Innovative Technologies Special Series
Physical Therapy 2.0: Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion Emily Knight, Robert J. Werstine, Diane M. Rasmussen-Pennington, Deborah Fitzsimmons, Robert J. Petrella Care for chronic conditions and noncommunicable diseases is dominating health systems around the globe. For physical therapists, this strain presents a substantial opportunity for engaging patients in health promotion and disease management in the years to come. Examples of social media being used to engage consumers in the business landscape are pervasive, and research reports suggest that patients are ready for social media to be incorporated into the way health care systems deliver care. We propose that leveraging the power and utility of existing technologies, such as social media, could innovate the way physical therapists engage patients in rehabilitation and health promotion practices, thus contributing to the evolution of the profession: Physical Therapy 2.0. To continue to be relevant in the community, physical therapist practice must respond to patients’ needs and expectations. Incorporating social media into how physical therapists are both designing and delivering care holds potential for enhancing patient engagement in prescribed health behaviors and improving treatment outcomes. This conceptual article presents the perspective that physical therapists can utilize social media to enhance care delivery and treatment outcomes.
E. Knight, Health & Rehabilitation Sciences, University of Western Ontario, and Rehabilitation & Geriatric Care Research Centre, Lawson Health Research Institute, London, Ontario, Canada. R.J. Werstine, HBA, BSc(PT), MSc(PT), DipManip, DipSport, FCAMPT, Fowler-Kennedy Sports Medicine Clinic at Fanshawe College, London, Ontario, Canada. D.M. Rasmussen-Pennington, PhD, Ashford University, Clinton, Iowa. D. Fitzsimmons, MHSc, PhD, Health Studies, University of Western Ontario. R.J. Petrella, MD, PhD, Schulich School of Medicine & Dentistry, University of Western Ontario, and Aging, Rehabilitation & Geriatric Care Research Centre, Lawson Health Research Institute, 801 Commissioners Road East, London, Ontario, Canada N6C 5J1. Address all correspondence to Dr Petrella at: [email protected]. [Knight E, Werstine RJ, RasmussenPennington DM, et al. Physical Therapy 2.0: leveraging social media to engage patients in rehabilitation and health promotion. Phys Ther. 2015;95:389 –396.] © 2015 American Physical Therapy Association Published Ahead of Print: March 13, 2014 Accepted: March 9, 2014 Submitted: September 10, 2013
Post a Rapid Response to this article at: ptjournal.apta.org March 2015
Volume 95
Number 3
Physical Therapy f
389
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion
L
ife expectancies in developed countries are increasing at a rate of approximately 2 years every decade.1–3 Although people are, and can continue to expect to be, living longer than previous generations, there is a disparity between longevity and healthy, independent living: adults are living longer, but this increased longevity is not matched to fewer years of disability and ill health.4 Global health care systems are progressively being dominated by care for chronic conditions and noncommunicable diseases.5,6 In the coming decades, it is projected that conditions such as cardiovascular disease, cancer, and diabetes will account for more than 50% of disease burden globally.6 As the number of patients continues to grow and health care resources continue to strain, the need to engage patients in self-management of these diseases becomes an essential strategy.7,8 This divergence of demand on and capacity of health care systems presents a substantial opportunity for physical therapists to engage patients in rehabilitation, health promotion, and disease management in the years to come. Patient engagement has previously been operationalized as a means to increase adherence to prescribed health behaviors by initiating treatment regimens that attract and involve patients in the management of their own care.5 The World Health Organization suggests that difficulty engaging patients, especially those with chronic conditions, leads to suboptimal treatment outcomes.9 We propose that leveraging the power and utility of existing technologies, especially social media, could innovate the way physical therapists engage patients in rehabilitation and health promotion practices.
Web 2.0 Web 2.0 is a popularized term that began to surface following the dot390
f
Physical Therapy
Volume 95
com collapse in 2001.10 The term describes the evolutionary framework of the Internet, with a focus on widespread engagement. Web 2.0 is a dynamic platform where content and applications are continuously modified by all users in a participatory and collaborative way.11 It has been suggested that users are more likely to consume health information when they are active participants in the dialogue.12 Therefore, Web 2.0 allows for the creation and exchange of content generated by the users and connects people through an interactive platform.11,13 Creating a “people-powered” health system through the bridging of social and health paradigms may facilitate improved treatment outcomes.1 The inherent dynamic and social nature of Web 2.0 supports its potential for engaging patients in prescribed health behaviors to enhance ongoing care and self-management.5 Social media is a broad descriptor, and platforms can be grouped according to common features. Similar to other authors,11 Knight5 previously reported 5 classifications of social media: (1) blogs, (2) content communities (eg, YouTube, Flickr), (3) collaborative projects (eg, wikis, consumer review sites), (4) social networking sites (eg, Facebook, Twitter), and (5) virtual worlds (eg, Second Life, World of Warcraft). Like other sectors and industries, health care delivery could improve by leveraging existing and emerging social media platforms. Previously, Knight5 explored the evidence base and research opportunities for leveraging these platforms for improved treatment outcomes with patients. The perspective explored in this conceptual article furthers the conversation about engaging patients in prescribed health behaviors using social media by drawing specific attention to the need for research informing best practices to address the gap between physical therapist
Number 3
and patient in health care service delivery, as well as highlighting areas for future research.
Health 2.0 In North America, it has been reported that the majority (range⫽ 60%– 83%) of Internet users seek health information online.11,14,15 Health 2.0 is a popularized term representing the presence of health information in Web 2.0.16 It differs from other technological evolutions in health (eg, eHealth) given its collaborative nature and emphasis on personalized health care.17 The large proportion of people seeking health information online necessitates the involvement of health care professionals, such as physical therapists, in the online dialogue. As consumers, individuals have been attracted to, retained, and engaged in the commercial landscape using social media.15,18 It has been suggested that these individuals, in their roles as patients, are ready for social media to be implemented as a part of their health care delivery.14
Physical Therapy 2.0 Incorporating social media into the way physical therapists both design and deliver care holds potential for engaging patients in prescribed health behaviors. Commentaries discussing the application of Web 2.0 in the practice of physical therapy date back to 2008.19 Social media have been described by physical therapists as a simple medium to reach individuals, answer questions, and educate.20 Building on understandings of Web 2.0 and Health 2.0, we propose that physical therapists can leverage social media platforms to engage in user-generated dialogues with their patient populations, thereby enhancing care delivery models and contributing to the evolution of the physical therapist practice: Physical Therapy 2.0. By extension of previous definitions in the Health 2.0 landscape,17 we concepMarch 2015
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion tualize Physical Therapy 2.0 as the use of Web 2.0 tools and platforms by physical therapists, utilizing principles of user-generated content and collaboration among networks and individuals to personalize health care and promote health education. We consider this approach a means to develop patient engagement in ongoing care, thereby enhancing patient self-management of health and contributing to optimal treatment outcomes.
