The ROI of the Tweet

Image by TW Collins via Flickr

Is Twitter a sales tool? Can it “drive” sales? If so, what’s the return on investment of a tweet? Most executive teams today still view the world through the lens of the assembly-line. They like metrics and clearly defined goals and well-thought decision trees. They prefer straight lines over curves with cloudy distances. They are largely justified in their lines of reasoning.

But the Web has opened up a decidedly non-linear fabric of novel media. Consequently, many organizations have been slow to adopt emerging media and technologies because they simply don’t see the return on investment. Often, they’re not even sure what the investment is. Or what the return might be. Or what the goals or purposes or opportunities of subsuming the Web into their going concerns could be for them.

So this post aims to provide a clearer, if alternate, view of what’s at stake. We’ll look at metrics. We’ll also examine how organizations can better understand the nature and essences of media – all media, old and new and media not even around yet.

If you work in an organization which has been struggling with keeping up-to-date, I offer this to you so you can go into C-Suite and answer the tough questions without looking like an unprepared stooge. You owe it to yourself to understand the media you sell to your executive team – and you owe it to yourself to ensure they understand how to properly enframe media in the 21st Century.

NOTE: This is a long post. My aim here is not to prove that Twitter is not valuable to business. Quite the contrary: I don’t believe enframing Twitter as a generator of financial ROI is the proper way to view the service. But I do believe that evangelists must be able to say to executive management something like this: We have crunched pro forma numbers and in our opinion Twitter is not really a direct (or even indirect) driver of ROI; we do believe, however, that Twitter can be a linchpin within a web of comprehensive web strategies. You can get this post as a document here.


In order to provide some insight into the difference between Twitter-as-sales-tool and Twitter-as-public-utility, I believe pro forma metrics may help to reveal some important properties of a medium like Twitter. Too often claims are made about Twitter’s business values – and usually the issue of metrics is explained away with vague optimism.

But why not take a crack at metrics, if only to reveal a basic truth of Twitter? After all, Twitter’s simplicity makes it a utility with varied uses. By seeing that Twitter’s effectiveness in driving revenues (even indirectly), allows conversations to focus on a more robust enframming of the service.

I’ll call the strict Financial ROI enframing of Twitter the brute force method. The brute force method makes several assumptions and follows an algorithmic, assembly-line logic. So here are the assumptions:

  • Number of followers are true fans – not just the count of followers according to Twitter – not bots,  or miscellaneous people who aren’t invested in a brand.
  • Followers are people who are likely to buy a product and who are actively paying attention to the Twitter stream of the business/product account.
  • The tweets include links to actionable web real-estate where conversion is possible.
  • Customers make at most one purchase per month.
  • Clickthrough and conversion rates are comparable with traditional web metrics.
  • The effect of retweets is actually minimal on tweets about products (at least in this case) and has been left out of the model.

So let’s look at a hypothetical. Let’s tackle a difficult industry: Pharmaceuticals. For this example, we will leave FDA regulations and other constraints on the industry out of the equation. We’ll say that the company runs a Twitter account for a particular drug and tweets links about an OTC medication (again, we’re assuming these are “FDA-compliant” tweets – yes: laugh – conversations around Twitter can be that ridiculous).

We’re going to assume that the labor time for running the Twitter account is based on $50 per hour. Furthermore, we’ll assume that only one hour a day of labor time is needed (for Twitter accounts with a very high volume of tweets, management will probably need many more hours of labor time in practice). But we’ll be conservative.

