I recently finished The Facebook Effect by David Kirkpatrick.  This is the most detailed account of the Facebook phenomenon thus far.  I think it’s worth a read if you want to understand precisely how Facebook evolved to its current form.  The book offers a history of Mark Zuckerberg’s climb more than a compelling discussion of Facebook’s cultural impact or meaning.

What struck me most about this book was Zuckerberg’s drive.  While his trademark fleece hoodie and Adidas flip-flops had many believe that his success was all a matter of luck, his relentless vision of relational connectivity tells another story.  And it was never about money.  From the earliest 10 million dollar bid while a student at Harvard to more recent stratospheric offers, Zuckerberg’s core motivation was to change the way the world communicates.  At every turn he resisted silicon valley’s build-and-flip culture to offer something with bigger value and meaning.

Perhaps what was most revealing to me was Mark Zuckerberg’s core beliefs surrounding privacy.  From his earliest days, Mark Zuckerberg has harbored some pretty extreme views on transparency and the greater good.  He and his Facebook leadership embrace what has been referred to as “radical transparency” – the belief that an enveloping transparency should and will overtake modern life.  Some of the direct quotes in the chapter on privacy are actually chilling.

Understanding Facebook’s history and Zuckerberg’s early ideas lends real insight into today’s Facebook product.  While the detail was a bit fine for me I’d recommend The Facebook Effect and predict that this will live in the long tail as Facebook’s early story.

The rest of the story has yet to be told.

The more social evolves, the more we communicate the same.  At least that’s the way it looks after reading today’s post by danah boyd.  She tells the story of a young girl, Carmen, who after breaking up with boyfriend wanted to find a way to express her despondency without freaking out her mom.  Carmen’s mother is her friend on Facebook and follows her posts.

Carmen used song lyrics which had one meaning for her mother yet another for her friends.  danah boyd describes this as social steganography.  As far as I can tell, this is the first formal description of a phenomenon that we all observe in teens and likely use ourselves.

boyd sums up Carmen’s tampering nicely:

“She’s hiding information in plain sight, creating a message that can be read in one way by those who aren’t in the know and read differently by those who are.  She’s communicating to different audiences simultaneously, relying on specific cultural awareness to provide the right interpretive lens.”

It’s interesting that social steganography isn’t a trick unique to teens.  I see varying forms of this on Twitter.  I also use this in my day-to-day work as a pediatrician.  Depending upon a child’s age and developmental level I’ll choose language that will appear innocuous to a child or tween but bear clear meaning to a mother.

I read danah boyd because she has a way of helping me understand what I see evolving around me.

Last week Facebook launched Places, a service that allows users to check-in to specific locations and feed that information into their stream.  But that’s Foursquare, you say.  Yes.  But the difference is that Foursquare has mayors, Places has 500 million citizens.

Until now, location apps like Foursquare and Gowalla were adopted by a pretty narrow niche.  Either you were in or you were out.  Places now puts location tagging squarely in front of the average social user in the world’s most trafficked social platform.

A few thoughts:

Places will have a different role. I’m interested to see if and how Places becomes integrated among Facebook users.  I think the absence of the mayorship nonsense will force the social marketplace to think about how they want to use location tracking.  How can identifying your location bring value to the average personal network?

I anticipate a honeymoon period of requisite experimentation.  Places will then settle in as a glorified status update for select circumstances.  I’m guessing I’ll reserve Places for remarkable events and places that may have real meaning for people who follow me.  Knowing that I’m drinking Coffee at Starbucks or shopping at Ace Hardware isn’t likely to help people understand me or want to connect to me.

Within the core of hardcore Foursquare and Gowalla users we all came to tolerate the inane.  It was part of the game.  It was interesting to watch and even more interesting to think through its potential applications.  Facebook’s adoption will serve as something of an experiment with the average social user.  I suspect that banal geoupdate will become an embarrassing part of social’s history.

Location has become a commodity. Places makes location functionality no longer a novelty.  In fact, as of last week, it’s official:  location tagging is old news.  And checking in alone won’t create the value necessary to drive broad adoption.  It’s what Facebook plans to do to incent participation that will make it or break it.

Expect derivative effect for Foursquare and Gowalla.  If Places gains any traction expect there to be a drafting effect on Facebook and Gowalla.  Curiosity with location may drive interest in mayorship among the vast population of those who have never heard of Foursquare.  I don’t expect Foursquare and Gowalla to be going anywhere soon.

Location features may offer professional value.  Location tagging can serve a very specific service in telling and selling your expertise.  It’s clear from watching my professional contacts on LinkedIn that location serves to tell a lot about who you are.  I find it valuable to see what my peers are up to in their work.  It helps me to understand how they work and what they do.

I’ve also noticed in my network that geotracking’s biggest critics are the first to advertise their specific location on Twitter when it serves to tell the world about their involvement on a panel or involvement in a particularly sexy meeting of influentials.  Only in the social media space is hypocry eclipsed by vanity.

