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Review the following scenario:

ABC Hospital is a small, privately-owned community hospital. It has been struggling to survive financially, as reimbursement rates have declined and consumers are being drawn to the larger state-of-the-art hospital facilities in urban areas that are perceived to have better quality. ABC Hospital was built in 1960 and has been operating in the same manner for many decades. The hospital meets legal and regulatory requirements but has not kept pace with some of the newer technologies and patient conveniences becoming more prevalent in the health care industry.

Write a 175- to 265-word response to the following:

  • What strategies can the organization take to survive, improve its performance, and compete with other hospitals over the next 5 years?
  • What are some advantages or disadvantages of these strategies?

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Journal List HHS Author Manuscripts PMC2835466

J Investig Med. Author manuscript; available in PMC 2010 Mar 9.

Published in final edited form as:

J Investig Med. 2009 Oct; 57(7): 748–755.

doi: 10.231/JIM.0b013e3181b91b3a

PMCID: PMC2835466

NIHMSID: NIHMS174869

PMID: 19730130

The Applicability of Lean and Six Sigma Techniques to
Clinical and Translational Research
Sharon A. Schweikhart, Ph.D. and Allard E Dembe, Sc.D.

▸ Author information ▸ Copyright and License information Disclaimer

The publisher’s final edited version of this article is available at J Investig Med

See other articles in PMC that cite the published article.

Abstract

Background

Lean and Six Sigma are business management strategies commonly used in production
industries to improve process efficiency and quality. During the past decade, these process
improvement techniques increasingly have been applied outside of the manufacturing
sector, for example, in health care and in software development. This article concerns the
potential use of Lean and Six Sigma to improve the processes involved in clinical and
translational research. Improving quality, avoiding delays and errors, and speeding up the
time to implementation of biomedical discoveries are prime objectives of the NIH Roadmap
for Biomedical Research and the NIH Clinical and Translational Science Award (CTSA)
program.

Methods

This article presents a description of the main principles, practices, and methodologies used
in Lean and Six Sigma. Available literature involving applications of Lean and Six Sigma to
health care, laboratory science, and clinical and translational research is reviewed. Specific
issues concerning the use of these techniques in different phases of translational research
are identified.

Results

Examples are provided of Lean and Six Sigma applications that are being planned at a
current CTSA site, which could potentially be replicated elsewhere. We describe how
different process improvement approaches are best adapted for particularly translational
research phases.

Conclusions

Lean and Six Sigma process improvement methodologies are well suited to help achieve
NIH’s goal of making clinical and translational research more efficient and cost-effective,
enhancing the quality of the research, and facilitating the successful adoption of biomedical
research findings into practice.

Keywords: Lean, Six Sigma, process improvement, translational research, quality, TQM,
CQI

Introduction

Various business management strategies have been developed to improve the performance
of organizations by improving the processes by which they carry out their work. These
strategies, which include Lean and Six Sigma, aim to implement process improvements
through a coordinated set of principles and practices that promote greater efficiency and
effectiveness, with fewer wasteful practices or errors. Evolving from their original
application in manufacturing industries, these process improvement strategies have been
extended to other settings including construction, software development, financial services,
health care delivery, and laboratory sciences.

The creation of the Clinical and Translational Science Awards (CTSA) initiative as part of
the National Institutes of Health (NIH) Roadmap for Medical Research is aimed at creating
a clinical and translational research enterprise that assures maximal value is obtained from
biomedical research investments. While the definition of clinical and translational research
is still being debated, there is broad consensus that formal and sustained processes are
needed to improve the timeliness and efficiency of research along the biomedical
continuum. Reducing the time between biomedical research discoveries and their adoption
into clinical practice requires increased coordination, systematic planning, and new types of
connections within biomedical research organizations. This article suggests that better
coordination, timeliness, efficiency and value of clinical and translational research can be
achieved by applying the set of principles, practices and methods represented by Lean and
Six Sigma.

What is Lean?

Lean (also known as Lean Production, Lean Enterprise, and Lean Thinking) involves a set
of principles, practices and methods for designing, improving and managing processes. The
development of Lean is attributed to Taiichi Ohno’s articulation of the Toyota Production
System. Ohno aimed to improve efficiency by eliminating particular kinds of waste (called
muda, in Japanese) which absorb time and resources but do not add value. Examples
include mistakes which need rectification, unneeded process steps, movement of materials
or people without a purpose, unnecessary waiting because upstream activity was not
delivered on time, and the creation of goods or services that are not really needed by end
users.

A Lean process reflects the goal of continually reducing waste and improving work flow to
efficiently produce a product or service that is perceived to be of high value to those who
use it. Implementation of Lean involves systematic process assessment and analysis. The
preliminary stages of Lean assessment include “value stream mapping” in which key
people, resources, activities and information flows required to deliver a product or service
are made explicit and depicted graphically. The value stream map is a key tool for
identifying opportunities to reduce waste and more tightly integrate process steps, thus
improving process efficiency.

Improvement approaches such as Lean and Six Sigma grow out of a long tradition of
quality and process improvement efforts in manufacturing. For example, Frederick Winslow
Taylor’s scientific management and Frank Gilbreth’s “time and motion” studies were
among the earliest prescriptions for improving the quality and efficiency of production
processes. Current thinking about process improvement draws heavily on the ideas of W.
Edwards Deming, Joseph Juran and other statisticians whose data analysis tools and
management philosophies were initially adopted by Japanese manufacturers, and have come
to be known as Total Quality Management (TQM) or Continuous Quality Improvement
(CQI).

What is Six Sigma?

