Social Media and the Patient Experience

Social Media and the Patient Experience

ORIGINAL ARTICLE Social Media and the Patient Experience C. Matthew Hawkins, MD a , Andrew J. DeLaO, BS b, Colin Hung, P. Eng c Abstract As patients ...

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Social Media and the Patient Experience C. Matthew Hawkins, MD a , Andrew J. DeLaO, BS b, Colin Hung, P. Eng c Abstract As patients continue to turn to online resources for health care information to guide their care decisions, it is becoming increasingly important for radiologists to engage with patients online via social media platforms. There are many ways physicians can use social media to provide patients with valuable information and improve the overall patient experience. By optimizing online discoverability, curating radiology content, engaging with patient communities, and producing mineable social media content, radiologists can emerge as thought leaders in this new form of patient-centered communication and information exchange. Key Words: Social media, patient experience, hashtag ontology, online content curation J Am Coll Radiol 2016;13:1615-1621. Copyright  2016 American College of Radiology

INTRODUCTION Social media in medicine is here to stay. The banter centered on social media’s “emergence” and “potential” has been largely replaced by discussions dissecting best practices and real-use case scenarios from practices that have successfully implemented social media strategies [1,2]. The uses for social media are boundless. Some practices have used social media to build their practices, whereas others have used various online platforms for education [3]. However, relative to other industries, adoption of social media has been slow in radiology. There are a number of myths that have delayed acceptance of social media in radiology, including (1) the perception that one must be technologically savvy to use a social media strategy, (2) that patients do not want to discuss their health online, and (3) the belief that there is a general lack of trust regarding information discussed within social media communities. Although physicians’ use of social media has been delayed in part by these misconceptions, there is one population that has enthusiastically integrated social

a Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia. b My Ideal Patient Experience Network, Greenville, Wisconsin. c Stericycle Communications Solutions, Toronto, Ontario, Canada. Corresponding author and reprints: C. Matthew Hawkins, MD, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA, 30322; e-mail: [email protected] The authors have no conflicts of interest related to the material discussed in this article.

ª 2016 American College of Radiology 1546-1440/16/$36.00 n

media use into their lives and continues to call for its increased use among physicians. That population is our patients. There has been a substantial amount of attention paid to the patient experience. Often, efforts targeting improved patient experience have focused on scheduling, ease of payment, improved communication of test results, price transparency, and the language used in radiology reports. Where in all of this does social media fit? Importantly, despite increasing use of social media by patients, navigating online engagement with this population can be challenging for physicians. Jain et al [4] recently demonstrated that different populations have varying opinions about what content is appropriate to share on publically available social media sites. Additionally, most health care organizations and institutions have their own social media use policies that impose varying regulations for physicians to abide by [5]. These facts provide context for the ensuing discussion and also demonstrate why further scholarly work in this field is warranted. The purpose of this report is to describe the role social media plays in improving the patient experience. Specifically, its role in improving physicians’ online presence, curating content, developing patient communities, and disseminating peer-reviewed literature are discussed. Finally, techniques for engaging diverse populations, including patients, to discuss radiology-specific topics are described.


PATIENTS’ PERCEPTIONS OF THE ONLINE PRESENCE OF PHYSICIANS When does a patient form a first impression about a physician or practice? The answer to this question can be largely informed by the concept of “pre-commerce.” From Bob Pearson’s [6] book Pre-Commerce, this entity is best described as the way in which consumers develop opinions about various products and brands before tangibly engaging with them. A beneficial exercise that best illustrates “pre-commerce” is thinking about the process by which people now buy cars, and comparing that with how car purchases occurred 30 years ago. Thirty years ago, people went to their local car dealerships and looked at the various cars on the lot. Perhaps their opinions regarding the various brands of cars were influenced by prior car purchases, by where they were raised, or by whom their parents worked for. However, consumers were otherwise largely unknowledgeable about the durability, safety, and features of the newest releases. Opinions about these cars were substantially affected by interactions with them during test drives or by the sales job of the car lot attendants. Often, the choice regarding which car to purchase was not made until after seeing it, driving it, and discussing it. Compare that with how car purchasing takes place now. Before driving to a car dealership, most car purchasers perform a number of tasks. These usually include reviewing the vehicle’s safety and durability via one of many consumer testing sites, obtaining peer reviews about the vehicle, and, if buying a used car, retrieving a complete history of the vehicle. Finally, the average price of the car, including access to geographic variability of the price, is reviewed. Ultimately, contemporary car buyers have already decided which car to buy (and how much they are willing to pay for it) before engaging with the car or car salesperson on the day of purchase. This is the concept of pre-commerce. Patients want similar access to this type of information for their physicians and hospitals as well. The days of making a first impression when you meet your patients in person are numbered. Rather, in the modern era, our patients have likely already formed opinions about us and our practices before we meet them. And those opinions are largely influenced by the information they discover online. In that respect, when was the last time you Googled your name and/or your practice? What did you find? Vijayasarathi et al [7] recently demonstrated that the first page of Google search results for radiologists in the United States is largely dominated by third-party physician rating sites that limit the amount of control 1616

