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Government Information Quarterly 29 (2012) 462–469
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Government Information Quarterly
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Social media in public health care: Impact domain propositions
Kim Normann Andersen a, Rony Medaglia b,⁎, Helle Zinner Henriksen b
a Department of Political Science, Aalborg University, Denmarkb Department of IT Management (ITM), Copenhagen Business School, Howitzvej 60, DK-2000 Frederiksberg, Denmark
⁎ Corresponding author.E-mail addresses: [email protected] (K.N. Ande
(R. Medaglia), [email protected] (H.Z. Henriksen).
0740-624X/$ – see front matter © 2012 Elsevier Inc. Alhttp://dx.doi.org/10.1016/j.giq.2012.07.004
a b s t r a c t
a r t i c l e i n f oAvailable online 19 August 2012
Keywords:Social mediaWeb 2.0e-Governmente-Health
This paper investigates the impacts of social media use in Danish public health care with respect to capabil-ities, interactions, orientations, and value distribution. Taking an exploratory approach, the paper draws onan array of quantitative and qualitative data, and puts forward four propositions: social media transformthe access to health-related information for patients and general practitioners, the uptake of social mediacan be a cost driver rather than a cost saver, social media provide empowerment to patients, and the uptakeof social media is hindered by legal and privacy concerns.
© 2012 Elsevier Inc. All rights reserved.
1. Introduction
The uptake of social media is leading to potential changes in howgovernments design, implement, and manage digital services. Web 2.0tools, such as social networking platforms, wikis, and microblogging,hold the potential to reshape theway citizens can interact with govern-ment, and perhaps more importantly, with each other. The opening ofhorizontal communication between citizens as users of governmentservices next to the traditional vertical communication channels be-tween government and citizens leads to speculation, and by some, an-ticipation of radical changes in behavior and organizational changes.Likewise, social media are being associated with the emergence of en-tire new public governance mechanism (Downey & Jones, 2012), thusreplacing new public management paradigms (Dunleavy, Margetts,Bastow, & Tinkler, 2006) through, for example, increases in transparen-cy and accountability (Bertot, Jaeger, & Grimes, 2012a, Bertot, Jaeger,& Hansen, 2012b) and cost savings through crowdsourcing (Brabham,2008; Doan, Ramakrishnan, & Halevy, 2011). Moreover, in the turmoilof the financial meltdown of government capacity due to a shrinkingtax base and to growing demands from an aging population(Niehaves, 2011), we have seen an increasing focus on using socialmedia to increase efficiency and effectiveness.
Yet, we are hesitant to accept propositions that public sector admin-istration will change overnight due to technology adoption and exploi-tation. Social media in public health care are developed and used in adynamic area of on-going political reforms and ideological controver-sies on privacy, payment schemes, and coverage. Consequently, issuessuch as cost effectiveness and the digital divide have become themesin the discussion of impacts of socialmedia in the public health care sec-tor (Andersen & Medaglia, 2009; Medaglia & Andersen, 2010).
rsen), [email protected]
l rights reserved.
This article, using a framework jointly developed during the last twodecades by researchers in UC Irvine and Copenhagen Business School inmetastudies on IT impacts (Andersen & Danziger, 1995; Andersen et al.,2010; Danziger & Andersen, 2002; Andersen & Henriksen, 2005), aimsat providing an exploratory study on the nature and direction of im-pacts of social media, drawing on the case of the Danish public healthcare sector. To broaden our understanding of the types of impact in asingular case, we also identify impacts for different user groups.
Our research question is the following: What impacts do socialmedia have in the public health care sector in the domains of capabil-ities, interactions, orientations, and value distribution at the levels ofpatients, general practitioners, and national policy?
The Danish health care sector is predominantly a government-regulated and tax-funded system that during the past thirty years hascomputerized and linked the various professional actors and institu-tions using dial-up, EDI, and internet technologies to access and ex-change health records. The advanced universal digitalization of thecommunication between the professional actors (hospitals, pharma-cies, general practitioners (GPs), laboratories, and the national healthinsurance) and the corresponding high access of the internet by the5.3 million population make it a captivating environment to study im-pacts of social media.
Although our research is within the health care area, we believe thatthe findings and propositions from our study are of relevance for thegeneral e-government field, since the health care in this specific studyis predominantly and almost exclusively regulated andfinanced by gov-ernment. We hope that the study design and findings will help inspirestudies in other areas of government where the focus is on the impactsof social media in government.
The remainder of the paper is structured as follows.We first presentthe theoretical framework that guides our analysis of impacts, and re-late it to the domain of social media and the public health care sector.In Section 3 we review and discuss existing research on the interplaybetween social media and government, and between social media and
463K.N. Andersen et al. / Government Information Quarterly 29 (2012) 462–469
the public health care sector in particular. Section 4 presents and dis-cusses the sources of data used and the methods adopted for thestudy. In Section 5 we report and summarize the findings from thestudy driven in the analysis by the categorization of the four domainsof impacts: capabilities, interactions, orientations, and value distribu-tion.We conclude the paper by drawing on the summary of the findingsto put forward four propositions on the impacts of social media inthe public health care sector, and discuss these propositions both in re-lation to existing research and as drivers for future studies in this area.