Six Sigma, like Lean, is a business management strategy used to improve the quality and
efficiency of operational processes. While Lean focuses on identifying ways to streamline
processes and reduce waste, Six Sigma aims predominantly to make processes more
uniform and precise through the application of statistical methods. Six Sigma was
originally developed by Bill Smith of Motorola in 1986 as a way of eliminating defects in
manufacturing, where a defect is understood to be a product or process that fails to meet
customers’ expectations and requirements. The name Six Sigma refers to a quality level
defined as the near-perfect defect rate of 3.4 defects per million opportunities. As a process
improvement strategy, Six Sigma gained much attention through its association with
General Electric and its former CEO Jack Welsh.

A variety of systematic methodologies for identifying, assessing and improving processes
have been developed as part of the Six Sigma approach. The Six Sigma improvement
model, Define, Measure, Analyze, Improve, and Control (DMAIC) specifies the following
sequence of steps for understanding and improving a process: 1) defining the project goals
and customer (internal and external) requirements; 2) measuring the process to determine
current performance; 3) analyzing and determining the root cause(s) of relevant defects; 4)
improving the process by eliminating defect root causes, and 5) controlling future process
performance. Another Six Sigma methodology, Design for Six Sigma (DFSS), is used to
systematically design new products and services that meet customer expectations and can
be produced at Six Sigma quality levels.

Six Sigma also involves the training and certification of designated process specialists
(called black belts, green belts, or other similar titles) within organizations to help guide Six
Sigma improvement efforts. Other distinctive Six Sigma features include the expectation
that process quality improvements be translated into financial metrics to assess value and
the active involvement of top management in all Six Sigma initiatives.

Various combinations of Lean and Six Sigma techniques have been developed, which
frequently are described as Lean Six Sigma approaches. The blended approach points to the
common process-centered and data-driven foundations of both Lean and Six-Sigma.
Proponents of a combined approach assert that organizations can benefit from utilizing both
the customer-orientation and focus on eliminating waste inherent in Lean along with the
statistical tools and systematic defect reduction strategies featured in Six Sigma.

Lean and Six Sigma are just two of numerous approaches that are in use for systematically
analyzing and improving process flow and efficiency within industries. Other similar
approaches include Business Process Modeling (BPM), Business Process Reengineering
(BPR), and Workflow Mapping (WM), as well as a variety of TQM and CQI-oriented
techniques such as management accounting systems, Kaizen, and Shewhart cycles (PDCA).
The selection of a particular process improvement approach will depend upon the specific
circumstances and needs existing in a working environment, including the type of
processes, the improvement objectives, and the skills, knowledge, and resources available
in that setting. For example, some approaches may b better suited to statistical analysis of
defects (e.g., Six Sigma), some to layout planning and product flow (e.g., BPM and WM),
and some to optimizing transitions between process steps (e.g., Lean). We chose to focus
primarily on Lean and Six Sigma in this article because of literature suggesting their
applicability to biomedical and research settings (reviewed below).

Application of Lean and Six Sigma to Health Care

Health care organizations, especially large health systems, began studying and adopting
industrial quality management methods in the late 1980’s including TQM and CQI
approaches Early applications focused primarily on establishing programs and
infrastructure to measure quality and enhancing organizational culture surrounding quality
issues. Some hospitals used TQM methods to implement process improvements and
redesign both non-clinical and clinical work flows. Examples of specific TQM
interventions included the formation of cross-disciplinary teams to examine and improve
work processes, training employees to identify quality improvement opportunities, and the
use and application of statistical methods for process improvement.

Under the banner of TQM and CQI (hereafter we will use “TQM” as short-hand for both
TQM and CQI) health care institutions began to evaluate and make changes to a variety of
care practices. For example, selected service functions such as basic laboratory, pharmacy,
admitting and discharge, medical records, housekeeping, and material support services were
relocated to patient care areas to improve organizational efficiency. Applying TQM
principles, hospitals restructured processes to make care more patient focused. In one TQM
application, the turnaround of radiology reports was improved by revising work flow to
feature electronic signature by radiologists, elimination of a trainee signature requirement,
accelerated transcription, structured reports, faster film delivery to reading desks, and
training about the importance of radiology reports for clinical decision making. Many
health care organizations, inspired by TQM, established broader and more customer-
focused quality measurement systems including patient questionnaires, quality and
appropriateness reviews, performance appraisals, patient monitoring reports, infection rate
surveillance, and other quality-oriented metrics.

Although TQM approaches became quite common in health care during the 1990s, many
authorities expressed skepticism and reservations about the effectiveness of TQM and its
ultimate effect on improving health care delivery and patient outcomes. Several critics
characterized TQM as a vague and indistinct fad, with little tangible content. Shortell
et al. (2000) found that whether or not a hospital adopted TQM had little effect on multiple
outcomes of care for patients receiving coronary artery bypass graft surgery. Blumenthal
and Kilo (1998) have summarized the shortcomings of early applications of TQM to health
care quality improvement.

As described by Black and Revere (2006), Lean and Six Sigma “emerged from the fertile
environment” created by TQM. Recent applications of Lean and Six Sigma in health care
attempt to improve on previous experiences with TQM by making project deliverables more
discrete and measurable, retaining a strong customer (rather than organizational) focus,
quantifying results, and attempting to deliver specific quality improvements within a
designated time frame.

Since 2000, there have been a variety of projects applying Lean and Six Sigma strategies to
health care quality improvement. For example, pilot programs utilizing Lean approaches at
Intermountain Healthcare resulted in substantially reduced turnaround time for pathologist
reports from an anatomical pathology lab. Other Lean-facilitated improvements at
Intermountain Healthcare included reducing IV backlog in the pharmacy, reducing the time
needed to perform glucose checks on patients, decreasing time to enter new medication
orders and complete chart entries, and streamlining electronic payment for large vendor
accounts.

