RESOURCES FOR CLINICIANS

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� 2010 by the AmericIssued by Elsevier Inc.

Web 2.0: Easy Tools for Busy CliniciansJulia C. Phillippi, CNM, MSN, and Margaret Buxton, CNM, MSN

Internet content has become interactive; new tools can help clinicians market their practice and provideevidence-based care. Many of these tools are free or low cost and are easily mastered using simple videotutorials found on the Internet. This article highlights the uses of e-mail, social networking, smartphones,RSS feeds, social bookmarking, and collaborative Web 2.0 tools in clinical practice. J Midwifery WomensHealth 2010;55:472–476 � 2010 by the American College of Nurse-Midwives.

keywords: evidence-based practice, Internet, smartphone, social networking, Web 2.0

INTRODUCTION

The Internet provides unprecedented levels of access to in-formation and has transformed the way people interact,stay in touch, and network with other professionals. TheWeb is expanding from a unidirectional, library-like atmo-sphere to a participatory, interlocking network where allcan engage in knowledge and content creation. This newinteractive version of the World Wide Web is often calledWeb 2.0. The purpose of this article is to provide an over-view of some recent technological developments and Web2.0 programs that can be beneficial to busy clinicians.

E-MAIL

E-mail is a useful, fast, and accessible way to communi-cate, but the etiquette surrounding electronic communica-tions is still developing.1 E-mail often is regarded as moreconversational than a formal letter; however, e-mails be-tween a patient and clinician need to be treated with thesame weight as written communication with careful atten-tion to word choice, proofreading, and tone. All nonverbalcommunication is absent from e-mails, making humor andsarcasm difficult to convey.1 Just as with written letters,a copy of the e-mail needs to be kept in the patient’s chartand the information incorporated into the medical record.E-mail correspondence with patients is a legal extension ofhealth care and should be treated with the same diligenceas in-office care.2

Privacy must be protected in corresponding with pa-tients. To meet Health Insurance Portability and Account-ability Act (HIPAA) guidelines for health informationprivacy, both the patient and the clinician need to have se-cure e-mail systems. Because regular e-mail can be inter-cepted or viewed by others, the patient’s regular e-mailaddress is not an acceptable forum for medical discussion.

ence to Julia C. Phillippi, CNM, MSN, Vanderbilt Uni-ursing, Basic Competency Section, 345 Frist Hall, 461lle, TN 37240. E-mail: julia.c.phillippi@vanderbilt.edu

an College of Nurse-Midwives

Many companies market secure e-mail systems that meetHIPAA guidelines. Policies and procedures surroundinge-mail communication with patients—including how of-ten it is checked, what queries can be answered, andhow the information will be placed in the medicalrecord—need to be communicated to patients before cor-respondence to avoid misunderstandings.2 A consent forelectronic communication can be included in new patientpaperwork to aid the process.

Clinicians should also be careful not to include poten-tially identifiable health information in any nonsecureform of electronic communication. For instance, many cli-nicians use e-mails groups, such as the American Collegeof Nurse-Midwives (ACNM) eMidwife discussion lists, toshare and request information about patient care, but allusers must be careful to highlight only the clinical problemand not mention dates, locations, or any information thatcould identify a specific patient. Even e-mail sent to oneperson can be easily disseminated. To ensure patient con-fidentiality, safeguard all electronic communication andconsider using e-mail designed specifically for medicalcommunication.

SOCIAL NETWORKING

Social networking is one of the most popular Web 2.0 ap-plications. Users can create a profile and connect withother users as friends or colleagues on numerous differenttypes of free and for-fee sites. Connected people areknown as ‘‘friends’’ or ‘‘contacts.’’ Some sites are primar-ily professional (e.g., LinkedIn3), while other sites are pri-marily social (e.g., Twitter,4 Facebook,5 and MySpace6).Increasingly, all of these sites include a blend of content.These sites allow for rapid, widespread dissemination ofinformation, which provides an opportunity for marketingideas and services, but also has many privacy pitfalls.

