The Federation of State Medical Boards (FSMB) recently released new guidelines for health care providers regarding the use of social media, in the interest of protecting patient privacy and personal boundaries. The guidelines, developed by the FSMB's Special Committee on Ethics and Professionalism, point out that despite the potential of social media for patient care, that potential must be reached within the “proper framework of professional ethics.”
The Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice provide guidance to the FSMB membership with regard to the use of electronic and digital media by physicians (and physician assistants, where appropriate) that may be used to facilitate patient care and nonprofessional interactions. Such electronic and digital media include, but are not limited to, e-mail, texting, blogs and social networks.
These guidelines are meant to be a starting point for the discussion of how physicians should properly communicate with their patients using social media. These guidelines will need to be modified and adapted in future years as technology advances, best practices emerge, and opportunities for additional policy guidance are identified.
QuantiaMD surveyed more than 4,000 physicians and reported in September 2011 that 87 percent use a social media website for personal use and 67 percent use social media for professional purposes. In addition, there is evidence that physicians connect with patients through social media websites. Research indicates that 35 percent of practicing physicians have received friend requests from a patient or a member of their family, and 16 percent of practicing physicians have visited an online profile of a patient or patient's family member.
Social media use presents several challenging questions for administrators and physicians, such as where the boundary of professionalism lies, and whether work experiences can be shared without violating the privacy and confidentiality of patients. One meta-analysis of physician blogs found that nearly 17 percent included enough information about patients for them to be identified.
most physician licensing authorities in the United States have reported incidents of physicians engaging in online professionalism violations, many of which have resulted in serious disciplinary actions. In a 2010 survey of Executive Directors at state medical boards in the United States, 92 percent indicated that violations of online professionalism were reported in their jurisdiction. These violations included Internet use for inappropriate contact with patients (69 percent), inappropriate prescribing (63 percent), and misrepresentation of credentials or clinical outcomes (60 percent). In response to these violations, 71 percent of boards held formal disciplinary proceedings and 40 percent issued informal warnings. Outcomes from the disciplinary proceedings included serious actions such as license limitation (44 percent), suspension (29 percent), or revocation (21 percent) of licensure.
The FSMB has developed this policy to encourage physicians who use social media and social networking to protect themselves from unintended consequences of such practices and to maintain the public trust by:
- Protecting the privacy and confidentiality of their patients
- Avoiding requests for online medical advice
- Acting with professionalism
- Being forthcoming about their employment, credentials and conflicts of interest
- Being aware that information they post online may be available to anyone, and could be misconstrued
Appropriate Physician-Patient Relationship
The physician-patient relationship can begin without a personal encounter, which allows for online interactions to constitute the beginning of the relationship. Physicians should remember that when using electronic communications they may be unable to verify that the person on the other end of the electronic medium is truly the patient; likewise, the patient may not be able to verify that a physician is on the other end of the communication. For that reason, the standards of medical care do not change by virtue of the medium in which physicians and their patients choose to interact.
Even seemingly innocuous online interactions with patients and former patients may violate the boundaries of a proper physician-patient relationship. Physicians should not use their professional position, whether online or in person, to develop personal relationships with patients. The appearance of unprofessionalism may lead patients to question a physician’s competency. Physicians should refrain from portraying any unprofessional depictions of themselves on social media and social networking websites.
Parity of Professional and Ethical Standards
To ensure a proper physician-patient relationship, there should be parity of ethical and professional standards applied to all aspects of a physician's practice, including online interactions through social media and social networking sites. Referencing the FSMB House of Delegate’s Model Guidelines for the Appropriate Use of the Internet in Medical Practice, adopted in 2002, physicians using social media and social networking sites are expected to observe the following ethical standards:
Candor: Physicians have an obligation to disclose clearly any information (e.g., financial, professional or personal) that could influence patients’ understanding or use of the information, products or services offered on any website offering health care services or information.
Privacy: Physicians have an obligation to prevent unauthorized access to, or use of, patient and personal data and to assure that “de-identified” data cannot be linked back to the user or patient.
Integrity: Information contained on websites should be truthful and not misleading or deceptive. It should be accurate and concise, up-to-date, and easy for patients to understand. Physicians using medical websites should strive to ensure that information provided is, whenever possible, supported by current medical peer-reviewed literature, emanates from a recognized body of scientific and clinical knowledge and conforms to minimal standards of care. It should clearly indicate whether it is based upon scientific studies, expert consensus, professional experience or personal opinion.
Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice
The following guidelines are recommended for physicians who use social media and social networking in their personal and professional lives.