The Evidence Building on the Experiences in Other Industries Examples of social media in the commercial landscape are pervasive. Social media sites are routinely near the top of the list for most visited websites. At the time this article was written, of the top 500 websites, the social media sites Facebook and YouTube were in the top 3—surpassed only by Google.21 Other social sites in the top 10 include collaborative sites (eg, Wikipedia) and consumerreview sites (eg, Amazon), with various social networking and blog sites (eg, Twitter, Blogspot.com, LinkedIn) rounding out the top 15.21 These data support the intuitive understanding that social media are pervasive in modern North American culture. Yet, the challenge to the health sector is leveraging this popularity to influence health care delivery in a positive and significant way for patients and practitioners. Based on previous literature, how can a health care practitioner engage in the social dialogue in a relevant and meaningful way? In a study comparing images with high versus low relevance on a social media platform (ie, Flickr), there was a statistically significant relationship between highly relevant pictures and both the number of views and number of “favorites” or “likes,” which suggested a relationship among views, favorites, and relevance.22 This inforMarch 2015
mation could be extended to suggest that when information is deemed important online (ie, ranked highly by search engines), there is a strong correlation with it also being viewed and being “favorited” by more site traffic. Moreover, previous work concluded that images displaying positive emotions (eg, happiness) were more likely to be viewed.22 This finding suggests that positive reinforcement through social media may lead to more views of the content posted (ie, user engagement with the content). Additionally, it has been demonstrated in the literature that emotions elicited (eg, happy, funny), impressions aroused (eg, intense, enjoyable), and perceived utility (eg, useful to self, network, or society) through user-generated content factor into an individual’s decision to share the content with others.23 This information about relevance, tags, emotion, utility, and engagement can be used by clinicians to ensure that their participation in the social dialogue is not only high quality but also reliable and relevant to a respective patient population. In turn, this type of participation may also relate to increased engagement by patients with the content. However, it remains to be established whether this increased engagement will lead to better self-management of chronic conditions or improved treatment outcomes for patients. Examples From the Health Sector Despite the abundance of experience with social media in many industries, evidence reporting its utility in the health landscape is only now emerging. Predominantly, the existing evidence base is descriptive and observational, with fewer examples of interventions using social media.24 In an experiment to influence social health policies, a project from the United Kingdom explored
the efficacy of social media tools (eg, blogs, social networking) in conjunction with “viral marketing techniques” to engage end-users and policy makers in health policy development.25 More specifically, the project used blogs with reader comments, Twitter, and online polling to engage the public and showed that social media were a powerful dissemination and discussion forum that may help to enable strategic change in health policies.25 This example illustrates how Web 2.0 tools can be used in the health sector to influence changes to policy that respond to patient and practitioner views. Exploration of content on social media sites, such as YouTube, is progressively becoming more prevalent in the research landscape. Reports describe available social content for specific conditions and disease states (eg, concussion, obesity), health promotion practices (eg, physical activity, smoking behaviors), and communicable disease prevention (eg, vaccination).26 –30 Research to date has suggested that a gap exists between the effort to define best practices for the inclusion of social media in health care design and delivery and the transfer of this information to educate end-users.29 Despite this gap, health care and educational organizations should continue to explore social media platforms for dissemination of evidence-based information and promotion of the health care profession.29,31 Establishing the credibility of information collated through collaborative sites (eg, wikis) is commonly cited as a challenge by practitioners and researchers, yet it has been suggested that individuals may view these media as extensive, useful, and credible sources of information.5,32 Moreover, it has been reported that patients with chronic conditions are
Volume 95
Number 3
Physical Therapy f
391
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion more likely to seek out information through this landscape.12,32 The ability of patients and physical therapists to critically appraise user-generated content to discern which information will improve care delivery and patient-important outcomes in an ethical and evidence-based way remains a challenge. Increased involvement of physical therapists in the social media dialogue may help to populate the landscape with credible information.33 For example, wikis specific to the physical therapy profession exist and provide an opportunity for collaborative sharing of physical therapy–related content. Although such wikis are promoted as having the potential to improve patient care, contribute to global health, and support the practice of physical therapy as well as connect practitioners,34 evidence of these outcomes has yet to be reported. The presence of physical therapist experts in the social media landscape will help to contribute credible, evidence-based information to the online dialogue.
Evolving Physical Therapist Practice Establish Best Practices for Incorporating Social Media It has been suggested that the use of social media in professional practice facilitates meaningful communication with patients, colleagues, and researchers, in part by providing clinicians with an online voice through which the profession may enhance its reputation and share credible health information.20 Recent reports have suggested that the cohorts of physical therapy graduates in the years to come are going to be versed in the use of social media in their educational and personal lives.35,36 However, what remains to be established is how this experience will translate into professional use of social media. Moreover, a previous report20 that largely focused on fundamentals and how-to cautions for 392
f
Physical Therapy
Volume 95
online communication also included valuable insights from practitioners currently engaging with various forms of social media in physical therapist practice, research, and education. The outcomes of these initiatives have yet to be reported and may provide evidence for the utility of including social media in care delivery and clinical education as well as contribute to the establishment of best practices for incorporating social media. The Canadian Medical Association has reported beginning the process of developing social media practice guidelines for physicians in Canada.37 Also, while the Canadian health landscape may be playing catch-up, American corporations in the health sector (eg, Kaiser Permanente, Mayo Clinic) have already developed social media policies to guide employee best practices. However, a challenge remains for implementing corporate social media policies in clinical practice. The American Physical Therapy Association has published standards of conduct for the use of social media by members.38 Moreover, it has been suggested that virtual communication by a health care practitioner should mimic that in real clinic settings—for example, maintaining patient privacy, confidentiality, and best practices for professional conduct.20 While implementing social media among regulated health professions may have similarities with its use in other industries, inherent, and perhaps unique, challenges also exist. In an interview with a representative of Kaiser Permanente, blogger daryl_ perieira39 posted suggestions that similarities include taking action when unsatisfied consumers (eg, patients) voice their concerns online and that challenges to overcome include identifying when action needs to be taken to alert regulating
Number 3
bodies regarding information posted publicly by patients and perhaps practitioners. It has been suggested that when social media platforms are used appropriately, with common sense and with professional integrity, they may offer many advantages to clinicians.20 Best practice guidelines may help direct health care practitioners in ethical and effective ways to engage in the online dialogue. Clinician Adoption Similar to the introduction of other “new” information and communications technology systems, the readiness of clinicians to adopt social media practices in the process of delivering routine care may vary among health care professions. The Canadian Medical Association reported that among a survey of 600 association members (ie, physicians), 46% had downloaded an app to use in practice, 49% believe social media will improve their practice by increasing patients’ sense of community, and 30% believe it will facilitate collaborative sharing of information.37 Moreover, a recent publication from the Canadian Physiotherapy Association highlights examples of clinicians who are actively engaged in social media to augment their existing practices.20 This information suggests that some health care practitioners are currently adopting various aspects of social media in clinical practice. Clinician adoption of social media practices also may be limited by factors that commonly arise when considering changes to health service delivery such as legislation, liability, scope of practice, access, safety, privacy, and time. These factors should be considered when developing the evidence base to inform practice guidelines for inclusion of social media in care delivery. To further enhance clinician adoption, funding and billing options need to be conMarch 2015
