August 2013

Can Social Media Data Find a Place in EHRs?
By Juliann Schaeffer
For The Record
Vol. 25 No. 11 P. 10

There’s a wealth of information to be gleaned, but several hurdles need to be leapfrogged.

Social media technologies and their popularity have exploded in the past decade, and it’s not just patients who are getting in on the action. Physicians and health care organizations alike are increasingly utilizing text messaging, Twitter, Facebook, and other social media technologies in an effort to explore their potential benefits.

It’s a wise strategic move, according to the PricewaterhouseCoopers (PwC) 2012 Health Research Institute report that found health care organizations that “ignore the virtual environment could find themselves losing customers to competitors that do use social media to listen to and engage with consumers.”

Thus far, most of the research in this area has focused on social media technologies as marketing tools, a way to listen to what patients are saying about their experiences and engaging them. “[In the PwC research paper], we gave examples of how hospitals are using social media, and they are not limiting their imaginations to just marketing and listening to people’s feedback about the company; they are starting to think about how to use social media for services and other aspects of their business,” says John Edwards, a PwC spokesperson and director in the Healthcare Strategy & Healthcare Business Intelligence Practice.

Edwards cites a 2012 research statistic from the Hospital Social Network List that shows more than 1,200 US hospitals now are using social media sites, a 30% increase from the previous year. “That is a pretty significant trend toward adopting social media, so it would suggest that hospitals are finding uses for social media as part of their strategies, and that it’s a growing trend,” he says.

But what about taking social media one step further and using it as a health record tool? What benefits could be seen from including social media exchanges in the patient record, and would such benefits override the obvious—and not-so-obvious—obstacles that arise?

A Place in the EHR?
Social media and health care experts seem to agree that social media exchanges could add important and interesting information to the care process, but where exactly this information fits in—and how to go about incorporating it—is up for debate.

Jared Rhoads, senior research specialist with CSC’s Global Institute for Emerging Healthcare Practices, says hospitals could benefit from exploring the possibility of including social media exchanges in the EHR, “but the key word here is ‘exploring’,” he says. “It stands to reason that there are tremendous opportunities for hospitals to tap into social media tools in order to get patients to become more engaged in their care. Information and data that are obtained or generated as a result of these interactions have a valid place in the patient record—as valid as nearly any other self-reported piece of information. But this is also relatively uncharted territory, and so best practices have not been widely established.”

Rhoads says incorporating social media interactions into the patient record can enhance care management, patient adherence, and even patient safety. “For instance, caregivers could learn more about how a patient is feeling, how a patient is responding to a new medication, and whether a patient is adhering to a certain care plan,” he notes.

Deborah Kohn, MPH, RHIA, FACHE, CPHIMS, principal of Dak Systems Consulting, who presented “The Impact of Social Media on the Integrity of Patient Record Information” at AHIMA’s November 2012 Data Integrity Summit, also likes the idea. “I truly believe that social media exchanges must be part of the patient’s record,” she says. “The next-generation computing platform will be—in many instances, already is—a social media-based platform. In other words, all Web-based applications will have the easy-to-learn look and feel of Facebook, LinkedIn, and Twitter webpages with walls, timelines, etc.”

Kohn notes that Practice Fusion already has incorporated social-media-style messaging for physician-to-physician communication into its EHR.

According to Christina Thielst, FACHE, vice president of patient experience consulting group TOWER and an expert on social media in health care, whether these exchanges should eventually end up in the patient record depends on where the information in question currently resides and how it relates to the care continuum. “I do believe communications and conversations that take place on social technologies can be made part of the patient record if they are part of care and treatment processes,” she says. “But these technologies need to be an integrated part of the organization’s entire communication and patient engagement strategy. Keep in mind, the official patient record documents the information gathered during the treatment episode.”

Thielst says that in addition to social technologies such as text messaging, blogging, social networking, and avatars being easy to use and familiar to consumers, they “are also convenient, engaging, and efficient for facilitating communication and scaling to accommodate population health needs.

“This isn’t to say that a doctor should have some communication with a patient on Facebook and then download the exchange into the health system/hospital’s record,” she adds. “For certain conversations, it may be appropriate for physicians to reference what they learn from these conversations, just as they might if [a conversation was] conducted in the grocery store aisle or at a cocktail party—unless a provider [were to someday] extend their treatment episodes to social media channels like Twitter and Facebook.”

Challenges Abound
PwC strongly supports the idea of building a more complete patient record through social media data, according to Edwards. “I think that some aspects of social media, such as self-reported conditions and outcomes associated with being on certain treatment protocols, could be really useful and interesting to have available,” he says.

While the idea may have promise, Edwards isn’t sure whether the EHR is the best place for that information. Many clinicians would likely balk at that possibility, at least given the lack of controls that can come with this type of information. “The idea of including social media content as part of the electronic health record would probably get some significant resistance internally from a hospital’s clinicians,” he says.

“The EHRs that have been built have focused on gathering data that exist within the hospital and making that information accessible to the doctor that needs to care for that patient,” Edwards continues. “And they’ve created vehicles by which they could gather other trusted information, from other hospitals and other doctor offices, and have that information available electronically.”

However, he notes patients in the Internet Age often come to office appointments armed with information—as well as misinformation—about their health care conditions. And unless there’s a clear way to distinguish highly controlled information from questionable data, Edwards says many clinicians likely will fight against its inclusion in the EHR.

Rhoads also views the possibility of including inaccurate information as a roadblock, although he believes it’s manageable and worth the effort. “Certainly, there is a risk of false or inaccurate data finding their way into the patient record and presenting a skewed picture of what is going on with a patient’s health,” he says. “Data extracted from social media interactions need to be segregated and stored with that context in mind.”

