Blogs, Tweets, Facebook, and Mobile - New IT Resources for Hospitalists
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Management of the Hospitalized Patient
Thursday Workshop | Systems
Blogs, Tweets, Facebook,
and Mobile
New IT Resources for Hospitalists
Russ Cucina, MD, MS
Associate Professor of Hospital Medicine
Medical Director of Information Technology, UCSF Medical Center
Director, UCSF Clinical and Translational Informatics Graduate Program
October 27, 2011
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Disclosures
• Many, many commercial products will be
discussed throughout this talk
• I have no financial interest in any of them
2
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
This talk will contain live demos
• No live demo goes unpunished
Resistentialism - inanimate objects possess
intentional resistance to human beings in
proportion to our urgency that they function
on our behalf, or the size of the audience
3
http://www.youtube.com/watch?v=6ILQrUrEWe8
“Did You Know? Globalization & The Information Age”, by Karl Fisch, Jeff Brenman, and Scott McLeod 4
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Workshop Agenda
• Part I : Social Media for Hospitalists
– Blogs and Blogging
– Facebook
– Ozmosis and Sermo
– LinkedIn
– Twitter
• Part II : Mobile and Networked Resources
– Clinical Uses of Email
– Mobile Applications
– Google Voice
– ChaCha
5
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs and Blogging
• Blog – a web page featuring periodic,
brief, and usually informal writings
– may be focused around a particular topic
– may be intended for a general audience
(strangers) or a specific group (your patients,
your friends and family)
WachtersWorld.com
6
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs and Blogging
• An independent online columnist
• Interesting if you have the time
• Very often advocate a position or point of view
• Often very specialized
• Excellent for awareness, less useful for a
complete understanding
7
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs and Blogging
• Do you blog?
• Why?
• How much time do you invest?
8
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs and Blogging
• Some prominent health care blogs
– Wall Street Journal Health Blog
blogs.wsj.com/health
– President’s Health Care Reform Blog
my.barackobama.com/page/content/hqblog
– The Health Care Blog
www.thehealthcareblog.com
– Wachter’s World
www.wachtersworld.com
– Dr. Gupta (CNN)
pagingdrgupta.blogs.cnn.com
9
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs and Blogging
• Do you regularly read a blog?
• Crowd favorites?
• What activity has this displaced?
10Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
Are you on Facebook?
11Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
• A web application where
• you share information about yourself –
thoughts, photos, “status updates” – to a
selected group of people, your “friends”
• you view and comment on information
shared by others
• Why would you do this?
12Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
• For personal use
• Keep up with distant relatives and friends
• Maintain close contacts particularly when
busy
• Creative expression
http://www.facebook.com/rjcucina/
13Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
• Wow, TMI ! What about privacy?
• Extensive privacy controls to limit who can see
what, by group or individual person
• Tremendous opportunity to make terrible
public mistakes that will haunt you forever,
if used incorrectly or injudiciously
• “Facebook Suicide”, similar to Career Suicide
• Spawned www.lamebook.com
14Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
• University of Florida School of Medicine study
• 44% of medical students on Facebook
• Only 37% made their entries private
• > 50% shared their sexual orientation
• 58% shared their relationship status
• 50% shared political opinions
15Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
University of Florida School of Medicine study
• 10 randomly selected profiles
• 7 had photos showing alcohol consumption
• 5 implied excessive drinking
• 3 students had joined groups that were either
flagrantly sexist or racially charged
16Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
Chretien et al., JAMA 2009
• Survey of all AAMC medical schools, 60%
response rate
• 60% students posting unprofessional content
• 48% frankly discriminatory language
• 39% depictions of intoxication
• 38% sexually suggestive material
• 13% violations of patient confidentiality
Chretien et al. Online Posting of Unprofessional Conduct By Medical Students.
JAMA 23 Sept 2009, 302(12) 1309 - 1315
17Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
• Survey of all AAMC medical schools, 60%
response rate
• 30 had given informal warnings
• 3 had dismissed a student
• Only 38% have policies
• 11% actively developing
Chretien et al. Online Posting of Unprofessional Conduct By Medical Students.