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion sidered. Social media are affordable, accessible, and user-friendly, allowing clinicians to utilize existing tools in practice to engage with social media, and existing platforms are generally free. However, the funding model to support the time clinicians are engaged in social media remains to be established. It is not clear whether billing platforms for practitioner involvement in the social media landscape will be developed and adopted. We speculate that evidence for cost-savings to payers would need to be demonstrated, for which many research opportunities exist. Alternatively, social media may find their place under the umbrella of online professionalism, which presents opportunities for continuing education as well as essential competency development for future clinicians (eg, physical therapist students). Issues that have previously been identified for involving social media in care delivery include tensions over perceived loss of control of the information available to patients, safety risk of inaccurate information, and challenges regulating ownership and privacy with the growing body of available information.17 Although these stumbling blocks were identified a number of years ago and sourced from a single health profession (physicians), they could be leveraged as reasons to support clinician engagement in the online dialogue. Engaging in the online dialogue may help to offset these issues by providing credible, accessible, evidence-based information. Moreover, timely development of evidence-informed best practices will help to ensure that patient safety and privacy are maintained as clinician practices evolve to meet the new demands of Physical Therapy 2.0. Establishing best practices is crucial for effective and appropriate integration of social media in current physical therapy delivery, as well as March 2015
for the education and training of future clinicians. Measuring the Effect of Social Media In cases where patients have the expectation to be able to use social media and clinicians are willing to implement online conduits for communications, how do we determine whether engaging in the social dialogue leads to improved treatment outcomes? Three principal constructs have been proposed for developing metrics to analyze the effectiveness of social strategies40: (1) determining what needs to be measured, (2) determining how to best measure it, and (3) determining whether using these metrics for analysis is related to improvement in patient engagement with prescribed health behaviors. Metrics need to be representative of a clinician’s patient population. Moreover, in terms of building the evidence base to support the use of social media for realizing improved treatment outcomes, there would be benefit to using standardized metrics to allow for comparisons across studies and professions. Metrics inherently exist among individual social media platforms, which could be tracked and reported. For example, websites such as YouTube include information such as video titles, tags (ie, key words), text, and viewer comments. Previous research analyzing condition-specific content on YouTube has used metrics such as top-5 tags, number of views, and months since the video was uploaded.29 Another metric worth considering would be crosspollination of information: for example, amount-specific content (eg, a clinician’s blog about a specific treatment approach) was reposted or shared on another social media platform. Moreover, extending metrics previously identified for social media sites,40 we propose that clinicians
and researchers consider the following metrics when implementing social media in care delivery: (1) social patient relationship management, (2) referred social traffic, (3) social impressions, and (4) social treatment outcomes. Social patient relationship management. Synonymous with social customer relationship management from the consumer landscape, this metric would provide insight into the value being created for patients as well as size of the engaged patient population. This insight could be achieved by tracking the size of the population that is enrolled in regular interaction with their care provider through social media platforms over time. Referred social traffic. This metric would provide information about reach of a user’s social media involvement. This information could be collected by tracking the number of users who accessed a site from a referring social media site (eg, blogs, social networking, content communities) using existing analytic tools (eg, Google Analytics, which is free of charge). Social impressions. This metric would help to provide information about the pervasive spread of a user’s social presence over a specified time period. Using alert tools will help track reference to the usergenerated content (eg, clinician’s Twitter feed, professional organization’s YouTube channel) in the greater online social community. Social treatment outcomes. This metric would help in determining whether social media engagement leads to improved treatment outcomes, which could be achieved by reporting the relationship between a patient’s treatment outcomes and his or her engagement in care delivery that is augmented with social media.
Volume 95
Number 3
Physical Therapy f
393
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion These 4 metrics, for example, may be tracked, which would facilitate comparison of care delivery within clinics and across treatment conditions and perhaps allow for comparisons with other care providers, jurisdictions, or industries. Engaging through social media may help facilitate a patient’s retention of the information discussed during treatment sessions.20 To determine whether including social media in care delivery is beneficial, physical therapists need to not only track involvement and online presence but also collect patient-centered outcome measures to evaluate whether this strategy improves treatment outcomes. Implementation in Practice For practitioners, researchers, and regulating bodies, there are many opportunities to implement various aspects of social media in practice. However, for the novice user, it can be daunting to make the foray into social media. It is an ever-evolving platform, and new opportunities will continue to present themselves. As previously mentioned, social media can be classified into 5 categories based on the platform,5 each of which presents opportunities for research and care delivery. Blogs. Blogs can be used by individual clinicians or groups of practitioners to engage in dialogue with each other and with patients about experience in practice and evidence for care delivery. They can be established to incorporate reader comments, which adds to the social nature of the platform. Additionally, they can be protected or secured to limit user access, which may be a feature attractive to clinicians or professional associations who want to engage with a limited population through this platform. One of the primary challenges with this platform is maintaining and updating the blog regularly. Therefore, it is recom394
f
Physical Therapy
Volume 95
mended that bloggers consider establishing a regular time frame for contributing to their blog (eg, weekly, monthly) and post this information so that users can set expectations for their own engagement with the blog. Content communities. Content community platforms such as YouTube and Flickr offer opportunities to share images and audio with the greater professional network. Posted content may be used to help patients remember proper execution of prescribed health behaviors after they leave the clinic and serve as an education tool for sharing evidenceinformed practices with patients and fellow practitioners. Collaborative projects. Collaborative projects such as wikis and consumer review sites hold much potential for physical therapy. In addition to profession-specific wikis (eg, Physiopedia), clinicians, researchers, and professional associations can contribute to more general wikis to enhance the profession’s online credibility and brand identity by posting evidence-based information. Moreover, engaging in this practice will help to ensure that the information accessed by lay-users (eg, patients) is more likely to be credible. Utilizing user-generated reviews (eg, patients’ reviews) on practice websites could help to ensure that the practice is responsive to its patient population and may help to generate increased business by allowing new or potential patients to learn about the experiences of current and past patients. Social networking sites. Social networking sites such as Twitter and Facebook offer the opportunity to collaborate with users in real time. Clinicians, researchers, and regulating bodies can use social networking sites to update patients and practitioners by sharing announcements for
Number 3
administrative updates (eg, hours of operation, equipment, services provided) and practice updates (eg, treatment guidelines, emerging evidence) as well as professional and research opportunities (eg, funding, training, employment). Moreover, private social networking sites in the health landscape (eg, tyze, patientslikeme) hold potential for engaging with patients and peers through a secure and confidential platform, which may further enhance care delivery and self-management. Virtual worlds. Virtual worlds require the establishment of a virtual environment and persona (eg, avatar) and may further require the establishment of a set of rules to confine avatar conduct in the virtual environment. This platform holds potential for education and engaging patients in virtual conduct of prescribed health behaviors. For example, augmenting patients’ visualization of their engagement in a prescribed behavior by allowing them to virtually execute it may help to build confidence and knowledge for on-going self-management. Although limited research exists demonstrating the utility of virtual worlds for improving health,5 more research is needed to establish the evidence base for using them in physical therapist practice. The ideas above for implementation are intended to incite and enhance the use of social media both in practice and research. In the absence of best practice guidelines for the evidence-based implementation of social media in physical therapist practice, it is suggested that clinicians and researchers use sound judgment to guide their practice. Ethical and patient-centered practices for safety and confidentiality should not be negated when adopting a new platform to augment care design and delivery.