De Koning et al. (2006) describe several applications of an integrated Lean Six Sigma
approach instituted at a Dutch hospital that led to reducing the complexity of hiring part-
time clinical staff, optimizing operating room scheduling by designing a new pre-surgical
admissions process, and developing a new work planning system to expedited completion
of equipment maintenance requests. The U.K.’s National Health System adopted a variety
of Lean strategies, including redesigning the number of steps, and hence the time, needed
for collection and processing of blood samples at Bolton Hospital. Successful
applications of Lean and Six Sigma have been reported at numerous other health care
settings.

Application of Lean and Six Sigma to Laboratory Science

Lean and Six Sigma methodologies are well suited for application to laboratory settings
because of the inherent need for statistical precision and quality control in laboratory testing
and measurement activities, as well as the highly repetitive nature of laboratory work. Most
laboratory applications of Lean and Six Sigma have occurred in clinical environments. A
recent review article by Gras and Phillippe (2007) describes many of these applications.
Nevalainen et al. have advocated using a Six Sigma scale (based on six standard deviations
in variance representing a defect rate of 3.4 per 1,000,000 opportunities) as a way of
tracking on laboratory quality, establishing benchmarks, and measuring changes in
laboratory performance over time. Applications of Lean and Six Sigma in clinical
laboratories have included efforts to reduce auto-verification errors in a laboratory
information system, ensure sufficient volume of blood samples for use in a clinical
microbiology laboratory, assure the repeatability and reproducibility of warfarin
anticoagulation testing among different laboratories within a community, and establish
continuous and efficient work flow within a hospital-based histology lab.

There is substantially less research literature describing Lean and Six Sigma applications in
basic science laboratories as compared to clinical laboratory settings. This difference may
reflect the greater access to process improvement expertise available to clinical laboratories,
as these facilities are generally part of larger health care delivery systems. Nonetheless,
Lean and Six Sigma approaches are potentially applicable in both clinical and non-clinical
laboratory settings. For example, Six Sigma techniques have been recommended as a means
to avoid cross contamination of cell lines. Hollensead et al. (2004) outline potential uses
of Lean, Six Sigma, and other quality assurance practices to reduce laboratory errors in a
host of disciplines including molecular biology, cytology, microbiology, and pathology.
Lean and Six Sigma have also been directed towards quality assurance in pharmaceutical
laboratories and production facilities.

Quality and Process Improvement in Clinical & Translational
Research

The NIH’s Roadmap for Medical Research calls for “re-engineering the clinical research
enterprise.” This initiative aims to develop new partnerships among organized patient
communities, community-based health care providers, and academic researchers. The NIH
envisions a clinical research process that becomes more efficient and effective by
improving linkages between system components and better integrating the continuum
spanning basic science, clinical studies, and the uptake of new practices by medical
practitioners and their patients. The NIH calls for “new and more efficient approaches to
discovery and clinical validation of research results . . .[that will] . . . contribute to
accelerating and strengthening clinical research by adopting a systematic infrastructure that
will better serve the evolving field of scientific discovery.”

To accomplish its vision, the NIH in 2006 initiated a program of Clinical and Translational
Science Awards (CTSA) for major medical research institutions throughout the United
States. As of early 2009, 38 sites have been awarded CTSA funding. The NIH has
charged the CTSA sites with four primary goals:1) to improve the way biomedical research
is conducted across the country, 2) to reduce the time it takes for laboratory discoveries to
become treatments for patients, 3) to engage communities in clinical research efforts, and 4)
to train the next generation of clinical and translational researchers.

Underlying the NIH’s Roadmap is the belief that the clinical research enterprise is not
currently as efficient or coherent as it ought to be. The NIH has identified a variety of
impediments plaguing the current research environment, particularly the lengthy timeframe
needed for conducting research, testing approaches in patient populations, and getting
effective approaches accepted into clinical practice. The NIH hopes that establishment of
the CTSA sites will address important problems, such as poor coordination between
existing research networks and lack of data sharing among researchers. The CTSA awards
contain funds for training of new researchers who will be expected to work collaboratively
in a transdisciplinary environment that fosters new ideas and creates more efficient
processes for moving novel practices and technologies into the health care delivery setting.

The NIH’s vision for the CTSA sites is clearly aligned with the objectives represented by
Lean and Six Sigma approaches. These management strategies for process improvement,
quality measurement, and reduction of errors and waste hold the potential for facilitating the
transformation of the clinical and translational research enterprise envisioned by NIH. The
remainder of this article will describe the specific components of clinical and translational
research, as currently understood, and provide examples of ways in which Lean and Six
Sigma methodologies can be applied to help achieve the specific goals of NIH’s clinical and
translational research program.

What is Clinical and Translational Research?

The NIH has defined clinical and translational science as follows: “’Clinical Research’
comprises studies and trials in human subjects. Translational research includes two areas of
translation. One is the process of applying discoveries generated during research in the
laboratory, and in preclinical studies, to the development of trials and studies in humans.
The second area of translation concerns research aimed at enhancing the adoption of best
practices in the community. Cost-effectiveness of prevention and treatment strategies is also
an important part of translational science.”

Several scholars have proposed conceptual models of clinical and translational research as
consisting of multiple linked phases. The Institute of Medicine’s Clinical Research
Roundtable, which met from 2000 to 2003, distinguished two types of translational research
domains, designated as T1 and T2. The “bench to bedside” T1 enterprise is concerned with
transferring the discoveries and advances of basic laboratory science to clinical testing in
human subjects. The T2 sphere extends the results of clinical studies into everyday clinical
practice and health decision making. Woolf (2008) has commented on the inherent
ambiguity in calling both types of activity “translational research,” and he has advocated a
stronger governmental commitment to supporting T2 studies examining the uptake and use
of new clinical care practices in community-based settings. Other researchers have
recommended alternative nomenclature for describing these two domains including
preclinical research and discovery research for T1 studies and applied clinical research and
knowledge translation for T2 studies.

