It’s Not What You Think You Know, It’s Who You Trust Maximizing Our Collective eHealth Knowledge

Internet Skills Performance Tests: Are People Ready for eHealth?. This recently published study by van Deursen, Ph.D and van Kijk, Ph.D points to some fundamental issues in eHealth and the Internet that affect SMHC group think. http://tiny.cc/bnmzh

During our Sunday 8PM central time #HCSM (Healthcare Social Media) Tweet chats SM (Social Media) is sometimes positioned as a solution to various HC problems, needs, and audiences. Many of us see SM as part of a larger strategy or program. I’m firmly in the camp of the later; SM is part of a larger strategy. I see SM’s biggest benefit as part of an eHealth learning strategy. (Later this month, I will post a view of SM, learning, and consciousness.)This study and the recent data presented by Pew Research points to a goal: improve the ability of all patients to access HC (healthcare) knowledge/information and apply it to their HC needs and goals. We don’t need more data. We need more knowledge translation.

The Deursen and Kijk study is an amazing read with each paragraph holding a nugget of information, a reference, or data that refines a currently held belief, or changes a long held belief. Highlights from the study that I found compelling were:

People frequently search online for health information when prescribed a new medication or course of treatment, dealing with a medical condition, having an unanswered questions post MD visit, or when to change diets/exercise.

Search engines and basic search terms do not seem to provide efficient access to health information. Finding fast and not evaluating is the rule along with exploring only a few links.

The study measured four skill sets: operational, formal, information, and strategic Internet skills

The principle results from this study are:
In the domain of healthcare having sufficient levels of information and strategic skills is important especially when the information is questionable or taken for granted.

They further found that operational, information, and strategic Internet skill do not grow with the years (bad habits are retained). Participation in a course had a minor positive influence on level of information and Internet skills while getting help from peers was a negative influence. (People reinforce bad habits among each other)

The most important skills when using the Internet for health purposes are information and strategic skill sets when making decisions based on retrieved information. The gap between content found and application must be improved.

Pew Research Center just published The Social Life of Health Information, 2011. http://tiny.cc/5846i

The Social Life of Information is another great read with reams of data and information regarding who and why people search the Internet for Health Information. The Summary of Findings section opens with the following quote “’I don’t know, but I can try to find out’ is the default setting for people with health questions”. This fits well with my view on adult learning: adults will only learn when they are seeking a solution to a problem they are having. It supports the Deursen and Kijk study.

Some of the key findings are:
80% of Internet users have looked online for information about any of 15 health topics such as a specific disease or treatment. This translates to 59% of all adults.

18% of Internet users, or 13% of adults, have gone online to find others who might have health concerns similar to theirs.

16% of Internet users, or 12% of adults, have consulted online rankings or reviews of doctors or other providers.

15% of Internet users, or 11% of adults, have consulted online rankings or reviews of hospitals or other medical facilities.

15% of social network site users, or 7% of adults, have gotten any health information on the sites.

“I know, and I want to share my knowledge” is the leading edge of health care. (Consider this in light of the Deursen and Kijk study. Are we reinforcing suboptimal knowledge?)

4% of Internet users, or 3% of adults, have posted their experiences with a particular drug or medical treatment.

4% of Internet users, or 3% of adults, have posted a review online of a doctor.

3% of Internet users, or 2% of adults, have posted a review online of a hospital.

These two studies that tell us: a whole lot of people are using the Internet for eHealth, social media is the currency of the realm, and people do not have the skills necessary to find the right information, qualify it, and apply it.
In my view the Pew data demonstrates the massive reach of the Internet for healthcare patients and its frequency in HC use. The Dutch study shows we may not be maximizing the user online experience (e.g. by not ensuring the quality of data and the application of knowledge). eHealth patients may not know what they don’t know. Those of us familiar with HC, the Internet, and SM should strive to improve patient skills at finding, assessing, and applying HC knowledge.

If healthcare professionals and those interested in HCSM are to improve patient outcomes we should strive to improve the ability of all to find and use knowledge. We need to stop talking to ourselves and begin to understand the needs of the majority of people seeking and applying HC knowledge from the Internet. We need to help improve learners’ skills at finding data and the ability of the user to apply new knowledge to their HC needs.

The Pew data shows respondents trust and respect their physicians. Doctors who are involved in SM and eHealth should strive to bring more of their patients online and participate in SM. This is not a call to practice medicine online. Rather it is a call to have those who know how to use the Internet for HC teach others how to become better patients and caregivers. We need to help people find the best information possible and apply it to their problems.