2. Theoretical framework
The first wave of research of emerging phenomena such as socialmedia has often focused on the uptake, with particular emphasis onthe characteristics of the phenomena (Magro, 2012). This is wellreflected in the adoption and diffusion of innovation contributions.This stream of literature generally reflects an enthusiasm for the in-novation, and also constitutes an understanding of the mechanismsfor uptake of innovations. Use and impacts from the innovation, how-ever, have not been emphasized. We focus particularly on the impactsof social media in health care in this study. Studies of impacts of ICTin healthcare have, to a large extent, focused on cases where dataare generated by professionals (Chang, Li, Wu, & Yen, 2012) or froma perspective where the attributes of ICT are emphasized (DeLone &McLean, 2003).
The present study deviates from these approaches. First, socialmedia data are mainly generated by patients, not by professionalsusing predefined templates and systems. Second, due to the speedof change in social media, the attributes of the applications are notfixed in a way that can easily be captured with frameworks of infor-mation system (IS) success, such as the DeLone and McLean (2003)model. The starting point for the study of social media in public healthcare is the impact from the perspective of users. Users here representboth patients and professionals.
Standing on the shoulders of those who could be considered thegiants of government IT studies (Danziger et al., 1982; Kraemer &King, 2003), the framework we draw upon in this article has been de-veloped as part of impact studies of IT in government. The frameworkconsists of four domains of impacts of IT on the public sector: capabilities,interactions, orientations, and values. For approximately three decadesthese four impacts have been the empirical foundation based on the
Table 1Domains and categories of impacts of IT in the public sector.Source: Danziger & Andersen (2002).
Domain of impact Description
Capabilities The impacts on the capabilities of a political unit assess whether IT hin which a unit deals with its environment, in an attempt to control ton its behavior and to extract values from the environment.
Interactions The impacts on the interactions between the political units assess howand control, communication among units, the coordination of tasks or
Orientations The impacts on orientation measure how IT affects the political unit'sevaluative considerations
Valuedistribution
The impacts on value distribution measure whether a political actor ethat is attributable to IT
meta-analysis of research of IT in the public sector (Andersen &Danziger, 1995; Andersen et al., 2010; Danziger & Andersen, 2002).Table 1 lists all categories of impacts related to each of the four domains.
Impacts of social media on capabilities concern the effects that so-cial media have on the way in which an individual or a collective actordeals with its environment in an attempt to control the environmen-tal effects on its behavior and to extract values from the environment.In particular, we consider impacts on the quality of information avail-able to actors and on changes in the efficiency or effectiveness of per-formance. Impacts on the quality of information concern the effect ofsocial media use on how easily data are accessed (data access) andhow the quality of data is affected (data quality). Impacts of efficiencyrelate to the capacity of actors to complete work tasks with a morefavorable ratio of outputs to input resources, such as costs (productivitygain), human resources (staff reduction/substitution), time (time-savingmeasures), and effects of improved control by managers. Impacts oneffectiveness concern the performance of decision-making (decision-making processes), improvements in, e.g., health services provided(improved products and services) and improvements in planning.
Impacts on interactions relate to how social media affect: patternsof power and control (organizational control and power); communi-cation among units and the coordination of tasks or policies; and co-operation among actors in performing a function within the healthsector (improved coordination/cooperation). Impacts on interactionsalso consider the relations between thehealth sector (e.g., governmentalagencies or public administrators) and citizens or private sector actors(citizen–public sector interaction, private sector–public sector interac-tion), as well as the relations among citizen groups (citizen–citizeninteraction).
Impacts on orientations capture the effects of social media on cogni-tive, affective, and evaluative considerations. For example, social mediacan encourage quantitative considerations – as opposed to qualitativearguments – to gain more importance in political decisions and actions(emphasis on quantitative criteria). Also, social media can encourageactors to structure problems differently in their decision-making(structuring of problems), and alter the level of discretion that publicadministrators have in making decisions (increased discretion).
Last, social media impacts on value distribution refer to the effects onvalues such as: the erosion or enhancement of the citizens' privatesphere (protection and improvement of the private sphere); the impactson job satisfaction by employees (job satisfaction and enrichment); the
Category
as an effect on the mannerhe environmental effects
1. Data access2. Data quality3. Productivity gain4. Staff reduction/substitution5. Improved control6. Time-saving measures7. Improved decision processes8. Improved products and services9. Improved planning
IT affects patters of powerpolicies, and the cooperation
10. Improved coordination/cooperation11. Citizen–public sector interaction12. Private sector–public sector interaction13. Citizen–citizen interaction14. Organizational control and power
cognitive, affective and 15. Emphasis on quantitative criteria16. Structuring of problems17. Increased discretion
xperiences a shift in values 18. Protection and improvement of the private sphere19. Job satisfaction and enrichment20. Job enlargement21. Protection of legal rights22. Improved standard of health, safety and well-being
464 K.N. Andersen et al. / Government Information Quarterly 29 (2012) 462–469
protection and enforcement of legal rights (e.g., ensuring that citizensare treated in a fair and equal manner and receiving services to whichthey are entitled) (protection of legal rights); and changes in levelsof health, safety, and well-being of citizens.