physicians have on the content hosted on those sites. Physicians and their practices can “displace” these thirdparty sites from Google search results (such as vitals. com and by starting and maintaining active social media profiles. These social media sites are preferentially prioritized compared with third-party sites and, if active, will likely be listed ahead of them accordingly. Recently, Google has further stated that social media activity will continue to be prioritized by the search algorithms it uses [8,9]. However, because the third-party physician ratings sites will still exist, and likely shift their strategies to adapt to future search algorithms, attention should also be paid to creating and populating physician profiles on these sites. Gilbert et al [10] previously demonstrated that fewer than 10% of radiologists have existing profiles on the dominant third-party physician rating sites, which represents an additional way radiologists can favorably mold their online presence if social media profiles are less preferred. The implications of increasing use of physician rating sites by patients remain largely unknown. Ranard et al [11] recently demonstrated that Yelp reviews of hospital care were bimodal in distribution, correlated with overall Hospital Consumer Assessment of Healthcare Providers and Systems survey ratings, yet also provided additional information that correlated most strongly with positive and negative experiences for patients that is not captured by these existing survey tools. These findings suggest that physician rating website reviews will be used with increasing frequency to determine patient satisfaction scores of physicians and hospitals. Despite these findings, questions still remain regarding whether this type of online content can be used to accurately judge the performance of physicians and health care organizations [12]. Prior studies have demonstrated that physicians maintain a largely unfavorable view of physician ratings sites [13] and that physician rating sites have a largely negative impact on physician welfare because of the emotional stress induced by public evaluation of professional skills and personal traits [14,15]. However, a recent analysis of 4,999 online physician ratings by Kadry et al [16] demonstrated that patients largely give favorable reviews of their physicians. Ultimately, the content patients are able to find about physicians before tangibly engaging with them will continue to have greater influence on their perceptions and opinions about individual physicians and physician practices. Social media is a key tool in optimizing an Journal of the American College of Radiology Volume 13 n Number 12PB n December 2016

online presence and complementing information populating physician rating sites.

PHYSICIANS AS CURATORS In addition to improving the online presence and discoverability of physicians, social media sites allow physicians to provide content that patients are seeking. What exactly that content is composed of is worthy of discussion. We live in an era when there is unlimited sharing of information and dissemination of knowledge. General information about medicine and health care is easily discovered by patients. Seventy-two percent of US adults use the Internet to seek information about health care. Twenty-four percent post about their health online; 27% post reviews about their experiences [17]. As discussed previously, these reviews can be complementary to information acquired by existing survey tools [11]. This flurry of online activity has led to the development of a number of online resources, such as WebMD, built for medically related knowledge consumption for health care customers. Consequently, a large portion of medical knowledge is widely available and consumed by patients, thus improving their overall sophistication as it relates to their health care. Subsequently, patients rely less and less on physicians for information. Rather, it is our opinion that patients have now become more reliant on physicians for their interpretations and opinions of the medical literature. Social media platforms provide physicians an opportunity to provide these opinions and interpretations to broad populations. For example, social media sites allow pediatric radiologists to post their opinions and related peer-reviewed literature regarding the risk for radiation exposure to children. Breast imagers can provide necessary interpretation of the widely variable online information related to breast tomosynthesis. Interventional radiologists can keep patients updated on the variety of minimally invasive therapeutic options that are available to them, about which they are often uninformed or misinformed. These opinions and interpretations are valued by patients. Plus, the social media platforms used to post this information allow physicians and practices to engage with patients in a meaningful way that will improve the overall patient experience. Specifically, O’Connor et al [18] recently demonstrated in a randomized trial that patients undergoing hip and knee replacements had decreased levels of preoperative

anxiety when given access to a YouTube library of videos related to their surgery. Few studies have analyzed the usefulness of patientgenerated content that results from online engagement via social media sites. Prior researchers demonstrated that approximately 9.4% of tweets directed at hospitals with Twitter accounts pertained to the patient experience [19]. Additionally, Lagu et al [20] demonstrated that patient comments on a single hospital’s Facebook page were related to four distinct themes—staff, specific departments, technical aspects of care, and hospital physical amenities—and were largely similar to comments obtained via more traditional methods to solicit feedback. Because this new source of information could potentially drive quality improvement efforts for health care organizations, further research in this field is warranted.