Hospital systems and/or departments may want to offer courses in online HC searching and how to critically appraise data. For example an OB/GYN department may offer this course and invite to ePatients, former patients, and outpatients for a general tutorial. This activity can be extended after the course to help create a working community of patients with common interests and problems. The department should take the lead as a learning community. Own the channel in teaching patients how to improve their ability to translate and apply knowledge.

Your department or practice can serve as a patient model of eHealth. Don’t think 500 users hits on your Web site. Think 50 newly trained and skilled HC and Internet users/patients who can each teach one or two more. It’s not the size of the community, but the collective knowledge and skill that ultimately improves outcomes. Healthcare is a team sport.

The future for eHealth is not the large aggregate models like WebMD, pharma web sites, or Facebook. The real future that will bend the HC cost curve and improve outcomes are small discreet communities of knowledge and expertise built around a trusted resource and health partner, my physician and his patients.

I trust my physician to care for me. It is only a small step to trust him/her for his/her links, documents, community, etc. If my physician makes me a better patient better at acquiring knowledge it’s as important to me as a fast, accurate, and cheap diagnosis. And what’s better I don’t have to talk to him (conversely he doesn’t have to spend hours teaching, texting, emailing, calling). He just has to help me know where to go, where to learn, what to trust, and how to use it. And he doesn’t have to do it all himself. He simply has to leverage his community. He will see the results in my outcomes.
What are your thoughts?

Measure Twice, Tweet Once

I confess I’ve been the lagging indicator on this blog for any number of reasons. My goal was to post a multipart examination of how to measure outcomes in Social Media (SM). In my genius moment, I wanted to interview a number of experts in outcomes measurement, market research, and users who would share their knowledge and expertise. Two trusted colleagues took the time to respond to my questions and thoughts on outcomes and SM. This is a starting point for this discussion.

I do not view SM in and of itself as a major driver of change in healthcare (HC). It is a tactic, a tool, and one element of any number of strategies (e.g. marketing, sales, awareness, listening, etc.). In my estimation, SM is a powerful tactic within a learning strategy. Measuring outcomes in SM will aid in understanding what works, what doesn’t, and why. With that knowledge we will be able to create strategies that include targeted SM in HC to drive change through learning and application of knowledge. And further analysis of hard clinical outcomes can follow.

The best definition I could find on outcomes is from a statistical glossary:
“An outcome is the result of an experiment or other situation involving uncertainty. http://www.stats.gla.ac.uk/steps/glossary/probability.html.

We are uncertain what works in HCSM, the degree to which outcomes are a function of other variables, and why.

The two colleagues I asked to help me with outcomes are:

Derek Dietze is the founder and owner of Improve CME (www.improvecme.com). During the past 10 years Derek has focused on measuring outcomes in CME and finding unique ways to measure learning.

Scott Fishman is a well-regarded market researcher and principal of Ethos Lifescience Advisors (www.ethoslifescience.com), which supports market development in the life sciences, and provides guidance on the clinical and commercial value of new technologies.

Derek and Scott each looked at the topic in a slightly different fashion but overlapped in some critical areas. I will share their comments and thoughts before my own.

Derek offered the following regarding HCSM:

“For many years, we in the CME community have agonized about how to measure the effects of learning interventions on performance change in healthcare professionals and patient outcomes in practical, objective ways within reasonable budget limitations.

While methods and means to do this have come some distance, I’ve discovered that you really have to walk before you run with respect to measurement, both in an individual organizational sense, and in a community of practice sense. I’ve found it most productive to build on a strong foundation of simple measurement, easily understood by the consumers of the results, than advance to higher forms of measurement based on experiential learning. So initially, we focused on measuring changes in knowledge, confidence, and intention to change behavior (called “competence” by many in the CME community). These are still our staple forms of measurement, but now we have advanced to self-reported performance change and self-reported observations of patient outcomes based on CME activity participation. We are also piloting studies using national scope medical claims data to objectively measure performance change for national scope CME initiatives.

While ultimately the goal might be to measure how the use of SM results in better patient and community health, I would recommend starting at lower measurement levels, such as changes in knowledge, attitudes, confidence, and intention to change behavior among those interacting through SM. An article by Moore et al 2009 provides a good frame of reference for measuring changes in physicians and other healthcare professionals, and the Transtheoretical Model may prove to be of some help with respect to changes in patients.