3. Previous research
In our previous studies on IT in government we have found that ITdoes lead to positive impacts on effectiveness and efficiency and thatthere are more mixed impacts on frequency and modes of interac-tions, orientations, norms, values, and health (Andersen & Danziger,1995; Andersen et al., 2010; Danziger & Andersen, 2002). Generally,the meta-analyses of IT in public sector and e-government researchhave identified a strong focus on impacts related to capabilities.
For social media, this pattern is most likely to be challenged. Thetechnologies included in the previous meta-reviews have mostlybeen adopted and implemented by top or middle managers to sup-port their agendas and interests (Kraemer & King, 2003). Socialmedia are, on the other hand, co-created with the users as the prima-ry drivers in the process. By having end-users defining the use andfurther development of the technology, there might be a shift in pri-orities from power and positioning (Kraemer & King, 2003) to utilityand user-satisfaction.
The uptake of social media can be interpreted as an institutionalreaction to a crisis in the public health care sector. This crisis is initi-ated by the emergence of commercial online health consultation ser-vices and social media forums where patients seek advice outsidegovernment. This can be considered as illustrative of the many formsin which responsive institutions manage change in the environment,finding new forms in order to manage legitimacy (Suchman, 1995).Following this argument, social media technologies in the health carearea, on the one hand, provoke stability in government. On the otherhand, the response by government to incorporate these new technolo-gies indicates how powerful the mechanisms are in seeking stability ina Weberian sense (Weber, 1972).
Ebbers, Pieterson, and Noordman (2008) observed that govern-ments' channel preferences are usually guided by considerations ofcost efficiency, while citizens may choose channels depending on,e.g., task characteristics, personal characteristics or situational factors.They find that governments prefer the website channel, while citizensprefer front desk or telephone, at least when it comes to consultationand conversation modes of communication. The citizens' documentedpreference for traditional channels is also grounds for suggesting gov-ernment strategies aimed at co-ordinating offline and online channels,in order to divert users from the former to the latter (Teerling &Pieterson, 2010). Governments need to provide multiple contact chan-nels for citizens, given that, e.g., the telephone is perceived to be a moreeffective service channel for solving problems, while a website is moreeffective for getting information (Reddick & Turner, 2012). The needfor governments to keep different channels open is also motivated bythe digital divide among citizens as users (Pieterson & Ebbers, 2008).
Table 2Mapping of research on impacts of social media on health care.
Domain ofimpacts
Individual level
I. Capabilities More effective health information retrieval (AlGhamdi & Moussa, 2012Empowered and well-informed patients (Lober & Flowers, 2011).
II. Interactions New ways for follow-up, post patient follow, patient education (Saleh
III. Orientations Increased transparency (Bertot et al., 2010),GPs reluctance to write text due to professionalism and fear of lawsuit (Sneddon, 2012)
IV. Valuedistribution
Violation of privacyUnintended consequences of exposure of information through social m(Mansfield et al., 2011).
The use of social media by governments has recently enjoyed an in-creased level of attention from the research community. Studies thatinvestigate the level of uptake of social media by government agencies(Bonsón, Torres, Royo, & Flores, 2012), often have the assumption thatwith the right government strategy, social media are an ideal way toadvance public goals (Landsbergen, 2010). In this stream of studies,the potential benefits of social media, such as increased transparency(Bertot, Jaeger, & Grimes, 2010), are considered together with pitfallsand risks, such as issues of quality and accuracy of the information re-trieved and circulated (Cline & Haynes, 2001). These issues need to beaddressed by governmental regulations (Bertot et al., 2012b).
In the healthcare sector, in particular, there are a growing number ofstudies that show a professional field that either lacks knowledge of thetechnologies or is hesitant to use social media, which is due to fear of,e.g., ethical and legal consequences (Cain, 2011; Penn, 2012; Sneddon,2012). Health professionals, for instance, are facedwith increasing chal-lenges in managing the exposure of personal information, and mitigat-ing the effects of unintended consequences (Mansfield et al., 2011). Theuse of social media points to the potential for new ways of conductingresearch and public health surveillance (Eke, 2011).
From the citizens' side, the starting point of studies focusing on theuse of social media in the health care sector is that citizens increasinglyuse the internet autonomously to search for health-related information(AlGhamdi & Moussa, 2012). Citizens use the internet and social mediaapplications to be more informed and to become empowered (Lober &Flowers, 2011). Patient education and empowerment are seen as a re-sult of the integration of information and communication technologiesinto health care practices: in searching for and sharing information onthe internet; in the use of social media to create new types of interac-tions with family, providers, and peers; and in e-patients who integratethese new roles and new technologies (Yamout, Glick, Lind, Monson, &Glick, 2011).
Social media are thus seen as a communication platform that canpromote patient welfare and safety, as well as serve as an educationaltool. In a recent study on orthopedic surgery, Saleh et al. (2012) havefound that “health care professionals have slowly begun to use socialmedia to stay connected with patients. The recent use of networkingsites aims to improve education, provide a forum to discuss relevantmedical topics, and allow for improved patient care.”
Table 2 summarizes findings from the research literature on the im-pacts of social media on capabilities, interactions, orientations, andvalue distribution in the health care sector, distinguishing between im-pacts at the individual and collective levels.
