Phil Baumann

better living through enquiry

Posts in the Medicine category

Is Twitter safe and effective?

Several years ago, as a second-career registered nurse practicing critical care – having a prior background in enterprise working with fairly sophisticated information technologies – it was all too easy for me get frustrated with paper medical records and laboratory reports laying in floors drenched in  Clostridium difficile.

How was it possible in the 21st Century that the informational flows in healthcare facilities could end up on contaminated floors? Surely, I thought, there must be technologies within our grasp that could spare us – our patients and the staff – such dangerous indignities.

I can’t remember where I was when I first heard of Twitter, but I was one of its early adopters. It occurred to me that Twitter’s essential feature – the power to share data instantly and briefly – was worthy of consideration in health care. But my early ideas about invoking Twitter into healthcare faced two hurdles: HIPAA always got in the way of my thinking and nobody else I knew at the time ever heard of “a Twitter”.

After Twitter deleted my first account, I gave up on the incompetent service. When I returned to Twitter sometime in early 2008, the use of Twitter (or any other social medium for that matter) in healthcare was still relatively unheard of.

Part of the reason I started blogging was to fill a relatively empty void in the healthcare social media space. Today, I believe we are seeing that space filling with more important voices. Since publishing 140 Healthcare Uses of Twitter in January, hundreds of hospitals have started up Twitter accounts. Every day we hear about Twitter’s role in health care, from disaster management to surgical live-tweeting.

So far, the word is largely positive concerning the experiences of a relatively small number of hospitals on Twitter. But has Twitter gone through the strainer, the one beyond the marketing and PR uses? I’m not so sure but I’m hopeful. Time and the further adoption of the service will tell us more about its safety and effectiveness.

BETWEEN EVANGELISM AND DEVIL’S ADVOCACY

A purpose of the list I published in January was to start a discussion about how micro-messaging technologies like Twitter could be used in health care. Twitter’s fame and hype continue to skyrocket and health care is one of the hottest topics of our time. I have no doubt now that micro-messaging and health care are important partners. My task then was to be an evangelist in a time of sparse awareness. The questions now are how far we will go with these technologies and what kinds of challenges and fears we are willing to face and overcome.

For as much as Twitter is now being examined by the healthcare and pharmaceutical industries (a welcomed step), we have yet to flesh out practical opportunities and dangers Twitter poses for them. I am encouraged that hospitals are tweeting. Some are doing remarkable work and learning as they proceed. But I also have concerns about the incorporation of Twitter in the healthcare setting. I know all too well about Twitter’s seductions. Twitter makes almost everything easy, including regret.

I have therefore assembled a collection of dark predictions about how Twitter may be misused or misappropriated. My task now is to be Devil’s advocate during a time of attention obesity.

I don’t know if I saved Follow Friday. I do hope that in the rush to embed Twitter into our daily lives that we strike the right chords between Twitter Evangelism and Devil’s Advocacy.

