The Internet has revolutionized the computer and communications world like nothing before. The Internet is at once a world-wide broadcasting capability, a mechanism for information dissemination, and a medium for collaboration and interaction between individuals and their computers without regard for geographic location (Leiner et al., 1997, p. 102). There is no doubt the Internet provided the necessary infrastructure to revolutionize the way scientists and researchers from the worlds of academia, business, and government could share data, interact, and collaborate with each other. But it was not until the introduction of the World Wide Web that “everyday people” without computer programming skills were enabled to reap the benefits of this revolution. The Web not only changed how governments and businesses operate, it has impacted every facet of society—how we work, learn, play, and now, even how we manage our health. In this chapter, there is a brief history of the evolution of the Internet to the Web and now to the Connected Age. There is a specific focus on the use of social media as digital health tools. This is particularly true as we evolve from the Web 2.0 era to the Connected Age where it is not only access and interactions but about establishing relationships. As Sarasohn-Kahn (2008, p. 2) noted, “social media on the Internet are empowering, engaging and educating consumers and providers in healthcare.” In the Connected Age, everything and everyone is interconnected that ultimately will have an impact on how we learn as well as how we receive healthcare. The benefits and challenges related to the growing use of these tools are also discussed. As early as the 1960s, computer scientists began to write about the creation of a network of interconnected computers where scientists could share and analyze data by interacting across the network (Leiner et al., 1997). According to Cerf (1995), “the name ‘Internet’ refers to the global seamless interconnection of networks made possible by the protocols devised in the 1970s through DARPA-sponsored research.” The Internet is defined as “a computer network consisting of a worldwide network of computer networks that use the TCP/IP network protocols to facilitate data transmission and exchange” (http://wordnetweb.princeton.edu/perl/webwn). Over the next decade, various government agencies and companies conducted considerable research to support the advancement of the Internet. It was not until 1985 that a broader community, in particular the academic community beyond the computer scientists, was given access to the Internet. NSF funding for the Internet continued for almost a decade before the Internet was redistributed to regional networks with the eventual move toward interconnecting networks across the globe. As the Internet came to expand, Tim Berners-Lee wrote his seminal paper “Information Management: A proposal” that circulated throughout the European Council for Nuclear Research (CERN) organization. The paper explicated his ideas that using a hypertext system that would allow for storage and retrieval of information in a “web of notes with links (like references) between them is far more useful than a fixed hierarchical system” (Berners-Lee, 1989). In 1990, Berners-Lee’s paper was recirculated and he began development of a global hypertext system that would eventually become the World Wide Web (WWW). As the WWW concept evolved, Marc Andreessen and Eric Bina at the University of Illinois developed a browser called Mosaic that provided a graphical interface for users. This browser is credited with popularizing the Web. It is important to note that although many use the terms Internet and Web synonymously, there are differences between them. While the Internet is the network of interconnected computers across globe, the Web is an application that supports a system of interlinked, hypertexted documents. One uses the Internet to connect to the Web. A Web browser allows the user to view Web pages that contain text, images, and other multimedia. Web 1.0. The Web in its first iteration (Web 1.0) allowed users to access information and knowledge housed on Web pages complete with text, images, and even some multimedia. It was considered a dissemination vehicle that democratized access to information and knowledge. Many in the field designate the time period between 1991 and 2004 as Web 1.0. This was an important era and, as noted by Friedman (2005), the world suddenly became flat—his metaphor for the leveling of the global playing field. The convergence of the personal computer with the world of the Internet and all its services facilitated the flattening. The flattening was particularly powerful in the world of commerce but also exploded in higher education, making it easier for students to access knowledge beyond their own academic campus. For healthcare, it was a time when consumers could then have access to health information and knowledge that was not locked in an academic library or in a distant place. Web 2.0. O’Reilly and Doughtery introduced the term Web 2.0 at a 2004 conference brainstorming session (http://oreilly.com/web2/archive/what-is-web-20.html) about the failures of the dot.com industry. It was apparent that despite the demise of the dot.com industry “the web was more important than ever, with exciting new applications and sites popping up with surprising regularity” (O’Reilly, 2005). There were several key concepts that formed the definition of Web 2.0. First, the Web is viewed as a platform rather than an application. Second, the power of the Web is achieved