Initially, I thought of SM as an “intervention” (like an educational intervention or activity in CME) when it’s focus is bringing about increases in knowledge, reshaped attitudes, and intention to change behavior. While I suppose it could be considered an intervention or “treatment” for the purposes of measurement, I realize it has many other functions that might be measured. SM seems to be a facilitator, and also has empathic and emotive characteristics, given its relative immediacy and potential frequency of use.”
A reasonable starting point for measuring the outcomes of social media (SM) in health care would be to clearly define:
• The different characteristics/uses of SM in healthcare
• What reasonably might be expected to change through its use in each of those circumstances
• In whom those changes are expected to occur, and
• What’s important about outcomes for the people/organizations invested in the results.

Scott Fishman responded to HCSM and some specific questions with this response:

I asked Scott:
Should our outcomes be qualitative or quantitative? Would you use combinations? Would we want to measure just clinical outcomes? His answer:

“Definitively both. Clinical outcomes measures are obvious and you’ll find them in any clinical paper or meta-analysis of a given condition. But there will also be references to “softer” metrics such as QOL scales, and I would suggest incorporating such measures. Of course, you will have to deal with the issue of generally accepted (e.g. “faces” pain scale) vs. novel metrics. The latter are also useful, but will need to be correlated with improvement in quantitative clinical and accepted QOL measures, which is another whole task in itself, and has the potential for either an “aha” moment or to entirely
undercut your hypotheses.”

Scott also addressed the health care provider (HCP). What would we measure there to determine outcomes in SM?

“Fewer phone calls from unsatisfied or frustrated patients. Shorter visits. Fewer changes in medication or dosages, less agita, fewer slaps from, and more incentives provided by insurers. Then, of course, there are all the “I’m a good doctor I have healthy patients” social acceptability measures.”

I asked him to address the question of what measures are most appropriate for patients?

Happiness. Does the patient feel better holistically? Do we see improvements on ADL scales? Of course we can measure condition-dependent clinical improvement (e.g. Hemoglobin A1c, BP, memory performance, and health). Are patients satisfied with their health care provider? Change in the number of days of lost work. Hospital admissions.
I might also include the quality and content of communications between HCP and patient as a potentially valuable measure for the effect of SM on outcomes.”

Both Scott and Derek have started the discussion that I would like to continue with you.

In healthcare SM’s most powerful application is as part of a learning strategy. HC is driven by knowledge and application of knowledge to improve an outcome. Knowledge is the locus for medicine. The physician is an intermediary in knowledge and treatment. Add to that these evidence-based conclusions about learning:

• Adults want to learn solutions to problems they already have (and, conversely, they seldom learn solutions to problems they do not have),
• Adults want to participate in their own learning, and
• Instruction for adults must respect the multiple demands in their lives.

Derek added the following comment:
“Mark, these measure a patient’s PERCEPTION of their own knowledge level and how it might have changed, which I admit may be valuable. However, when measuring physicians, I don’t trust them to self-evaluation whether they are knowledgeable. Instead I ask knowledge questions to test their knowledge. Anyone of use may be confidently misinformed or have incorrect perceptions regarding our illness/disease. A really simple way to validate correct knowledge (without making the patient feel like they are being tested), is to use “clinical assertion” agreement scale questions. Make a correct statement about a disease or condition, then ask for their level of agreement with the statement using a Likert scale or semantic differential.”

If we accept the fact HCSM is first and foremost a learning tool I believe Derek has presented a way to begin to understand HCSM strength and its potential. We can observe what happens to those patients engaged in SM with a HCP or others. Has the patient (caregiver)/learner: improved/increased knowledge, gained confidence, and intention to change behavior.
Patients get ill, get a diagnosis, and want to avoid an illness*. All of these are triggers to begin a process of learning. They come into the moment with a specific set of information. Patients will surf, call, read, tweet, FB and more. At some point they either stop adding to their personal compendium of knowledge because they have changed or are satisfied they have the knowledge they need. They have closed a personal knowledge gap. If we can measure changes in that gap comparing those who use social media against those who don’t in HC we can begin to understand SM as a learning tool and its value. We can compare it to non SM learning.

Areas of inquiry we may ask patients, caregiver, and HCP using SM in HC are:
• What is their current level of knowledge regarding the illness/dx/treatment you are seeking information on?
• Has their knowledge or understanding changed?
• Which formal and informal information of the following sources provided the greatest knowledge to them? (e.g. web sites, physicians, friends, others with similar conditions, networks on FB, tweeting, chat rooms)
• Based on what they have learned, how are they changing their behavior and/or approach to your care and management? What actually happens when we measure longitudinally from intent to behavior?