Transparency will set you free – or maybe not. The Church of Facebook believes that the truth will set us free.  The more we know about one another the more we will be forced to face the music of our own actions.  While the Facebook ideology never referred to health and individual responsibility, there may be something to it.

So that leads me to think that location-based services like Places can serve some very specific roles concerning health. While theoretical privacy concerns are the target of criticism, I think an understanding of location may have real power in understanding the relationship between variables like where we hang and our predisposition for chronic disease.  Let’s see if Facebook is interested in the health outcomes business.

Finally, check out Facebook’s Places promotional clip on YouTube.

Beyond the desperately global feel to the vid, what struck me was the image of the family at the table with the voiceover stating, “I expect in the future a lot of people will share their lives this way.”  Just at that moment the father feeds the child.  Chilling in a strange way – but then again that comes from someone raised with a rotary phone.

Facebook sees itself as the next generation’s global platform for communication with the same impact as the invention of the telephone.  Places is just another step in that direction.

Yesterday’s piece in the LA Times created quite a kerfuffle in the social health infosphere.  When Facebook goes to the hospital, patients may suffer detailed some of the issues facing hospitals that have chosen to flirt with Facebook.  Stories of nurses posting images of dead patients.  Lawsuits and employee rights.  An interesting read.  It offered up a serving of fresh red meat for those health professionals looking to keep their heads squarely in the sand.

A couple of thoughts.

Blocking Facebook won’t stop stupidity. Read Paul Levy’s most recent post on the issue.  He reminds us that administrative legislation will not stop ignorance.  It’s the messenger, not the medium.  As healthcare administration’s most vocal advocate for social adoption, I’d recommend you check out Paul Levy.  His point of view is remarkable.

Good employees may not understand privacy. We need to go to the next step and address the fact that many hospitals have employees who don’t understand the privacy laws.  We still have a responsibility to protect patients from the misinformed.  While it’s suggested that you ‘can’t stop the conversation’, it’s important that hospitals take responsibility and educate their employees regarding what’s appropriate and what isn’t.  Many health professionals I know innocently believe that by simply excluding an individuals name you’ve protected their privacy.  We have work to do.

You can block but you can’t hide. The natural course of human conversation will occur whether or not hospitals block Facebook.  The adoption of smart phones has created avenues for conversation that were barely on the radar two years ago.  Tablets will soon be found in every purse.  WiFi is ubiquitous.  Technology will continue to become more accessible but the way health care employees understand patient privacy needs to stay the same.

The media never cared about patient privacy until Facebook came along. It’s interesting that privacy infractions were never a media concern until social media became sexy.  Sure the scale of Facebook exposure is greater that that of an employee sharing protected information on a cell phone.  But you have to admit that there’s a subtle element of schadenfreude surrounding these stories.  Be certain that Andrew Keen has this piece bookmarked for prominent mention in his next book.

I thought this was a generally fair piece but a little attention to social’s upside might have helped the cause.  My server isn’t big enough to hold the examples of how our connections have improved the way we see ourselves and our diseases.

Ed Bennett was quoted in the piece and amidst the chatter on Twitter yesterday afternoon suggested that we all stay calm and remain seated.  This too shall pass.

Last week I suggested that the social disclosure of health issues could create future problems. I never considered, however, that a patient’s social media trail could be used to corroborate need for disability or special services.

That’s what happened last week when a Quebec woman on sick leave for depression lost her benefits over Facebook photos that were judged inconsistent with her claim. You can read more about it here.

While I know nothing of this woman’s medical history or her claims, it’s safe to assume that a patient’s level of impairment can’t be established from a couple of Polaroids. But perception trumps reality.

It’s interesting that while your personal health footprint can create problems, telling what you’re doing can potentially create an entirely different set of questions about what you don’t have.

If nothing else, this story represents a first for patients, insurance companies and social media. Look for industry to begin exploring social platforms as a tool for the validation of health and disability claims.

h/t to e-patient.net

I had lunch with a physician colleague recently. In the course of our discussion Twitter came up and I tried to explain its potential benefits. But despite my spot-on analogies he just didn’t understand why this would be of value to him.

Then I realized it may very well have no value for him.

As a middle-aged divorcee with college-aged children and a stable practice he freely admits that he doesn’t yearn for much. Investment into his career isn’t a priority. He has few aspirations beyond digital photography which he prefers to do alone. He’s actually very happy just as he is.

So what’s value proposition for Facebook with someone like this? What’s the return on involvement with Twitter? I’m not sure there is one.

There are those who recognize the value of relationships and there are those who don’t. There are those who recognize the value of relationships but find them less important. While the benefits of social media are obvious to those who reap the benefits, there are those who have no aspirations beyond what’s in their immediate environment.

And technology will never change that.