66 OMINOUS PREDICTIONS ABOUT TWITTER

  1. That physician you’re following on Twitter will turn out to be an impostor.
  2. Your Direct Message will FAIL. Horribly.
  3. Your organization/practice will violate HIPAA. Repeatedly.
  4. Patients who don’t fully understand Twitter’s viral powers will find themselves woefully embarrassed.
  5. Your surgeon will tweet the wrong body part.
  6. Disaster management will be a disaster thanks to spam.
  7. Pandemic alerting will be a mess thanks to spam, panicked retweets, amateur microbiology and the Baumann Uncertainty Principle.
  8. Twitter will never reserve hashtags for sole use by the CDC or FDA or any other public service to guard against spam and keep channels of authority clear.
  9. Big Pharma will pay out tens of billions of dollars in fines and civil lawsuits related to alleged misleading statements in the course of tweet-marketing.
  10. Pharmaceutical company Twitter accounts will be hacked and the exploits will tweet misleading drug information, malicious links, confidential legal settlements and other embarrassing material.
  11. Twitter’s curious effects on  Dopamine will lead to addictive behaviors interfering with activities of daily living.
  12. Some disappointed healthcare marketers will revert to the traditional broadcast model of marketing after realizing quarterly earnings aren’t immediately boosted by providing free value to the communities they serve.
  13. Twitter will accelerate the proliferation of self-diagnoses.
  14. Insurance companies will find and track patients by viewing the follow lists of public-timeline hospital Twitter accounts.
  15. Insurance companies will set up dashboards to monitor insureds and use the information profitably.
  16. Twitter chats about healthcare reform will be infiltrated by Townhall-like Hashtagging.
  17. Patient dignity will be violated by nurses and doctors who tweet about their shifts from hell.
  18. Big Pharma and medical device companies will pay out tens of billions of dollars in fines (again) years after the FDA decides what regulatory rules to impose on tweeting.
  19. Lawyers will set up dashboards to monitor the tweets of pharmaceutical companies, device manufacturers, doctors and healthcare organizations in search of opportunities.
  20. Big Pharma will find itself finally engaging with patients on Twitter, only to realize that having 1,550,000 followers on Twitter means having to employ armies of drug safety associates 24/7/365.
  21. Twitter chats around specific disease processes will be polluted not only with spam but also misinformation masquerading as evidenced-based medicine.
  22. Patient-provider boundaries will be broken at alarming rates.
  23. A patient with depression will enter an unstoppable cycle: depressing tweets which lead to being un-followed and ignored, leading in turn to more depressing tweets…
  24. During a live-tweeted procedure that goes wrong, staff will forget to personally attend and inform the family reading the tweets.
  25. Privacy settings in Twitter will be reset to public, either by a Twitter glitch or hack or user-error and patient data will be inadvertently published.
  26. Psychotherapists using Twitter to communicate with patients will misinterpret or miss a patient’s tweet, resulting in a suicide.
  27. Hospital staff will tweet out information related to an incident.
  28. The overuse of Twitter will increase hypomania in patients with bipolar affective disorder.
  29. Obesity will continue to proliferate as healthcare consumers spend more time on Twitter looking for diet and exercise tips.
  30. Tweeters expressing suicidal ideation will be trolled by malicious malcontents.
  31. The wrong kind of medical crowdsourcing will lead to the wrong diagnostic judgements.
  32. Nurses who are not accustomed to the safe use of clinical micro-messaging will be distracted from their bedside duties.
  33. Doctors in facilities that employ enterprise micro-blogs may issue the right order to the wrong patient.
  34. The wrong laboratory results will be mis-tweeted. Fortunately, a smart nurse will notice the discrepancy between the lab value and the patient’s signs. This time.
  35. Patient timelines in facilities using micro-sharing technologies will be confused, causing all sorts of mayhem during shifts.
  36. The tweets of doctors will be used in courts to contradict testimony regarding timeline claims.
  37. The content of doctors’ tweets will be compiled and analyzed to challenge their competencies.
  38. Twitter chats about Obsessive-Compulsive Disorder will never end. Twitter chats about Obsessive-Compulsive Disorder will never end. Twitter chats about Obsessive-Compulsive Disorder will never end. Twitter chats about Obsessive-Compulsive Disorder will never end. Twitter chats about Obsessive-Compulsive Disorder will never end.
  39. Nurses will lose their jobs for posting TwitPics of patients in undignified positions.
  40. Family members will stick their unsolicited noses in each others’ health matters.
  41. CDC will inadvertently create panic during a major outbreak after a single malformed tweet is retweeted relentlessly. CNN and Fox News, confusing Twitter with sourcing, will re-broadcast the tweet, fueling more retweets and distortions of the original tweet.
  42. Small practices using Twitter for scheduling will tweet the wrong patient or time.