ONLINE PATIENT COMMUNITIES There has been a shift in the way patients protect their privacy as it relates to their health. Historically, people were less likely to share details about their health or particular diseases, except for with those closest to them. However, today’s patients actively seek out peers with similar diseases or advocates for health care as it relates to their diagnoses. This has led to a surge in online patient communities that are organized predominantly by patients with similar diseases or ailments. The newfound “openness” to discussing very personal issues related to health care is a paradigm shift that further underscores the importance of social media as it relates to the patient experience. There is a broad variety of patient groups on social media, some open and some private. These online patient communities are active in a variety of ways, including providing peer-to-peer support, empowering patient advocacy, and increasing awareness of rare diseases [21]. A recent review of advocacy-related campaigns initiated by online patient groups demonstrated that 35% of the analyzed case studies related to increasing access to experimental drugs, some of which (eg, pembrolizumab) were subsequently approved by the FDA [22]. With more than one billion users worldwide and easy ways to establish online communities, Facebook is currently the dominant home for disease-centric patient groups [23]. Many of these groups are related to disease awareness, whereas some provide advocacy for research and funding. Other groups have been effective at allowing patients with very rare diseases to find peers

Journal of the American College of Radiology Hawkins, DeLaO, Hung n Social Media and the Patient Experience


Fig 1. Growth of online social media activity between 2012 and 2014 [15].

with similar ailments and become integrated into communities of people with helpful resources and empathy. Physicians can effectively interact with members of these groups by providing up-to-date information and peer-reviewed content that can help patients seek appropriate care and better inform the questions they ask of their physicians. Obviously, although physicians might be willing to provide information about a general disease process, they should avoid providing patient-specific medical advice or “advertising” their services within these groups on social media forums. Necessary caution and common sense aside, doctors and hospitals should realize that this increased physician engagement with patient groups can substantially improve the patient experience for those patients actively seeking information and advocating on behalf of other patients with similar diseases. Patients have also begun organizing on other social media platforms via hashtags. For example, the #LCSM (lung cancer social media) and #BCSM (breast cancer social media) groups on Twitter have developed two of the most robust communities on the microblogging network. As radiologists who play a vital role in screening for these two disease processes, we would be well served to engage with these well-informed, sophisticated patient groups that serve to improve advocacy and research funding for these communities. By including these hashtags in tweets and searching social media sites for these hashtags, radiologists can begin to generate, discover, and share content of interest to these patient communities. 1618

Social Media and the Peer-Reviewed Literature There has been a strong push recently for open access to the peer-reviewed literature. Traditional publishing pricing models, which are composed primarily of institutional subscriptions or hefty per-article fees for individuals ($30 and more), are being threatened by this surge. Recently, it was announced that all publicly funded scientific articles will be made free to access by 2020 in Europe [24]. It is likely that similar actions will be taken in other countries. Additionally, JACR, in cooperation with Elsevier, hosted the first annual JACR Hackathon in conjunction with the ACR’s 2016 annual meeting [25]. The “problem” that hackathon participants were charged with solving centered on the challenges patients face when seeking peer-reviewed literature and access to content experts. The challenges patients face when being forced to interpret peer-reviewed content were also explored [26]. In addition to the public outcry for more readily available access, some scholars have recently published analyses in open-access journals approach equivalent methodologic quality as those published in subscription journals [27]. Suffice it to say, peer-reviewed literature will become increasingly available at a price ranging from cheap to free. How can the health care community use social media to embrace this movement and improve the patient experience? It could be hypothesized that as patients and patient advocates increasingly gain access to the peer-reviewed literature, more questions will arise on social forums. In addition to confusion surrounding basic epidemiologic Journal of the American College of Radiology Volume 13 n Number 12PB n December 2016

Table 1. Radiology Tag Ontology #OncoRad #IRad #IROnc #PedsRad #HNRad #NeuroRad #NucMed #MSKRad #AbdRad #CVRad #ChestRad #MRI #CTRad #USRad

Clinical Tags Oncologic radiology Vascular interventional radiology Interventional oncology Pediatric radiology Head/neck radiology Neuroradiology Nuclear medicine Musculoskeletal radiology Abdominal radiology Cardiovascular imaging Chest radiology MRI CT Ultrasound

#MolRad #RadPhys #RadHSR #RadLeaders #FOAMRad #RadRes #GlobalRad #RadSafety #RadQI #HITRad #TeleRad #POCUS #radiology #RadCME

