Abstract

Summary:
Background and Objective: The nature of health communication is changing as people increasingly seek health information on the internet. The objective of this study was to investigate how hospital websites utilize a variety of e-health tools; online communication technologies such as social media, video, podcasts, and interactive formats.
Methods: An inductive content analysis was performed on the websites of 14 top-ranked US hospitals from January 5, 2011 to February 28, 2011. A total of 1,330 web pages were analyzed to identify the types of online communication technologies utilized by hospitals to provide e-patients with health information.
Findings: The findings provided an exploratory look at how hospitals provide web-based health information to patients. All hospitals used social media platforms such as Facebook, Twitter, or YouTube. Most hospitals offered web-based broadcasting of health information. Online health tools such as body mass index (BMI) calculators and health dictionaries were also a common website feature. Less frequently employed were mobile applications, hospital-patient interaction tools and health blogs.
Implications: The convergence of interactive media formats with web-based communication tools will likely enhance e-patient education and promote patient involvement in ways that alter traditional health care interactions, and may lead to enhanced levels of participatory medicine.
Keywords: Hospital websites, social media, podcasts, online tools, mobile applications, blogs, Facebook, Twitter, YouTube, e-health, health information.
Citation: Gallant LM, Irizarry C, Boone G, Kreps G. Promoting participatory medicine with social media: new media applications on hospital websites that enhance health education and e-patients’ voice . J Participat Med. 2011 Oct 31; 3:e49.
Published: October 31, 2011.
Competing Interests: The authors have declared that no competing interests exist.

Introduction

The nature of health communication is changing as people increasingly rely on the internet for health information.[1] Frydman[2] asserted that patients have used the internet since its early inception “to share experiences, learn about diseases and treatments, and become advocates” for their own health care. A recent Pew Research Center study found that 80% of internet users look online for health information, making it the third most popular activity behind email and search.[3] More than half of online health searches have had an impact on health decisions by e-patients.[4] E-patients are internet-savvy users who seek online health information for education and decision making. Understanding web-based communication tool development that engages e-patients can better guide effective healthcare strategies and interventions[5] and enhance participatory medicine.

While hospitals are cornerstones of public health information and health education,[6][7][8] it is not known to what extent hospital websites are helping to achieve these important health goals. Past research has indicated that hospitals are just starting to use web 2.0 technologies to communicate and interact with e-patients.[9] Thus, it is important to examine how hospitals use their websites to carry out their critical health care mission with various media and content delivery formats.

The current study examines how 14 top-ranked US hospitals serve the information needs of e-patients through online interactive media formats on their websites. Health organizations and professionals need to use social media channels to promote reliable and accurate health information to e-patients.[10] Yet, there is little research regarding the nature of presentation of health information on hospital websites to guide this process. Knowledge about the use of new media by top-ranked US hospital websites may help health care administrators and other professionals assess and improve web-based health communication. The importance of web-based communication media formats for e-health leads to the following research question: How is health information represented in online media formats for e-patients on hospital websites?

Methods

This research employed an inductive content analysis to examine the websites of 14 top-ranked US hospitals, based on a national report published in 2010 by US News and World Report.[11] Inductive content analysis is increasingly being used to study internet content.[12] Since there is limited empirical work on hospital website content and virtually no research on hospital websites and online multimedia formats, an inductive analysis was appropriate to utilize for this study.

The 14 hospitals, ranked in order, include: (1) Johns Hopkins Hospital, Baltimore; (2) Mayo Clinic; Minnesota; (3) Massachusetts General Hospital, Boston; (4) Cleveland Clinic; (5) Ronald Reagan UCLA Medical Center, Los Angeles; (6) New York-Presbyterian University Hospital of Columbia and Cornell; (7) University of California, San Francisco Medical Center; (8) Barnes-Jewish Hospital/Washington University, St. Louis; (9) Hospital of the University of Pennsylvania; Philadelphia; (10) Duke University Medical Center, Durham, N.C.; (11) Brigham and Women’s Hospital, Boston; (12) University of Washington Medical Center, Seattle; (13) UPMC-University of Pittsburgh Medical Center; and (14) University of Michigan Hospitals and Health Centers, Ann Arbor.[13]