Owing to the complexity of translational research and its continuum over a wide scope of
activities bridging laboratory experiments, preclinical testing, clinical trials, knowledge
transfer, adoption into accepted clinical practice, and ultimately assessing the effects on
individuals and communities, some authorities have recommended more finely detailed
conceptual models of translational research. Several theorists have developed translational
research models with three or more stages.

Westfall et al. (2007), for example, have distinguished three domains of translational
research: T1, in which preclinical and animal testing is shifted to human subjects; T2, in
which the results of initial testing in human subjects migrates to patients, and T3, involving
implementation and dissemination of research discoveries into accepted clinical practice.
Dougherty and Conway’s (2008) model shares Westfall’s conception of a linear process
bridging the boundaries of discovery to broad-scale implementation, with T1 representing
bench to bedside research, T2 designating clinical trials to test safety and efficacy, and T3
involving transfer to practices settings and populations. A four-phase model has been
proposed by Khoury et al. (2007) in which the T1 phase concerns transfer for laboratory to
potential health application, the T2 phase from health application to evidence-based
guidelines, the T3 phase from guidelines to health care practice, and T4 from health care
practice to effects in individuals and populations.

The picture emerging of clinical and translational research is that of a complicated multi-
phase process involving numerous participants including laboratory scientists, researchers,
clinicians, patients, academic institutions, external funding sources, health care
organizations, manufacturers and suppliers of health care technologies, communities, and
others. The end goal of clinical and translational science initiatives sponsored by NIH is to
make this process more rationale, coordinated, efficient, cost-effective, and timely, with
fewer impediments and less wasted effort. NIH’s goal is to support integrated research
efforts across the broad spectrum of phases in order to accelerate the entire process and
increase the likelihood that research will identify effective clinical treatments and practices.

Application of Lean and Six Sigma to Clinical and
Translational Research

There is a clear correspondence between NIH’s vision of a more integrated and efficient
clinical and translational science enterprise and the process-focused strategies embodied by
Lean and Six Sigma. These management strategies, imported from the industrial
environment, can be applied to help systemically analyze and improve the array of process
steps involved in most clinical and translational research projects. The CTSA structure that
NIH has adopted facilitates the selection and introduction of process management
techniques that can be applied to clinical and translation research programs. We are not
aware of any published articles to date describing Lean or Six Sigma approaches to redesign
the clinical and translation research enterprise at any of the CTSA sites. This is an
opportunity that is waiting to be tested.

A few applications of Lean and Six Sigma techniques at other clinical and translational
research sites have been reported. Ablowitz et al. (2008) describe a complex systems
engineering analysis of the translational research process at the University of Virginia. In
that analysis, the investigators developed and utilized a Translational Research Performance
Index to quantify performance measures of translational research, such as the number of
researchers in various cross-functional teams and the number of existing research
partnerships. Based on their analysis, various “solution strategies” for enhancing the
translational research process were proposed, including incentives to stimulate trans-
departmental collaboration, design recommendations for facility infrastructure, and the
recruitment of a specialist in Lean/Six Sigma to undertake studies of additional process
changes.

Liu (2006) describes an application of Six Sigma methods to achieve a reduction of 70% in
cycle time for entry of case record forms in a phase III clinical trial, while maintaining a
statistically acceptable error rate requirement. The process redesign involved such steps
as implementing an optical mark technique to convert study data into optically recognizable
binary characters for processing data directly into data management systems without human
intervention. Marti (2005) reported on an application of Lean Six Sigma in which the time
needed to complete a phase 1 clinical trial was improved by redesigning standardized case
record forms, setting up a dashboard system for monitoring key performance indicators, and
acquiring new hardware and software systems for reducing cycle time for data analysis.
Lean techniques have been applied to streamline the drug discovery process in the
preclinical phase of research. For example, Lean techniques were used by a contract
research organization to improve assay turnaround times and reduce assay result variance.
In another preclinical pharmacologic research setting, Lean and Six Sigma were used for
redesigning laboratory layout to align better with workflows, grouping work by assay type,
and repositioning equipment and instrumentation to be in closer proximity to their eventual
point of use.

The Center for Clinical and Translation Science at The Ohio State University, a CTSA site,
is planning to pursue various process improvement projects using Lean and Six Sigma
methods. Some of the projects that are now being designed and initiated include:

A process improvement study using Lean and Six Sigma techniques to review, assess,
and improve the process for establishing clinical research contracts between a
sponsor (typically a pharmaceutical company) and the university’s clinical research
center. This process is often prolonged and burdensome owing to the need to develop
appropriate disclosure agreements, arrange and conduct sponsor qualification visits,
and develop the language and attain legal review for the clinical research contract.

Studying the complex issues involved in transforming NIH’s former model of a
“General Clinical Research Center” (GCRC) as a nexus for organizing and
conducting clinical trials to the new paradigm of clinical and translational research
units. There are questions about whether the GCRC should be retained as is,
modified, or merged into the new “Center for Clinical and Translational Research”
that was established at the university. A Lean analysis is being considered to examine
these issues.

A related process study is being designed to expand a charge-back process for the
clinical trials unit by which costs for different services will be compared (e.g.,
overnight stays, multiple blood draws), with charges being applied and routed back to
appropriate cost units. Similar “charge-back” processes are being considered for other
services offered by the Center for Clinical and Translational Science including
biostatistical support and services being offered through biomedical informatics and
their data warehouse.

Six Sigma and Lean methods are being used to investigate the process steps and
issues involved in establishing reciprocal IRB agreements between affiliated
academic and non-academic research institutions. The goal is to enact a new “fast-
track” process to expedite the time needed to obtain final IRB approval.