Many special interest groups have established them-selves in social networking sites. Individuals can sign upto be a part of special interest groups to read about currentideas or upcoming events or connect with others who shareinterests. For example, ACNM has a page on Facebook

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with a ‘‘fan’’ base of more than 2,700 individuals as of thiswriting. The site has links to recent events, articles of in-terest, information about midwifery, and daily postingsfrom midwives around the country. Sites like these canprovide midwifery practices an opportunity for free mar-keting. Midwives and groups can send announcementsto their ‘‘friends,’’ and patients can write their birth storiesfor others to see.

Twitter is another version of social networking usingtext messages, known as ‘‘tweets,’’ that must be lessthan 140 letters or numbers.4 People who agree to receivetweets are known as ‘‘followers.’’ Tweets can be sent andread from the Twitter Web site, cell phones, and via third-party applications. Practices can use Twitter to alert will-ing patients of upcoming events. This can be used toencourage engagement with the practice so the patient ismore likely to come in for care or refer others. Twitter,or group texting, can also be used to reinforce health teach-ing.7 For instance, women with gestational diabetes canreceive a helpful tweet to encourage exercise. It is impor-tant to remember that Twitter is a public conversation.People can reply to tweets or forward tweets on to others,known as ‘‘retweeting.’’

ACNM has partnered with other national agencies tosponsor health information texts to users’ phones in a pro-gram known as Text4Baby.8 These texts, tailored to thewoman’s week of pregnancy or her infant’s birthday, aresimilar to tweets in that they provide communication viathe cell phone, but they are not public and cannot receivereplies.

Patients can also be reminded of appointments throughpersonal texting.9 It is important to get consent before text-ing patients. Many cell phone users must pay a fee for in-coming texts. Texts can be viewed on the cell phone screenby others and are traceable, so patients may feel theirprivacy is violated. This might be especially problematicfor teens who have not disclosed to their parents thatthey are seeing a health care provider.

Blogs are similar to online personal diaries or profes-sional commentaries. Authors of blogs are known as‘‘bloggers.’’ They ‘‘post’’ stories and comments on theWeb for others to read. Blogs can belong to individualsor organizations, such as ACNM’s blog Midwife Connec-tion.10 These blogs can be a source of community referralsif the blogger comments favorably on care or services.Practices may want links to supportive blogs or blog posts

Julia C. Phillippi, CNM, MSN, is an instructor at Vanderbilt UniversitySchool of Nursing in Nashville, TN, and a PhD student at the Universityof Tennessee, Knoxville, TN. She is the chair of the Basic Competency Sec-tion of the American College of Nurse-Midwives.

Margaret Buxton, CNM, MSN, is a clinical instructor at Vanderbilt Univer-sity and practices full-scope midwifery care with the Vanderbilt Nurse Mid-wifery Faculty Practice, Nashville, TN. She is a member of the AmericanCollege of Nurse-Midwives Informatics Committee.

Journal of Midwifery & Women’s Health � www.jmwh.org

on their Web sites. Clinicians also can blog about theirexperiences, but they must be careful not to disclose infor-mation that can be associated with patients. For instance, ifa midwifery student is blogging about her experiences inclinic X, she should not state that she saw a patient witha herpetic lesion on Tuesday because this information istraceable back to a small number of women.

There are several privacy concerns related to social net-working. The posted information is easily disseminated,and, once information is posted, it cannot be fullyretracted. Clinicians can avoid pitfalls by never postingany information about the content of their work or birthsand instead providing a place for women to post theirown stories. Many clinicians keep two social networkingaccounts or profiles: a professional account for patientsand colleagues that posts information advertising theirwork and professional progress, and a friend accountthat has more casual and social posts that are unrelatedto work. Advanced users can edit settings to display infor-mation only to selected groups of contacts.