JAMA 23 Sept 2009, 302(12) 1309 - 1315
18Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
Sound Advice:
“When you’re young, you know, you make
mistakes and you do some stupid stuff. I want
everybody here to be careful about what you
post on Facebook, because in the YouTube age,
whatever you do will be pulled up again later
somewhere in your life. That’s number one.”
The President of the United States
September 8th, 2009
Speaking to a group of 9th graders
at Wakefield High School, Virginia
19Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
So again, why would you do this?
• Extensive privacy controls to limit who can see
what, by group or individual person
• Safe and effective, if you use common sense
• Very effective at maintaining the strength of social
ties, particularly to distant people
20Facebook Demographics
Not just for kids
Fastest growing demographic:
Women over the age of 55
Source: iStrategyLabs 21Facebook Demographics
Not just for kids
only 12% teenagers
45% age 26+
22% age 35+
Source: InsideFacebook.com 22Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
For professional use
• Puts your practice or institution where the people are
http://www.facebook.com/pages/San-Francisco-CA/Russ-Cucina-MD-MS/
23Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
For professional use
• Many companies, health care institutions, and
groups are on Facebook
Mayo Clinic http://www.facebook.com/MayoClinic
Kaiser http://www.facebook.com/kpthrive
SHM http://www.facebook.com/Hospitalists
UCSF Medical Center
http://www.facebook.com/pages/UCSF-Medical-Center/116800315034746
24Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
Images courtesy Vince Golla, Kaiser Health Foundation
vincegolla@kp.org
25Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Facebook
For professional use
• How valuable is this for a Hospitalist Group?
• For recruitment
• For marketing, where applicable
• For community and hospital relations
Is your group or institution using it,
or planning to?
26Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
LinkedIn
• Strictly professional, limited functionality
networking site
• An enhanced online CV and the ability to link, give
references, and message LinkedIn
27Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
LinkedIn
• Very popular
• A useful way to create a professional, low-
maintenance web presence for yourself
• Used for the same reasons any real-world
professional network is used
• Extended features for recruiters and HR departments
• Who is on LinkedIn?
• Any success stories?
28Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Ozmosis and Sermo
• Social networking sites limited to US physicians
• Sermo is anonymous, Ozmosis fully identified
• Sermo has collaborations with Pharma
• Run cases by other physicians
• Online grand rounds
• Online journal club
• Anyone using these?
1 May 2009
29Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Twitter
Who is Tweeting?
30Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Twitter
• A web and mobile service where
• you send messages of 140 characters or
less that are viewed by your “followers”
• Essentially multi-point text messaging
• you “follow”, and therefore view, messages
from others
• Everything is completely public
• Why would you do this?
31Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Twitter
• Mass, high-frequency, low-content socializing
• Mass public contact, e.g. celebrities, news
outlets, or public agencies
• often with imbedded web links
32Twitter Demographics
Not just for kids
10% teenagers
47% age 35+
Source: Quantcast.com 33Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Twittering Hospitals
634 US Hospitals are broadcasting on Twitter1
• Dr. Sanjay Gupta, CNN, sanjayguptacnn
• Gwenn O’Keefe, MD, drgwenn
• Jennifer Shu, MD, livingwelldoc
• CDC, cdcemergency, cdcflu, and cdc_ehealth
• American College of Emergency Physicians (ACEP),
emergencydocs
• The President of the United States
• barack_obama
1 August 2010
34Hospital Social Networking Accounts
Data as of 6/2011
Slide courtesy of Ed Bennett, Director of Web Strategy
University of Maryland Medical System, http://ebennett.org/Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Twitter
• Short, ephemeral nature of tweets define
your audience as people who spend a lot of
time looking at a screen
• As a tweet-er, you have to be very connected
and interested in frequently tweeting
• 60% of Twitter users drop out in < 1 month
• Would a Hospitalist or Hospitalist Group
have any use for Twitter?
36Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Twitter
Images courtesy Vince Golla, Kaiser Health Foundation
vincegolla@kp.org
3738
Source: Gartner
39Source: Gartner
40Clinical Uses of Email
• Do you email your patients?
• Do you email colleagues
about patients?