  43. Hospitals will monitor their staff’s Twitter streams for violations of confidentiality and other reasons for discipline or termination.
  44. Hospitals who don’t understand the subtle dynamics of Twitter-sociology will find themselves in front of public relations nightmares.
  45. Healthcare information consumers will be under-served by over-reliance on 140 characters, especially by organizations that don’t have a well-rounded social presence on the web.
  46. Hospital administrators will tweet annoying requests to staff busy with more important tasks.
  47. In a maternity ward, somewhere in the Midwest, the grandparents of twelve girls will read a tweet saying “It’s a boy!”, only to find out someone saw something that wasn’t there.
  48. A drug guide application accessible via Twitter’s API will tweet back the wrong dosage information.
  49. Shortly after retweeting the funniest thing she ever read, a newlywed will find out about her husband’s STD.
  50. Pharma will receive an unprecedented volume of Warning Letters for its uses of Twitter.
  51. A pharmaceutical company will inadvertently issue a drug safety alert about the wrong drug, resulting in billions of dollars in lost sales with a single tweet.
  52. A pharmaceutical company will not issue a drug safety alert, resulting in billions of dollars in lost sales with a single tweet.
  53. The FDA will issue a drug safety alert about the wrong drug, resulting in billions of dollars in lost sales with a single tweet.
  54. Practices using Twitter for patient care reminders will mix up patient Twitter accounts, causing confused home-care.
  55. A psychiatrist being sued for breech of confidentiality on Twitter will be relieved when she discovers that Twitter’s search engine no longer returns her troublesome tweet. Unfortunately for her, the lawyer suing her will find the tweet on FriendFeed’s search.
  56. Hospitals who should be blogging or otherwise investing in a larger social media landscape will over-invest in Twitter, since everybody has Dopamine receptors (see #11).
  57. Segments of the health care population who aren’t using Twitter will be overlooked or under-served.
  58. Allied care coordination, will be hampered by confusing tweets.
  59. Patients will increasingly realize that they can tweet adverse events on Twitter.  4Chan will catch on to this too. The big heart of a near-retirement CEO in Big Pharma will enter ventricular fibrillation. He will survive and will be prescribed the medication fictively referred to in #52.
  60. David will become internet famous during the next major infectious outbreak. The public, unaware of  @CDCemergency, will go to the most logical Twitter name for CDC:  @CDC. The confusion will lead to the conclusion that CDC is not on Twitter and will turn to bogus accounts and spammed hashtags for updates. This oversight by CDC and Twitter will go down as one of the biggest failures to capitalize on brand equity.
  61. The FDA will finally issue guidance allowing pharmaceutical companies to tweet links to products. Curiously, the FDA will encourage those tweets to be “non-retweetable”, stating that it will use its discretion in fining companies $10,000 for each retweet if, in the FDA’s opinion, the tweet appears “overtly re-tweetable”.
  62. The FDA will allow healthcare applications to be built on Twitter’s API. What’s more, the FDA, in its recognition of the importance of real-time technologies in our daily lives, will outline an efficient seven-year approval process for each application.
  63. Remarkable healthcare applications will be built on top of Twitter’s API, spurring wider acceptance of Twitter in serving the health care needs of the public. Unfortunately, Twitter will make unannounced changes in its API.  Jesse Stay, having helped to develop one of the most downloaded Diabetes iPhone apps, will suffer a brain aneurysm while discussing the changes with Twitter. He will survive and recover but will go on to delete his Twitter account and give up application development.
  64. The FDA, realizing Twitter’s role in public health, will require pharmaceutical companies and device manufacturers to publicly tweet Serious Adverse Events within 24 hours of receipt of notification. The hypothetical executive referred to in #59, in an extraordinary episode of psychosis, will go postal and use Twitter to live-tweet his rage. From that day onward, the phrase “going postal” will be replaced by “going Twitter”.
  65. HIPAA will be repealed and replaced with the Health Insurance Tweetability and Liability for Electronic Records Act of 2010. Among the provisions is the requirement that hospitals with public Twitter profiles not display their Following and Followers on their accounts. Twitter, of course, will offer no way to do this.
  66. Highlighting the power of Twitter’s monopolistic communications platform after a series of national health emergencies and a major terrorist attack coordinated in part via Twitter, the U.S. Congress will pass the Public Health And Safety Communications Act of 2012. Twitter Inc. is deemed a public utility holding company and enters an indefinite licensing agreement with the Department of Energy, whose charge is “to ensure the safe and uninterrupted use of Twitter and other micro-messaging services during times of national and international crises”. Twitter’s long-standing liquidity issues are finally resolved.