RSS FEEDS AND GOOGLE ALERTS

RSS (which stands for ‘‘really simple syndication’’) feedsare a method of creating a personal publication from favor-ite news sources.11,12 RSS is denoted by an orange squarewith curving white lines (Figure 1). An RSS feed lists newcontent from favorite news sites, both personal and profes-sional. For instance, an RSS feed from PubMed could sendnew abstracts on the second stage of labor, or the New YorkTimes could feed in articles on birth and childbearing. TheRSS feed requires a ‘‘reader’’ to receive the articles.Readers are free through many sources, including Google.The reader collects articles on favorite topics for review.This saves the effort of checking multiple news sourcesand can alert readers when important publications arereleased. RSS feeds can also show the new postings onfavorite blogs. Several online instructional videos demon-strate how to sign-up.13

Google Alerts are similar to RSS feeds in that theyscreen the Web, blogs, and news sources for user-selected topics.14 When an interesting news article isfound, an alert is sent to the user’s e-mail or cell phone.Many clinicians use media alerts to keep abreast of currentevents surrounding midwifery or birth.

COLLABORATIVE TOOLS

The Internet has many collaborative tools for clinicians.Web 2.0 technologies can assist professionals across theglobe in communication, collaboration, and research.Many of these tools are free and open to the public, whileothers are fee-based and provide security provisions mak-ing them safer for use with patient data.

Google Docs is an online collaborative program that hasmany free tools that can benefit clinicians, including

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Figure 1. RSS feed icon.

survey functions and document collaboration. These toolsallow users in different locations to work together on doc-uments by editing and collaborating on a single copy ofa document.15 For example, when revising midwifery clin-ical practice guidelines, the input of all midwives in thepractice group and the consulting physicians is needed.Google Docs allows users to store one copy online andinvite all the key stakeholders to edit that copy of the doc-ument. Because there is only one copy, no one needs toreconcile different documents or change the title to reflectthe newest revision.

Google Docs also can be used to send surveys embed-ded in e-mails. The recipient fills out the survey withinthe e-mail itself and the responses are automatically en-tered into a spreadsheet that creates graphs and other visualdepictions of the data. This technology can be used for cli-nician surveys or polling coworkers about vacation timesand call schedules. Before entering patient e-mails intothe Google system, obtain a signed consent.

While Google Docs provides many tools in one loca-tion, other Web sites provide more niche services. Pro-grams such as SlideShare allow collaboration on andsharing of voice and PowerPoint presentations.16 Skypeprovides a method to use the Internet for free video andvoice meetings between two or more people.17 Doodle isan easy way to schedule meetings and has been used byACNM to quickly schedule large meetings.18

The Web also can facilitate perinatal research. For in-stance, the American Association of Birth Centers(AABC) allows participants to enter their data into a securedatabase. Practices can use the system to study their ownstatistics, and researchers can apply to study the entiredatabase.19 Web tools, such as AABC’s Uniform DataSet, allow clinicians the opportunity to participate in re-search with minimal time investment.

Collaborative tools allow clinicians many ways to facil-itate communication and collaboration on administrativetasks and current research. The minimal training neededis provided through video tutorials with screen shots.The tools discussed can be located through the Web siteslisted in the references or by entering the Web site name ina Google search.

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SOCIAL BOOKMARKING

Bookmarking organizes favorite Web sites with minimalwork. Many clinicians already use the bookmark and fa-vorites features included in their Internet software; how-ever, those features are tied to the computer itself. AWeb site bookmarked at work would not be bookmarkedon a home computer. In addition, with traditional book-marking, it is not easy to share favorite sites. Social book-marking expands the ability to use and share bookmarksby placing them on an Internet server where they can beaccessed from any computer with Internet access.

The ability to share favorite Web sites makes the Web 2.0version of bookmarking ‘‘social.’’ Clinicians can share pa-tient education sites across the country, and users are able toview sites marked by others. Bookmarking sites organizefavorite sites into categories based on user descriptions,known as ‘‘tags.’’ The sites function like a filing systemfor great Web sites. Many users find that social bookmark-ing sites reduce the clutter that comes with a Google searchof the whole Internet. For instance, a midwife finds a sitethat has great consumer-friendly information about first-trimester testing and bookmarks the site with the tags ‘‘con-sumer,’’ ‘‘first trimester,’’ and ‘‘testing.’’ A women’s healthnurse practitioner who is looking for a good resource canuse the social bookmarking site to find this Web site bysearching for all bookmarks tagged with the term ‘‘first tri-mester.’’ These Web sites tend to work best when manysimilar users are tagging favorite Web sites.