This is not an exhaustive analysis of HCSM and outcomes. It is a starting point to an open source discussion. What are your thoughts on how to measure outcomes in SM? Can we determine its relative value within HC? Are strict clinical outcomes the only measure we should make? This is one hypothesis on SMHC and outcomes. How can we dive into this area and improve it?

*I am fascinated by the idea that those patients who are heavy users of HCSM represent a small subset of all patients and are patients who are pre-disposed to learning etc.

Social Media in Healthcare is More Effective When It Drives Knowledge Not Marketing

Topic 1 for the Sunday nights #HCSM Chat: There’s been a lot of talk about physicians and patients in HCSM lately – but what about HC organizations?

Let’s define social media:

Wiki: ”Social media are media for social interaction, using highly accessible and scalable publishing techniques. Social media uses web-based technologies to turn communication into interactive dialogues.” This is what happen Sunday night during our #HCSM chats, in our Tweeter feeds and posts.

Wiki also identified:
Social Media Marketing “Social media marketing is a recent addition to organizations’ integrated marketing communications plans. Integrated marketing communications is a principle organizations follow to connect with their targeted markets. Integrated marketing communications coordinates the elements of the promotional mix; advertising, personal selling, public relations, publicity, direct marketing, and sales promotion.” This is using SM as part of business plan. It is the intersection of SM and marketing,

Many of the comments Sunday night captured the essence of these definitions.

nickdawson @bjoconnell agree. “Some still haven’t left the 1-way push and use the “we” voice non-stop.”

@RichmondDoc T1: “The only orgs I follow are those that provide me w/useful and consistently valuable info; I follow relatively few for that reason.”

@HealthSocMed “I’m not sure I *do* want to engage with the organization. I want to engage with people, maybe orgs should B blind?”

@jacquehealth: “Agree with @quality1 – Use SM to increase awareness, understanding, and health behaviors, not mktg.”

Brands and corporations realized that various SM platforms are valuable listening tools to identify trends, find loyal customers, drive brand messages into conversations, etc. And that is what SM became to these organizations, part of their marketing mix. Social media for brands is a way to use people/patients as extensions of marketing plans.

How active are HC organizations in SM? Ed Bennet continues to compile a frequently updated list of Hospital Social Networks. http://ebennett.org/hsnl/ As of October 19, 2010 there are 2,259 Hospital Social Networking Sites. His page has it broken down by various media (e.g. YouTube, FB, Twitter, LinkedIn, and Blogs) and by state. This is a great resource worth monitoring.

Frequently SM in HC organizations takes on a single goal and strategy: business development. A HC organization might look at a SM strategy based on a narrowly focused set of objectives: increase awareness, improve image, change census, increase use of a new piece of equipment, etc. This is not 100% of the time, Mayo Clinic uses SM to drive knowledge and improve patient-care as do other HC organizations.

Consider the following segments of a marketing plan: Broadcast (print, radio, outdoor), Digital Marketing (banners, Web sites, e-mail, search, etc.) and Social Media (networks, communities, blogs, microblogs). Each segment serves a specific set of strategies within a marketing plan. These are not fixed. They are flexible but their power to achieve objectives is maximized when they are applied appropriately. Broadcast is passive and used to promote messages. It can be used to engage readers but engagement is less effective. SM offers higher engagement between participants but has a low broadcast potential.

I believe HC organizations may be short sighted when they use SM to drive a message that can be best achieved via Broadcast and to fail to use SM to achieve what it can do best, actively engage participants in knowledge seeking behaviors.

SM is all about dialogue, interactivity, spontaneity, people and technology. It offers HC organizations the chance to not only listen and market, but to position itself at the center of HC knowledge and information for a unique network, their patients’ current and future knowledge and behavior. I have advocated that we need to help patients and people who are seeking solutions to HC problems move beyond WebMD etc. as single sources of knowledge and have them learn instead from their MD, their hospital, specialty societies, and networks of friends who share similar HC concerns. Make no mistake that patients are reaching out for answers using all of these resources. HC organizations should step in and become the final resource for them. A place to focus what they want to solve and what they have solved. Who do patients trust more than their own physician and the hospital they are affiliated with? If they don’t, then HC organizations need to position themselves that way in the mind of the patient and caregiver community.