It happened again last week. A patient contacted me via Twitter with a clinical question about her child. As always, I never engage patients in the social media space. When they try to initiate an online encounter I track ‘em down immediately to let them know the safe of social media and our relationship.

Here are a few things I think about when discussing the matter with patients (or parents):

1. Take the discussion offline. All dialog concerning attempts at online contact are done by phone or in person.

2. Understand they’re just looking for help. Keep in mind that when patients try to reach you via Facebook they’re just looking for help. Twitter and Facebook are now becoming standard means of interaction so why would it be so strange to contact your doctor? In my dialog with patients who have crossed the line I try to approach the issue in a way that respects where they’re coming from.

3. Give them the facts. While I’m not a lawyer, I do my very best to discuss the importance of online health privacy. Social media is for casual conversation, not privileged health information. While we will likely see the proliferation of secure social media platforms for doctor-patient communication in the future, we’re not there yet.

4. Remind them you’ll get in trouble. When I remind parents that they’re going to get me in trouble they feel bad. I don’t want to make anyone feel bad but they have to understand the potential gravity of the situation when it comes to the law, state licensing bodies and hospital privacy.

5. Point out why social media represents a risky means of communication. After detailing how I could find myself in hot water, I then try to illustrate how social media isn’t built for patient care. Among other things it’s not easy to follow what happens between a practitioner and patient on a social application. Who said what or, more importantly, was the intended plan even understood by the patient? And how do you and other members of the healthcare team refer to a plan of care? Very high tech but very sloppy.

6. Document everything. Any attempt by my patients to discuss clinical matters via Twitter or other platforms is immediately documented in the patient’s medical record. I also document that I have discussed with the patient or family the appropriate ways to contact me.

7. Make a social media policy of your own. One way to keep your patients from reaching out to your online is by creating an office social media policy of your own. Rules of engagement via social media should be just as important as on call or billing procedures. Along those lines I occasionally post friendly online reminders that public discussion of care with health professionals isn’t appropriate. I keep a few clipped screen shots of thes  posts in the event that my social medial judgment is ever called into question.

8. Block repeat offenders. Patients who don’t understand the importance of health privacy represent a risk to themselves and a major liability to you. Offer one warning and block after that.

As physicians we have the responsibility to help patients understand what isn’t always obvious. And teaching the pitfalls of online health dialog fit with that responsibility.

So it happened again. Yesterday a patient mom friended me on Facebook and asked me for advice The answer was an easy no.

So what’s the big deal? Why not just offer some friendly advice? Truthfully, the nature of the question was one that could easily have been answered.

Here’s the thing. Patient interaction in the public domain is a no no for doctors. But what about a personal message? Still, public domain. And there’s no way to insure that you have all the information you need on the problem. The proper dialogue would be too cumbersome.  How would I document what I’ve suggested? I could go on all day but that’s not me.

Bottom line:  This kind of interaction is loose. It’s cool, it’s convenient, but it’s loose.

While we’re not ready to formally interact with patients in the social media space, we are getting close. Jay Parkinson’s Hellohealth broke the ice last month with a platform that allows patients and docs to be closer through video, text, email on a platform that looks and feels like Facebook. Clever but not ready for mass consumption.

Until then, I’ll continue to meet, talk and touch, the old-fashioned way.

Recently I received a friend request from a woman in the community where I practice. I didn’t recognize her so politely sent a message apologizing for not remembering where we had met. She promptly responded and informed me that we had never met but she had read my book. Her baby it seemed was miserable and the wait for an appointment in my clinic was too long for her to bear. Politely pleading for her baby to be seen, I arranged a phone call and subsequently saw the baby in my office.

Now I’ve always helped out those I’m connected to. As a doc I offer friendly advice to friends and neighbors when they need help with medical stuff. Frequently I speak on the phone to the relatives of close friends needing direction with their child. Sometimes I even go the extra mile to help facilitate a consult with a colleague. And why not? I have a connection with these people given our common acquaintance. All physicians and health professionals do it and we think nothing of it.

So should it be different with my social network? Probably not. But just as in life, the depth of the relationships I build on social media platforms is variable. And those I share a strong bond with are more apt to earn my time, mental energy, and concern. Strangers and transients are nothing other than that despite our sometimes-flirtatious Twitter repartee.  While I am developing some great relationships, most remain superficial.

Okay, so regarding my screaming baby from Facebook. I didn’t know this mother so why did I offer to help? Social media empathy you might call it. Or perhaps I’m just a big softie. You could even argue that once I chose to reply on that friend request I had some obligation to see to it that the baby was checked out by someone. But that’s the subject of another post.

The relationships we share with those who we choose to connect with on social media platforms will give rise to new social, ethical and legal challenges for physicians. And while I think that raw connectedness and transparency are Parkinsonian traits that we want to achieve in this new medical order, we’re still working to define the doctor-follower relationship.