– Primary MDs about admit &
discharge
– Hospitalist colleagues with
handoffsIs it legal? The HIPAA Security Rule Not the same as the more familiar HIPAA Privacy Rule “ There is not yet available a simple and interoperable solution to encrypting e-mail communications with patients. As a result, we decided to make the use of encryption in the transmission process an addressable implementation specification. ” 45 CFR § 164.312(e)(1) Federal Register 20 Feb 2003; 68(34) p 8357
Is it legal? The HIPAA Security Rule What is an addressable specification? • You are required to formally study the feasibility • You are required to implement it, or to document in writing why you concluded it was infeasible
Is it legal? The HIPAA Security Rule “ Covered entities are encouraged, however, to consider use of encryption technology for transmitting electronic protected health information, particularly over the Internet. ” “ Where risk analysis shows such risk to be significant, we would expect covered entities to encrypt those transmissions ” 45 CFR § 164.312(e)(1) Federal Register 20 Feb 2003; 68(34) p 8357
Is it legal? The HIPAA Security Rule “ Three commenters asked for clarification and guidance regarding the unsolicited electronic receipt of health information in an unsecured manner, for example, when information was submitted by a patient via email …. The manner in which electronic protected health information is received … does not affect the requirement that security protection must subsequently be afforded to that information by the covered entity once that information is in possession. ” 45 CFR § 164.312(e)(1) Federal Register 20 Feb 2003; 68(34) p 8357
Is it legal? The HIPAA Security Rule
Probably not
Penalty for your first HIPAA violation :
$50,000 fine and/or 1 year in prison per disclosure
42 USC § 1320(d)(6)There is no such thing as “consent” to
HIPAA-violating communications
• Does not matter if the patient started the
conversation
• Does not matter if the patient thinks it is OK
1. Names 10. Account numbers
2. Geography smaller than State 11. Certificate/license numbers
3. All elements of dates except year 12. Vehicle identifiers and license plates
3.1 Age 13. Device identifiers and serial numbers
4. Phone numbers 14. URLs
5. Fax numbers 15. IP addresses
6. Email addresses 16. Biometric identifiers
7. SSNs 17. Full face photographs
8. Medical record numbers 18. Any other unique identifying number,
9. Health plan numbers characteristic, or codeWhat to do?
Do not send protected health
information over unsecured email, ever
1. Names 10. Account numbers
2. Geography smaller than State 11. Certificate/license numbers
3. All elements of dates except year 12. Vehicle identifiers and license plates
3.1 Age 13. Device identifiers and serial numbers
4. Phone numbers 14. URLs
5. Fax numbers 15. IP addresses
6. Email addresses 16. Biometric identifiers
7. SSNs 17. Full face photographs
8. Medical record numbers 18. Any other unique identifying number,
9. Health plan numbers characteristic, or codeWhat to do?
Using a third party commercial email
service constitutes disclosure to that
third party
• PHI on Gmail = unauthorized disclosure to Google, Inc.
• PHI on Yahoo mail = unauthorized disclosure to Yahoo, Inc.
• PHI on Hotmail = unauthorized disclosure to Microsoft, Inc.Clinical Email Do not send protected health information over unsecured email, ever Preferred Solutions 1. Keep your clinical email inside your EMR 2. Use only your institution’s secure email If your institution doesn’t offer secure email, it needs to. Bad things really happen.
Clinical Email Do not send protected health information over unsecured email, ever Less preferred – solving this yourself
What is the weakest link in any
information security solution?
The Human BeingsFrom the collection … The signout is attached. Russ encrypted it for HIPAA. The password is ‘morphine’.