For example, there is no reason why an oncology department in a regional hospital cannot create a network for breast cancer patients. This network uses resources in and outside the hospital to improve and share knowledge. Bi-monthly the department can hold tweet chats to discuss issues in breast cancer. Results and reviews of the topics can be posted with references. This site becomes a resource for patients and the hospital. It is less about marketing and more about knowledge. It is a resource for patients seeking solutions to problems in HC. HC organizations are not pushing a message they are the message. The medium becomes the message.

HC organizations should consider SM as a tool to educate and improve patient care, not an extension of the marketing department. Ultimately patients will trust and respect where they find knowledge, understanding, and people they share common problems with. Success, if measured in marketing terms will follow.

The Health Care Revolution Will Be Tweeted

When asked about the large bronze camel on his desk LW Frohlich owner of a design/advertising agency during the 1950’s and 60’s (one of the first in the world to do advertising for the pharmaceutical industry) would say, “It’s a horse designed by committee.” A sentiment apparently shared by Gladwell on the impact social networking sites like Twitter yield on society, expressed in his latest New Yorker article: http://tiny.cc/hkoi2.

On October 3rd 2010, participants in the Health Care Social Media (#HCSM) chat on Twitter were challenged to take up Gladwell’s opinion:
“ Malcolm Gladwell said FB/Twitter can’t change the world (http://bit.ly/c1YSIr) or solve ‘human problems’ of motivation. So, can Twitter and Facebook really impact healthcare (and motivation)? (Gladwell theorizes no).”

It appears the #HCSM participants felt differently:
• MeredithGould Consider this: Gladwell might be wrong.

• sixuntilme @HealthSocMed The diabetes community is VERY motivated through FB and Twitter connections. Patient communities = better outcomes, IMO

• @MHoskins2179: Communicating w/my D-tweeps keeps me accountable, sane, healthier. I am in better health becuz of Fcbk/Twitter/blogging.

• RichmondDoc I think the extent to which SM will influence motivation & behavior will depend on the extent to which we make meaningful connections

• @kstansberry: T3: FB and Twitter won’t cure disease, but can be great tools for collab. & attitude change. Many small changes lead to better health

• @hgazay: #hcsm T3 obviously! In cases such as orphan disesases FB might be the only way to connect with similar patients and share

• doctoranonymous #hcsm T3 Advocating change is done in the digital world. Performing change is done in the analog world

Gladwell sums up his thoughts nicely when he says, “Are people who log on to their Facebook page really the best hope for us all?” For those of us in the medical field, is social media (SM) the best hope for health care (HC)? Will participants in HC and SM drive changes to patient outcomes? Will SM change HC behavior?

To answer these questions, let’s begin with Gladwell’s premises, boiled down to the key points below:
• SM will not change the world because activism that can motivate population changes will not occur through SM. True activism is based on a different type of network and participants.
• The key to successful activism are strong ties to others who are active and reside within a hierarchy.
• SM is driven by weak links. Weak links are the source for new ideas and information. But weak links do not create strong ties that drive activism and change.
• Living , breathing networks have a hierarchy. SM by design has a very weak hierarchy and is, in most cases, leaderless.
• SM succeeds best when you don’t ask much of the network participants. To drive change participants must be highly active and reside in a hierarchy.

Can SM change the world? In my mind, “no,” especially when Gladwell uses the definition of activism as that of the 60’s Greensboro, NC version as the standard. A Tweet-up will not drive racial equality. A Tweet-up can bring those who are true activists together but, as Gladwell asserts, Tweeters are not the highly motivated “Red Brigade activists.”

Recent data indicates a small percent of participants in SM/networks are creators (see Josh Bernoff’s article on Social Technographics http://tiny.cc/rhkmj0y4oz ). The vast majority of participants in SM watch, listen and learn (spectators). Since there is not centralized leadership or hierarchy motivating and driving the majority into taking action, change is difficult. Joiners must be highly motivated so change can occur or to even move up the ladder to creators. Mr. Gladwell, you do not have to be a creator to be motivated, active, learn and change.



Science tells us that there are self-reported differences in empowerment between “lurkers” and “posters” in online patient support groups, according to a recent study conducted by researchers in the Netherlands (read the full study at http://tiny.cc/e0e0m). “Lurkers” (those who do not actively participate by sending postings) scored significantly lower than “posters” (those who actively contribute by sending postings on patient support group web sites) with regard to “the empowering process,” “the exchange of information,” and “finding recognition.” The outcomes between lurkers and posters did not differ in regard to, “feeling more confident in the relationship with their physician,” “improved acceptance of the disease,” “feeling more confident about the treatment,” “ enhanced self-esteem,” etc. (p<.0011). The conclusion of this study established that lurkers benefit from support groups and networks. This is important because it supports the idea that communities or network participants can rise equally in knowledge and understanding, no matter their level of participation. So, weak connections count online.

