RESOURCES FOR CLINICIANS Web 2.0: Easy Tools for Busy Clinicians Julia C. Phillippi, CNM, MSN, and Margaret Buxton, CNM, MSN Internet content has become interactive; new tools can help clinicians market their practice and provide evidence-based care. Many of these tools are free or low cost and are easily mastered using simple video tutorials found on the Internet. This article highlights the uses of e-mail, social networking, smartphones, RSS feeds, social bookmarking, and collaborative Web 2.0 tools in clinical practice. J Midwifery Womens Health 2010;55:472–476 Ó 2010 by the American College of Nurse-Midwives. keywords: evidence-based practice, Internet, smartphone, social networking, Web 2.0
INTRODUCTION The Internet provides unprecedented levels of access to information and has transformed the way people interact, stay in touch, and network with other professionals. The Web is expanding from a unidirectional, library-like atmosphere to a participatory, interlocking network where all can engage in knowledge and content creation. This new interactive version of the World Wide Web is often called Web 2.0. The purpose of this article is to provide an overview of some recent technological developments and Web 2.0 programs that can be beneficial to busy clinicians. E-MAIL E-mail is a useful, fast, and accessible way to communicate, but the etiquette surrounding electronic communications is still developing.1 E-mail often is regarded as more conversational than a formal letter; however, e-mails between a patient and clinician need to be treated with the same weight as written communication with careful attention to word choice, proofreading, and tone. All nonverbal communication is absent from e-mails, making humor and sarcasm difficult to convey.1 Just as with written letters, a copy of the e-mail needs to be kept in the patient’s chart and the information incorporated into the medical record. E-mail correspondence with patients is a legal extension of health care and should be treated with the same diligence as in-office care.2 Privacy must be protected in corresponding with patients. To meet Health Insurance Portability and Accountability Act (HIPAA) guidelines for health information privacy, both the patient and the clinician need to have secure e-mail systems. Because regular e-mail can be intercepted or viewed by others, the patient’s regular e-mail address is not an acceptable forum for medical discussion.
Address correspondence to Julia C. Phillippi, CNM, MSN, Vanderbilt University School of Nursing, Basic Competency Section, 345 Frist Hall, 461 21st Ave. S, Nashville, TN 37240. E-mail:
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472 Ó 2010 by the American College of Nurse-Midwives Issued by Elsevier Inc.
Many companies market secure e-mail systems that meet HIPAA guidelines. Policies and procedures surrounding e-mail communication with patients—including how often it is checked, what queries can be answered, and how the information will be placed in the medical record—need to be communicated to patients before correspondence to avoid misunderstandings.2 A consent for electronic communication can be included in new patient paperwork to aid the process. Clinicians should also be careful not to include potentially identifiable health information in any nonsecure form of electronic communication. For instance, many clinicians use e-mails groups, such as the American College of Nurse-Midwives (ACNM) eMidwife discussion lists, to share and request information about patient care, but all users must be careful to highlight only the clinical problem and not mention dates, locations, or any information that could identify a specific patient. Even e-mail sent to one person can be easily disseminated. To ensure patient confidentiality, safeguard all electronic communication and consider using e-mail designed specifically for medical communication. SOCIAL NETWORKING Social networking is one of the most popular Web 2.0 applications. Users can create a profile and connect with other users as friends or colleagues on numerous different types of free and for-fee sites. Connected people are known as ‘‘friends’’ or ‘‘contacts.’’ Some sites are primarily professional (e.g., LinkedIn3), while other sites are primarily social (e.g., Twitter,4 Facebook,5 and MySpace6). Increasingly, all of these sites include a blend of content. These sites allow for rapid, widespread dissemination of information, which provides an opportunity for marketing ideas and services, but also has many privacy pitfalls. Many special interest groups have established themselves in social networking sites. Individuals can sign up to be a part of special interest groups to read about current ideas or upcoming events or connect with others who share interests. For example, ACNM has a page on Facebook Volume 55, No. 5, September/October 2010 1526-9523/$36.00 doi:10.1016/j.jmwh.2010.05.009