#Mammo #OBRad #EMRad

Mammography Obstetrics radiology Emergency radiology

#RadEcon #RadPolicy #FOAMus


Musculoskeletal ultrasound

Scientific Disciplines Molecular imaging Radiology physics Radiology health services research Radiology leadership Free open-access medical education radiology Issues pertinent to trainees and education Global radiology Radiation safety Radiology quality improvement Radiology informatics Teleradiology Research related to point-of-care ultrasound Generic reference to radiology Continuing medical education offerings in radiology Radiology economics Radiology health policy Free open-access medical education ultrasound

Source: Reprinted with permission from Hawkins [30].

and statistical terminology—such as all-cause mortality, lead-time bias, relative risk reduction, and confidence intervals—patients may also need further clarification

regarding the clinical efficacy of a newly studied technology or whether a single-institution, retrospective review is broadly implementable across populations. As

Table 2. Oncology Tag Ontology #caenv #caepid #CardioOnc #gerionc #globonc #hemeonc #hpeonc #hsronc #ImmunoOnc #intonc #lgbtonc #medonc #onconav #oncopath #oncorad #oncorn #PallOnc #pedonc #psyonc #radonc #supponc #surgonc #uroonc

Clinical Tags Cancer and the environment Cancer epidemiology Cardio-oncology Geriatric oncology Global oncology Hematologic oncology Health policy and economics in oncology Health services research in oncology Immuno-oncology Intimacy oncology LGBT oncology Medical oncology Cancer navigator Oncologic pathology Oncologic radiology Oncology nursing Palliative care in oncology Pediatric oncology Psycho-oncology Radiation oncology Supportive care in oncology Surgical oncology Urologic oncology

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#caangio #cactc #cagenome #cametab #camets #camicroenv #camoldx #cananomed #caproteo #castemc #caxtx #radbiol

Scientific Disciplines Cancer angiogenesis Circulating tumor cells Cancer genomics Cancer metabolomics Cancer metastasis Cancer microenvironment Cancer molecular diagnostics Cancer nanomedicine Cancer proteomics Cancer stem cells Experimental therapeutics Radiation biology


mentioned previously, physicians can help patients with some of these questions. Perhaps more important, by engaging on social forums, physicians may better learn what questions our patients are asking when they are not sitting in examination rooms.

THE RADIOLOGY HASHTAG ONTOLOGY The vast amount of information that is produced on social media platforms is staggering. (Fig. 1). In 2014, there were 3.3 million Facebooks posts, 120 hours of YouTube video uploaded, and 342,000 tweets every 60 seconds [28]. How can the content that is shared on these social sites ever become a meaningful, mineable data source when each bit of information is akin to a grain of sand on the beach? For patients interested in radiology, how can they go about finding the best resources for radiology-related information on social media? And for physicians and practices producing radiology-related content, how can they reach patients and audiences that are not yet following them via social media forums? By tagging social media content in a programmatic, ontologic manner, the newsfeeds, live streams, and timelines all become mineable. To this end, a social media ontology for radiology (Table 1) is hosted by Symplur [29]. In 2015, there were 123,911 tweets from 28,045 unique Twitter users using the Radiology Hashtag Ontology [30]. If patients and patient advocates want to learn more about interventional radiology, they can search for #IRad and see all of the social media posts that have included this hashtag to catalogue them as interventional radiology–related social media content. For patients seeking more information about radiation safety, searching for #RadSafety will provide them with similar information from any users who embedded that hashtag in their content. The ontology creates a meaningful data source that may eventually provide the information necessary for advanced analytics algorithms to determine what topics various populations are or were interested in, what questions were most commonly asked, and what issues were most pressing over time. Ultimately, the ontology is an organizational tool that makes social media content related to radiology useable. For patients, it opens new doors to discover information that might otherwise only be heard within difficult-to-find social media forums. A similar ontology has been created by the oncology community [31], which is summarized in Table 2. 1620

Members of the radiology profession can meaningfully interact with patients and professionals in this online community by searching and sharing content with the #radbiol, #oncorad, and #radonc hashtags, for example.

CONCLUSIONS It is easy to be distracted by the technology of social media. But social media is not about technology. Rather, social media is redefining the way people communicate. In health care, more specifically, it is redefining how our patients communicate: how they communicate with each other and how they seek information from content experts. As discussed throughout this article, there are a number of ways radiologists can embrace social media to improve the patient experience. By becoming more discoverable, curating desperately wanted information, engaging with patient communities, and producing findable content, radiologists can take the lead in embracing this contemporary form of patient-centric communication and information exchange. TAKE-HOME POINTS -




Social media profiles can aide in improving the information patients find online about physicians and are often listed preferentially in Google search results. Social media platforms may be a way radiologists can improve interactions with online patient communities. Patients are increasingly seeking access to the peerreviewed literature. Social media can serve as a platform for radiologists to curate and interpret this information for patients. The Radiology Hashtag Ontology can help organize social media content for patients seeking topicspecific information.

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