THE RESCUING ELEMENT

That last prediction may be the most dramatic, but given the tenuous state of our world’s psyche, it’s not far-fetched. Would it surprise you if it happened?

Am I being sarcastic or serious here? Does it matter? I mean: if we are to put safety and effectiveness above all else, shouldn’t we plumb the dangers posed by a real-time web?

Here’s another way to look at this list: as implied solutions to problems we may not have considered. Nothing is necessarily inevitable – awareness can prompt avoidance.

Twitter is telephony. Twitter is telepathy. Twitter is good. Twitter is bad. Twitter is useless. Twitter is useful. Twitter is whatever you make of it.

Twitter’s uses in Healthcare or Pharma or Politics or Marketing or any other field don’t so much depend on the technology as much as our willingness to be creatively courageous in the face of rapid change.

How we use Twitter in healthcare to streamline clinical operations, to provide richer experiences for consumers of healthcare information and to effectively propagate critical messages in times of crises depend on how willing we are to re-examine our traditions and re-envision what remarkable health care looks like given our new powers. We need leaders who aren’t afraid to break stupid rules and flush out deep prejudices.

In healthcare and other life sciences, following the rules is a vital part of the game. In fact, it usually is the game. Which is to say: leadership in healthcare is uniquely risky business.

For those of you who are currently using or planning to use real-time technologies in health care, think optimistically but responsibly about how you go about using them. Twitter and its yet-to-be-developed analogues bring forth into our world dangerous opportunities. When thinking about these dangers, here is a tweet-sized pearl of wisdom from Frederich Holderlin:

But where there is danger,

a rescuing element grows as well.

What do you think are the dangers of real-time social communities in healthcare? How would you propose we overcome those dangers? What are the rescuing elements among evolving – and sometimes unpredictable – threats from social technologies?

Reblog this post [with Zemanta]

Virtual Health – however that’s defined – has become a hot topic lately, especially in light of the rapidly evolving two-way real-time Web. Power dynamics – the interplays between patient and provider – must be protected in order to safeguard patient rights and protect their dignity, privacy and well-being. There’s more to virtualized practice than may be apparent on the surface.

Here are some thoughts, including an explanation of what I am (half-humorously) calling the “intimacy-boundary membrane”. [Link to video]

Power Dynamics & Virtual Health: Protecting Professional Boundaries in an Unbounded Web from Phil Baumann on Vimeo.

Patients are increasingly demanding online ways of interacting with their providers. As social media evolve, improve and proliferate, the ePatient movement will continue to expand and the healthcare industry will have to develop ways to meet the demand.

This movement, however, will have to ensure that it does not overlook the important behaviors all health care providers must express. It will also have to mature so that we aren’t left with a virtual health care landscape that is little more than a circus of amateurs. Experience matters more than content.

But social media is also rapidly shortening the spaces of intimacy and boundaries between people. This means that as health care professionals interactively enter the Web, the tension between intimacy and boundaries will increase.

We could say that there exists a safety zone between intimacy and professional boundary. These zones have traditionally been worked out for in-person clinical relationships. Online, however, we have a long way until we establish a collective understanding of how these technologies affect our virtual health care experience.

Since the space is shrinking to a thin wall, I’ve decided to call this problem the intimacy-boundary membrane. How do we go about protecting that membrane? Is this metaphor useful? You tell me.

//

Reblog this post [with Zemanta]
Image representing Twitter as depicted in Crun...
Image via CrunchBase

Twitter may either be the greatest prank ever played on the internet community or it may be the best thing since sliced bread. It’s easy to make the first case if you read the public timeline for a few minutes. It’s a bit harder to make the second case, but I’ll do my best to make it. Specifically, I’d like to take a stab at offering 140 health care uses for Twitter.

Twitter’s simplicity of functional design, speed of delivery and ability to connect two or more people around the world provides a powerful means of communication, idea-sharing and collaboration. There’s potency in the ability to burst out 140 characters, including a shortened URI. Could this power have any use in healthcare? After all, for example, doctors and nurses share medical information, often as short bursts of data (lab values, conditions, orders, etc.).

CHALLENGES OF HEALTH CARE MICRO-SHARING

Unlike most other kinds of uses of Twitter (daily exchanges between friends, the kind of work @Comcastcares does, etc.), health care related matters pose unique challenges, including but not limited to:

  • Patient dignity and privacy
  • Professional oaths to do no harm
  • Litigation concerns
  • HIPAA

The possibilities that I believe Twitter offers currently far exceeds the constraints. I won’t offer work-around solutions to these constraints in this post. I want to focus on the possibilities because once we see the potential, we may have stonger motivations to deal intelligently with the constraints. So when reading this list, don’t get hung up on the details, the fears, the anxieties that may be provoked by the realities of health care as it is practiced today. It’s the 21st Century: let’s be imaginative, determined and innovative. Let’s be remarkable.