March 2015
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion
Conclusion Augmenting, Not Replacing, Existing Patient Care As presented previously, the statistics indicate that the majority of Internet users seek out health information while online and that patients are ready for social media platforms to enter the health space. Yet, not all patients are likely to support adoption of Web 2.0 platforms in their care delivery. Patients who are skeptical of its value may be hesitant to engage in rehabilitation and health promotion care programs that involve social media. Moreover, regulating bodies (eg, professional health care licensing colleges and other government agencies) have yet to engage in the discussion of Health 2.0.16 Lack of regulation may limit a health care professional’s willingness to engage in the social media dialogue and may limit a user’s ability or confidence in determining both the accuracy and applicability of information on Web 2.0 platforms to his or her personal health.29 However, the current lack of regulation may allow for practitioners to shape how social media can best be used in practice, in turn, influencing the development of future regulations. Our perspective is not that social media should replace existing care models and treatment regimens but that these existing Web 2.0 platforms, which have been successful in other sectors, could be leveraged to augment care delivery and potentially improve treatment outcomes. Build the Evidence Base Social media are pervasive in our daily lives, and research investigating their clinical utility is crucial so that the physical therapy profession can respond to, and not avoid, this reality. The engagement of physical therapists in the Health 2.0 landscape will help to build the brand identity of the profession by creating and maintaining a social voice and contributing to the development and March 2015
sharing of credible and evidencebased health information across this platform. Physical Therapy 2.0 involves participants (eg, clinicians, patients, regulating bodies) interacting collaboratively to influence practice, health care service delivery, and both clinician and patient education. This conceptual article presents our perspective that physical therapists may be able to leverage the power and utility of social media to enhance care delivery and treatment outcomes. However, the evidence to support this aim in clinical practice remains sparse. To help build the evidence, clinicians should continue to explore social media in their physical therapist practices and report their utility and feasibility for engaging patients in prescribed health behaviors. To inform the development of best practices, it is suggested that metrics be identified and reported to help determine whether incorporating social media does, in fact, lead to improved treatment outcomes and cost-savings. All authors provided concept/idea/research design, writing, and consultation (including review of manuscript before submission). Ms Knight provided project management and clerical support. Ms Knight and Dr Petrella provided institutional liaisons. Ms Knight is supported by a Doctoral Research Award from the Canadian Institutes of Health Research/Canadian Physiotherapy Association/Physiotherapy Foundation of Canada. DOI: 10.2522/ptj.20130432
References 1 Kahn H. Five Hours a Day: Systemic Innovation for an Ageing Population. London, United Kingdom: Nesta Operating Co; 2013. 2 Kirkwood T. Ageing: too fast by mistake. Nature. 2006;444:1015–1017. 3 Oeppen J, Vaupel JW. Demography: broken limits to life expectancy. Science. 2002;296:1029 –1031. 4 Heart and Stroke Foundation. Make health last. Available at: https://makehealthlast. ca. Accessed June 10, 2013.
5 Knight E. Leveraging the power of social media to engage patients and achieve treatment outcomes. Crit Rev Phys Rehabil Med. 2012;24:169 –177. 6 Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3: e442. 7 Remmers C, Hibbard J, Mosen DM, et al. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009;32:320 –327. 8 Solomon M, Wagner SL, Goes J. Effects of a web-based intervention for adults with chronic conditions on patient activation: online randomized controlled trial. J Med Internet Res. 2012;14:e32. 9 Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003. 10 O’Reilly T. What is Web 2.0: design patterns and business models for the next generation of software. Available at: http://www.oreillynet.com/pub/a/oreilly/ tim/news/2005/09/30/what-is-web20.html. Published September 30, 2005. Accessed 2013. 11 Kaplan AM, Haenlein M. Users of the world, unite: the challenges and opprtunities of social media. Bus Horiz. 2010;53: 59 – 68. 12 Thackeray R, Crookston BT, West JH. Correlates of health-related social media use among adults. J Med Internet Res. 2013; 15:e21. 13 Giustini D. How Web 2.0 is changing medicine. BMJ. 2006;333:1283–1284. 14 Fisher J, Clayton M. Who gives a tweet: assessing patients’ interest in the use of social media for health care. Worldviews Evid Based Nurs. 2012;9:100 –108. 15 Gold J, Pedrana AE, Stoove MA, et al. Developing health promotion interventions on social networking sites: recommendations from the FaceSpace Project. J Med Internet Res. 2012;14:e30. 16 Van De Belt TH, Engelen LJ, Berben SA, Schoonhoven L. Definition of Health 2.0 and Medicine 2.0: a systematic review. J Med Internet Res. 2010;12:e18. 17 Hughes B, Joshi I, Wareham J. Health 2.0 and Medicine 2.0: tensions and controversies in the field. J Med Internet Res. 2008; 10:e23. 18 Using Social Media to Improve Healthcare Quality: A Guide to Current Practice and Future Promise. Toronto, Ontario, Canada: The Change Foundation Health Strategy Innovation Cell; 2011. 19 Barsky E, Guistini D. Web 2.0 in physical therapy: a practical overview [article in English, French]. Physiother Can. 2008; 60:207–214. 20 Canadian Physiotherapy Association. Eyes wide open: the risks and benefits of using social media. Physiotherapy Practice. 2012;2:13–16. 21 Alexa. The web information company. Available at: http://www.alexa.com. Accessed March 3, 2013.
Volume 95
Number 3
Physical Therapy f
395
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion 22 Neal DM. Emotion-based tags in photographic documents: the interplay of text, image, and social influence. Canadian Journal of Information and Library Science. 2010;34:329 –353. 23 Izawa M. What Makes Viral Videos Viral: Roles of Emotion, Impression, Utility, and Social Ties in Online Sharing Behavior. Baltimore, MD: John Hopkins University; 2010. 24 Moorhead SA, Hazlett DE, Harrison L, et al. A new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res. 2013;15:e85. 25 Weiler R, Neyndorff C. BJSM social media contributes to health policy rethink: a physical activity success story in Hertfordshire. Br J Sports Med. 2013;47:593–594. 26 Ache KA, Wallace LS. Human papillomavirus vaccinataion coverage on YouTube. Am J Prev Med. 2008;35:389 –392. 27 Paek HJ, Kim K, Hove T. Content analysis of antismoking videos on YouTube: message sensation value, message appeals, and their relationships with viewer responses. Health Educ Res. 2010;25:1085–1099. 28 Richardson CG, Vettese L, Sussman S, et al. An investigation of smoking cessation video content on YouTube. Subst Use Misuse. 2011;46:893– 897.
396
f
Physical Therapy
Volume 95
29 Williams D, Sullivan SJ, Schneiders AG, et al. Big hits on the small screen: an evaluation of concussion-related videos on YouTube. Br J Sports Med. 2014;48:107– 111. 30 Yoo JH, Kim J. Obesity in the new media: a content analysis of obesity videos on YouTube. Health Commun. 2012;27:86 – 97. 31 Waters RD, Jones PM. Using video to build an organization’s identity and brand: a content analysis of nonprofit organizations’ YouTube videos. J Nonprofit Public Sector Marketing. 2010;23:248 –268. 32 van Velsen L, van Gemert-Pijnen JE, Beaujean DJ, et al. Should health organizations use Web 2.0 media in times of an infectious disease crisis: an in-depth qualitative study of citizens’ information behavior during an EHEC outbreak. J Med Internet Res. 2012;14:e181. 33 International Telecommunications Union website. Available at: http://www.itu.int/ en/ITU-D/Statistics/Pages/stat/default. aspx. Accessed June 2013. 34 Physiopedia website. Available at: http:// www.physio-pedia.com/Main_Page. Accessed March 4, 2013. 35 Ciordano C. Health professions students’ use of social media. J Allied Health. 2011; 40:78 – 81.
Number 3
36 White J, Kirwan P, Lai K, et al. “Have you seen what is on Facebook?” The use of social networking software by healthcare professions students. BMJ Open. 2013;3: pii.e003013. doi: 10.1136/bmjopen-2013003013. 37 Sullivan P. CMA developing social-media guidelines for MDs. Published June 2, 2011. Available at: http://www.cma.ca/ cma-social-media-guidelines. Accessed March 13, 2013. 38 American Physical Therapy Association. Social media tips and best practices. Updated September 11, 2013. Available at: http://www.apta.org/SocialMedia/Tips/. Accessed January 20, 2014. 39 Pereira D. Social business school [blog]. Published February 20, 2012. Available at: http://www.ibm.com/developerworks/ mydeveloperworks/blogs/social-business/ entry/social_media_in_healthcare_a_ view_from_kaiser_permanente7?lang⫽ en. Accessed March 14, 2013. 40 McDaniel C. Three key metrics to measure social media success. Published May 30, 2011. Available at: http://searchengine watch.com/article/2073592/3-KeyMetrics - To - Measure - Social - Media Success. Accessed June 2013.