4. Collection of data and methodological issues
With the research problem areas being at a preliminary stage andthe body of research still emerging, we have adopted the exploratoryresearch approach to unfold what type of impacts are occurring withthe uptake of social media and where the social media impacts areoccurring. By addressing these we also aim at generating hypotheses
Collective level
). Gains on overall reduction in cost due to crowdsourcing(Doan et al., 2011)Channel cost savings
et al., 2012) Connecting peers, families, and patients in newconfigurations (Yamout et al., 2011).
Cain, 2011; Penn, 2012;Use of the stored data for research (Eke, 2011).
ediaOverall well-being improvement (Lober & Flowers, 2011).
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for future work. This methodological approach is guided by the de-scription of exploratory research by Babbie (1989) and Schutt (2012).
In order to explore our research question on social media impactson capabilities, interactions, orientations, and value distribution inthe public health care sector, during the period 2009–2012 weemployed a mixture of quantitative and qualitative data in an explor-atory research approach. This long-term empirical engagement in so-cial media led us to view social media as a continuum of technologiesand practice. Therefore, we were inclusive rather than exclusive inthe sources of data from the Danish case in order to obtain a rich pic-ture of potential impacts of social media in the public health care sec-tor. The inclusive approach to social media means that we includednot only data on, e.g., government-established peer-to-peer health fo-rums, social media use between patients and general practitioners,and social media use by the GPs prior and during the physical consulta-tions, but also some data on online one-to-one consultations betweenpatients and general practitioners, which we argue to be part of a com-mon trend of reshaping of communication patterns between citizensand governmental actors as a result of channel digitalization. Thistrend includes one-to-one communication (such as in onlineGP consul-tations), aswell as socialmedia platforms (Medaglia &Andersen, 2010).
We conducted three workshops (in 2009, 2010 and 2011) withhealth care professionals to explore the potential impacts of onlineconsultations and social media. Each workshop was attended by morethan 50 health care professionals who engaged in discussions and pre-sentations on the areas of impacts. The workshops were used to qualifythe variables of impacts to help develop an interview guide for the in-terviews with civil servants in health care associations.
During 2011 we conducted eight open-ended interviews exploringimpacts with civil servants in the General Practitioner Association, theDanish Health Agency, and the Association of Danish Counties. Duringeach interview, notes were taken and simultaneously recorded with adigital live-scribe pen. We held four formal meetings at the premisesof the Danish Health Agency and the Association of Danish Counties(2009–2011), and exchanged emails and phone conversations beforeand after the meetings, primarily to obtain numerical data.
During 2011 and 2012 we collected, computed, and analysed sec-ondary data (number of users and postings) on the use of the Danishnational health forum (www.sundhed.dk), and retrieved data on sup-ply and demand of digital health care services from Statistics Denmarkand Eurostat. Moreover, throughout the research process we retrieveddocuments on the digitalization of e-consultations, not only performinga detailed review of studies on e-consultations by the medical profes-sions, but also compiling data on mass media coverage of social mediaand public health care through the Danish media database Infomedia.
The analysis of the qualitative and quantitative data raises a rangeof epistemological and axiological challenges. In particular, the quan-titative data on social media uptake lack the rigour of an establishedscientific discipline. Overall, the phenomenon of social media is notnecessarily understood in a uniform manner by informants and re-searchers. As a research team, we discussed intensively our interpre-tations of the data in relation to the context. Our aim was to reach aconsensus on illustrative examples of impacts for each of the fourcategories of impacts.
5. Findings
Using the framework presented in Section 2, in the following sectionswe categorize the areas of impact of social media on the public healthcare sector in relation to the four domains of capabilities, interactions,orientations, and value distribution. We have populated each sectionwith examples derived fromour empirical data. At the end of this sectionwe provide a summary of the explored areas of impacts that were divid-ed into propositions of impacts at the levels of patients, GPs, and thenational level.
5.1. Capabilities
Capabilities include facilitating data access with: 1) the improve-ment of data quality with the possibility for patients to log on andshare data before and during consultation, 2) productivity gains forGPs via having an increased flow of patients, 3) improved control ofdata and communication by patients, and 4) time-savings in retriev-ing the information.
One of the most profound examples of positive impacts of socialmedia in the Danish public health care sector is represented in find-ings from a study on the digital platform on prostate cancer surgery“Online Patient Book” developed in a Danish hospital (Bjørnes, 2011).A key finding of the study is the identification of an innovative combina-tion and use ofWeb 1.0 and social media technologies designed to “em-power the men, as it assists the patients in being active participants intheir own care with the freedom to use the tool as and when needed.These health informatics tools can enhance the continuity of care,through the patients' increased ability to stay in control, which reducesthe dependence on the healthcare professionals.” In this example,the information access and sharing of data, together with the abilityfor users to ask questions and keeping a log of the dialogue areunique. This particular example points to a more blurred distinctionbetween the types of impacts. Apart from the strengthening of capa-bilities, the example also indicates strengthened citizen–public sec-tor interactions.