As units of analysis, the authors first identified different types of online media formats utilized by each hospital (eg, blogs, instant-messaging, audio clips, and video clips etc.). After identifying media formats, patient health information content (eg, disease information, symptom checkers, and health education) was identified within each media format.
The total number of pages analyzed was 1,330, an average of 95 web pages per hospital website. The time frame for the content analysis of the 14 websites was January 5, 2011 to February 28, 2011. The first author identified six major content categories in the presentation of health information using hospital online media formats. These content categories include: social media; blogs; web-based broadcasting; web-enabled e-patient communication tools; mobile applications; and online health tools. These content categories and relevant sub-categories were corroborated by the second and third author. The analysis continued until saturation was reached.[14]

Results

This exploratory look into how hospitals provide web-based health information to e-patients provides details on the presence of various online media formats such as social media platforms, text-based, video, and webinars. Six content categories emerged in the analysis: social media, blogs, web-based broadcasting, web-enabled e-patient communication tools, mobile applications, and online health tools. The categories are defined below. Because of the developing nature of online technologies, some areas are more mature than others. For example, mobile applications, as a newer technology, presented less content compared to other categories. However, this category represents an important type of online communication which will grow in the future and so we included it in this analysis.

Two levels of content analysis are reported for each category, as depicted in Tables 1-6. The left column reports how many websites have a particular format, whereas the right column provides the number of these online media formats that contain patient health information.

Category 1: Social Media Applications

Social media applications connect one group of people to another. More importantly, social media applications enable hospitals to target e-patients with health communication messages. Table 1 illustrates that the vast majority of top-ranked hospitals use Facebook, hospital sponsored YouTube videos, and Twitter to communicate with e-patients.

Table 1: Social media.

This study found that typical health information content on social media sites included a mixture of patients’ stories, expert opinions by medical professionals, and details about what to expect from a particular test or procedure. Some content provided health tips, eg, diet, pediatric care, and cancer prevention.

Johns Hopkins offered a comprehensive and interactive approach, using social media to provide health information and refer e-patients to needed online or offline resources. Johns Hopkins used Twitter to refer to its Facebook page, its clinical web pages and other hospital resources. Most hospitals, however, did not sync their social media platforms to each other. This means that a hospital employee must enter messages individually on each social media platform hosted by the hospital.

The degree to which social media platforms promoted interactivity varied. For example, of the 13 hospitals that included Facebook pages, nine featured a Facebook link on the landing page making it easily accessible to e-patients. Six of the 13 hospitals with Facebook pages offered a dedicated health discussion forum on the site to promote interaction between health care providers and e-patients. While inconclusive, review of each hospital’s Facebook wall revealed some degree of interaction between hospital staff and e-patient inquiries. Hospital staff normally referred patient health inquires to the appropriate clinical care website. Facebook wall posts appeared to promote interaction among e-patient Facebook users on matters regarding their health inquiries, hospital services and hospital events. Further, the Facebook wall also became a forum for e-patients to voice their concerns or complaints regarding hospital services.

Most of the hospitals reviewed also offered a YouTube channel featuring a comments function. However, the interactivity potential of such videos was minimal, with little to no e-patient comments noted. Duke disabled the commenting function. Eleven of the 14 hospitals reviewed offered a “share” function which allowed e-patients to exchange information from hospital websites with other e-patients. Share functions included sending content to another person via email or posting information on an individual’s social media account such as Facebook or Twitter. Twitter postings were used most often by hospitals to promote community health events and news. This function provided easy one click linkages for visitors to repost hospital tweets to their individual Twitter feeds.

Category 2: Blogs

Blogs are a web-based, text-heavy format. Typical blog content on the websites studied contained health communication messages from medical experts and personal stories from patients (see Table 2). Physicians provided specialty medical information and advice through blogging in five of the hospital websites reviewed. Allied health professionals, such as nutritionists, wrote blogs about health information for hospital audiences. In both physician and allied health professional blogs, comment functions were available for e-patients. Depending on the topic, e-patients would engage each other through the blog. Very little additional engagement was noted between e-patients and blogging health providers.

Table 2: Blogs.