Here are a few scenarios (pulled the pro forma spreadsheet which you can view here):

1,000 Followers x 5% Clickthrough x 5% Conversion x $5 Margin x 12 Months – $12,500 Labor = ($12,350)

128,000 Followers x 5% x 5% x $5 Margin x 12 Months – $12,500 Labor = $6,700

1,024,000 Followers x 5% x5 % x $5 Margin x 12 Months – $12,500 Labor = $141,100

8,192,000 Followers X 5% x 5% x $5 Margin x 12 Months – $12,500 Labor = $1,216,300

In order to achieve over a million dollars in revenues, tweets would need to yield a ROI of 9,630%! Use your common sense: it’s utterly delusional to think that ten tweets per day over a year would provide that kind of return. Even to achieve over $1 Million, this pharmaceutical company would have to have over 8 Million followers! And each of those followers would have to be devoted true fans. Think of the investment required to generate a tribe of 8 Million followers – the time, the electrifying tweeting style, the power to be loved.

You can tweak any of the variables and crunch new figures. You can input a higher margin, for instance – but you may need to re-think clickthrough and conversion rates and follower counts. Go work up a brute force model for you business or client and see what you get. Just be realistic and understand the properties of Twitter (or whatever other medium you’re working with). That’s one of the problems I think (some) marketers have: they don’t really understand the media out of which they’re seeking to extract value.

I won’t say that you can’t generate these kinds of numbers – but there are weaknesses and paradoxes in this approach which I’ll reveal in a moment. And yes, I’m fully aware of the general effect of positive WOM but that’s not the point of this story. I’ll touch on brand awareness in a bit – wait for it. 🙂

As you can see, given these assumptions, this brute-force approach to Twitter doesn’t release a lot of financial return (not for larger enterprises with capitalizations greater than $1 Billion). Sure if you run a relatively small enterprise and can cultivate a massive and committed fan-base in the long-run, there’s a chance Twitter may provide substantial gains in line with your revenue stream. Of course, your margins may be larger (but as margins grow, you may encounter diminishing actual conversions). Most importantly: building a tribe of true fans is hard work – very very hard work.

Yes, Dell has claimed it earned $3 Million from Twitter, but Twitter was simply an ancillary service to their wider web presence – and Dell indeed has over a million followers (and a larger margin than in my pro forma).

None of this means, of course, that Twitter has no business value. In fact, I would argue that Twitter can be an essential linchpin for overall web presences: Twitter enables a pliant means to connect various media and web real estate together. It’s also real-time which means you can literally stream your presence and respond swiftly to shifting currents.

But there are paradoxes hidden within the brute-force approach. Let’s take a look at them.


There’s a sort of Uncertainty Principle underlying Twitter: the more directly you mechanize a given strategy, the more dilute the attention of followers becomes.

For any Twitter strategy to “work”, the tweeting must be remarkable, attention-enlivening, creative. Tweets need to be interesting day-to-day, week-to-week, year-to-year. Annoyance and boredom are easily un-followed. Value and connection and humor are followed more sustainably. Thus, the only way a business can hope to achieve long-term attention via Twitter is to relentlessly be creative and captivating and social and valuable. Tweeting coupons and links to products alone doesn’t work all by itself.

There’s another paradox on Twitter: Promotion of Other is a greater promotional tool than promotion of Self. This is one of the hardest concepts most organizations have to understand.

Retweet your competition.

If you can’t retweet your competition, you probably don’t have the confidence and faith in your enterprise to stand out. If you’re not standing out, just what are you doing with your marketing dollars?

Marketing not only has to be effective but it also has to be respectable. For an industry like Pharmaceuticals, anything less than respectable is unprofessional.


I hope I’ve made it pretty clear that achieving a robust Financial ROI of Twitter directly is not a realistic proposition in most cases. If that’s your only enframing, I would suggest you forget Twitter.

I would suggest, however, that Twitter’s pliancy and immediacy and connectivity provide means to many other ends. It’s basically just a telephone for our century. The most valuable enframing of Twitter is in a Relational context.

Building and sustaining relationships are bricks and mortar for all successful businesses. Smart businesses understand the paradox of the un-sales approach to relationships: the more sincere and mature the relationships, the better the conditions for business development.