The ability to keep a log of the communication is similar to the ben-efit demonstrated in the Danish national health portal, sundhed.dk,which is the second example we have identified in the national publichealth care system. This national online health portal is a technical plat-form that aligns communication within the healthcare system, includ-ing appointments with doctors, patient forums, practice declaration,public health insurance, medication profiles, dialogues with patients,practical information, laboratory test results, medicine directory, andgeneral information. In this platform, patients can see which otherhealth care professionals access their online patient journal, and theycan communicate with their doctor online.
Commenting on the impact of the use of portal features by patients,a general practitioner member of themain board of theMedical Associ-ation reported that “patients save time that the secretary may use forother purposes. And it is a good service to patients who only have toknow the results of a test or to renew a prescription. They avoid thehassle of calling” (BT, 2006). The portal encapsulates most of the im-pacts related to capabilities. Apart from improved data access, this plat-form provides better data quality for the benefit of the patient andmorethorough information that patients can study at home in amore relaxedenvironment.
On an annual basis, there are about 2.8 million online GP consulta-tions through the sundhed.dk platform (Statistics Denmark, 2012).The GPs experience an increase in the overall consultations thatlead to an increase in income, since GPs are reimbursed by the gov-ernment for each online consultation they carry out. This increase inonline GP consultations can be also attributed to the emergence ofthe use of social media for searching and discussing health-related in-formation. As stated by a GP: “The net increases the amount of thingsthe patients want me to look at. Patients are rarely guided by a con-cern to go online. It is rather the case that they have one concern asthey go online, which becomes two as they shut down the computer”(BT, 2008). Moreover, data on the number and cost of online andoffline consultations show that offline consultations tend not to de-crease in time as a result of the increase in online consultations —
there are no substitution effects between the two channels (Medaglia& Andersen, 2010).
The rapid uptake of the sundhed.dk platform is due to a mandato-ry supply of e-consultations from this platform and a long-term dig-italization of the health care sector. Social media are a recent add onthat capitalizes on the previous gains in the national health network.
466 K.N. Andersen et al. / Government Information Quarterly 29 (2012) 462–469
5.2. Interactions
The second main group of variables we explore is the impacts oninteractions. Within this group of variables, we focus on the follow-ing: impacts on communication between citizens and the public sec-tor, between citizens, and between health professionals and citizens.
The Danish population has extensively adopted social media.Eurostat's data for 2010 placed Denmark at the top of the ranking ofEuropean countries, with 45% of citizens using the internet for postingmessages to social media sites or instant messaging (Eurostat, 2012).Danes use the internet very frequently for interacting with publicauthorities and searching for information on health-related issues.About half of the citizens contact their GP at least once a year throughthe internet (Eurostat, 2012). According to the Danish health portal,sundhed.dk, “few citizens find it impossible to process the amount ofaccessible health information. For the remaining, the biggest problemis making sense of the information and assessing the credibility.”
Fig. 1 plots the percentage of individuals using the internet forinteraction with public authorities (horizontal axis) against the per-centage of individuals using the internet to search for health-related in-formation (vertical axis). The analysis includes data on the period2008–2011 retrieved from Eurostat for 27 European countries (EU27).The intersection point between the two axes corresponds to the averagevalues of countries in the EU27 in 2011, namely, 41% of individualsusing the internet for interaction with public authorities, and 38%using the internet to search for health-related information. In the period2008–2011 there is an increase in the average levels of EU27 of around13% in the share of individuals using the internet for interaction withpublic authorities, and a remarkable increase of 35% in the share ofindividuals using the internet to search for health-related information.
The Danish figures are all in the top-right quadrant of the diagram,showing an above average representation for all four years. For theperiod 2008–2011, Denmark is the country that, on average, featuresthe second highest percentage of individuals using the internet for in-teraction with public authorities (70%), and the fourth highest percent-age of individuals (47%) using the internet to search for health-relatedinformation.
A curve for each of the countries' series for the four years from2008 to 2011 can be drawn, and they show to have a relativelygood fit (between 0.596 and 0.740 R2) in describing the series. Thefour curves from 2008 to 2011 tend to slightly flatten in time. Thiscan be interpreted as indicating that the proportion of individualsthat use the internet to search for health-related information ineach country is slightly reducing, in comparison to the proportion ofindividuals that use the internet just for interaction with public au-thorities. In other words, a country that in 2011 had a high percentage
Fig. 1. European-wide use of internet to communicate with the public sector and tosearch for health-related information, 2008–2011.Source: Eurostat (2012)).
of individuals using the internet for interaction with public authori-ties would be less likely to also have a higher percentage of individ-uals using the internet to search for health-related information thanin 2008.
The engagement in social networking platforms includes a numberof international health forums. The use of these is often free for patients,but there are also forums where one can buy online consultations, orthere are networks where the social medium is associated with bothother patients and medical professionals. The number of users on thecommercially-driven media is significantly higher than that of theDanish National Health Agency. For example, the commercially-drivenplatform netdoktor.dk in the period 1 July 2011 to 30 June 2012 hadhosted a total of 145 debate forums with 31,604 threads, as well as188,439 postings and comments. In comparison, at the end of June2012 the government-run national health portal, sundhed.dk, hadhosted only seven forums with a total of 1724 postings (see Table 3).
5.3. Orientations
In the orientations group of variables, we explored the impacts onimprovement in the use of quantitative criteria, and ease of structur-ing problems, among others.
