’ reluctance to fully embrace information technology, he was asked to participate in a Washington, D.C., summit on health care reform.

“Social media has given me these opportunities, but my participation has also made me a more enlightened physician, I think,” he said, “and makes me feel less powerless.”

Physician Networking Sites on the Rise
As physician use of social media has grown, platforms for physician-to-physician networking — social and professional — have proliferated in tandem. Sites such as Sermo, Medpedia, iMedExchange, and Ozmosis have attracted tens of thousands of members/participants.

Sermo is designed to enable physician members to freely discuss difficult cases, diagnosis challenges, treatments, and a range of other clinical issues. Medpedia, a long-term project being developed in association with Harvard Medical School, UC–Berkeley School of Public Health, Stanford Medical School, and the University of Michigan Medical School acts as a collaborative encyclopedia for health professionals and enables physicians to engage in discussions or develop “customized” networks based on their professional interests.

iMedExchange serves as a sort of “doctors’ lounge” and information resource, blending personal and professional networking. Initially supported by physician investors, iMedExchange is expanding by giving “partner” companies in gourmet foods, travel, technology, and financial services a venue for promoting their products.

Sermo uses a markedly different revenue model. For a fee, it provides companies in the pharmaceutical, medical device, and other sectors access to the physician discussions and exchanges and the ability to post information on the site. It also sells reports, created by compiling, qualifying, and quantifying the exchanges on clinical topics such as diabetes. For their part, Sermo physician participants may earn honoraria for participating in surveys, panels, and case conferences.

Pediatrician Lloyd Fisher, MD, who practices at the Fallon Clinic in Worcester, Massachusetts, finds Sermo useful for finding out how his colleagues in far-flung places approach particular clinical or practice issues. “The appeal of Sermo is that a huge group of people in various fields and with varying areas of expertise can very quickly have a discussion about a particular topic,” he said.

Dr. Fisher has used Sermo to tap into discussions ranging from the management of fever in newborns or approaches to handling adolescent-patient confidentiality to health care reform. “I haven’t necessarily gotten something that I could apply to a particular patient, but it’s helpful to read about challenging cases and to interact with people who have different approaches, practice types, and experiences than I do,” he said. He notes, however, that he takes what he reads with “a grain of salt because some people may lie about or exaggerate their expertise.” Unfortunately, this emerging problem places physicians in a situation not unlike one consumer’s face — difficulty verifying the source of medical information.

Dr. Jones thinks that Sermo offers a potentially valuable professional forum for physicians but takes issue with the company’s business model. “My sense is that they’ve possibly found a way to get doctors to consult for free. In the past, Wall Street types would have to pay key opinion leaders for input,” she said.

Social Media Activity Risks Difficult to Predict

Despite the potential professional benefits of social networking participation, some physicians are approaching the social media realm with trepidation, for fear that personal and professional presences will overlap in a manner that increases liability exposure.

That’s a valid concern, some physicians and lawyers concede, because the medico-legal aspect of social media activities has been little explored and is not well understood. In addition, the obvious risks of incurring HIPAA violations should patients’ health information be unwittingly exposed are a deterrent. “The laws haven’t caught up with social media and networking, so to be safe I don’t blog about my patients,” Dr. Pho said. “Even though I think that interesting or challenging cases can be used as a learning tool, too much of my professional livelihood is at stake.”

None of the physicians interviewed for this article have accepted patients’ requests to become Facebook friends, and all cited concerns that doing so would “cross the boundary” between a personal and professional relationship.

Dr. Jones, who practices part-time since she launched her business, concurs with Dr. Pho that the liability risks of even responsible social media participation, even if they ultimately prove somewhat unfounded, are deterring physician activities on public forums.

“I think that very few doctors are interacting with patients directly on Facebook because we’re so terrified of being accused of practicing medicine and getting sued. Whatever you type is eternal and a perfect record of whatever you said,” she said. “That makes it all even more scary.” At the same time, she acknowledges that a forum for hematologist-oncologists, for example, in which challenging cases were discussed, would be immensely valuable. “If you wanted to curb all of those cases, the wisdom of that crowd would clearly be better than the sum of its part. The problem is that you can’t be sure that no one else will see it,” she said, noting that anything that comes close to violating HIPAA could have serious repercussions. “That’s put the kibosh on some of that usage of social media.”

