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?