A potentially high impact relates to new ways of overseeing epi-demic outbreaks, as exemplified in the European UnionM-Eco project(www.meco-project.eu). In the M-Eco project, health authoritiesmonitor citizen blogs that mention colds, fevers, etc., and analyze/systematize them. This is an example of the potential of collecting datafrom new sources.
In the patient forums on the Danish national portal, sundhed.dk,the way of structuring problems is very different from that of regularhealth consultations, since the patient-to-patient network and theassigned health professional aim to have a more synchronous com-munication, adopting a more unedited/informal tone in the commu-nication. We logged the traffic (number of postings and number ofregistered users) on seven health subject networks. Table 3 displaysthe accumulated figures of the seven networks at the end of July2010, November 2011, and June 2012. Although one should be ex-tremely careful in interpreting these data, our interpretation is thatthere is a very modest and weak growth in the number of users andnumber of postings. With the exception of the debate forum on recur-rent miscarriages, there are more registered users than postings foreach of the forums. Most of the forums have so few users that it isvery difficult to interpret them as social media in use.
One reason for the modest growth could be that a platform such assundhed.dk increasingly faces the competition of privately fundedand operated forums, as well as that of patient-driven forums. Theseare health forums that do not aim at minimizing, but rather at maxi-mizing, online traffic and interaction. The underlying business logic ofsocial media applications and that of the majority of private health fo-rums is to reach a high volume of traffic and a high turnover ratio.
One could well imagine that the massive use of social media andpublic health forums would ultimately help reduce the informationneeds of the public sector; however, existing data suggest the opposite.As the chairman of theDanish patient organization states: “It's very nicethat patients now have the opportunity to communicate with theirdoctor online. Not least because previous studies have shown that 27per cent of those calling the doctor give up because they cannot getthrough to him/ her on the telephone. However, obviously e-mail con-sultation can never replace the thorough examination or interviewwiththe doctor face-to-face” (BT, 2006).
5.4. Value distribution
In the value distribution group of variables we explore the impactareas of the following: protection and improvement of the privatesphere; job satisfaction and enrichment; job enlargement; protection
Table 3Patient network at the portal sundhed.dk: number of messages and registered users.
Patient network July 2011, ultimo (accumulated) November 2011, ultimo (accumulated) June 2012, ultimo (accumulated)
Number ofpostings
Number of registeredusers
Number ofpostings
Number of registeredusers
Number ofpostings
Number of registeredusers
Recurrentmiscarriagesa
935 388 1081 430 1159 477
Cervical cancera 266 362 292 380 332 412Incontinence(children and youngpatients)
32 83 48 127 70 182
Rape and other sexualharassment
29 65 39 105 67 152
Lymphedema 6 22 8 32 16 42Modic changes 32 44 50 87 74 146Overweight 4 12 6 24 6 31
a Has existed since 2008, the others since Summer 2011. Source: Sundhed.dk.
467K.N. Andersen et al. / Government Information Quarterly 29 (2012) 462–469
of legal rights; and impacts on standard of health, safety andwell-being.This group of variables contains a heavy arsenal of arguments againstmore use of social media in public health care, and can be consideredas the group of variables comprising the most social controversy andpolitical debate.
Moreover, it is the group of variables that is the most difficult foridentifying short-term changes, making it challenging to find empiri-cal documentation for support.
An illustration of the potential impacts on value distribution fromthe perspective of the Danish GPs is the use of social media duringthe consultation to provide links for follow-up treatments and forsearching for information about the patient. Referring to the practiceof looking up information on a patient's Facebook profile, a GP ex-plains: ”I have not done it before, but I will do it if the patient doesnot do as I say, or if there is a complex medical history which the pa-tient cannot explain, and I can find the answer to it on the internet.Facebook is like graffiti on a public wall, so if the patients write some-thing secret there, it is their own problem. If you do not want some-thing to be seen, you should refrain from writing anything. And I willof course tell the patient that I've seen it on Facebook. It should not bekept secret, but be part of a dialogue” (DagensMedicin, 2011a). This ex-ample points to the use of social media as a lever to improved stan-dard of health, safety and well-being because it strengthens thelevel of information by which the GP treats the patient.
Contrasting this daring approach, the GPs have been very carefulin communicating on the social media with the patients and in theirprofessional forums, which have also had a relatively modest uptake.Although there are forums, such as vis.dk and doctorsonly.dk, the num-ber of users and frequency of communication on them is much moremodest, as compared to the 180,000 registered in the UK-based www.doctors.net.uk and the 115,000 GPs on the platform www.sermo.com,launched in the U.S. The Association of Danish counties launched thesocial platform, vis.dk, for all professionals to exchange data. Accordingto a GP, there are five main problems with this social platform for thehealth professionals: “The social media assumes that health profes-sionals want to ask for advice. That is the first flaw. It is not a key com-petence in the health sector to acknowledge your own shortcomings. Inparticular this is unlikely to take place in a public forum. Second, whywould anyone expose their success? There is always the risk that some-onewill challenge you. Therefore, manywill beat around the bush rath-er than come forward. Third, the actors in the health care sector love theconcept of being anonymous, and vis.dk exposes the users. Third partiescan easilymonitor your actions: everything is in the open. Fourth, vis.dkaims to bridge different actors. Doctors, nurses, administrative staff, etc.are in the same (virtual) room. Some of them can't stand each other.Last, since this forum is hosted by the government, some of the healthprofessionals might not step forward, because this could be interpretedas trying to ingratiate yourself with the boss, while others might feelcontrolled” (Dagens Medicin, 2011b).