There are several free social bookmarking Web sites; oneof the most popular is known as delicious.20 Most require ane-mail address but minimal personal information to create anaccount. Once signed in, users create a library of Web sitesby clicking the bookmarking icon on the header bar whileat favorite sites. The user then identifies several tags, orfolder names, to catalog and retrieve the Web site. Most so-cial bookmarking Web sites have online tutorials to assist inaccount set-up.21 There are few patient-related privacy con-cerns for social bookmarking because users are not generat-ing new content, but only flagging existing Web sites.

SMARTPHONES

Personal digital assistants (PDAs) were previously popu-lar handheld electronic daily planners. PDAs have mergedwith cell phones and become the new smartphones. Smart-phones store files, access the Internet, and download soft-ware. They can also record, play music and videos, andread Web publications.22 PDAs have been used widelyin clinical settings since they first emerged on the scenein the 1980s.22 The difference with smartphones is theaddition of Internet access and phone service over the cel-lular network.

Smartphones provide clinicians and students withaccess to evidence-based information to impact practiceat the point of care, even in areas without wireless

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networks.23 The newer smartphones combine many re-sources clinicians need: phone, pager, contacts, Internetaccess, and personal clinical ‘‘cheat sheets’’ into one de-vice, thereby saving both pocket space and time. Smart-phones also can receive text messages and Twitter alerts.

Beyond the basic functions, clinicians can personalizetheir mobile devices by loading applications, known as‘‘apps.’’ Application ‘‘stores’’ are offered on smartphonesand have thousands of programs, from simple games tocomplex databases for clinicians. Apple has the AppStore24 and Blackberry has App World.25

The cost of applications varies depending on their com-plexity. Many helpful applications are free. For instance,the Centers for Disease Control and Prevention (CDC)reader brings current articles on public health matters,flu updates, emergency preparation, and other key topicsto the phone.

Clinicians also can download a variety of applicationsto streamline frequent calculations. Body mass index(BMI) and estimated day of confinement/delivery/birth(EDC/EDD/EDB) calculators are more accurate and easierto read than wheels or tables.26 Another useful program,the Electronic Preventative Services Selector (ePSS)from the Agency for Healthcare Research and Quality(AHRQ),27 allows the input of patient’s age, gender, andrisk factors, and provides a list of appropriate healthscreenings. Epocrates allows clinicians to determine a pa-tient’s medication based on their report of pill color andshape.28 These programs can speed care, eliminate unnec-essary tests, and encourage evidence-based care.23

A growing number of applications also are marketed to-ward health care consumers. There are more than a thousandapplications consumers can use to track or improve theirhealth.24 Patients can download applications to ‘‘time’’ con-tractions or display calories for common convenience foods.Clinicians can refer patients who enjoy this style of healthlearning and participation to these resources but should becareful to prescreen resources for content accuracy.

Clinical reference books are available for reasonableprices and are automatically updated using the network,so unlike books, the information provided is never out-dated. These electronic references also have search fea-tures to find information easily.

Smartphones are brought into a variety of settings andhandled frequently and can be a disease vector. Protectivecoverings, also known as shells or skins, protect the devicefrom damage and facilitate surface disinfection. Deviceswith smooth screens instead of buttons are best for surfacedisinfection.29

Protecting patient information is another priority formobile devices. It is possible to house sensitive data ona smartphone and keep it secure. Options are availableto password-protect phones, and specific applicationsrequire an additional password. In addition, methods areavailable to remotely erase all data if a phone is lost orstolen.

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CONCLUSION

The Internet has moved from just displaying informationto allowing users to interact and manipulate content.Web 2.0 tools have many uses for busy clinicians and offerlow-cost or free ways to market a practice, access currentresources, and work on documents or research. Manyvideo tutorials are available on online that demonstratethese practical and easy tools. While clinicians have tobe careful to safeguard patient confidentiality, these simpletools assist with personal organization, networking, col-laboration, and clinical practice and can be accessed read-ily with mobile handheld devices, such as smartphones, aswell as personal computers.

REFERENCES

1. American College of Obstetricians and Gynecologists. Howto begin using e-mail with your patients. ACOG Today 2009;9.

2. Kane B, Sands D. American Medical Informatics Associationwhite paper: Guidelines for the clinical use of electronic mail withpatients. J Am Med Assoc 1998;5:104–11.