with a ‘‘fan’’ base of more than 2,700 individuals as of this writing. The site has links to recent events, articles of interest, information about midwifery, and daily postings from midwives around the country. Sites like these can provide midwifery practices an opportunity for free marketing. Midwives and groups can send announcements to their ‘‘friends,’’ and patients can write their birth stories for others to see. Twitter is another version of social networking using text messages, known as ‘‘tweets,’’ that must be less than 140 letters or numbers.4 People who agree to receive tweets are known as ‘‘followers.’’ Tweets can be sent and read from the Twitter Web site, cell phones, and via thirdparty applications. Practices can use Twitter to alert willing patients of upcoming events. This can be used to encourage engagement with the practice so the patient is more likely to come in for care or refer others. Twitter, or group texting, can also be used to reinforce health teaching.7 For instance, women with gestational diabetes can receive a helpful tweet to encourage exercise. It is important to remember that Twitter is a public conversation. People can reply to tweets or forward tweets on to others, known as ‘‘retweeting.’’ ACNM has partnered with other national agencies to sponsor health information texts to users’ phones in a program known as Text4Baby.8 These texts, tailored to the woman’s week of pregnancy or her infant’s birthday, are similar to tweets in that they provide communication via the cell phone, but they are not public and cannot receive replies. Patients can also be reminded of appointments through personal texting.9 It is important to get consent before texting patients. Many cell phone users must pay a fee for incoming texts. Texts can be viewed on the cell phone screen by others and are traceable, so patients may feel their privacy is violated. This might be especially problematic for teens who have not disclosed to their parents that they are seeing a health care provider. Blogs are similar to online personal diaries or professional commentaries. Authors of blogs are known as ‘‘bloggers.’’ They ‘‘post’’ stories and comments on the Web for others to read. Blogs can belong to individuals or organizations, such as ACNM’s blog Midwife Connection.10 These blogs can be a source of community referrals if the blogger comments favorably on care or services. Practices may want links to supportive blogs or blog posts
on their Web sites. Clinicians also can blog about their experiences, but they must be careful not to disclose information that can be associated with patients. For instance, if a midwifery student is blogging about her experiences in clinic X, she should not state that she saw a patient with a herpetic lesion on Tuesday because this information is traceable back to a small number of women. There are several privacy concerns related to social networking. The posted information is easily disseminated, and, once information is posted, it cannot be fully retracted. Clinicians can avoid pitfalls by never posting any information about the content of their work or births and instead providing a place for women to post their own stories. Many clinicians keep two social networking accounts or profiles: a professional account for patients and colleagues that posts information advertising their work and professional progress, and a friend account that has more casual and social posts that are unrelated to work. Advanced users can edit settings to display information only to selected groups of contacts. RSS FEEDS AND GOOGLE ALERTS RSS (which stands for ‘‘really simple syndication’’) feeds are a method of creating a personal publication from favorite news sources.11,12 RSS is denoted by an orange square with curving white lines (Figure 1). An RSS feed lists new content from favorite news sites, both personal and professional. For instance, an RSS feed from PubMed could send new abstracts on the second stage of labor, or the New York Times could feed in articles on birth and childbearing. The RSS feed requires a ‘‘reader’’ to receive the articles. Readers are free through many sources, including Google. The reader collects articles on favorite topics for review. This saves the effort of checking multiple news sources and can alert readers when important publications are released. RSS feeds can also show the new postings on favorite blogs. Several online instructional videos demonstrate how to sign-up.13 Google Alerts are similar to RSS feeds in that they screen the Web, blogs, and news sources for userselected topics.14 When an interesting news article is found, an alert is sent to the user’s e-mail or cell phone. Many clinicians use media alerts to keep abreast of current events surrounding midwifery or birth. COLLABORATIVE TOOLS
Julia C. Phillippi, CNM, MSN, is an instructor at Vanderbilt University School of Nursing in Nashville, TN, and a PhD student at the University of Tennessee, Knoxville, TN. She is the chair of the Basic Competency Section of the American College of Nurse-Midwives. Margaret Buxton, CNM, MSN, is a clinical instructor at Vanderbilt University and practices full-scope midwifery care with the Vanderbilt Nurse Midwifery Faculty Practice, Nashville, TN. She is a member of the American College of Nurse-Midwives Informatics Committee.