Added to this sceptical picture are the guidelines for GPs to use socialmedia published by the Danish GP Association (Lægeforeningen, 2012),requesting GPs to be very careful and warning them throughout on thedangers of social media use. For example, the guidelines point to thechallenges of balancing private activity with professionalism.
However, there are some positive elements. As the Chief Consultantat Danske Patienter (Danish patients) states: “As a patient you get a lotout of talking to others in the same situation — we know how manypatients have that opportunity from our patient groups. At the sametime we also know that in the dialogue between patients there canalso emerge many issues that they need to have clarified with a healthprofessional. Therefore, creating new online networks where there isalso the possibility of consulting with professionals has been a reallygood idea.”
At the national level, political controversies related to digital di-vide themes have surfaced along with concerns on whether the trans-parency of the health sector and the ability for users to migrateamong commercial and publicly funded social media and other healthservices from government will erode the legitimacy of public healthprograms. For example, it has been argued in political debates thatsocial media might create additional divide issues by giving the digi-tally privileged more access and use of channels to a health care sec-tor that is short of supply. As the political communication coordinatorfrom the Association of Elderly in Denmark states: “If your rights andmeans depend on your ability to communicate through digital chan-nels, then you have created and widened a digital divide, an “A” anda “B” team. Unfortunately, the elderly, who is also the most sick, isand will be marginalized in the “B” team. That paradox will challengefuture generations and their willingness to pay taxes if they can seetheir parents not getting the health care they need, while youngsterscan go online and bypass the waiting lines.”
5.5. Summary of impacts
Table 4 summarizes the distributions of the four domains ofimpact identified in our framework (capabilities, interactions, orien-tations, and value distribution), as well as the distinction of threelevels of analysis: patient, GP, and national policy level.
6. Conclusion
This article has explored the uptake of social media in publichealth care with respect to the impacts that social media have inthe public health care sector in the domains of capabilities, interac-tions, orientations, and value distribution at the levels of patients,general practitioners, and national policy. We acknowledge the limi-tations of the exploratory approach, in particular, the limited possibil-ity of generalizing the findings. However, we believe that at this stageof the development of the research body on social media in the public
468 K.N. Andersen et al. / Government Information Quarterly 29 (2012) 462–469
health care sector an exploratory study approach can provide signifi-cant insights into, and reduce the ambiguity of, the phenomena underinvestigation.
Based on this study, we formulate four propositions. We see thesepropositions as drawing on the twelve sets of impacts listed inTable 4 (four impact domains times three levels of analysis). Wehave highlighted these four propositions not only because we see themas summarizing themain trends in the uptake of socialmedia in thepub-lic health sector, but also because they have the potential to providean initial evidence-based agenda for future research in this topic area.
Our first proposition is that social media in the public health caresector are transforming the access to information through the com-munication with GPs using online platforms. The increase in informa-tion access is the most profound impact of social media in the publichealth care sector. This proposition is in the same line of argument ofthe stream of research that is looking at social media as a rich digitalchannel for government–citizen communication, highlighting the po-tential benefits of increased access to data, such as increased govern-ment transparency and accountability (Bertot et al., 2010). However,future research might draw on this proposition to move beyond theobservation of a quantitative increase in the access to informationprovided by social media in the health care sector. By potentiallyreshaping the traditional vertical communication channels betweengovernment and citizens, social media pose new challenges concerningthe quality and reliability of information exchanged in relation to healthcare services. For example, it would be worth investigating further theactual quality of information exchanged between patients in forumsthat do not have health professionals participating, and comparingthis with other types of social media-enabled channels. The scenariothat information circulating in a peer-to-peer fashion can posit chal-lenges of accuracy and reliability when notmoderated by a professionalshould be further focused on in future studies.
Second, our proposition is that, due to imbalance of payment of use ofsocial media, the uptake of social media can be a cost driver. Through so-cial media citizens tend to be more informed and therefore aware ofhealth problems; as a result, they tend to consult the free public healthcare more. This effect is in direct contrast to findings of Doan et al.(2011), suggesting efficiency gains to arise due to social media. Instead,we find social media to be a potential cost driver due to the automaticcost-reimbursement of health care consultations. This effect is, of course,closely linked to the institutional arrangement of the health care sector ofa country such as Denmark, where consultations are fully and automati-cally reimbursed to the health care professionals by the government,andwhere the health care sector is supported by taxpayermoney. Futureresearch should investigate the role of institutional arrangements notonly in the type of media available to facilitate digital information ex-change on health-related issues (Medaglia & Andersen, 2010), but alsothe impacts on cost-benefit issues.
Table 4Summary of impact propositions distributed on areas of impact and unit of analysis.