However, there were a number of hospitals hosting e-patient blogs on their websites. In general, e-patients wrote about their medical conditions and hospital experiences on the blogs. Moreover, specialized online social media platforms such as CaringBridge or CarePages were utilized by more than half of the hospitals to provide patients with a way to report their progress and well-being. It also allowed a patient’s friends and family members to view entries and to make comments on patient posts. Such patient-driven social media combined blogging and online community building around an individual patient’s medical journey.

Category 3: Web-Based Broadcasting

Web-based broadcasting uses the typical broadcast media formats in an online environment. As reported in Table 3, these formats included: online videos, podcasts, and webinars. All of these media were hosted directly on the hospital websites, rather than using YouTube and Facebook. The online videos reviewed presented a variety of health information from hospital physicians and allied health professionals. Similarly, podcasts (audio productions) were also produced to provide health information for e-patients. Webinars are slightly different in that the initial webinar can be live and allow audience members to interact online with other guests. After the live webinar, the productions may be posted for future viewing. In this study, eight webinars were identified, in which half were devoted to medical and support staff training and half provided health information to e-patients.

Table 3: Web-based broadcasting.

Category 4: Web-Enabled e-Patient Communication Tools

Web-enabled communication tools allow two-way communication between hospital health care providers and e-patients. E-patient web-enabled communication tools identified in this study included email, online chat, and text messaging, and online support groups. The occurrences are reported in Table 4. A standard email link to contact the hospital was available on the majority of hospital websites. Only the University of Washington Medical Center-Seattle website required that contact with the hospital occur via phone. More innovative web-enabled communication tools were found in online chat forums. For example, the Cleveland Clinic’s online health library offered e-patients an opportunity to chat with a health care provider to aid their search. The hospital also offered the ability to submit a question online throughout their site.

Table 4: Web-enabled e-patient communication tools.

While most hospitals reviewed offered support group lists on their websites, only five hospitals provided web enabled links to online support groups. In most cases, hospitals simply listed the telephone number of local support groups.

Category 5: Mobile Applications

Mobile applications support health information and messages in a wireless format available through mobile devices like smartphones and web-based tablets such as the iPad. These applications included walking exercises, symptom checkers, and meditation exercises. Only Ronald Reagan UCLA Medical Center, offered the entire website in a mobile format. As indicated in Table 5, only five of the 14 hospitals had mobile applications available. However, all of the mobile applications reviewed offered patient health information content.

Table 5: Mobile applications.

Category 6: Online Health Tools

Online health tools were provided for e-patients to learn more about their personal health needs. These tools ranged from static information such as health dictionaries, health topic guides, and event calendars, to more interactive information such as BMI calculators and an option to request a second opinion online (see Table 6).

The most interactive and personalized online tool available on hospital websites was the patient portal to access information from a hospital’s electronic health records. Patient portals are individualized, password protected accounts for which a patient must register. Unlike general health tools on hospital websites, a patient portal contains personal health information, which must be protected under healthcare privacy laws. Since privacy prevents direct examination of a patient’s portal web content, this research relied on hospital descriptions of their patient portal functions.

Of the 14 hospitals reviewed, 11 hospital websites provided patient portals through personalized accounts. Three types of online functions involved administrative tasks, accessing personalized medical information, and interacting with health professionals. Common tasks included:

• Making appointments;
• Requesting referrals;
• Requesting prescription refills;
• Making bill payments;
• Updating contact information;
• Updating insurance information; and
• Pre-registering and filing forms for appointments.

Common personalized medical information available to e-patients through portal access included attaining lab results, medical records to review health conditions, and managing medical information of family members, especially children. Interacting with health professionals allows users to send questions to their medical care team and receive health reminders.

Only four patient portal descriptions stated that users can search for general health and disease information from within the portal application. Further, the University of Pittsburgh Medical Center offered the only mobile patient portal. The mobile tasks offered allowed e-patients to check test results, review their medical history, conduct secure communication with doctors, and view upcoming appointments.

Table 6: Online health tools.