The chart below is from a 2008 report written by Noah Elkin from iCrossing based on research by Opinion Research Corporation. This presents a pretty compelling argument about the importance of SM for patients seeking to access health data. We see patient online behavior before a physician visit and afterward. The patient gleans information, researches more and participates online. Hence, learning is occurring. It is interesting to note that “health care provider” is not surveyed in the chart. If there was a physician resource that patients could access, I wonder what this data would look like?

Some additional facts about healthcare and the web, taken from Kantar Media (http://tiny.cc/dygu6):
• 89% of the 178 million Americans who have gone online in the past month have performed health research.
• Reasons for going online: 71% seek knowledge about a condition, 59% are researching a symptom for themselves or someone else
• 56% of respondents said a health care provider makes a health web site trustworthy. 46% look for inclusion of academic articles or scientific research to indicate trustworthiness.
• 79% feel the web offers a wealth of resources in HC and 74% are cautious about which web sites they access for HC
• 77% of recently diagnosed patients turn to online sources for information, while 81% turn to a HCPs, and 51% rely on traditional print media

I agree with Gladwell and believe SM is primarily made up of weak links that are not especially capable of achieving activism that changes society. Still, SM remains a place to learn and listen. Because it is a weak link, it exchanges new knowledge and information quickly and efficiently. (See the post titled “SM in HC is More Than a Cute Name” to learn more about weak links and strong links in networks.) Members of networks absorb vast amounts of knowledge and information. This is one reason SM and HC works as well as peanut butter & jelly. I see patients involved seeking to solve health care problems as varied as they are.

Health care motivates us differently. Health care in many instances is about survival. Health care is complex and fraught with problems not easily solved. People with illnesses are more motivated than people without illness. Someone fighting cancer is as motivated for themselves or their family member as anyone in the Red Brigade. Health care activism is about one’s own self. The shortsightedness of Gladwell’s statement is that when it comes to social media and health care, the transformation concerns one person—yourself—not a landscape or a society.

As an advocate of SM, I know the power of patients who help each other, who tweet, blog, chat and challenge their health care providers with new ideas and questions. But this is not the activism Gladwell speaks about. It is one patient at a time multiplied by thousands every day. HC now is about individuals advocating for themselves and each other. It is a movement of one created by a vast network of information, knowledge and experience.

Let’s return to Gladwell’s quote: “Are people who log on to their FB page really the best hope for us all?” I see his words differently; people who log onto FB have the best hope for themselves in learning to solve their HC problems. They are doing it. What we are not seeing are the outcomes. It is easy to see outcomes or movement when 10 people sit in at a Woolworths. We can’t see outcomes if one patient lowers his blood pressure and that change over time when measured against someone not active in SM. Was it the diagnosis, the diet learned online, the friends on the network nagging the patient to exercise or the physician? Outcomes take time and need to be designed. As a group, we should be recommending and pushing for outcomes to measure the effect of SM on HC.

In the end, Gladwell is right that SM will not save the world. But SM, networks and other technologies, when used within a smart HC strategy, can improve patient outcomes. Patients want to change and get better and live and learn—the research data demonstrates that. The weaknesses Gladwell identifies are real but can be overcome to improve HC if we leverage the elements in health care, social media, and our primary care providers (PCP). SM networks for HC should be smaller and more functional to increase patient participation. SM networks for HC need to have some type of hierarchy in order to keep growing at a steady pace. SM networks for HC should welcome “long ties” for new information, as in offering a space for new information to be shared from external sources, while also supporting “short ties” among influencers, as in providing greater means and opportunities for key stakeholders to offer their insights and wisdom.

How can we achieve this? The revolution in HC can, in part, happen with SM if we identify strategies that focus on smaller units of measure. Functional networks should be built around a physician’s practice base. The physician becomes the natural leader of the online network. (Physicians should not practice here, but they should participate.) It becomes a “Red Brigade” cell. Members are highly motivated and active in their HC because they share a common need to solve their HC problems. They are motivated by each other, guided by their PCP. At its core, it involves one patient and one practice applying SM to drive change. It shares knowledge and experience from the Web. It is not WebMD but MyMD, the home of my HC network. That is the best hope we have to change HC.