Sure, we can talk about buzz-concepts like brand awareness. (Of course, you could also stick a finger down your throat and achieve a similar effect.) But I actually think that’s a sub-set of the brute-force approach to Twitter. Once you make that your purpose on Twitter, you lose your followers’ attention. Brand awareness, at best, must be a pleasant side-effect of much more remarkable ways to employ Twitter.

Yes, it’s a cliche but social media is social. If you have poor social skills, you better develop them now. Since relationships operate in non-linear geometries, you’re going to have to learn to think beyond rigid lines. The Web can be an unforgiving creature and will eventually break you if you don’t have the pliancy to turn on a dime.


By hoping to achieve financial gain via an inhuman algorithmic enframing of Twitter, you forgo several important and valuable business opportunities. If I were a Public Relations guy, I’d look at Twitter and say: Wow! We finally have a way to re-humanize our communications and how we connect – We can finally go back and re-work those arcane methods we developed when we had only broadcasting media.

The fundamental truth of the Web is that organizations composed of cogs – people with little incentive to shine their talents – simply don’t have the supple musculature demanded of a public sphere laden with real-time technologies.

Organizations must cultivate cultures of creative, ambitious, informed and swift-thinking human beings. If you’re going to invest in Twitter, you better have remarkable people working for you – do it yourself if you have to.

A narrow focus on Financial ROI will enframe a human context within a technological one. In other words, it’s putting the right shoe in the wrong box.

The opportunity cost of enframming the business value of Twitter within fincancial ROI is the larger frame of possibilities which Twitter offers. The most important of these are the re-humanization of corporate communications and the connecting of disparate elements of an active online and offline presence.


The ROI of the tweet is elusive.

The ROI of the tweet is what you make it.

The ROI of the tweet is the expression of your daily artistic creativity.

The ROI of the tweet can be mechanized – but at enormous expense and opportunity cost and risk.

The ROI of the tweet is relational.

The ROI of the tweet is conditional.

The ROI of the tweet is contextual.

The ROI of the tweet is human.

How you enframe tools influences what you get out of them. Sales people enframe sales uses around media. Marketing people enframe marketing uses around media. Public relations people enframe public relations uses around media.

The fact, however, is that the Web is Mother of All Media. It not only spawns new media with differing properties, the media it spawns all inter-relate among each other in novel ways. We don’t have a Grand Unified Theory of the Web, but we can at least understand the fundamental properties of individual media. When I get asked how to “use such and such a tool”, what people are asking is: What’s the theory here. But there isn’t any tested theory: at best we have intuition and reason and experience and imagination. Of course, if your lack these then a theory probably won’t help you.

My recommendation to anyone interested in new media’s role in business is to go back to fundamentals. Language like “old media is being replace by new media” can lead you down misguided paths. Marketing is more than messaging, of course, but it’s important for marketers and communicators and public relators to understand Media. Here are some questions to ask yourself and your team about media:

  • What is this medium? What’s is its essence?
  • What are the properties of this particular medium?
  • What are the possibilities of this medium?
  • What category(ies) does this medium fill: social, impersonal, synchronous, asynchronous, unilateral, bilateral?
  • What does this medium enhance?
  • What does this medium obsolesce?
  • What does this medium retrieve?
  • What does this medium reverse? What happens when this medium is pushed to its limits?
  • What happens when a person encounters this medium?
  • How does this medium relate to other media?
  • How might this medium change the world?
  • How should this medium be enframed?

These are simple but difficult questions (I will expand on them in future posts). When was the last time you asked any of these questions? What have you done to acquire an orientation about new media? That’s the purpose of the above questions: to get you to pan back from your accustomed views and assumptions and experiences and re-frame things in clearer contexts.

It’s also important to understand the different kinds of connections between media and people and things. Social isn’t the only connection. People have connections with products and services – but those connections aren’t social. For example, the connection between a customer and a brand isn’t social. It’s something else – knowing what kind of connection binds medium to medium or people to products helps you determine what media you choose.

