Compared to other industries, the medical profession has been late in recognizing the many benefits of social media. In the past few years, it has entered into an uneasy relationship with the new medium.

On the one hand, social media can be a tool to motivate patients to be more active participants in their healthcare. In specialties like oncology, where having a strong support group is sometimes as important to recovery as treatment, social media has created invaluable communities for information and encouragement.

However, because of confidentiality rules in the Health Insurance Portability and Accountability Act (HIPAA) and potential medical-legal repercussions, the medical community must be cautious when engaging with social media. Healthcare is a profession that is dependent on establishing trust and credibility—and social media has the potential to undermine a strong reputation built over years with one careless post or tweet.

Social media is broadly defined and includes many forms of electronic communication through which users create content for public dissemination. Beyond direct interaction with patients, physicians use social media to collaborate with other physicians and for marketing purposes. Physicians in many of the more elective specialties have embraced social media marketing to set themselves apart in the competitive market.

With the plethora of social media platforms available, it is easier than ever to communicate with patients. If a patient sends a friend request to his or her physician through Facebook, the physician may feel pressured to accept the request. But by doing so, the physician is potentially giving the patient access to personal posts, contacts, and pictures—despite privacy controls, it takes constant vigilance to completely separate one’s professional and personal life online.

Those who advocate for physicians interacting with patients through social media are quick to point out that social media is bringing back the days when patients had a personal relationship with their doctor. With the limited time that physicians have to spend with patients in the exam room, interacting with patients through social media might be seen as a way of strengthening the physician-patient relationship. However, liability can result from blurring professional and personal boundaries. In a profession where objectivity is paramount, having a personal relationship with the patient may compromise professional judgment.

Communication with patients either directly or en masse through social media also may lead to HIPAA violations if protected health information (PHI) is revealed online. Penalties for data breaches were increased under the American Recovery and Reinvestment Act. PHI in electronic form must be encrypted to ensure security, but the majority of social media platforms are not capable of encryption. Although the patient may identify himself or herself on social media as a patient of the practice, the physician is held to a different standard. The physician does not have to disclose the patient’s name to violate HIPAA—posting just a few distinguishing characteristics, which might enable another person to figure out the identity of the patient, could be enough to be a violation in itself.

The Federation of State Medical Boards specifically discourages physicians from “interacting with current or past patients on personal social networking sites such as Facebook.”

 The American Medical Association strongly suggests that physicians distinguish their public and professional digital identities.

Even if the physician is aware of the privacy and security concerns with social media, staff training is important.  A physician’s staff could incur liability on behalf of the practice through unprofessional social media activities that portray patients or the practice in a poor light. Because employees are representatives of the practice, their actions could undermine the patient-physician relationship. Ensure that there is a social media policy that is reviewed with all staff members on an annual basis. The social media policy should discourage employees from engaging with patients on social media and should require that employees not mention patient-related matters on their personal social media sites.

In addition to blurring professional and personal boundaries, social media also can create confusion about when the patient-physician relationship is established. Traditionally, the relationship did not begin until the patient presented for an office visit and a full examination occurred.

However, there are certain social media sites where patients post medical questions about the symptoms they are experiencing. If a physician responds in a manner that may be construed as providing medical advice, a patient-physician relationship may be established. To further complicate matters, if the potential patient is in a different state than the physician, the interaction could be construed as practicing medicine without a license in the state where the patient resides. There is significant variation among state jurisdictions regarding licensing, and the standard of care/scope of practice is determined by the location of the patient, not the location of the physician.

Certain social media sites are intended to facilitate discussions between physicians to share knowledge and information. This can be a useful resource, particularly for cases with rare presentations or for rural areas where specialists are difficult to find. Physician-to-physician collaboration on social media may be a safer use of social media than physician-to-patient engagement, but precautions still must be taken.

The potential for collaboration through social media is vast, and the speed of technology is faster than the legislation that regulates it. Therefore, as a peer or colleague participating in these collaborative forums, each physician should provide a disclaimer that states that the commentary is not to be considered a consultation. HIPAA confidentiality applies when presenting a case or posting a patient scenario, so be sure to sanitize the details of the case to protect the identity of the patient.

With the sophistication of search engines, any commentary posted online can be permanent and searchable. Online communication can be discoverable and used against the physician in the event of a malpractice lawsuit. Ultimately, the physician’s online presence also can be used to establish character or lack of judgment.

Some of the early adopters of social media have used it as an effective marketing tool and have taken a proactive approach by hiring marketing directors to expand their online presence. Consumer review sites such as Yelp and RateMD can promote or dissuade potential patients from physician practices. As some physicians may have experienced, there is a tipping point when, after receiving a certain number of positive reviews, they are more “searchable” online, which can generate more referrals.

The Pew Internet and American Life Project estimates that 8 in 10 Internet users go online for health information, which makes it one of the most popular activities on the Internet.

 Physicians can use microblogging sites or Twitter to educate patients and other followers on health conditions, treatments, and available resources, while strengthening the practice’s online presence.

However, HIPAA privacy rules give individuals control over how their PHI is used and disclosed for marketing purposes. HIPAA rules require an individual’s written authorization before using his or her information for marketing. Additionally, any potential conflict of interest must be fully disclosed, including whether the physician received any form of compensation for mentioning the product or services.

Due to the highly regulated nature of the healthcare industry, physicians who use social media should be aware of the associated legal and regulatory risks. There is no easy answer to whether a physician should use social media or how a physician should use social media. The issue is complicated and should be evaluated on a regular basis.

			Federation of State Medical Boards Special Committee on Ethics and Professionalism. Model policy guidelines for the appropriate use of social media and social networking in medical practice. http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/pub-social-media-guidelines.pdf. Accessed October 6, 2014.

			Fox S, Duggan M. Health online 2013. http://www.pewinternet.org/files/old-media/Files/Reports/PIP_HealthOnline.pdf. Accessed October 6, 2014.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Julie Song, MPH, CPHRM, Patient Safety Risk Manager, The Doctors Company

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