Discussion

The current findings suggest that top-ranked US hospitals are utilizing many different forms of interactive web-based media to serve e-patients. These findings are consistent with reports that large hospitals with higher numbers of beds have more resources to develop websites containing consumer health information.[15][16] Top-ranked US hospitals’ embrace of new media technology may help inform other medical institutions considering development of interactive web technologies that facilitate participatory medicine.

e-Health Information Seeking and Education

Finding reputable health information online allows e-patients to educate themselves and others to make informed medical decisions, stay healthy, and manage diseases.[17][18] Hospital websites are seen as trusted sources of e-health information.[19]

Interactive online communication tools on hospital websites, such as those in this study, allow e-patients to forward and share online health information. Social media “share” functions are also important for promoting participatory medicine because they extend online health searches beyond the individual user to wider populations. Research has determined that e-patients conduct online health information searches for themselves, family members, and friends20 on topics such as health improvement, medical treatments, family health, healthy eating, alternative medicine, and exercise.[20][21]

Further, interactive formats may present opportunities to enhance e-patient health literacy. The change from text-based online information to more visual and interactive web-based media provides the opportunity for increased user engagement with health information.[22][23][24][25][26] Engagement in e-health has been defined as “the process of involving users in health content in ways that motivate and lead to health behavior change.”[26] Past research suggests that multimedia and interactive content increase people’s engagement with health information.[26] All of the six content categories reported in this study (social media, blogs, web-based broadcasting, web-enabled e-patient communication tools, mobile applications, and online health tools) were interactive forms of online media.

The findings also suggest that hospital websites may also provide additional sources of quality health information by linking e-patients to other websites such as governmental, health care, and medical organizations. These types of website offer specialized knowledge for patients with particular disease concerns such as cancer and organ donation.[19][17] Such linking enhances participatory medicine by allowing ready access to medical information that is tailored to the health needs of e-patients.

The current study’s findings continue to show that e-health opportunity gaps are being addressed by top US hospital websites. In 2004, Fulda, Kwasik, and Ische[15] reported that top US hospital websites fill e-health opportunity gaps (what people are doing online in contrast to what they would like to be doing online). In particular, the increased use of interactive and multimedia based content, as found in this study, offered e-patients more ways to search, learn, and interact with online health information. Interactive media formats for e-health allow website users to retrieve health information in ways that best meet their needs and expectations. Plus, the choice of media formats may better match users’ specific and personalized learning styles.

Patient Portals

With 11 out of 14 hospitals having patient portals, it is clear that there is a commitment by health care providers to communicate with patients online. The purpose of patient portals is to improve health outcomes by facilitating engagement in health care by patients and medical providers.[28][29][30] However, such web-enabled technologies require additional research to assess their impact on participatory medicine. For example, Jones and colleagues[31] argued that these applications need more standardization to improve “interoperability, transportability, and security” in order to enhance their uses for positive patient health outcomes.

This study’s findings, specifically three types of online functions e-patients can perform utilizing patient portals, are a step towards identifying similarities and differences across patient portals. These three types (administrative tasks, accessing personalized medical information, and interacting with health professionals) can guide future user-centered research to help determine what functions e-patients identify as most important. Further studies are needed to determine portal tasks that help patients understand and use their health information most effectively. Further, future usability studies of patient portals may also consider varying levels of health literacy. Patient portals that offer multimedia (video, audio, graphics), may reduce health literacy difficulties.[32] Some patient portals charge users for certain applications, while others have fees paid by health providers, payors, or employers.[31] Patient portal access issues, especially cost, calls attention to the issue of the economic “digital divide. [33]” Patients, principally those with lower incomes, may not have access to a health care provider, insurer, or employer that will provide and cover the cost. As the health care industry increasingly relies on information technology to manage health care, this problem is likely to become even more significant. Research in health policy may provide insight about ways to decrease economic barriers for the use of patient portals.

Social Media Applications

Social media applications provide convenient web-based interactive communication tools that may promote dialogue between health educators and e-patients. We agree with Friedman[33] that “participatory medicine may be the most important driving force for new models and experiments in patient-centric practice, cost reform, and medical research….” Moreover, the use of social media applications could be better utilized by hospital staff to promote greater interaction between e-patients and health care providers. For example, while hospitals may use Facebook for marketing and public relations, the technology also allows e-patients to voice their questions and opinions with other e-patients and medical professionals.