Interacting with Patients
Physicians are discouraged from interacting with current or past patients on personal social networking sites such as Facebook. Physicians should only have online interaction with patients when discussing the patient’s medical treatment within the physician-patient relationship, and these interactions should never occur on personal social networking or social media websites. In addition, physicians need to be mindful that while advanced technologies may facilitate the physician-patient relationship, they can also be a distracter which may lessen the quality of the interactions they have with patients. Such distractions should be minimized whenever possible.
Discussion of Medicine Online
Social networking websites may be useful places for physicians to gather and share their experiences, as well as to discuss areas of medicine and particular treatments. These types of professional interactions with other physicians represent an ancillary and convenient means for peer-to-peer education and dialogue. One current example is Doximity, a professional network with more than 567,000 U.S. physician members in 87 specialties. Using Doximity, physicians are said to be able to exchange HIPAA-compliant messages and images by text or fax and discuss the latest treatment guidelines and medical news in their specialty.
While such networks may be useful, it is the responsibility of the physician to ensure, to the best of his or her ability, that professional networks for physicians are secure and that only verified and registered users have access to the information. These websites should be password protected so that non-physicians do not gain access and view discussions as implying medical advice, which may be counter to the physicians’ intent in such discussions. Physicians should also confirm that any medical information from an online discussion that they plan to incorporate into their medical practice is corroborated and supported by current medical research.
Just as in the hospital or ambulatory setting, patient privacy and confidentiality must be protected at all times, especially on social media and social networking websites. These sites have the potential to be viewed by many people and any breaches in confidentiality could be harmful to the patient and in violation of federal privacy laws, such as HIPAA. While physicians may discuss their experiences in non-clinical settings, they should never provide any information that could be used to identify patients. Physicians should never mention patients’ room numbers, refer to them by code names, or post their picture. If pictures of patients were to be viewed by others, such an occurrence may constitute a serious HIPAA violation.
At times, physicians may be asked or may choose to write online about their experiences as a health professional, or they may post comments on a website as a physician. When doing so, physicians must reveal any existing conflicts of interest and they should be honest about their credentials as a physician.
Physicians should be aware that any information they post on a social networking site may be disseminated (whether intended or not) to a larger audience, and that what they say may be taken out of context or remain publicly available online in perpetuity. When posting content online, they should always remember that they are representing the medical community.
Physicians should always act professionally and take caution not to post information that is ambiguous or that could be misconstrued or taken out of context. Physician employees of health care institutions should be aware that employers may reserve the right to edit, modify, delete, or review Internet communications. Physician writers assume all risks related to the security, privacy and confidentiality of their posts. When moderating any website, physicians should delete inaccurate information or other’s posts that violate the privacy and confidentiality of patients or that are of an unprofessional nature.
To use social media and social networking sites professionally, physicians should also strive to adhere to the following general suggestions:
- Use separate personal and professional social networking sites. For example, use a personal rather than professional e-mail address for logging on to social networking websites for personal use. Others who view a professional e-mail attached to an online profile may misinterpret the physician’s actions as representing the medical profession or a particular institution.
- Report any unprofessional behavior that is witnessed to supervisory and/or regulatory authorities.
- Always adhere to the same principles of professionalism online as they would offline.
- Cyber-bullying by a physician towards any individual is inappropriate and unprofessional.
- Refer, as appropriate, to an employer’s social media or social networking policy for direction on the proper use of social media and social networking in relation to their employment.
Medical Board Sanctions and Disciplinary Findings
State medical boards have the authority to discipline physicians for unprofessional behavior relating to the inappropriate use of social networking media, such as:
- Inappropriate communication with patients online
- Use of the Internet for unprofessional behavior
- Online misrepresentation of credentials
- Online violations of patient confidentiality
- Failure to reveal conflicts of interest online
- Online derogatory remarks regarding a patient
- Online depiction of intoxication
- Discriminatory language or practices online
State medical boards have the option to discipline physicians for inappropriate or unprofessional conduct while using social media or social networking websites with actions that range from a letter of reprimand to the revocation of a license.
Ryan Greysen, M.D., co-author of a recently published research letter in the Journal of the American Medical Association focusing on the online behavior of doctors, told Slate, however, that following such directions is often easier said than done.
"Like everyone else, doctors sometimes stumble in their online behaviors and make mistakes in judgment about content they post," he said. "They think they're doing nothing wrong, but unfortunately, the disciplinary responses can be a big deal."
FSMB is not the first entity to offer its input on guiding social media use by providers. Earlier this year, the ECRI Institute published a report outlining ways to mitigate social media risk in healthcare. And last fall, legal resource Avvo published a report on social media tactics for physicians