The review process for soliciting, evaluating, and awarding of pilot project awards,
clinical research traineeships, and test-bed projects for novel technologies will be
examined using Six Sigma and Lean techniques, with the goal of making the process
quicker, more efficient, and fair.

Faculty and doctoral students from the university’s systems engineering department
are conducting work flow assessments in the clinical trials unit in which acuity
factors are calculated estimating …

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Journal List P T v.39(7); 2014 Jul PMC4103576

P T. 2014 Jul; 39(7): 491-499, 520. PMCID: PMC4103576

PMID: 25083128

Social Media and Health Care Professionals: Benefits,
Risks, and Best Practices
C. Lee Ventola

▸ Author information ▸ Copyright and License information Disclaimer

This article has been cited by other articles in PMC.

INTRODUCTION

Many social media tools are available for health care professionals (HCPs), including social
networking platforms, blogs, microblogs, wikis, media-sharing sites, and virtual reality and
gaming environments. These tools can be used to improve or enhance professional
networking and education, organizational promotion, patient care, patient education, and
public health programs. However, they also present potential risks to patients and
HCPs regarding the distribution of poor-quality information, damage to professional image,
breaches of patient privacy, violation of personal–professional boundaries, and licensing or
legal issues. Many health care institutions and professional organizations have
issued guidelines to prevent these risks.

WHAT ARE SOCIAL MEDIA?

The definition of “social media” is broad and constantly evolving. The term generally refers
to Internet-based tools that allow individuals and communities to gather and communicate;
to share information, ideas, personal messages, images, and other content; and, in some
cases, to collaborate with other users in real time. Social media are also referred to as
“Web 2.0” or “social networking.”

Social media sites provide a variety of features that serve different purposes for the
individual user. They may include blogs, social networks, video- and photo-sharing sites,
wikis, or a myriad of other media, which can be grouped by purpose, serving functions such
as:

Social networking (Facebook, MySpace, Google Plus, Twitter)

Professional networking (LinkedIn)

Media sharing (YouTube, Flickr)

Content production (blogs [Tumblr, Blogger] and microblogs [Twitter])

Knowledge/information aggregation (Wikipedia)

Virtual reality and gaming environments (Second Life)

Participation in social media by the general public has increased sharply over the past nine
years. In the U.S., the proportion of adults using social media has increased from 8% to
72% since 2005. The use of social media is prevalent across all ages and professions
and is pervasive around the world. In 2012, Facebook users exceeded one billion people
worldwide, a number that represents one-seventh of the world’s population. In addition,
each day 100 million active Twitter users send more than 65 million tweets, and two billion
videos are viewed on YouTube. Social media have been linked to highly significant
political events, such as the Arab Spring revolution, as well as to widespread societal
trends, including the shortening of individuals’ attention spans and the decline of print news
media.

PARTICIPATION IN SOCIAL MEDIA BY HEALTH CARE
PROFESSIONALS

Social media provide HCPs with tools to share information, to debate health care policy and
practice issues, to promote health behaviors, to engage with the public, and to educate and
interact with patients, caregivers, students, and colleagues. HCPs can use social
media to potentially improve health outcomes, develop a professional network, increase
personal awareness of news and discoveries, motivate patients, and provide health
information to the community.

Physicians most often join online communities where they can read news articles, listen to
experts, research medical developments, consult colleagues regarding patient issues, and
network. There they can share cases and ideas, discuss practice management challenges,
make referrals, disseminate their research, market their practices, or engage in health
advocacy. A growing minority of physicians also uses social media to communicate
directly with patients to augment clinical care.

A survey of more than 4,000 physicians conducted by the social media site QuantiaMD
found that more than 90% of physicians use some form of social media for personal
activities, whereas only 65% use these sites for professional reasons. Nearly a third of
physicians have reported participating in social networks. However, both personal and
professional use of social media by physicians is increasing.

Unlike physicians, pharmacists have been relatively slow to adopt social media. Much of
the growth in the professional use of social media among this group appears to involve
pharmacist-specific social networks. Surveys have shown that many pharmacists use
Facebook. Although this use is most often for personal communications, more than 90
pages on Facebook are related to the pharmacy profession, such as the Pharmacists Interest
Page, the American Pharmacists Association, and the Cynical Pharmacist. Only 10% of
pharmacists use Twitter, and a search for “pharmacist” on LinkedIn identified 274,981
profiles.

SOCIAL MEDIA SITES FOR HEALTH CARE PROFESSIONALS

Social Networking Sites

As social networking has evolved, medically focused professional communities have been
established. These networks are often private and protected from nonmembers, such as
the lay public and even members of other health professions. Funding sources for these
sites vary, with financial support often being provided by professional associations,
advertising or data sales, research funding, and pharmaceutical companies.

Sermo is a “physician-only” social networking community that verifies the credentials of
new members during registration. Physicians representing 68 specialties in all 50 states
gather on this site to network, to discuss treatment options, and to query peers for expert
advice. As of April 2014, Sermo boasted a U.S. membership of 260,000 physicians, most
of whom use pseudonyms for anonymity. Sermo consists primarily of a large message
board on which physicians create topics for discussion. It also provides a rating system by
which doctors rank posts on the site on the basis of perceived credibility.

Doximity is a newer “physician-only” social networking community that offers text and
images that are compliant with the Health Insurance Portability and Accountability Act
(HIPAA), which allows point-of-care information crowdsourcing. As of 2013, more than
100,000 physicians and students were members. Doximity uses a national database to create
“placeholder” accounts with demographic and contact information for all U.S. physicians.
Therefore, although only 12% of U.S. physicians are active members of Doximity, nearly
100% can be messaged through the network.