March 2015
Physical Therapy 2.0: Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion Emily Knight, Robert J. Werstine, Diane M. Rasmussen-Pennington, Deborah Fitzsimmons, Robert J. Petrella Care for chronic conditions and noncommunicable diseases is dominating health systems around the globe. For physical therapists, this strain presents a substantial opportunity for engaging patients in health promotion and disease management in the years to come. Examples of social media being used to engage consumers in the business landscape are pervasive, and research reports suggest that patients are ready for social media to be incorporated into the way health care systems deliver care. We propose that leveraging the power and utility of existing technologies, such as social media, could innovate the way physical therapists engage patients in rehabilitation and health promotion practices, thus contributing to the evolution of the profession: Physical Therapy 2.0. To continue to be relevant in the community, physical therapist practice must respond to patients’ needs and expectations. Incorporating social media into how physical therapists are both designing and delivering care holds potential for enhancing patient engagement in prescribed health behaviors and improving treatment outcomes. This conceptual article presents the perspective that physical therapists can utilize social media to enhance care delivery and treatment outcomes.
E. Knight, Health & Rehabilitation Sciences, University of Western Ontario, and Rehabilitation & Geriatric Care Research Centre, Lawson Health Research Institute, London, Ontario, Canada. R.J. Werstine, HBA, BSc(PT), MSc(PT), DipManip, DipSport, FCAMPT, Fowler-Kennedy Sports Medicine Clinic at Fanshawe College, London, Ontario, Canada. D.M. Rasmussen-Pennington, PhD, Ashford University, Clinton, Iowa. D. Fitzsimmons, MHSc, PhD, Health Studies, University of Western Ontario. R.J. Petrella, MD, PhD, Schulich School of Medicine & Dentistry, University of Western Ontario, and Aging, Rehabilitation & Geriatric Care Research Centre, Lawson Health Research Institute, 801 Commissioners Road East, London, Ontario, Canada N6C 5J1. Address all correspondence to Dr Petrella at: [email protected]. [Knight E, Werstine RJ, RasmussenPennington DM, et al. Physical Therapy 2.0: leveraging social media to engage patients in rehabilitation and health promotion. Phys Ther. 2015;95:389 –396.] © 2015 American Physical Therapy Association Published Ahead of Print: March 13, 2014 Accepted: March 9, 2014 Submitted: September 10, 2013
Post a Rapid Response to this article at: ptjournal.apta.org March 2015
Volume 95
Number 3
Physical Therapy f
389
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion
L
ife expectancies in developed countries are increasing at a rate of approximately 2 years every decade.1–3 Although people are, and can continue to expect to be, living longer than previous generations, there is a disparity between longevity and healthy, independent living: adults are living longer, but this increased longevity is not matched to fewer years of disability and ill health.4 Global health care systems are progressively being dominated by care for chronic conditions and noncommunicable diseases.5,6 In the coming decades, it is projected that conditions such as cardiovascular disease, cancer, and diabetes will account for more than 50% of disease burden globally.6 As the number of patients continues to grow and health care resources continue to strain, the need to engage patients in self-management of these diseases becomes an essential strategy.7,8 This divergence of demand on and capacity of health care systems presents a substantial opportunity for physical therapists to engage patients in rehabilitation, health promotion, and disease management in the years to come. Patient engagement has previously been operationalized as a means to increase adherence to prescribed health behaviors by initiating treatment regimens that attract and involve patients in the management of their own care.5 The World Health Organization suggests that difficulty engaging patients, especially those with chronic conditions, leads to suboptimal treatment outcomes.9 We propose that leveraging the power and utility of existing technologies, especially social media, could innovate the way physical therapists engage patients in rehabilitation and health promotion practices.
Web 2.0 Web 2.0 is a popularized term that began to surface following the dot390
f
Physical Therapy
Volume 95
com collapse in 2001.10 The term describes the evolutionary framework of the Internet, with a focus on widespread engagement. Web 2.0 is a dynamic platform where content and applications are continuously modified by all users in a participatory and collaborative way.11 It has been suggested that users are more likely to consume health information when they are active participants in the dialogue.12 Therefore, Web 2.0 allows for the creation and exchange of content generated by the users and connects people through an interactive platform.11,13 Creating a “people-powered” health system through the bridging of social and health paradigms may facilitate improved treatment outcomes.1 The inherent dynamic and social nature of Web 2.0 supports its potential for engaging patients in prescribed health behaviors to enhance ongoing care and self-management.5 Social media is a broad descriptor, and platforms can be grouped according to common features. Similar to other authors,11 Knight5 previously reported 5 classifications of social media: (1) blogs, (2) content communities (eg, YouTube, Flickr), (3) collaborative projects (eg, wikis, consumer review sites), (4) social networking sites (eg, Facebook, Twitter), and (5) virtual worlds (eg, Second Life, World of Warcraft). Like other sectors and industries, health care delivery could improve by leveraging existing and emerging social media platforms. Previously, Knight5 explored the evidence base and research opportunities for leveraging these platforms for improved treatment outcomes with patients. The perspective explored in this conceptual article furthers the conversation about engaging patients in prescribed health behaviors using social media by drawing specific attention to the need for research informing best practices to address the gap between physical therapist
Number 3
and patient in health care service delivery, as well as highlighting areas for future research.
Health 2.0 In North America, it has been reported that the majority (range⫽ 60%– 83%) of Internet users seek health information online.11,14,15 Health 2.0 is a popularized term representing the presence of health information in Web 2.0.16 It differs from other technological evolutions in health (eg, eHealth) given its collaborative nature and emphasis on personalized health care.17 The large proportion of people seeking health information online necessitates the involvement of health care professionals, such as physical therapists, in the online dialogue. As consumers, individuals have been attracted to, retained, and engaged in the commercial landscape using social media.15,18 It has been suggested that these individuals, in their roles as patients, are ready for social media to be implemented as a part of their health care delivery.14
Physical Therapy 2.0 Incorporating social media into the way physical therapists both design and deliver care holds potential for engaging patients in prescribed health behaviors. Commentaries discussing the application of Web 2.0 in the practice of physical therapy date back to 2008.19 Social media have been described by physical therapists as a simple medium to reach individuals, answer questions, and educate.20 Building on understandings of Web 2.0 and Health 2.0, we propose that physical therapists can leverage social media platforms to engage in user-generated dialogues with their patient populations, thereby enhancing care delivery models and contributing to the evolution of the physical therapist practice: Physical Therapy 2.0. By extension of previous definitions in the Health 2.0 landscape,17 we concepMarch 2015
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion tualize Physical Therapy 2.0 as the use of Web 2.0 tools and platforms by physical therapists, utilizing principles of user-generated content and collaboration among networks and individuals to personalize health care and promote health education. We consider this approach a means to develop patient engagement in ongoing care, thereby enhancing patient self-management of health and contributing to optimal treatment outcomes.