Journal of Midwifery & Women’s Health www.jmwh.org
The Internet has many collaborative tools for clinicians. Web 2.0 technologies can assist professionals across the globe in communication, collaboration, and research. Many of these tools are free and open to the public, while others are fee-based and provide security provisions making them safer for use with patient data. Google Docs is an online collaborative program that has many free tools that can benefit clinicians, including 473
SOCIAL BOOKMARKING
Figure 1. RSS feed icon.
survey functions and document collaboration. These tools allow users in different locations to work together on documents by editing and collaborating on a single copy of a document.15 For example, when revising midwifery clinical practice guidelines, the input of all midwives in the practice group and the consulting physicians is needed. Google Docs allows users to store one copy online and invite all the key stakeholders to edit that copy of the document. Because there is only one copy, no one needs to reconcile different documents or change the title to reflect the newest revision. Google Docs also can be used to send surveys embedded in e-mails. The recipient fills out the survey within the e-mail itself and the responses are automatically entered into a spreadsheet that creates graphs and other visual depictions of the data. This technology can be used for clinician surveys or polling coworkers about vacation times and call schedules. Before entering patient e-mails into the Google system, obtain a signed consent. While Google Docs provides many tools in one location, other Web sites provide more niche services. Programs such as SlideShare allow collaboration on and sharing of voice and PowerPoint presentations.16 Skype provides a method to use the Internet for free video and voice meetings between two or more people.17 Doodle is an easy way to schedule meetings and has been used by ACNM to quickly schedule large meetings.18 The Web also can facilitate perinatal research. For instance, the American Association of Birth Centers (AABC) allows participants to enter their data into a secure database. Practices can use the system to study their own statistics, and researchers can apply to study the entire database.19 Web tools, such as AABC’s Uniform Data Set, allow clinicians the opportunity to participate in research with minimal time investment. Collaborative tools allow clinicians many ways to facilitate communication and collaboration on administrative tasks and current research. The minimal training needed is provided through video tutorials with screen shots. The tools discussed can be located through the Web sites listed in the references or by entering the Web site name in a Google search. 474
Bookmarking organizes favorite Web sites with minimal work. Many clinicians already use the bookmark and favorites features included in their Internet software; however, those features are tied to the computer itself. A Web site bookmarked at work would not be bookmarked on a home computer. In addition, with traditional bookmarking, it is not easy to share favorite sites. Social bookmarking expands the ability to use and share bookmarks by placing them on an Internet server where they can be accessed from any computer with Internet access. The ability to share favorite Web sites makes the Web 2.0 version of bookmarking ‘‘social.’’ Clinicians can share patient education sites across the country, and users are able to view sites marked by others. Bookmarking sites organize favorite sites into categories based on user descriptions, known as ‘‘tags.’’ The sites function like a filing system for great Web sites. Many users find that social bookmarking sites reduce the clutter that comes with a Google search of the whole Internet. For instance, a midwife finds a site that has great consumer-friendly information about firsttrimester testing and bookmarks the site with the tags ‘‘consumer,’’ ‘‘first trimester,’’ and ‘‘testing.’’ A women’s health nurse practitioner who is looking for a good resource can use the social bookmarking site to find this Web site by searching for all bookmarks tagged with the term ‘‘first trimester.’’ These Web sites tend to work best when many similar users are tagging favorite Web sites. There are several free social bookmarking Web sites; one of the most popular is known as delicious.20 Most require an e-mail address but minimal personal information to create an account. Once signed in, users create a library of Web sites by clicking the bookmarking icon on the header bar while at favorite sites. The user then identifies several tags, or folder names, to catalog and retrieve the Web site. Most social bookmarking Web sites have online tutorials to assist in account set-up.21 There are few patient-related privacy concerns for social bookmarking because users are not generating new content, but only flagging existing Web sites. SMARTPHONES Personal digital assistants (PDAs) were previously popular handheld electronic daily planners. PDAs have merged with cell phones and become the new smartphones. Smartphones store files, access the Internet, and download software. They can also record, play music and videos, and read Web publications.22 PDAs have been used widely in clinical settings since they first emerged on the scene in the 1980s.22 The difference with smartphones is the addition of Internet access and phone service over the cellular network. Smartphones provide clinicians and students with access to evidence-based information to impact practice at the point of care, even in areas without wireless Volume 55, No. 5, September/October 2010
networks.23 The newer smartphones combine many resources clinicians need: phone, pager, contacts, Internet access, and personal clinical ‘‘cheat sheets’’ into one device, thereby saving both pocket space and time. Smartphones also can receive text messages and Twitter alerts. Beyond the basic functions, clinicians can personalize their mobile devices by loading applications, known as ‘‘apps.’’ Application ‘‘stores’’ are offered on smartphones and have thousands of programs, from simple games to complex databases for clinicians. Apple has the App Store24 and Blackberry has App World.25 The cost of applications varies depending on their complexity. Many helpful applications are free. For instance, the Centers for Disease Control and Prevention (CDC) reader brings current articles on public health matters, flu updates, emergency preparation, and other key topics to the phone. Clinicians also can download a variety of applications to streamline frequent calculations. Body mass index (BMI) and estimated day of confinement/delivery/birth (EDC/EDD/EDB) calculators are more accurate and easier to read than wheels or tables.26 Another useful program, the Electronic Preventative Services Selector (ePSS) from the Agency for Healthcare Research and Quality (AHRQ),27 allows the input of patient’s age, gender, and risk factors, and provides a list of appropriate health screenings. Epocrates allows clinicians to determine a patient’s medication based on their report of pill color and shape.28 These programs can speed care, eliminate unnecessary tests, and encourage evidence-based care.23 A growing number of applications also are marketed toward health care consumers. There are more than a thousand applications consumers can use to track or improve their health.24 Patients can download applications to ‘‘time’’ contractions or display calories for common convenience foods. Clinicians can refer patients who enjoy this style of health learning and participation to these resources but should be careful to prescreen resources for content accuracy. Clinical reference books are available for reasonable prices and are automatically updated using the network, so unlike books, the information provided is never outdated. These electronic references also have search features to find information easily. Smartphones are brought into a variety of settings and handled frequently and can be a disease vector. Protective coverings, also known as shells or skins, protect the device from damage and facilitate surface disinfection. Devices with smooth screens instead of buttons are best for surface disinfection.29 Protecting patient information is another priority for mobile devices. It is possible to house sensitive data on a smartphone and keep it secure. Options are available to password-protect phones, and specific applications require an additional password. In addition, methods are available to remotely erase all data if a phone is lost or stolen. Journal of Midwifery & Women’s Health www.jmwh.org
CONCLUSION The Internet has moved from just displaying information to allowing users to interact and manipulate content. Web 2.0 tools have many uses for busy clinicians and offer low-cost or free ways to market a practice, access current resources, and work on documents or research. Many video tutorials are available on online that demonstrate these practical and easy tools. While clinicians have to be careful to safeguard patient confidentiality, these simple tools assist with personal organization, networking, collaboration, and clinical practice and can be accessed readily with mobile handheld devices, such as smartphones, as well as personal computers.