The information should be supplemental in nature and never viewed as replacing or overriding data obtained directly through inpatient visits and other face-to-face interactions. “This is the bare minimum needed for quality control,” Rhoads notes.

Managing the inherent risks related to sharing social media information comes down to policy, Rhoads says. “Risks like privacy, security, and liability can be managed, but it means starting from scratch and designing policies that are suited specifically to your institution and then making sure that you’ve adequately trained everyone on them,” he says.

Edwards believes privacy concerns aren’t onerous because social media exchanges are a form of public information. “I don’t believe that the use of social media is PHI [protected health information]; it’s not personal health information that only you have as the physician,” he says. “It’s information that people are freely disclosing online.”

However, not everyone may be aware that is the case. “I don’t think that everyone who discloses and uses social media tools carefully reads all of the authorizations that they’re giving when they use a site,” Edwards says. “And I think it might cause concerns from a public that’s been informed but is not completely aware of thinking that way about their information and its use.”

Bryan Vartabedian, MD, a pediatric gastroenterologist at Texas Children’s Hospital/Baylor College of Medicine who blogs at www.33charts.com, says integration and workflow issues are even bigger obstacles to including social media data in EHRs. “One big challenge that we’re facing with the integration of these new technologies into our current workflows as physicians is the fact that many of our EHRs are really not amenable to building in these sorts of applications,” he says. “While patient-specific exchanges on public platforms are strongly discouraged, such encounters would be practically impossible to integrate into the EMR.”

There also are legal ramifications to consider. “Similar to e-mail messages, every tweet, blog post, blog comment, text message, and wall entry you and/or your organization colleagues upload—and every one you and/or your organization colleagues receive—is a piece of content that, theoretically, should be reviewed and managed to ensure control, decorum and, perhaps, regulatory and records compliance,” Kohn says. “For example, an individual social network status update or a tweet might not rise to the level of a record, but a protracted discussion on a particular topic over a given period on someone’s wall or via Twitter might qualify.”

Rhoads agrees: “One big legal ramification is that, as an industry norm, doctors are responsible for information to which they have ‘reasonable access.’ If patients start reporting emergency-type problems through inappropriate channels because they mistakenly believe that those channels are being monitored 24/7, then there could be some painful legal experiences, not to mention potentially tragic clinical outcomes. This is why it is important to move steadily but deliberately, with full knowledge and participation of the organization’s legal experts and with proper training all around.”

How Would It Work?
For the most part, speculation is the name of the game when looking at how social media exchanges may be incorporated into EHRs. However, there are a few possibilities to consider.

Vartabedian envisions a future in which EHRs will have built-in social elements to allow for physician-patient communication in a HIPAA-compliant, private venue. “I can imagine five years from now coming out of an exam room and going to a screen, on my left having an EHR and on my right having a Twitter-type screen where, while I’m sitting there, a pediatrician I work with sends me a message about a patient in his office,” he says. “I quickly message back about what he should do, and that message is then tagged to the patient so that it goes directly to the EHR. Then the next time that patient is in the office with me, it’s part of the record.

“I think that these public tools that we’re using right now such as Facebook and Twitter probably are not appropriate for doctor-patient interaction, but I think that tools similar to these will likely evolve into our EHR and are actually already under development,” Vartabedian adds. “I think that’s where we’re headed.”

Rhoads sees hospitals first experimenting with specialized, specific situations to test the idea’s feasibility. “You don’t roll out a new initiative to allow every patient in your community to feed their medical record with Twitter updates, but maybe you’d like to develop a special mobile app for just a certain subset of oncology patients to enter in information remotely,” he says. “Or, to take a real-world example, the University of Iowa Children’s Hospital tapped into the popularity of Facebook to address a growing problem of medication adherence among teenage kidney transplant patients. They put out a mobile app that was populated with information from the EHR on patients’ medications and dosage instructions, and allowed patients to get reminders through a custom and private Facebook page.”

According to Edwards, data analytics is central to the issue of how social media information can be utilized in patient records. “It’s not just about getting the raw data; it’s about figuring out how to interpret it and apply it to your business,” he explains. “By having the right algorithms in place, you could interpret signals from the raw data from social media sites that would be of value in an electronic health record, possibly something that said a person was activated and ready to take action in their health condition based upon the flags that we’re seeing about what they’re talking about—their activity of investigating a gym, for example. There could be signals that could be captured and turned into meaningful information for the clinician.”

Moving Forward
Judging by the 30% increase in the number of hospitals using social media and the fact that 50% of health care providers use social media, the technology definitely is making a dent in the industry, says Edwards, who’s unsure if the trend will extend into the EHR world. “Time will tell,” he says.

“As with other types of data,” he continues, “maybe it’s baby steps. Maybe there are ways to think about select information harvested through a social media vehicle that would be useful. I think it would require prioritization and thinking carefully about what subsets make sense to enhance that business process. And I don’t think it would be every time a person chats about their condition online or their experience with a physician’s office. But I do believe that the idea of how social media could complement the patient experience—and the physician experience—is viable and will happen in the near future.”

Thielst says the question of whether to include social media information in the EHR may be answered on a case-by-case basis, based on what is relevant to the patient’s care. “[Either way] we need to figure that out,” she says, “and now is a good time to start thinking it through because it is coming.”

From a legal and eDiscovery perspective, Kohn advises organizations to ask themselves the following questions: Does the social media content document a transaction or a care decision? Could the content be subject to requests for disclosure, subpoena, and eDiscovery?

No matter the challenges, Vartabedian says it would be wise to take advantage of social media’s winning attributes: “We have this amazing technology. We need to find ways to integrate it into the physician workflow, into the EHR. I think it’s going to have remarkable results.”

— Juliann Schaeffer is a freelance writer and editor based in Allentown, Pennsylvania.