The Evidence Building on the Experiences in Other Industries Examples of social media in the commercial landscape are pervasive. Social media sites are routinely near the top of the list for most visited websites. At the time this article was written, of the top 500 websites, the social media sites Facebook and YouTube were in the top 3—surpassed only by Google.21 Other social sites in the top 10 include collaborative sites (eg, Wikipedia) and consumerreview sites (eg, Amazon), with various social networking and blog sites (eg, Twitter, Blogspot.com, LinkedIn) rounding out the top 15.21 These data support the intuitive understanding that social media are pervasive in modern North American culture. Yet, the challenge to the health sector is leveraging this popularity to influence health care delivery in a positive and significant way for patients and practitioners. Based on previous literature, how can a health care practitioner engage in the social dialogue in a relevant and meaningful way? In a study comparing images with high versus low relevance on a social media platform (ie, Flickr), there was a statistically significant relationship between highly relevant pictures and both the number of views and number of “favorites” or “likes,” which suggested a relationship among views, favorites, and relevance.22 This inforMarch 2015
mation could be extended to suggest that when information is deemed important online (ie, ranked highly by search engines), there is a strong correlation with it also being viewed and being “favorited” by more site traffic. Moreover, previous work concluded that images displaying positive emotions (eg, happiness) were more likely to be viewed.22 This finding suggests that positive reinforcement through social media may lead to more views of the content posted (ie, user engagement with the content). Additionally, it has been demonstrated in the literature that emotions elicited (eg, happy, funny), impressions aroused (eg, intense, enjoyable), and perceived utility (eg, useful to self, network, or society) through user-generated content factor into an individual’s decision to share the content with others.23 This information about relevance, tags, emotion, utility, and engagement can be used by clinicians to ensure that their participation in the social dialogue is not only high quality but also reliable and relevant to a respective patient population. In turn, this type of participation may also relate to increased engagement by patients with the content. However, it remains to be established whether this increased engagement will lead to better self-management of chronic conditions or improved treatment outcomes for patients. Examples From the Health Sector Despite the abundance of experience with social media in many industries, evidence reporting its utility in the health landscape is only now emerging. Predominantly, the existing evidence base is descriptive and observational, with fewer examples of interventions using social media.24 In an experiment to influence social health policies, a project from the United Kingdom explored
the efficacy of social media tools (eg, blogs, social networking) in conjunction with “viral marketing techniques” to engage end-users and policy makers in health policy development.25 More specifically, the project used blogs with reader comments, Twitter, and online polling to engage the public and showed that social media were a powerful dissemination and discussion forum that may help to enable strategic change in health policies.25 This example illustrates how Web 2.0 tools can be used in the health sector to influence changes to policy that respond to patient and practitioner views. Exploration of content on social media sites, such as YouTube, is progressively becoming more prevalent in the research landscape. Reports describe available social content for specific conditions and disease states (eg, concussion, obesity), health promotion practices (eg, physical activity, smoking behaviors), and communicable disease prevention (eg, vaccination).26 –30 Research to date has suggested that a gap exists between the effort to define best practices for the inclusion of social media in health care design and delivery and the transfer of this information to educate end-users.29 Despite this gap, health care and educational organizations should continue to explore social media platforms for dissemination of evidence-based information and promotion of the health care profession.29,31 Establishing the credibility of information collated through collaborative sites (eg, wikis) is commonly cited as a challenge by practitioners and researchers, yet it has been suggested that individuals may view these media as extensive, useful, and credible sources of information.5,32 Moreover, it has been reported that patients with chronic conditions are
Volume 95
Number 3
Physical Therapy f
391
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion more likely to seek out information through this landscape.12,32 The ability of patients and physical therapists to critically appraise user-generated content to discern which information will improve care delivery and patient-important outcomes in an ethical and evidence-based way remains a challenge. Increased involvement of physical therapists in the social media dialogue may help to populate the landscape with credible information.33 For example, wikis specific to the physical therapy profession exist and provide an opportunity for collaborative sharing of physical therapy–related content. Although such wikis are promoted as having the potential to improve patient care, contribute to global health, and support the practice of physical therapy as well as connect practitioners,34 evidence of these outcomes has yet to be reported. The presence of physical therapist experts in the social media landscape will help to contribute credible, evidence-based information to the online dialogue.
Evolving Physical Therapist Practice Establish Best Practices for Incorporating Social Media It has been suggested that the use of social media in professional practice facilitates meaningful communication with patients, colleagues, and researchers, in part by providing clinicians with an online voice through which the profession may enhance its reputation and share credible health information.20 Recent reports have suggested that the cohorts of physical therapy graduates in the years to come are going to be versed in the use of social media in their educational and personal lives.35,36 However, what remains to be established is how this experience will translate into professional use of social media. Moreover, a previous report20 that largely focused on fundamentals and how-to cautions for 392
f
Physical Therapy
Volume 95
online communication also included valuable insights from practitioners currently engaging with various forms of social media in physical therapist practice, research, and education. The outcomes of these initiatives have yet to be reported and may provide evidence for the utility of including social media in care delivery and clinical education as well as contribute to the establishment of best practices for incorporating social media. The Canadian Medical Association has reported beginning the process of developing social media practice guidelines for physicians in Canada.37 Also, while the Canadian health landscape may be playing catch-up, American corporations in the health sector (eg, Kaiser Permanente, Mayo Clinic) have already developed social media policies to guide employee best practices. However, a challenge remains for implementing corporate social media policies in clinical practice. The American Physical Therapy Association has published standards of conduct for the use of social media by members.38 Moreover, it has been suggested that virtual communication by a health care practitioner should mimic that in real clinic settings—for example, maintaining patient privacy, confidentiality, and best practices for professional conduct.20 While implementing social media among regulated health professions may have similarities with its use in other industries, inherent, and perhaps unique, challenges also exist. In an interview with a representative of Kaiser Permanente, blogger daryl_ perieira39 posted suggestions that similarities include taking action when unsatisfied consumers (eg, patients) voice their concerns online and that challenges to overcome include identifying when action needs to be taken to alert regulating
Number 3
bodies regarding information posted publicly by patients and perhaps practitioners. It has been suggested that when social media platforms are used appropriately, with common sense and with professional integrity, they may offer many advantages to clinicians.20 Best practice guidelines may help direct health care practitioners in ethical and effective ways to engage in the online dialogue. Clinician Adoption Similar to the introduction of other “new” information and communications technology systems, the readiness of clinicians to adopt social media practices in the process of delivering routine care may vary among health care professions. The Canadian Medical Association reported that among a survey of 600 association members (ie, physicians), 46% had downloaded an app to use in practice, 49% believe social media will improve their practice by increasing patients’ sense of community, and 30% believe it will facilitate collaborative sharing of information.37 Moreover, a recent publication from the Canadian Physiotherapy Association highlights examples of clinicians who are actively engaged in social media to augment their existing practices.20 This information suggests that some health care practitioners are currently adopting various aspects of social media in clinical practice. Clinician adoption of social media practices also may be limited by factors that commonly arise when considering changes to health service delivery such as legislation, liability, scope of practice, access, safety, privacy, and time. These factors should be considered when developing the evidence base to inform practice guidelines for inclusion of social media in care delivery. To further enhance clinician adoption, funding and billing options need to be conMarch 2015