REFERENCES 1. American College of Obstetricians and Gynecologists. How to begin using e-mail with your patients. ACOG Today 2009;9. 2. Kane B, Sands D. American Medical Informatics Association white paper: Guidelines for the clinical use of electronic mail with patients. J Am Med Assoc 1998;5:104–11. 3. LinkedIn Web site. What is LinkedIn: Getting the most from your professional network. Available from: www.linkedin.com [Accessed May 5, 2010]. 4. Twitter Web site. Twitter 2009. Available from: http://twitter. com/[Accessed January 11, 2010]. 5. Facebook Web site. Facebook 2010. Available from: www. facebook.com/[Accessed May 5, 2010] 6. MySpace Web site. MySpace 2010. Available from: www. myspace.com/[Accessed May 5, 2010]. 7. Krishna S, Boren SA, Balas EA. Healthcare via cell phones: A systematic review. Telemed J E Health 2009;15:231–40. 8. Text4BabyWeb site. Text4Baby 2010. Available from: www. text4baby.org/index.html [Accessed April 23, 2010]. 9. Raine R, Cartwright M, Richens Y, Mahamed Z, Smith D. A qualitative study of women’s experiences of communication in antenatal care: Identifying areas for action. Matern Child Health J 2009 June 25 (Epub ahead of print). 10. American College of Nurse-Midwives. Midwife Connection. American College of Nurse-Midwives, 2010. Available from: http:// acnm-midwives.blogspot.com/[Accessed May 5, 2010]. 11. Cohen SM. Confessions of a newshound. Information Today 2009;26:20. 12. Lamb A, Johnson L. Web feeds delivered to your digital doorstep. Teacher Librarian 2009;36:66–70. 13. LeFever L. RSS in plain English. CommonCraft, 2007. Available from: www.youtube.com/watch?v=0klgLsSxGsU [Accessed August 18, 2009]. 14. Google Web site. Google Alerts: Beta. Google 2009. Available from: www.google.com/alerts [Accessed January 7, 2010]. 15. LeFever L. Google Docs in plain English. Available from: www.youtube.com/watch?v=eRqUE6IHTEA [Accessed August 25, 2009]. 475
16. SlideShare Web site. What is SlideShare. Available from: www.slideshare.net/tour [Accessed January 7, 2010]. 17. Skype Web site. Use Skype: Get connected. Available from: www.skype.com/intl/en/getconnected/?c=101 [Accessed January 7, 2010]. 18. Doodle AG Web site. Doodle: Easy scheduling. Available from: www.doodle.com/[Accessed January 6, 2010]. 19. American Association of Birth Centers Web site. AABC uniform data set. American Association of Birth Centers, 2007. Available from: www.birthcenters.org/data-collection/features. php [Accessed January 7, 2010]. 20. Delicious.com Web site. Social bookmarking. Available from: http://delicious.com/[Accessed April 24, 2010]. 21. LeFever L. Social bookmarking in plain English. CommonCraft, 2007. Available from: www.youtube.com/watch?v=x66lV 7GOcNU [Accessed August 18, 2009]. 22. McLeod RP, Mays MZ. Back to the future: Personal digital assistants in nursing education. Nurs Clin North Am 2008; 43:583–92.
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23. Leo´n SA, Fontelo P, Green L, Ackerman M, Liu F. Evidencebased medicine among internal medicine residents in a community hospital program using smart phones. BMC Med Inform Decis Mak 2007;7:5–11. 24. Apple Web site. App store. Available from: www.apple.com/ downloads[Accessed June 17, 2009] 25. Research in Motion Web site. BlackBerry app world. Available from: http://appworld.blackberry.com/webstore/[Accessed January 10, 2010]. 26. Hunter LA. Issues in pregnancy dating: Revisiting the evidence. J Midwifery Womens Health 2009;54:184–90. 27. Agency for Healthcare Research and Quality Web site. ePSS: Electronic Preventative Services Selector. Available from: http:// epss.ahrq.gov/PDA/index.jsp [Accessed May 5, 2010]. 28. Epocrates Web site. Epocrates. Available from: www. epocrates.com/[Accessed May 5, 2010]. 29. Center for Global eHealth Innovation. Human factors evaluation of PDAs and smartphones in nursing practice. Toronto: 2009. Available from: www.humanfactors.ca/pda [Accessed May 29, 2010].
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