In the health care industry there is often a fine line between caution and fear. It is the fear of change so common in health care that I hope we can overcome. Twitter may be a proving ground of how we overcome our fears, satisfy our cautions and extend the reach of our health care system with web-based technologies and communities.

What follows are uses than can be adopted right now and uses that remain to be developed. What do you think health care will look like in 2099? Will we still be using paper medical records or will we be using technologies that other industries use? Will we transcend our accustomed ways of thinking and re-socialize ourselves for how we interact with each other in an exponentially changing technoscape?

I hope this list sparks debate to help answer those questions. Here are the suggestions.

140 HEALTH CARE USES FOR TWITTER

  1. Tissue recruitment (for kidney and other organs, including blood)
  2. Epidemiological survey
  3. Disaster alerting and response
  4. Emergency response team management
  5. Supportive care for patients and family members
  6. Diabetes management (blood glucose tracking)
  7. Maintaining a personal health diary
  8. Adverse event reporting in the clinical setting and other pharmacovigilance functions
  9. Emitting critical laboratory values to nurses and physicians
  10. Alarming silent codes (psychiatric emergencies, security incidents)
  11. Drug safety alerts from the FDA
  12. Risk management communication
  13. Augmenting telemedicine
  14. Issuing Amber alerts
  15. Issuing alerts for missing nursing home residents
  16. Exercise management and encouragement
  17. Weight management and support
  18. Biomedical device data capture and reporting
  19. Nutritional diary and tracking
  20. Coordinating preoperative, perioperative and postoperative care (among pharmacy, nursing and surgical services)
  21. Medical service collaboration in the clinical setting
  22. Triage management in emergency rooms
  23. Census management/monitoring
  24. Arranging outpatient care
  25. Crowdsourcing for health care resources
  26. Shift-bidding for nurses and other health care professionals
  27. Mood tracking (for patients with bipolar and other mood disorders)
  28. Patient care reminders in the clinical setting
  29. Prescription management, including pharmacy refill reminders
  30. Daily health tips from authoritative sources
  31. Location awareness during crisis
  32. Occupational safety response
  33. Hazardous materials communication
  34. “Quick and dirty” diagnostic brainstorming between physicians (e.g. ’symptom clustering’)
  35. Clinical case education for (residents following attendings)
  36. Physician opinion-sharing
  37. Promoting Domestic Violence awareness
  38. Raising Child Abuse awareness
  39. USMLE preparation for medical licensing
  40. NCLEX for preparation for nursing licensing
  41. Recruitment of health care staff
  42. Alcohol and other substance abuse support
  43. Issuing doctor’s orders
  44. Environmental alerts: pollen counts, pollution levels, heat waves, severe weather alerts
  45. Remote wound care assistance
  46. Rural area health care communication
  47. Micro-sharing of pertinent patient information
  48. Micro-sharing of diagnostic results (blood tests, echocardiography, radiological images)
  49. Internal facility customer service (a hospital equivalent of @Comcastcares – c’mon hospitals!)
  50. Publishing health-related news
  51. Psychiatric “check-ins” for patients
  52. Nursing mentoring and collaboration
  53. Publishing disease-specific tips
  54. Childcare support
  55. Fund raising for hospitals and health-related causes
  56. Updating patient family members during procedures
  57. Live-tweeting surgical procedures for education
  58. Rare diseases tracking and and resource connection
  59. Reporting hospital staff injuries
  60. Tracking patient trends
  61. Tracking disease-specific trends
  62. Checking hospital ratings with other health care consumers
  63. Providing around-the-clock disease management
  64. Connecting genetic researchers with physicians
  65. Publishing the latest advances in biomedical devices
  66. Tracking antibiotic resistance
  67. Real-time satisfaction surveys with immediate follow-up for problem resolution
  68. Issuing asthma alerts
  69. Data collection for tracking facility patterns (process-performance, supply-chain and staffing problems)
  70. Live-tweeting medical conferences
  71. Keyword-tracking of health-related topics via Search.Twitter
  72. Posting quick nursing assessments that feed into electronic medical records (EMRs)
  73. Improving medical rounding systems
  74. Clinical trial awareness
  75. Hospital administration
  76. Sharing peer-to-peer reviews of articles of interest
  77. Connecting patients with similar disease processes
  78. Enhancing health-related support groups (e.g. buddy-systems for depression)
  79. Providing smoking cessation assistance
  80. Medical appliance support (e.g. at-home: colostomy care, infusion-pumps, wound-vacs)
  81. Reporting medical device malfunctions
  82. Tweeting updates to facility policies and procedures
  83. Arranging appointments with health care providers
  84. Product safety alerts
  85. Food safety alerts
  86. Information on women’s health
  87. Pain management
  88. Hospital reputation monitoring
  89. Publishing hospital-sponsored events in local communities
  90. Community health outreach
  91. Bioterrorism awareness and preparedness
  92. Issuing updates to hospital services to the public
  93. Insurance claim management
  94. Ethical, permission-based following of patients
  95. Micro-sharing consent for surgical and other procedures
  96. Patient-sharing of health-related experiences
  97. Posting ‘bread crumbs’ of facility experiences (”I had a bypass at this hospital and it went well but the food almost killed me.”)
  98. Patient searches for others confronting similar problems
  99. Stress management
  100. Mental health awareness
  101. Posting homeless shelter needs
  102. Food bank resource management
  103. Transmitting patient data to patients who are traveling abroad
  104. Generating streams of authoritative health care content online
  105. Exposing medical quakery
  106. Micro-sharing documentation for advanced medical directives
  107. Discussing public health care policy
  108. Developing stronger patient-provider relationships
  109. Tracking the safety and efficacy of pharmaceuticals
  110. Following health marketing
  111. Tracking influenza alerts from the CDC
  112. Exchanging/soliciting scientific validation of alternative health claims
  113. Following ad-hoc conferences on eHealth like HealthCampPhila
  114. Tracking toxic diseases
  115. Tracking HIV news
  116. Issuing/exchanging dietary tips
  117. Tweeting what you eat
  118. Comparing nursing home performance
  119. Coordinating clinical instruction
  120. Communicating with nursing supervisors
  121. Public safety announcements
  122. Tracking FDA guideline updates
  123. Tracking the progress of developing pharmaceuticals
  124. Broadcasting infant care tips to new parents
  125. Publishing vaccination/immunization services locations, hours and reminders
  126. Reporting adverse events to FDA (currently not available via Twitter: why not?)
  127. Obtaining information on Medicare and Medicaid
  128. Case management functions
  129. Clinical education coordination
  130. Facilitating patient-transfer processes
  131. Patient-information retrieval
  132. Reporting breeches of universal precautions in health care facilities
  133. Posting daily nursing tips
  134. Exchanging physician humor (we’re all human)
  135. Closing the digital divide with respect to health care information
  136. Coordinating allied health care services during patient admissions
  137. Coordinating patient discharges with all services
  138. Post-discharge patient consultations and follow-up care
  139. Helping device technicians to communicate directly with manufacturers
  140. Discussing HIPAA reform in the age of micro-sharing