The Medical Directors Forum (www.medicaldirectorsforum.skipta.com) is a social
networking site for medical directors that provides a verified, secure, closed-loop
environment for peer-to-peer interaction. The resources on this site include a
comprehensive library, discussion groups, calendar postings, and alerts. The site also
provides dedicated group pages for medical directors working in a wide range of sectors,
including: hospital, veterans affairs, Medicare, group practice, employer, behavioral health,
managed care, correctional facility, and long-term care.

Other physician networking sites include QuantiaMD (www.quantiamd.com), Doctors’
Hangout (www.doctorshangout.com), and Doc2Doc (doc2doc.bmj.com). Many of these
sites require doctors to submit their credentials to a site gatekeeper, recreating the intimacy
of a “physicians’ lounge” in an online environment.

The nonprofit Student Doctor Network is a popular social community site for undergraduate
and practicing physicians, dentists, and veterinarians in the U.S. and Canada. It claims
more than 40,000 active members and 1.5 million unique monthly visitors. The forums on
Student Doctor Network focus on clinical career topics, do not support detailed user profiles
or “friending,” and encourage anonymity.

Social networking sites are also available for pharmacists. These sites include ASHP
Connect (www.connect.ashp.org), which is sponsored by the American Society of Health-
System Pharmacists; PharmQD (www.pharmqd.com); and The Pharmacist Society
(www.pharmacistsociety.com). Professional networking forums for nurses include the
American Nurses Association’s ANANurseSpace (www.ananursespace.org), NursingLink
(www.nursinglink.com), and SocialRN (www.twitter.com/socialRN).

In addition, HCPs can easily connect with each other via “general purpose” online social
networks, such as Facebook, Twitter, and LinkedIn. Facebook is the most popular social
media site in the U.S., while LinkedIn is the most popular professional networking
site.

Blogs

The “blog,” a term formed by truncating “Web log,” is the oldest and most established form
of social media, which has been used in medicine since as early as 2004. Blogs can reach
wide audiences, especially if one writes content that is of significant interest. Posts that
garner enough interest can be shared and viewed again and again by readers (referred to as
“going viral”). Content that goes viral can establish a reputation or an online presence.

Blogs can also provide the opportunity to publish large amounts of information in a variety
of media (text, video, and audio) in an open forum. Most blogging platforms allow
readers to respond to published content by posting their own comments. This enables an
ongoing dialogue between the blogger and his or her audience. Examples of widely used
free “long-form” blogging platforms include Tumblr (www.tumblr.com), WordPress
(www.wordpress.org), and Blogger (www.blogger.com).

Some physicians use blogs to communicate with other HCPs or the public. For example,
the Clinical Cases blog (www.clinicalcases.org) features case studies in a wide range of
medical specialties. This blog also includes a special section on admission note templates,
procedure guides, and related material. Blogs are becoming more popular among
pharmacists, but approximately two-thirds of these blogs are written anonymously.

Microblogs

Microblogs provide the most dynamic and concise form of information exchange via social
media. This format allows users to post a large number of brief messages or updates over
a short period. Numerous microblogging platforms exist; however, Twitter is the most
prominent. On Twitter, users publish messages (called “tweets”) that consist of a
maximum of 140 characters. Tweets can be supplemented with hyperlinks to other online
media, such as videos or websites. Tweets can also include “hashtags,” a form of
information indexing that allows people to search for tweets that are related to a particular
discussion or topic. Hashtags followed by HCPs include #HCSM (for Health Care Social
Media), #MDChat, and #Health20.

There are more than 140 reported uses for Twitter in health care. The Penn State College
of Medicine has used Twitter to facilitate discussions between students and instructors, to
conduct course evaluations, to solicit class responses, and to monitor students’ progress.
A Twitter Journal Club also provides advance posts about papers and questions to be
discussed, along with a hashtag, so that students, doctors, and anyone interested in the
subject can interact. Twitter has also been used at medical conferences to discuss and
enhance speaker presentations by posting real-time comments from the audience. Some
physicians have used Twitter to develop a large following, enabling them to reach a broad
audience and potentially even affect health policy decisions.

Wikis

Wikis are public forum websites featuring text and multimedia content that can be edited by
users. “Wiki” is a Hawaiian word meaning “quick,” which refers to the speed with which
information on a wiki can be accessed, added, edited, or deleted.

Surprisingly, Wikipedia is the most commonly used wiki in the medical community. It is
often used as a reference by clinicians, despite its known shortcomings, such as errors and
narrow breadth of information. One study found that 35% of 1,056 pharmacists used
Wikipedia, although only 19% trusted it. In another survey of more than 1,000
pharmacists, one in five respondents said they trusted Wikipedia, but only one in four knew
that anyone could edit the site. One reason for the popularity of Wikipedia is its
prominence in Google searches. A study found that 70% of 35 junior physicians used
Wikipedia to find medical information during a week-long period, with 93% citing ease of
use as their primary motivation.

As the accuracy and completeness of Wikipedia are often debated, the drug information on
that site was compared with a validated and trusted information source, the Medscape Drug
Reference. This analysis found that Wikipedia included approximately 76% of the content
found in Medscape and had very few factual errors (most were errors of omission). In
contrast, other studies have found that Wikipedia includes factual errors and has a lack of
depth compared to traditionally edited, peer-reviewed, evidence-based information
sources.

Other wiki projects emulate Wikipedia in that they crowd-source medical content. However,
to maintain editorial credibility, they also verify the credentials of contributors. RxWiki
(www.rxwiki.com) allows only pharmacists to add or edit drug information. This was also
the model for Medpedia (an initiative from Harvard University, Stanford University, the
University of Michigan, and the University of California at Berkeley), which verified
authors’ credentials before allowing them to generate content. However, when most
articles posted on “author verified” wikis were compared with open initiatives, such as
Wikipedia, they were found to be shorter, to be of equal or lesser quality, and to include
fewer references. Wikipedia was also found to promote quality and accuracy more
actively over a period of 90 days because of crowdsourcing, compared with Medpedia,
which had a comparatively restrictive editorial process.