Posting and updating social media content takes time and resources that may be difficult for hospital staff to manage. Utilizing applications that post the same content on multiple social media platforms can cut down on staff workload while increasing communication with wider e-patient audiences. Social media content can be posted to numerous social media platforms concurrently with such tools as TweetDeck and Hootsuite. These cross-platform tools allow content posted on one social media website to be simultaneously placed on other social media platforms, such as Twitter, Facebook, LinkedIn, Google Buzz, and Foursquare.

Mobile Applications

Less than half of the hospitals studied had any mobile application capabilities on their websites. While mobile communication is currently used most heavily by younger adults and teenagers, growth of these tools by all age groups is predicted for the future.[4] Fox and Jones suggested that the spread of wireless devices, coupled with generational shifts, will require greater attention to mobile applications in e-health. They contend:

Adults between the ages of 18 to 49 are more likely than older adults to participate in social technologies related to health. As younger adults face more health care questions and challenges, they will turn to the tools they have sharpened in other contexts of their lives to gather and share health advice.[4]

In fact, the current study’s findings revealed that health promotion is currently the most common use of mobile communication on hospital websites. Currently, mobile online health promotion for younger adults and teenagers can be an important part of participatory medicine.

Social Media Analytics & Practical Implications

Many web-based media formats provide instruments to track how content and information is being accessed and utilized by online consumers. With this feedback, hospital administrators responsible for website development can determine how to improve online health media for users. User data can help determine what information is being viewed, posted, and shared with others. Administrators have the ability to examine unique visitors, registrations, page views, satisfaction, engagement, return visits, shared posts, influencer posts, and other social interaction metrics.[34] With this knowledge, websites may better advance strategic goals for e-health information that enhances participatory medicine.

Future Research

Hospitals and other health care organizations can serve as a primary source for disseminating relevant health information to e-patients through strategic and effective utilization of online interactive media. For example, given the real-time nature of online communication, the use of hospital websites for informing e-patients of immediate health threats can be an important area for future study. For instance, a case analysis of patients from three Toronto hospitals discovered that after the SARS outbreak people were interested in using hospital websites to gather relevant health information during epidemics.[35] Greater attention directed toward how online interactive media formats can help prepare and safeguard public health in crisis situations such as epidemics and natural disasters is warranted. Mobile communication, often used for instantaneous communication, is increasingly used by people for e-health concerns as stated by Fox.[36]

Finding useful health information is also essential for a web-based participatory medicine model. Past research has shown that online health information should flow from general to specific paths.[17][24][37] Research on the organizational structure of health websites should help determine how and where health information should be placed on websites for an optimal user experience and for most effectively educating e-patients. This may include identifying how e-patients conceptualize general to specific health information, then adapting websites to follow e-patients’ expected information flows.

Another important area for future research in participatory medicine and interactive online communication tools is the use of language. Research has called for health websites to be better designed to accommodate the various languages used by members of diverse communities, as well as to meet the health literacy levels of different groups of consumers.[16][38] The concern about accommodating language and health literacy differences of diverse communities should extend to the development of language-appropriate online interactive tools for e-patients.

Limitations

This study is limited in that only 14 hospital websites were reviewed. As top-ranked hospitals, they provided an instructive sample to review the technological capabilities available at this time. Although greater interaction with online media can increase participatory medicine, without direct observation, participant interviews, or participant surveys, information about which online interactive media tools best facilitates participatory medicine is limited.

Conclusion

As the National Action Plan to Improve Health Literacy calls for improvement of health websites to better promote health,[39] the results of this study provide insights into how hospitals and other health-based websites can utilize various media in online environments for future health advocacy. Using online media formats bolsters e-patients’ engagement in health information while reinforcing health care institutions’ objectives in providing health care resources to improve health outcomes. More specifically, the findings present guidance on how six types of online interactive media (social media, blogs, web-based broadcasting, web-enabled e-patient communication tools, mobile applications, and online health tools) can be used to strategically manage health communication messages and information to strengthen participatory medicine.

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Copyright: © 2011 Linda M Gallant, Cynthia Irizarry, Gloria Boone, Gary Kreps. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.