Areas ofimpact
Patient GPs
Capabilities Increase in access to information frommultiple channelsCost and time reductions in getting theinformationPatient empowerment
Income increases due to m(complementary effects)
Interactions Increases in C2C interaction (peer-to-peer)Increases in citizen–GP interaction
Increases in citizen-GP inLimited professional socia
Orientations Information search prior to consultations Check of information aboconsultationsAdoption of informal tone
Valuedistribution
Willingness to share personal information atsocial mediaFollow-up treatment communicationPotential information overload
Professional fights betweNo-failure cultureChallenges in balancing pprofessionalism
Third, we have seen an empowerment of patients and an improve-ment of the health care with more continuous contact (e.g., regardingpost-surgery issues) and the use of social media to provide richercommunication — such as streaming of instruction videos, etc.These two findings are in line with previous studies on social mediaand health information retrieval (AlGhamdi & Moussa, 2012), patientempowerment (Lober & Flowers, 2011), and patient education (Salehet al., 2012). Future research could investigate further the various di-mensions of the trends of patient empowerment and health care ser-vice improvement observed. The increase in frequency of contact andrichness of information exchange between patients and healthcareprofessionals could, however, also include some downsides. Some ofthe findings from the personal experience of health professionals in-vestigated in this study, for instance, point to the fact that often theincreased use of social media by patients leads to patients becomingunnecessarily alarmed, eventually leading to an increase in pressureon the health care system with new service demands.
Fourth, although GPs are seeing social media as a potential addi-tional revenue channel, the GPs are raising concerns about privacy,legal issues, and professionalism with the uptake of social media inthe direct communication with patients. Although in the Danish casethe fear of lawsuits is not referred to in the explanation of the reluctanceto write on open social media platforms, the fourth of our propositionsis in line with conclusions from existing research (Cain, 2011; Penn,2012; Sneddon, 2012), and could also be interpreted as supporting thepropositions byMansfield et al. (2011) on the unintended consequencesof exposure of information through social media. However, despite thisfear and reluctance, there appears to be an uptake of social media,e.g., during consultations as an information search tool to empower GPs.
Regarding the issues of privacy and legal implications of the use ofsocial media, further investigation could focus on understanding thedifferences in perceived threats/benefits between different actors inthe health care sector. For instance, the high concerns by health careprofessionals, as documented in, for example, the guidelines issued bythe Danish GP Association (Lægeforeningen, 2012), do not appear tobe shared to the same extent by social media citizen users. The lattershow fewer (and/or less identifiable for researchers) concerns on priva-cy and legal issues in their massively increased use of social media forhealth-related purposes.
The case of Denmark investigated in this study can be considered as anational laboratory of social media impacts due to its extreme high pene-tration rate of internet access and use of social media, extensive publichealth care system, and generous funding schemes for stimulating the up-take of newmedia in the health care sector. Due to the explorative natureof the study design,we are aware that the propositions have low externalvalidity. However,we believe that these four propositions could providestimulation for futurework onwhatwe see as a technology that has juststarted its diffusion and adoption in the health care sector.
National policy level
ore consultations Overall cost increases due to complementarity,no substitution effects
teractionl media interaction
National health system monopoly on informationprovision challenged
ut the patient during
in the communication
New ways of collecting data (e.g., epidemic outbreak)
en different groups
rivate activity with
Digital divide issuesLegitimacy of public health sector challenged
mation Technology and Organizations (1991-92+1993). He has authored more than200 titles, among these, journal papers and books on IT in government.
Rony Medaglia is Assistant Professor at the Department of IT Management (ITM) atthe Copenhagen Business School in Denmark. His research focus is on IT in the public
469K.N. Andersen et al. / Government Information Quarterly 29 (2012) 462–469
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Kim Normann Andersen is Professor at the Department of Political Science at AalborgUniversity. He has been a visiting professor at the School of Information Systems, DeakinUniversity, Australia (2004), the Department of Economics, Statistics, and InformationSystems (ESI), Örebro University, Sweden (2003), part-time visiting professor, AalborgUniversity, Denmark (Fall 2005), visiting researcher at Tokyo University (1996–1997),and visiting scholar at the University of California at Irvine, Center for Research on Infor-
sector, and hehas authored publications in international journals and conferences, includ-ing Government Information Quarterly, the International Journal of Public Administration,Communications of the Association for Information Systems, Information, Communicationand Society, the International Conference on Information Systems (ICIS), and the InternationalConference on Database and Expert Systems Applications (DEXA).
Helle Zinner Henriksen holds a position as Associate Professor in digital government at theDepartment of IT Management (ITM) at Copenhagen Business School. She has a degree inLaw from University of Copenhagen and a PhD in MIS from Department of Informatics atCopenhagen Business School. Her research interests include e‐government with particularfocus on adoption and diffusion of IT innovations in the public sector including the under-standing of institutional instruments which can stimulate adoption and diffusion of IT. Mostrecently she has worked on inclusive e‐Government and IT investments in the public sector.Helle Zinner Henriksen has published in some of the leading e‐government journals such asGovernment InformationQuarterly, The Electronic Journal of e-Government and Internation-al Journal of Electronic Government Research and in IS journals such as the European Journalof Information Systems, Scandinavian Journal of Information Systems, Journal of InformationTechnology and Knowledge, Technology, and Policy, and has presented her work at leadinge‐government and IS conferences. For more information see www.HelleZinnerHenriksen.info.