Media-Sharing Sites

Media-sharing sites, such as YouTube, offer a large selection of social media tools that are
optimized for viewing, sharing, and embedding digital media content on the Web. They
also provide features that are typically found on other types of social media sites, such as
profiles, connections, comments, and private messaging. Most media-sharing sites are
easy to use, provide free basic accounts, and are accessible from both desktop and mobile
devices.

In medicine, media-sharing sites can be important resources for education, community
building, marketing, and branding. Among the most notable media-sharing sites for HCPs
is The Doctors’ Channel (www.thedoctorschannel.com), which hosts videos featuring
medical news, continuing medical education, and health care-related entertainment.

Virtual Reality and Gaming Environments

Multi-User Virtual Environments (MUVEs) are three-dimensional environments that allow
users to interact with each other through a virtual representation of themselves (known as an
avatar). The application of MUVEs in health care is growing rapidly. They are
increasingly being used for patient education, for the simulation of epidemiology and mass
prophylaxis, for psychotherapy, for surgery, and for research. However, the fact that
MUVEs are often perceived as computer games rather than as serious clinical tools may
impede their adoption by health care institutions.

MUVEs can be classified as general-purpose or health care–specific. The most well-
known general-purpose MUVE is Second Life. This general-purpose environment,
however, is often used for health care education. One study found 68 health-related
virtual locations on Second Life. These included the Centers for Disease Control and
Prevention (CDC) education center, which aims to influence the real-life decision-making
abilities of visitors. Health care–specific MUVEs are typically used for one purpose, such
as medical education (e.g., CliniSpace [www.clinispace.com]), surgical simulation (e.g.,
OpenSim [www.opensimulator.org]), or psychiatric treatment (e.g., InWorld Solutions
[www.inworldsolutions.net]).

USES FOR SOCIAL MEDIA IN HEALTH CARE

Professional Networking

The most popular social media sites for physicians are those where they can participate in
online communities, listen to experts, and network and communicate with colleagues
regarding patient issues. The use of social media by pharmacists also frequently focuses on
communication with colleagues. The social-networking platforms used for professional
networking are often solely accessible and specifically cater to people within these
professions. Besides clinical topics, discussions on these sites address diverse subjects,
such as ethics, politics, biostatistics, practice management, career strategies, and even
dating in a medical environment. They can also provide a supportive environment for
HCPs who subspecialize.

Another example of professional networking among HCPs is crowdsourcing, which
involves harnessing the knowledge and skills of a community to solve problems or to gather
information and opinions. Social media can also be used to connect HCPs in third-world
countries with specialists in more medically advanced locations. For example, surgical
procedures can be streamed via the Internet and questions can be asked via Twitter in real
time. Thus, social media provide a new communication channel for HCPs to network
professionally to share and exchange medical information in ways and at a pace that was
never before possible.

Professional Education

The communication capabilities provided by social media are also being used to improve
clinical education. The high usage rate of social media by 18- to 29-year-olds has
motivated the adaptation of clinical curricula to reflect the changing habits and culture of
incoming students. Many studies have described the use of social media tools to enhance
clinical students’ understanding of communication, professionalism, and ethics.
Universities are also using social media to recruit students, to increase access to academic
libraries, and to create virtual classrooms and office hours, as well as other unique learning
experiences.

Social media are also being widely implemented in undergraduate pharmacy curricula.
One-third of pharmacy programs have reported using Twitter in some capacity. A 2011
survey also found that 38% of pharmacy faculty members use Facebook for teaching, with
half reporting that they plan to use social media in the future. In one example, an instructor
in a geriatric pharmacotherapy course at the University of Rhode Island used Facebook to
encourage class discussions and to connect students with senior citizens who had
volunteered to participate in the course. This experience improved student perceptions of
older adults and also introduced the senior citizens to Facebook. At Auburn University,
instructors established Twitter handles so that pharmacy students could participate in class
discussions anonymously. By semester’s end, 81% of students felt Twitter had let them
express opinions they wouldn’t have shared otherwise, although 71% thought that Twitter
had been distracting.

Online social media platforms have also influenced the educational experience for nurses,
with one survey reporting that 53% of nursing schools are now using these tools. For
example, Twitter has been used to enhance the clinical decision-making skills of nursing
students in critical care situations. The students viewed videos of clinical scenarios and
tweeted their observations on the patient’s condition for instructor feedback. Other uses of
Twitter in nursing education include posting a live stream of student insights during class,
or creating a class hashtag so that resources such as videos, websites, articles, and
photographs could be shared. Media sharing sites such as YouTube can also be used in the
classroom to stimulate discussion, to illustrate a point, or to reinforce a concept. Students
can view a video and then respond to questions that promote clinical reasoning.

The incorporation of social media into clinical education has met with mixed reviews,
however. Courses that incorporate such tools have generally been positively received, but
in some cases, students have reported feeling that the use of Facebook for teaching purposes
is an intrusion into their social lives. Balancing the enhanced communication opportunities
provided by social media with the downside of increased distraction in an educational
environment is also a challenge. Unfortunately, standards guiding the appropriate use of
social media tools in education are in their infancy.

Organizational Promotion

Health care organizations, including hospitals, health systems, professional societies,
pharmaceutical companies, patient advocacy groups, and pharmacy benefit companies, are
using social media for many purposes. Uses include communicating with the community
and patients; enhancing organizational visibility; marketing products and services;
establishing a venue for acquiring news about activities, promotions, and fund-raising;
providing a channel for patient resources and education; and providing customer service
and support. It has been estimated that 70% of U.S. health care organizations use
social media, with Facebook, Twitter, and YouTube being the most popular. Blogs are
also used by many medical centers and hospitals.