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion sidered. Social media are affordable, accessible, and user-friendly, allowing clinicians to utilize existing tools in practice to engage with social media, and existing platforms are generally free. However, the funding model to support the time clinicians are engaged in social media remains to be established. It is not clear whether billing platforms for practitioner involvement in the social media landscape will be developed and adopted. We speculate that evidence for cost-savings to payers would need to be demonstrated, for which many research opportunities exist. Alternatively, social media may find their place under the umbrella of online professionalism, which presents opportunities for continuing education as well as essential competency development for future clinicians (eg, physical therapist students). Issues that have previously been identified for involving social media in care delivery include tensions over perceived loss of control of the information available to patients, safety risk of inaccurate information, and challenges regulating ownership and privacy with the growing body of available information.17 Although these stumbling blocks were identified a number of years ago and sourced from a single health profession (physicians), they could be leveraged as reasons to support clinician engagement in the online dialogue. Engaging in the online dialogue may help to offset these issues by providing credible, accessible, evidence-based information. Moreover, timely development of evidence-informed best practices will help to ensure that patient safety and privacy are maintained as clinician practices evolve to meet the new demands of Physical Therapy 2.0. Establishing best practices is crucial for effective and appropriate integration of social media in current physical therapy delivery, as well as March 2015
for the education and training of future clinicians. Measuring the Effect of Social Media In cases where patients have the expectation to be able to use social media and clinicians are willing to implement online conduits for communications, how do we determine whether engaging in the social dialogue leads to improved treatment outcomes? Three principal constructs have been proposed for developing metrics to analyze the effectiveness of social strategies40: (1) determining what needs to be measured, (2) determining how to best measure it, and (3) determining whether using these metrics for analysis is related to improvement in patient engagement with prescribed health behaviors. Metrics need to be representative of a clinician’s patient population. Moreover, in terms of building the evidence base to support the use of social media for realizing improved treatment outcomes, there would be benefit to using standardized metrics to allow for comparisons across studies and professions. Metrics inherently exist among individual social media platforms, which could be tracked and reported. For example, websites such as YouTube include information such as video titles, tags (ie, key words), text, and viewer comments. Previous research analyzing condition-specific content on YouTube has used metrics such as top-5 tags, number of views, and months since the video was uploaded.29 Another metric worth considering would be crosspollination of information: for example, amount-specific content (eg, a clinician’s blog about a specific treatment approach) was reposted or shared on another social media platform. Moreover, extending metrics previously identified for social media sites,40 we propose that clinicians
and researchers consider the following metrics when implementing social media in care delivery: (1) social patient relationship management, (2) referred social traffic, (3) social impressions, and (4) social treatment outcomes. Social patient relationship management. Synonymous with social customer relationship management from the consumer landscape, this metric would provide insight into the value being created for patients as well as size of the engaged patient population. This insight could be achieved by tracking the size of the population that is enrolled in regular interaction with their care provider through social media platforms over time. Referred social traffic. This metric would provide information about reach of a user’s social media involvement. This information could be collected by tracking the number of users who accessed a site from a referring social media site (eg, blogs, social networking, content communities) using existing analytic tools (eg, Google Analytics, which is free of charge). Social impressions. This metric would help to provide information about the pervasive spread of a user’s social presence over a specified time period. Using alert tools will help track reference to the usergenerated content (eg, clinician’s Twitter feed, professional organization’s YouTube channel) in the greater online social community. Social treatment outcomes. This metric would help in determining whether social media engagement leads to improved treatment outcomes, which could be achieved by reporting the relationship between a patient’s treatment outcomes and his or her engagement in care delivery that is augmented with social media.
Volume 95
Number 3
Physical Therapy f
393
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion These 4 metrics, for example, may be tracked, which would facilitate comparison of care delivery within clinics and across treatment conditions and perhaps allow for comparisons with other care providers, jurisdictions, or industries. Engaging through social media may help facilitate a patient’s retention of the information discussed during treatment sessions.20 To determine whether including social media in care delivery is beneficial, physical therapists need to not only track involvement and online presence but also collect patient-centered outcome measures to evaluate whether this strategy improves treatment outcomes. Implementation in Practice For practitioners, researchers, and regulating bodies, there are many opportunities to implement various aspects of social media in practice. However, for the novice user, it can be daunting to make the foray into social media. It is an ever-evolving platform, and new opportunities will continue to present themselves. As previously mentioned, social media can be classified into 5 categories based on the platform,5 each of which presents opportunities for research and care delivery. Blogs. Blogs can be used by individual clinicians or groups of practitioners to engage in dialogue with each other and with patients about experience in practice and evidence for care delivery. They can be established to incorporate reader comments, which adds to the social nature of the platform. Additionally, they can be protected or secured to limit user access, which may be a feature attractive to clinicians or professional associations who want to engage with a limited population through this platform. One of the primary challenges with this platform is maintaining and updating the blog regularly. Therefore, it is recom394
f
Physical Therapy
Volume 95
mended that bloggers consider establishing a regular time frame for contributing to their blog (eg, weekly, monthly) and post this information so that users can set expectations for their own engagement with the blog. Content communities. Content community platforms such as YouTube and Flickr offer opportunities to share images and audio with the greater professional network. Posted content may be used to help patients remember proper execution of prescribed health behaviors after they leave the clinic and serve as an education tool for sharing evidenceinformed practices with patients and fellow practitioners. Collaborative projects. Collaborative projects such as wikis and consumer review sites hold much potential for physical therapy. In addition to profession-specific wikis (eg, Physiopedia), clinicians, researchers, and professional associations can contribute to more general wikis to enhance the profession’s online credibility and brand identity by posting evidence-based information. Moreover, engaging in this practice will help to ensure that the information accessed by lay-users (eg, patients) is more likely to be credible. Utilizing user-generated reviews (eg, patients’ reviews) on practice websites could help to ensure that the practice is responsive to its patient population and may help to generate increased business by allowing new or potential patients to learn about the experiences of current and past patients. Social networking sites. Social networking sites such as Twitter and Facebook offer the opportunity to collaborate with users in real time. Clinicians, researchers, and regulating bodies can use social networking sites to update patients and practitioners by sharing announcements for
Number 3
administrative updates (eg, hours of operation, equipment, services provided) and practice updates (eg, treatment guidelines, emerging evidence) as well as professional and research opportunities (eg, funding, training, employment). Moreover, private social networking sites in the health landscape (eg, tyze, patientslikeme) hold potential for engaging with patients and peers through a secure and confidential platform, which may further enhance care delivery and self-management. Virtual worlds. Virtual worlds require the establishment of a virtual environment and persona (eg, avatar) and may further require the establishment of a set of rules to confine avatar conduct in the virtual environment. This platform holds potential for education and engaging patients in virtual conduct of prescribed health behaviors. For example, augmenting patients’ visualization of their engagement in a prescribed behavior by allowing them to virtually execute it may help to build confidence and knowledge for on-going self-management. Although limited research exists demonstrating the utility of virtual worlds for improving health,5 more research is needed to establish the evidence base for using them in physical therapist practice. The ideas above for implementation are intended to incite and enhance the use of social media both in practice and research. In the absence of best practice guidelines for the evidence-based implementation of social media in physical therapist practice, it is suggested that clinicians and researchers use sound judgment to guide their practice. Ethical and patient-centered practices for safety and confidentiality should not be negated when adopting a new platform to augment care design and delivery.