From the collection … Screw HIPAA. Here is the signout. Jones, Robert MRN 05144100 54 y/o male with HIV, p/w …
Mobile Clinical References • Predate iPhone “apps” by 10+ years, iPhone has enlarged the audience • Electronic textbooks − Convenient form factor − Potential to be more frequently updated • Structured calculators • Interactive patient education
Hundreds of Offerings
… buyer bewareThe two leading pharmacopoeia
applications
ePocrates
free
very widely used
space hog
contains targeted advertising
!! collects and sells usage data
Available for Android, Blackberry, Palm, Windows Mobile, and iPhoneThe two leading pharmacopoeia
applications
Tarascon
not free ($40/year)
not widely used
not a space hog
no advertising
doesn’t collect use data
Available for Blackberry, Palm, Windows Mobile, and iPhoneThe two leading pharmacopoeia
applications
ePocrates Tarascon
free not free ($40/year)
very widely used not widely used
space hog not a space hog
contains targeted advertising no advertising
!! collects and sells usage data doesn’t collect use data
Both are extremely useful and you should try one if
you have notePocrates and your Privacy • I have been talking about ePocrates’s privacy policy since 2006 • Last year at this time, I received the following From: Morgenstern, Erica To: Cucina, Russ Subject: Social media presentation Hello Dr. Cucina, I saw a copy of your social media presentation. It was fantastic with a lot of great information. I did want to make one point of clarification. Please rest assured that Epocrates does not sell individual physician information to pharmaceutical companies. We take the privacy of our subscribers very seriously and would not compromise the integrity of our products. Please refer to our privacy policy for more information: http://www.epocrates.com/company/privacy.html I’d also welcome you to meet with an Epocrates executive to discuss any questions or product suggestions. We welcome the feedback and appreciate the opportunity to learn from industry leaders. Thank you, Erica Erica Sniad Morgenstern Director, Public Relations and Communications (emphasis added)
ePocrates and your Privacy
From: Cucina, Russ
To: Morgenstern, Erica
Subject: RE: Social media presentation
Erica –
[…]
I appreciate the opportunity to learn more about your privacy practices. You state that “Epocrates does not sell
individual physician information to pharmaceutical companies”. However, your Privacy Policy does not exclude this
possibility, and indeed appears to carefully allow it.
Your Privacy Policy promises the following:
Please note that WE DO NOT SELL PERSONALLY IDENTIFIABLE INFORMATION about your use of
Epocrates products to any third parties, including Pharmaceutical Companies, HMOs or others. [ … ]
"Personally identifiable information" is any information that can be used to identify, contact or locate
you as an individual, as well as any additional data tied to such information. [ … ]
Non-personally identifiable information is information — either in "profile" or "aggregate" form —
that, in contrast, is not intended to identify you as an individual. For instance, we may store a profile
of an oncologist in New York without linking this information to a name, address, or other
personally identifiable information.
Your prohibition against selling information is emphatic about “PERSONALLY IDENTIFIABLE INFORMATION”,
and its narrow definition. Your Privacy Policy permits Epocrates to sell a user’s individual profile information to a
pharmaceutical company, including attached to a unique identifier, as long as that unique identifier is not tied back
to my real-world identity.
(emphasis added)ePocrates and your Privacy
This introduces at least two privacy concerns. First, it allows me to be targeted through Epocrates for advertising,
for example, as a unique individual based on information collected by Epocrates, even if the targeting entity doesn’t
know my real-world identity. Secondly, real-world identities are surprisingly easy to reconstruction from
“anonymized” data, particular in small-bin situations. How many Oncologists are there in Wyoming? It would likely
be trivial to reconstruct their real-world identities based on the information your Privacy Policy allows to be sold.
The two statements about Epocrates on this subject in my presentation read as follows:
X contains targeted advertising
!! collects and sells usage data
Having re-read your privacy policy, I find these statements reinforced rather than refuted. Please let me know if you
disagree.
Thank you,
Russ CucinaePocrates and your Privacy From: Kania, Stephen [mailto:skania@epocrates.com] To: Cucina, Russ Subject: RE: Social media presentation Dear Dr Cucina, The e-mail thread (included below) between you and Erica Morgenstern has been forwarded to me for comment. […] I can assure you that we at Epocrates take privacy very seriously and do go to considerable effort to take into account the very types of consideration that you raise. For example, our analytics group have policy, procedure, and algorithms in place to eliminate cells from datasets where the sample size falls below a threshold that might theoretically allow for re-identification (as in your theoretic example of oncologists in Wyoming). This is consistent with the requirement of our privacy policy that we not disclose “any” information which could lead to identifying a user as any individual. I hope that the above allays any concerns you might have. Thank you for support of our products and for the constructive feedback. Best regards, //Steve// Stephen Kania, MD VP, Medical Information (emphasis added)
ePocrates and your Privacy So what does it mean? • ePocrates is keeping a personal profile of your individual use of its application • ePocrates sells your personal profile, minus the ability to identify you, to third parties • ePocrates uses your personal profile to target you with ads • ePocrates has “policy, procedure, and algorithms” (NOS) to prevent reidentification
ePocrates and your Privacy
Does this bother you?