Studies have shown that this use of social media can greatly enhance the image and
visibility of a medical center or hospital. In one study, 57% of consumers said that a
hospital’s social media presence would strongly influence their choice regarding where to
go for services. A strong social media presence was also interpreted by 81% of consumers
as being an indication that a hospital offers cutting-edge technologies. In another study,
12.5% of surveyed health care organizations reported having successfully attracted new
patients through the use of social media.

The rate of social media adoption by nonprofit health care organizations is also increasing.
The Mayo Clinic became an international leader in such efforts when it established the
Social Media Health Network (http://socialmedia.mayoclinic.org) in 2010. In its mission
statement for the network, the clinic said it sought to provide an “authentic voice for
patients and health care professionals, building relationships through the revolutionary
power of social media.” To that end, this initiative has created a presence on Facebook,
YouTube, and Twitter. It also provides a vast library of blog posts, podcasts, conferences,
and webinars to engage various community stakeholders. The Mayo Clinic and other
educational health care institutions have also used blogs to foster peer-to-peer learning and
to implement new protocols. Many universities also have a branded YouTube channel,
where videos can be shared through the university’s social media site.

Social media also allow pharmacies to communicate with large groups of customers
simultaneously, to conduct surveys, and to enable patients to feel that they are part of a
pharmacy community. Many pharmacies use social media to reach out to followers about
products, services, discounts, newsworthy events, and health information. Several large
pharmacies and insurers have piloted programs that provide prescription refill and
appointment reminders via social-media text messaging.

Patient Care

Although there has been a reluctance among HCPs to use social media for direct patient
care, this practice is slowly being accepted by clinicians and health care facilities. For
example, Georgia Health Sciences University has provided patients with access to a
platform called WebView, which allows the patients to reach their doctors to ask questions
or to request prescription refills.

Recent studies have found that physicians have begun to develop an interest in interacting
with patients online. Some physicians are using social media, including Twitter and
Facebook, to enhance communication with patients. Approximately 60% of physicians
were found to favor interacting with patients through social media for the purpose of
providing patient education and health monitoring, and for encouraging behavioral changes
and drug adherence, with the hope that these efforts will lead to “better education, increased
compliance, and better outcomes.” However, other studies have shown that considerable
resistance still exists to using social media to interact with patients. In a survey of
approximately 480 practicing and student physicians, 68% felt it was ethically problematic
to interact with patients on social networks for either personal or professional reasons.

Evidence indicates that electronic communication with patients can improve their care and
health outcomes. Studies have shown that supplemental electronic communication
emphasizes physicians’ advice and improves adherence for patients with chronic diseases.
It may also improve patient satisfaction by increasing the time spent communicating with
and having questions answered by their physicians. A survey of patients at an outpatient
family practice clinic found that 56% wanted their HCPs to use social media for reminders,
for scheduling appointments, for diagnostic test results, for prescription notifications, and
for answering general questions. Patients who did not use social media said they would
start if they knew they could connect with their health care provider.

Patient Education

Social media can also improve patients’ access to health care information and other
educational resources. In the U.S., eight in 10 Internet users search for health information
online, and 74% of these people use social media. Through social media, patients can
join virtual communities, participate in research, receive financial or moral support, set
goals, and track personal progress.

Physicians are also using social media to promote patient health care education. They
tweet, make blog posts, record videos, and participate in disease-specific discussion forums
focused on patient education. Such forums provide an important opportunity for
physicians to distribute evidence-based information to counter inaccurate material on the
Internet. In some social media forums, the public is provided with an opportunity to
participate in these discussions.

Unlike other health advice that a patient might encounter online, physicians could use social
media to develop messaging that may be more likely to resonate with and be acted on by
patients. Some physicians believe that social media would be particularly beneficial for
patients with chronic, rare, or fatal diseases; with questions about maternal or infant care; or
with personal health-related goals, such as weight management. The distribution of
credible information has been proved to motivate observable behavioral changes within
social networks. Research has begun to show that interventions based on social media can
positively affect weight loss, tobacco cessation, risky sexual behaviors, and physical
activity.

Patients are also using social media to connect with others affected by similar conditions.
For example, the social networking site PatientsLikeMe (www.patientslikeme.com)
provides a venue for patients to access information, suggestions, and support from other
people who have the same disease or condition. Facebook groups also frequently focus on
specific medical conditions. These groups actively engage in peer-to-peer support as well
as fund-raising efforts for affiliated organizations and individuals.

Public Health Programs

Social media have created vast global networks that can quickly spread information and
mobilize large numbers of people to facilitate greater progress toward public health goals.
Social media can therefore be a powerful tool for public education and advocacy regarding
public health issues. Some states’ public health departments are using Twitter and other
social media for these purposes.

Other public health organizations use keyword content from Twitter and other social
networks, in combination with location-tracking technologies, to respond rapidly to
disasters and to monitor the health and welfare of populations. The CDC maintains an
active presence on Twitter and Facebook to track “tweets” that might indicate a flu outbreak
and to share updates about such incidents. The CDC has also used social media to locate
and monitor sources and suspected cases of Legionnaire’s disease.

Organizations such as the Red Cross track Twitter posts during natural disasters, such as
hurricanes and earthquakes, to gather information about where the greatest needs are.
Citizen-report blogs have also been monitored by hospitals for information about potential
mass casualty events. When used in this way, real-time social media sites provide greater
agility and enhanced preparedness for responses to disasters and public health
emergencies. Social media sites also provide disaster and emergency response personnel
with a means to rapidly share and access important information provided by agencies such
as the CDC and the U.S. Preventive Services Task Force.

The widespread use of social media can also influence public health behaviors and goals
through social reinforcement. Because human beings are a highly social species, they are
often …