There they are: 140 health care uses for micro-sharing platforms like Twitter. Implementing these uses can be enormously challenging (and even impossible) on Twitter given today’s constraints. For many of these uses, other more robust and secure micro-sharing platforms will be needed (e.g. Yammer or ESME). Certainly, Twitter offers a model of how micro-sharing can be used for a wide range of purposes. If social media marketers can figure out how to use Twitter, health care professionals can also figure out how to use micro-sharing.

HEALTH CARE SHOULD BE THE LEADER IN MICRO-SHARING

With 26 letters in the alphabet arranged within 140 characters, there are over 1.2 x 10^198 possible character combinations (thank you @symtym). Of course, the number of meaningful sentences is far less than that but a point stands out: there’s a virtually infinite number of short pulses of (meaningful) information that Twitter can facilitate.

With that kind of power, health care should be a leader in micro-sharing, not a lagger.

WHAT HAVE I MISSED? WHAT CAN YOU CONTRIBUTE?

I have probably missed some incredibly important healthcare uses for Twitter. I am also probably missing specific Twitter accounts that should be included as links in the list. Please contribute and I will continue to refine the list.

Visitors: please add to the list, make comments, ask questions, offer critique. It’s your health, it’s your century and it’s your right and responsibility to make this list as practical as possible. I’m doing my best to do my part. Your turn.

Download the eBook version of this post!

[NOTE: Major edits to this list based on feedback and the nature of the content will be disclosed.]

[Post to Twitter] Tweet This

Reblog this post [with Zemanta]