For instance, by understanding what a medium enhances, obsolesces, retrieves and reverses, you can better compare novel media with familiar media. You can develop insights into what features of traditional approaches can and can’t be ported into new media. If you’re unfamiliar with McLuhan’s Tetrads, you can learn more here.

If you work in an agency – PR or Marketing – you need to answer these questions so that you can equip yourself with the resources to properly view emerging media. It’s no longer enough to “get” Twitter or Facebook or Blogging: you must have a fresh philosophy about media in general because the Web is evolving. You need to hone an intuition about emerging media and these questions offer a good practice for you.


The lesson here is that there is return on the tweet. But before you get to return you must get to re-frame. This is going to be a turbulent century. It’s easy to get tossed about and disoriented. Assumptions and methods which were once effective may no longer give lift. Orienting is itself a skill to be treasured.

Focusing on one narrow objective like financial ROI before fully understanding an asset is not all too wise. Not when your competition has figured out things you haven’t even considered.

I have tried to address the legitimate concerns of “old-school” executives who rightly question the expected returns of social media. I believe they are entitled to an honest accounting about the limits of media. The smart ones will see the folly of attempts to port assembly-line thinking into territories in which it makes no sense to do. The smart ones will also then be able to see things aright and perhaps your organization or client will understand the proper context and enframming needed to be remarkable.

You can go the brute-force method and miss a much larger party. Or you can be something far more interesting and ultimately financially rewarding. My advice on Twitter is to be a Lovable Peacock: someone with the goods worth showing off but with a warm heart for the flock. Many executives won’t like that metaphor. But then, not many businesses here today will be around in 2020.

So, what’s your take? Is my brute-force analysis flawed? Does it help to demonstrate and to admit up-front that Financial ROI isn’t a wise enframing of Twitter? Does it advance the conversation?

Will you re-enframe everything you think you know? Will your Corporate Philosophy take to wing…or fold?

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Digital Vertigo and the Cult of Authenticity


When status quos collapse, for whatever reasons, are their replacements necessarily better? Does the demise of traditional media powers mean that new media powers will lead to more Democracy? Will cultivated professions which require years of training and mistakes and experience – such as Medicine – give way to amateurs who can succeed in creating appearances of Authenticity?

Last century, not everybody could publish their thoughts without expending some form of considerable energy. Now, with Twitter, anyone can tell the world what s/he thinks at virtually zero expense (save the time value of their tweets). This is no doubt a radical shift in communications and publishing and connecting.

It’s easy to call this democratizing. But is it? Or is what’s happening a radical shift from one era of power dynamics to another: one where those who accumulate the greatest amount of social capital emerge as the major powers, powers which will dominate and rule over a new kind of oligarchic imperialism? One where a few hold sway to enormous influence while the many busy themselves in self-reinforced delusions of democratic liberation, confusing technological connection with the human kind?

Real-time media like Twitter sure do give off the seductive appearances of level playing fields where I can connect with you and you me. But what are the essential realities of the evolving Web? Are they balances-of-power? Or are they in fact towers-of-power, new status quos which create a condition of what Andrew Keen calls Digital Vertigo?

Here is the Antichrist of Silicon Valley himself discussing the dangers of the  Real-time web and Power.

We are living through the inflection phase of technological evolution. It’s hard to see beyond the exponential curve rising above our heads. Today’s gifts may be tomorrow’s sorrows. With Twitter, I can tell a friend something that makes her day. In the not-too-distant future, though, someone else just might detonate a bomb with a tweet. And then we can say Goodbye to Twitterville.

Is the Web bringing forth more opportunity than danger? Granted, it can’t be stopped at this point. But: may one promise of the Web (Democracy) eventually be betrayed by one danger (Tyranny)? Are we truly creating a Digital Level Playing Field or might we in fact be creating the conditions for chronic Digital Vertigo complicated by the illusion of Authenticity?

What do you think?

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66 Ominous Predictions About Twitter in Healthcare

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.


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.


  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.


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?

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