Social-ized medicine

Translating talk into action is always a challenge, and perhaps never more so than when the “talk” is so easy with a social network such as Twitter. Some participants in a weekly healthcare social media chat on Twitter, hosted on Sunday nights using the hashtag #hcsm, decided to take on that challenge.

“Everybody likes to talk, but not everybody likes to act,” says April Foreman, a clinical psychologist from Frontenac, Kan., who was one of those who wanted to act. “If we say we can do it, we should try to see if we can.”

One of Foreman's like-minded fellow Twitter users noted that immunizations are the most successful public health interventions ever recorded, and they further honed the idea to focus on improving the immunization rate in the Kansas City, Mo., area, which has the lowest toddler immunization rate in the country, Foreman says. The project got its own hashtag, #hcsmvac, pronounced “hik-sem-vac.” The participants collected information regarding where to get immunizations and flu vaccines in the Kansas City area, and healthcare blogger Chris Hall (hallicious.com) produced an online map that patients can call up on their smartphones via a QR code to find the closest site to them.

The #hcsmvac project is an example of the clinical use of social media that is gaining some traction as clinicians and patients alike become more comfortable with social media tools. A related, and often interrelated, idea is called mobile health, or connecting to patients via text messaging or smartphone applications, or apps.

Dave deBronkart says he believes that clinicians are starting to come around to these ideas, although the general public is still largely unaware of them. DeBronkart was diagnosed with late-stage kidney cancer in 2007, with a median survival time of only 24 weeks, but his participation in a clinical trial halted the disease. DeBronkart became a full-time advocate of e-patients—the late Dr. Tom Ferguson's definition of patients who are empowered, engaged, equipped and enabled—and writes a blog at epatientdave.com.

“The overriding principle that has emerged in the Twitter chats and conference discussions is you don't practice medicine on social media,” deBronkart says. “You talk about it. You can spread information. You can exchange information. But a clinician would not interact on the patient's social media space.”

Physicians make for powerful voices through social media, deBronkart says. One example he cites is Dr. Wendy Sue Swanson, a pediatrician and parent who writes the Seattle Mama Doc blog on the website of Seattle Children's Hospital, Research and Foundation and also maintains a Twitter account, @SeattleMamaDoc. “She uses social media to help her patients understand all the information on the Internet, a lot of which is crap,” deBronkart says. “It's our job to counteract that.”

Social media also can help patients connect with each other, deBronkart says. His primary-care physician suggested an online patient community that deBronkart says helped him greatly during his cancer treatment. Physicians can assist these communities by lending their expertise, and they can also stay up to date with the latest research shared in them, he says.

The #hcsmvac project founders used social media to distribute information and connect patients and clinicians. “We didn't want it to be generic advocacy,” says Nate Osit, a health information technology implementation specialist for a software company. “We wanted it to be more specific. We thought the way to do that is to make a Google map with all the vaccination locations in Kansas City and use social media to distribute that message.”

Osit set up a website (about.me/hcsmvac) and an online folder that contained all the materials the group produced so others could use them, he says. The group provided the vaccination map's QR code to physicians, who could then have stickers printed up to give to patients. Carmen Gonzalez, who works for a consulting firm that recruits patients for clinical trials, produced three short videos that depicted the emotional case for immunizations—all the people in our lives who would not be there if they had not been immunized.

Members of the project also blogged and tweeted about these efforts and used social media to communicate with parents who have concerns about immunizing their children, Gonzalez says. One father whose daughter is autistic provided his reasons for having her vaccinated, providing a powerful peer story for parents, she says.

Gonzalez hopes the group will renew the effort next year, probably in the Kansas City area again. Next time, she hopes that they can connect to local public health and charitable groups.

Two clinicians who connected through social media are looking at a clinical use of social media that should be of particular interest to providers: Can social media help reduce hospital readmissions? Dr. Mark Ryan, a family physician with the Virginia Commonwealth University School of Medicine, Richmond, and Ben Miller, a clinical psychologist and an assistant professor in the department of family medicine at the University of Colorado at Denver's School of Medicine, have collaborated on possible ways that clinicians and hospitals might use social media to help patients after discharge to prevent readmissions.

The federal Agency for Healthcare Research and Quality has studied why preventable readmissions occur, and social media might be able to help with two of the problems the agency identified, Miller says: poor transfer of information to patients and the lack of a timely post-discharge visit.

Hospitals often show patients a video related to their stay just before discharge, but patients and their caregivers often have so much going through their minds as they prepare to leave the hospital that they don't retain much of this information, Ryan says. Producing short videos on a series of typical post-discharge questions—such as how to care for a newborn's bellybutton or what a congestive heart failure patient should do after discharge—and making those available through social media would be an effective way to reach these caregivers and patients, Ryan says.

Patients also could agree to have their social media posts monitored for signs that they need a clinician visit, Ryan says. An effort such as this could be focused on a few patients, usually with chronic diseases, who make up a disproportionate share of treatment costs, Ryan says.

Another example marries social media to mobile health: Using a Facebook page set up by the hospital for a specific disease to send text messages that provide tips for daily living with a disease, Ryan suggests.

Little if any research has been done on these ideas, Miller and Ryan acknowledge. “I think there's an awful lot of potential, but there's not any hard proof,” Ryan says. Medicare's policy to penalize hospitals with high readmission rates starting in 2013 could provide incentive to try these strategies, as avoiding Medicare penalties could more than pay for the staff costs of monitoring social media sites or creating videos, Miller and Ryan say.

The efforts of an Ohio physician turned entrepreneur may provide more proof of the efficacy of mobile health. The Text4Baby program by the National Healthy Mothers, Healthy Babies Coalition provides weekly text messages to mothers for their own care during pregnancy and for newborn care after delivery. Some studies also have shown that text message prompts can improve drug adherence.

Dr. Jennifer Shine Dyer, a pediatric endocrinologist in Columbus, Ohio, did a small trial with some of her teenage diabetes patients to text them reminders to take their insulin. “It really makes sense when you're seeing kids text during their appointments,” Dyer says. “Texting is the way that they like to communicate. When you communicate with people the way that they like to communicate, you get better results was my hypothesis.”

The results were good, but she can't text reminders to 200 patients, Dyer says. That led her to work with Eproximiti, a Columbus-based mobile software developer, to create a smartphone app that automates those reminders and also provides a journal for patients to record their insulin injections, Dyer says. Her EndoGoddess app, released for Apple's mobile devices in September and downloaded about 400 times, combines three things that form the core of the behavior design model championed by B.J. Fogg, director of the Persuasive Tech Lab at Stanford University, Dyer says. The app provides education and the ability to help manage their condition to patients; it provides reminders to do healthy behaviors; and it provides motivation, she says.

The motivation part is still in the works. When patients check their blood sugar and log the results in the app, they earn points. These points eventually will translate into credits for Apple's iTunes store. The credits will be funded by pledges from loved ones of the app users, Dyer says. The feature could be ready by year-end.

Early in 2012, Dyer will work with a local physician practice in Columbus to use the app in a randomized controlled trial with about 50 diabetes patients, she says.

“Why am I in mobile health? It's because that's where the patients are,” Dyer says, echoing the famous line attributed to bank robber Willie Sutton. “If you want to have an impact, you have to go where the people are.”