Only you can decide
My personal take
• I am mildly bothered by the practice
• I am much more bothered by its obscurity
(in my opinion)The Sanford Guide • Has both iOS and Android versions for $30 Better than the book ($17) in my opinion
Up To Date online www.uptodate.com Are textbooks obsolete? extremely popular complete and updated often well-written practical (to a fault?) very expensive $500 first year $400 / yr thereafter “So, we looked it up on Up To Date, and…”
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Google Voice
• The Almighty Goog reinvents your telephone
– A central Google Voice telephone number to receive
all of your calls
– Rule-based routing of calls to one or more physical
phones or directly to voicemail
– Automated transcription of voicemail, and optionally,
text-paging of those transcripts
https://www.google.com/voice/
68Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Google Voice
• Not for clinical use!
– Disclosure of PHI to Google is a HIPAA violation
• Useful if you have a multi-site work life, travel
frequently, or do not otherwise have access to
a “business” phone number
• Some sites are pursuing a Business
Associates Agreement (BAA) with Google to
permit clinical use
69Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Cha Cha (242 242)
• Who has a cell phone with an
SMS plan?
• Ask any question you can fit in 160 characters,
and can be answered in 160 characters
70What is the street address of the Fairmont Hotel in San
Francisco?
71< 1 minute
What is the street address of the Fairmont Hotel in San
Francisco?
Fairmont Hotel San Francisco, 950 Mason St, San
Francisco, CA 94108
72Who coined the term “Hospitalist"?
732 minutes later
Who coined the term “Hospitalist"?
Dr Lee Goldman and Dr. Bob Wachter coined the term
"hospitalist" in the August 1996 issue of the New England
Journal of Medicine.
74What is the starting dose of hydrochlorathiazide for
treatment of hypertension in an elderly patient with normal
kidney function?
752 minutes later
What is the starting dose of hydrochlorathiazide for
treatment of hypertension in an elderly patient with normal
kidney function?
The recommended starting dose of hydrochlorothiazide
for treating high blood pressure is hydrochlorothiazide
25mg once daily. *Txt GIFTMENU 4 Gift Ideas!
76What are the indications for Xigris?
77< 1 minute later
What are the indications for Xigris?
Xigris(r) is indicated for the reduction of mortality in adult
patients with severe sepsis who have a high risk of death
78Which is superior for advanced coronary atherosclerosis:
coronary artery bypass grafting, angioplasty with stenting,
or medical management?
794 minutes later
Which is superior for advanced coronary atherosclerosis:
coronary artery bypass grafting, angioplasty with stenting,
or medical management?
Combined coronary artery bypass grafting and coronary
endarterectomy is associated with good long-term
outcomes. Thank u 4 using ChaCha!
80Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Cha Cha (242 242)
What the heck?
• Actual human beings are receiving the text
messages and being paid 20¢ per question to
answer
• Free to you but includes the in-line advertising
• Limit per interval of time (NOS) on questions
81Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Cha Cha (242 242)
What the heck?
• Useful when you have forgotten an address or
telephone number
• Obviously not a health care application
82Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Blogs, Tweets, Facebook, and Mobile : New IT Resources for Hospitalists
Workshop Agenda
• Part I : Social Media
– Blogs and Blogging
– Facebook
– Ozmosis and Sermo
– LinkedIn
– Twitter
• Part II : Mobile and Networked
– Clinical Uses of Email
– Mobile Applications
– Google Voice
– ChaCha
83Management of the Hospitalized Patient
Thursday Workshop | Systems
Blogs, Tweets, Facebook,
and Mobile
New IT Resources for Hospitalists
Questions and
Discussion
October 27, 2011Management of the Hospitalized Patient
Thursday Workshop | Systems
Blogs, Tweets, Facebook,
and Mobile
New IT Resources for Hospitalists
Thank you!
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