March 2015
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion
Conclusion Augmenting, Not Replacing, Existing Patient Care As presented previously, the statistics indicate that the majority of Internet users seek out health information while online and that patients are ready for social media platforms to enter the health space. Yet, not all patients are likely to support adoption of Web 2.0 platforms in their care delivery. Patients who are skeptical of its value may be hesitant to engage in rehabilitation and health promotion care programs that involve social media. Moreover, regulating bodies (eg, professional health care licensing colleges and other government agencies) have yet to engage in the discussion of Health 2.0.16 Lack of regulation may limit a health care professional’s willingness to engage in the social media dialogue and may limit a user’s ability or confidence in determining both the accuracy and applicability of information on Web 2.0 platforms to his or her personal health.29 However, the current lack of regulation may allow for practitioners to shape how social media can best be used in practice, in turn, influencing the development of future regulations. Our perspective is not that social media should replace existing care models and treatment regimens but that these existing Web 2.0 platforms, which have been successful in other sectors, could be leveraged to augment care delivery and potentially improve treatment outcomes. Build the Evidence Base Social media are pervasive in our daily lives, and research investigating their clinical utility is crucial so that the physical therapy profession can respond to, and not avoid, this reality. The engagement of physical therapists in the Health 2.0 landscape will help to build the brand identity of the profession by creating and maintaining a social voice and contributing to the development and March 2015
sharing of credible and evidencebased health information across this platform. Physical Therapy 2.0 involves participants (eg, clinicians, patients, regulating bodies) interacting collaboratively to influence practice, health care service delivery, and both clinician and patient education. This conceptual article presents our perspective that physical therapists may be able to leverage the power and utility of social media to enhance care delivery and treatment outcomes. However, the evidence to support this aim in clinical practice remains sparse. To help build the evidence, clinicians should continue to explore social media in their physical therapist practices and report their utility and feasibility for engaging patients in prescribed health behaviors. To inform the development of best practices, it is suggested that metrics be identified and reported to help determine whether incorporating social media does, in fact, lead to improved treatment outcomes and cost-savings. All authors provided concept/idea/research design, writing, and consultation (including review of manuscript before submission). Ms Knight provided project management and clerical support. Ms Knight and Dr Petrella provided institutional liaisons. Ms Knight is supported by a Doctoral Research Award from the Canadian Institutes of Health Research/Canadian Physiotherapy Association/Physiotherapy Foundation of Canada. DOI: 10.2522/ptj.20130432
References 1 Kahn H. Five Hours a Day: Systemic Innovation for an Ageing Population. London, United Kingdom: Nesta Operating Co; 2013. 2 Kirkwood T. Ageing: too fast by mistake. Nature. 2006;444:1015–1017. 3 Oeppen J, Vaupel JW. Demography: broken limits to life expectancy. Science. 2002;296:1029 –1031. 4 Heart and Stroke Foundation. Make health last. Available at: https://makehealthlast. ca. Accessed June 10, 2013.
5 Knight E. Leveraging the power of social media to engage patients and achieve treatment outcomes. Crit Rev Phys Rehabil Med. 2012;24:169 –177. 6 Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3: e442. 7 Remmers C, Hibbard J, Mosen DM, et al. Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes? J Ambul Care Manage. 2009;32:320 –327. 8 Solomon M, Wagner SL, Goes J. Effects of a web-based intervention for adults with chronic conditions on patient activation: online randomized controlled trial. J Med Internet Res. 2012;14:e32. 9 Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization; 2003. 10 O’Reilly T. What is Web 2.0: design patterns and business models for the next generation of software. Available at: http://www.oreillynet.com/pub/a/oreilly/ tim/news/2005/09/30/what-is-web20.html. Published September 30, 2005. Accessed 2013. 11 Kaplan AM, Haenlein M. Users of the world, unite: the challenges and opprtunities of social media. Bus Horiz. 2010;53: 59 – 68. 12 Thackeray R, Crookston BT, West JH. Correlates of health-related social media use among adults. J Med Internet Res. 2013; 15:e21. 13 Giustini D. How Web 2.0 is changing medicine. BMJ. 2006;333:1283–1284. 14 Fisher J, Clayton M. Who gives a tweet: assessing patients’ interest in the use of social media for health care. Worldviews Evid Based Nurs. 2012;9:100 –108. 15 Gold J, Pedrana AE, Stoove MA, et al. Developing health promotion interventions on social networking sites: recommendations from the FaceSpace Project. J Med Internet Res. 2012;14:e30. 16 Van De Belt TH, Engelen LJ, Berben SA, Schoonhoven L. Definition of Health 2.0 and Medicine 2.0: a systematic review. J Med Internet Res. 2010;12:e18. 17 Hughes B, Joshi I, Wareham J. Health 2.0 and Medicine 2.0: tensions and controversies in the field. J Med Internet Res. 2008; 10:e23. 18 Using Social Media to Improve Healthcare Quality: A Guide to Current Practice and Future Promise. Toronto, Ontario, Canada: The Change Foundation Health Strategy Innovation Cell; 2011. 19 Barsky E, Guistini D. Web 2.0 in physical therapy: a practical overview [article in English, French]. Physiother Can. 2008; 60:207–214. 20 Canadian Physiotherapy Association. Eyes wide open: the risks and benefits of using social media. Physiotherapy Practice. 2012;2:13–16. 21 Alexa. The web information company. Available at: http://www.alexa.com. Accessed March 3, 2013.
Volume 95
Number 3
Physical Therapy f
395
Leveraging Social Media to Engage Patients in Rehabilitation and Health Promotion 22 Neal DM. Emotion-based tags in photographic documents: the interplay of text, image, and social influence. Canadian Journal of Information and Library Science. 2010;34:329 –353. 23 Izawa M. What Makes Viral Videos Viral: Roles of Emotion, Impression, Utility, and Social Ties in Online Sharing Behavior. Baltimore, MD: John Hopkins University; 2010. 24 Moorhead SA, Hazlett DE, Harrison L, et al. A new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res. 2013;15:e85. 25 Weiler R, Neyndorff C. BJSM social media contributes to health policy rethink: a physical activity success story in Hertfordshire. Br J Sports Med. 2013;47:593–594. 26 Ache KA, Wallace LS. Human papillomavirus vaccinataion coverage on YouTube. Am J Prev Med. 2008;35:389 –392. 27 Paek HJ, Kim K, Hove T. Content analysis of antismoking videos on YouTube: message sensation value, message appeals, and their relationships with viewer responses. Health Educ Res. 2010;25:1085–1099. 28 Richardson CG, Vettese L, Sussman S, et al. An investigation of smoking cessation video content on YouTube. Subst Use Misuse. 2011;46:893– 897.
396
f
Physical Therapy
Volume 95
29 Williams D, Sullivan SJ, Schneiders AG, et al. Big hits on the small screen: an evaluation of concussion-related videos on YouTube. Br J Sports Med. 2014;48:107– 111. 30 Yoo JH, Kim J. Obesity in the new media: a content analysis of obesity videos on YouTube. Health Commun. 2012;27:86 – 97. 31 Waters RD, Jones PM. Using video to build an organization’s identity and brand: a content analysis of nonprofit organizations’ YouTube videos. J Nonprofit Public Sector Marketing. 2010;23:248 –268. 32 van Velsen L, van Gemert-Pijnen JE, Beaujean DJ, et al. Should health organizations use Web 2.0 media in times of an infectious disease crisis: an in-depth qualitative study of citizens’ information behavior during an EHEC outbreak. J Med Internet Res. 2012;14:e181. 33 International Telecommunications Union website. Available at: http://www.itu.int/ en/ITU-D/Statistics/Pages/stat/default. aspx. Accessed June 2013. 34 Physiopedia website. Available at: http:// www.physio-pedia.com/Main_Page. Accessed March 4, 2013. 35 Ciordano C. Health professions students’ use of social media. J Allied Health. 2011; 40:78 – 81.
Number 3
36 White J, Kirwan P, Lai K, et al. “Have you seen what is on Facebook?” The use of social networking software by healthcare professions students. BMJ Open. 2013;3: pii.e003013. doi: 10.1136/bmjopen-2013003013. 37 Sullivan P. CMA developing social-media guidelines for MDs. Published June 2, 2011. Available at: http://www.cma.ca/ cma-social-media-guidelines. Accessed March 13, 2013. 38 American Physical Therapy Association. Social media tips and best practices. Updated September 11, 2013. Available at: http://www.apta.org/SocialMedia/Tips/. Accessed January 20, 2014. 39 Pereira D. Social business school [blog]. Published February 20, 2012. Available at: http://www.ibm.com/developerworks/ mydeveloperworks/blogs/social-business/ entry/social_media_in_healthcare_a_ view_from_kaiser_permanente7?lang⫽ en. Accessed March 14, 2013. 40 McDaniel C. Three key metrics to measure social media success. Published May 30, 2011. Available at: http://searchengine watch.com/article/2073592/3-KeyMetrics - To - Measure - Social - Media Success. Accessed June 2013.
March 2015