On the downside of the social media trend, studies such as one published in the September 23 to 30, 2009, edition of the Journal of the American Medical Association have shown that medical students have used the forums inappropriately to discuss individual patients. Other incidents have involved physician office staff posting entries on Facebook or Twitter about difficult patients, thereby potentially exposing the employing physicians to liability. And in rare cases, some physicians, like the Boston area pediatrician who blogged throughout his malpractice trial, have failed to use common sense in their social media activities.

“I don’t ‘friend’ my patients on Facebook, and I don’t make [care] recommendations on social media,” Dr. Lamberts said. “Think of Twitter as the hospital elevator. You just don’t talk about patients there because news can travel.”

In the “gray area” in terms of legal ramifications are activities that may make it appear that a physician is dispensing medical advice to a patient or patients with whom there’s no established relationship, according to Philadelphia attorney Bruce Armon, a partner in the health care practice of Saul Ewing, LLP. “There’s still a large degree of legal uncertainty, and whenever there is, physicians should exercise caution and be prudent in using social media venues,” he said. “Physicians, by virtue of their training, want to be helpful to individuals, but once they post an entry, it can take on a life of its own and have a degree of permanence and unintended consequences that a telephone conversation or office visit does not.”

Physicians should proceed, Mr. Armon advises, from the premise that “what they post is permanent.” They should also use disclaimers to state clearly that they’re not giving medical advice to individuals, should clearly establish guidelines for any postings in advance, and should consult with their attorneys beforehand on their intended activities before posting medical or clinical information. He also urges physicians to take extra precautions when using social media sites to ensure they’re not in violation of employer or professional-liability carrier policies or hospital or professional societies’ ethics codes.

Bob Coffield, an attorney with Flaherty, Sensabaugh & Bonasso, PLLC, in Charleston, West Virginia, who writes a health law blog, takes a more measured view of the new world of social media. “It’s here, and I don’t think that physicians should turn away from it. They should learn how it works so that they won’t make errors,” he said. “Treat it like it’s a cocktail party consult or a curbside consult. But they should also remember that before we used to assume that everything was private until it was made public; there’s been a shift, and physicians should assume that everything is public until they decide to make it private.”

Liability insurers are just beginning to survey the social media landscape, and it’s entirely possible that some may adjust policies or coverage based on situations that result in either risk concerns or actual lawsuit-spawned claims. Members of the Physician Insurers Association of America, located in Rockville, Maryland, plan to address the topic in an upcoming risk management workshop, for example. Interestingly, the Napa, California-based The Doctors Company, the country’s largest medical malpractice carrier with 47,000 physician policyholders, recently added CyberGuard coverage enhancement for solo and small group members as protection against claims arising from the theft, loss, or accidental transmission of patient information. At the same time, the company is eyeing potential liability situations with a watchful eye, and cautioning physicians against using social media for physician-patient communications.

“We’re concerned about this because there have been instances in which physicians have used Facebook in an inappropriate manner,” said David Troxel, MD, The Doctors Company’s medical director. “Social media networks are not HIPAA compliant and are just not appropriate for any physician-patient communication, so it’s a real liability threat because it’s so easy to lapse into a casual conversation.”

Donna Young, risk manager for the Mutual Insurance Company of Arizona (MICA) in Phoenix said that her company is also looking at the privacy pitfalls of social networking. MICA warns physicians that physician or employee use of personal e-mail accounts on the job is a real area of potential risk. There have been incidents, she noted, in which employees have used social networking sites to unwittingly or intentionally violate patient-privacy laws. To protect against such risk-ridden situations, physician practices should institute written communication policies and confidentially agreements. “They should also require staff to acknowledge annually that they have read and understand those documents,” she said.