3. LinkedIn Web site. What is LinkedIn: Getting the most fromyour professional network. Available from: www.linkedin.com[Accessed May 5, 2010].

4. Twitter Web site. Twitter 2009. Available from: http://twitter.com/[Accessed January 11, 2010].

5. Facebook Web site. Facebook 2010. Available from: www.facebook.com/[Accessed May 5, 2010]

6. MySpace Web site. MySpace 2010. Available from: www.myspace.com/[Accessed May 5, 2010].

7. Krishna S, Boren SA, Balas EA. Healthcare via cell phones: Asystematic review. Telemed J E Health 2009;15:231–40.

8. Text4BabyWeb site. Text4Baby 2010. Available from: www.text4baby.org/index.html [Accessed April 23, 2010].

9. Raine R, Cartwright M, Richens Y, Mahamed Z, Smith D. Aqualitative study of women’s experiences of communication in an-tenatal care: Identifying areas for action. Matern Child Health J 2009June 25 (Epub ahead of print).

10. American College of Nurse-Midwives. Midwife Connection.American College of Nurse-Midwives, 2010. Available from: http://acnm-midwives.blogspot.com/[Accessed May 5, 2010].

11. Cohen SM. Confessions of a newshound. Information Today2009;26:20.

12. Lamb A, Johnson L. Web feeds delivered to your digital door-step. Teacher Librarian 2009;36:66–70.

13. LeFever L. RSS in plain English. CommonCraft, 2007.Available from: www.youtube.com/watch?v=0klgLsSxGsU [AccessedAugust 18, 2009].

14. Google Web site. Google Alerts: Beta. Google 2009. Availablefrom: www.google.com/alerts [Accessed January 7, 2010].

15. LeFever L. Google Docs in plain English. Available from:www.youtube.com/watch?v=eRqUE6IHTEA [Accessed August25, 2009].

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16. SlideShare Web site. What is SlideShare. Available from:www.slideshare.net/tour [Accessed January 7, 2010].

17. Skype Web site. Use Skype: Get connected. Available from:www.skype.com/intl/en/getconnected/?c=101 [Accessed January7, 2010].

18. Doodle AG Web site. Doodle: Easy scheduling. Availablefrom: www.doodle.com/[Accessed January 6, 2010].

19. American Association of Birth Centers Web site. AABCuniform data set. American Association of Birth Centers, 2007.Available from: www.birthcenters.org/data-collection/features.php [Accessed January 7, 2010].

20. Delicious.com Web site. Social bookmarking. Availablefrom: http://delicious.com/[Accessed April 24, 2010].

21. LeFever L. Social bookmarking in plain English. Common-Craft, 2007. Available from: www.youtube.com/watch?v=x66lV7GOcNU [Accessed August 18, 2009].

22. McLeod RP, Mays MZ. Back to the future: Personal digitalassistants in nursing education. Nurs Clin North Am 2008;43:583–92.

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23. Leon SA, Fontelo P, Green L, Ackerman M, Liu F. Evidence-based medicine among internal medicine residents in a communityhospital program using smart phones. BMC Med Inform Decis Mak2007;7:5–11.

24. Apple Web site. App store. Available from: www.apple.com/downloads[Accessed June 17, 2009]

25. Research in Motion Web site. BlackBerry app world. Avail-able from: http://appworld.blackberry.com/webstore/[AccessedJanuary 10, 2010].

26. Hunter LA. Issues in pregnancy dating: Revisiting the evi-dence. J Midwifery Womens Health 2009;54:184–90.

27. Agency for Healthcare Research and Quality Web site. ePSS:Electronic Preventative Services Selector. Available from: http://epss.ahrq.gov/PDA/index.jsp [Accessed May 5, 2010].

28. Epocrates Web site. Epocrates. Available from: www.epocrates.com/[Accessed May 5, 2010].

29. Center for Global eHealth Innovation. Human factors evaluationof PDAs and smartphones in nursing practice. Toronto: 2009. Avail-able from: www.humanfactors.ca/pda [Accessed May 29, 2010].

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