by harnessing the collective intelligence of the users. A third important principle was that the Web provided rich user experiences. The introduction of Web 2.0 embodies the long history of community spirit of the Internet conceived by its originators. As Leiner et al. (1997, p. 206) noted, “the Internet is as much a collection of communities as a collection of technologies, and its success is largely attributable to satisfying basic community needs as well as utilizing the community effectively to push the infrastructure forward.” The transition from an information dissemination platform to an engaging, customizable, social and media-rich environment epitomizes this next generation of the Web. As Downes (2005) stated, “the Web was shifting from being a medium, in which information was transmitted and consumed, into being a platform, in which content was created, shared, remixed, repurposed, and passed along.” Another important feature was the idea of users interacting and sharing information, ideas, and content. Owen, Grant, Sayers, and Facer (2006) aptly described the transition of the Web, “we have witnessed a renaissance of this idea in the emergence of tools, resources and practices that are seen by many as returning the web to its early potential to facilitate collaboration and social interaction.” Although some have predicted (Berners-Lee, Hendler, & Lassila, 2001) that there will be Web 3.0, known as the Semantic Web, this never materialized as projected. There have been more recent references to such terms as the Internet of Things (IoT) and the Connected Age. Both are fairly similar but there are some distinctions. Ashton (2009) first described the IoT as “a system where the Internet is connected to the physical world via ubiquitous sensors.” In the 2012 Horizon Report (Johnson, Adams, & Cummins, 2012, p. 30), IoT “is the latest evolution of network-aware smart objects that connect the physical world with information.” Skiba (2013, p. 63) noted, “Several attributes are associated with these smart objects; they are small, easy to attach and unobtrusive, contain a unique identifier and data or information, and can connect with an external device on demand (e.g., your smartphone or tablet).” Oblinger (2013) introduced the concept of the Connected Age in higher education. Abel, Brown, and Suess (2013) described the Connected Age as an environment that “offers new ways to connect things that were previously considered disparate and ‘un-connectable’: people, resources, experiences, diverse content, and communities, as well as experts and novices, formal and informal modes, mentors and advisors.” Oblinger (2013, p. 4) further noted, “Connecting is about reaching out and bringing in, about building synergies to create a whole that is greater than the sum of its parts. Connecting is a powerful metaphor. Everyone and everything—people, resources, data, ideas—are interconnected: linked and tagged, tweeted and texted, followed and friended. Anyone can participate.” As noted by Skiba (2014, p. 63), “In higher education, we can think of these as learning pathways, created by the individual or guided by other students or faculty. The bottom line is that learning pathways are about connecting the dots—in the classroom, online, or even with people and places outside the traditional academic environment.” In healthcare, Caulfield & Donnelly (2013) offered a model of Connected Health that “encompasses terms such as wireless, digital, electronic, mobile, and tele-health and refers to a conceptual model for health management where devices, services or interventions are designed around the patient’s needs, and health related data is shared, in such a way that the patient can receive care in the most proactive and efficient manner possible. In this model, patients, caretakers, and providers are ‘connected’ by means of timely sharing and presentation of accurate and pertinent information regarding patient status through smarter use of data, devices, communication platforms and people.” Iglehart (2014, p. 2) concurred that Connected health is “an umbrella term to lessen the confusion over definitions of telemedicine, telehealth and mHealth.” Iglehart (2014) also considered connected health as an emerging disruptive technology that has the potential to transform the healthcare delivery system. Although both terms, IoT and Connected Age, speak to connections to everything and everyone, IoT focuses on those connections with physical objects whereas the Connected Age refers to more virtual connections especially with people, resources, and ideas. Cisco (https://www.cisco.com/c/dam/global/en_my/assets/ciscoinnovate/pdfs/IoE.pdf) considers this the Internet of Everything (IoE) as it represents an “intelligent connection of people, process, data and things.” Skiba et al. (2016) refer to this as Connected Care as the intersection of high tech and high touch (Fig. 47.1). • FIGURE 47.1. The concept of connected care. (From Skiba, D.J. (2016) Nursing & Connected Care: Blending High Touch with High Tech. Faculty Presentation at Florida Atlantic University College of Nursing. Boca Raton, Florida.) It is within the context of the Connected Care that we examine the use of social media as one digital health tool being used to transform healthcare. The increasing use of digital health tools is part of a healthcare revolution. According to Bazzoli (2018), there are six trends that are catalyzing this revolution. The first and probably the most important is the rise of consumerism and patients wanting more control of their health. The growth of nontraditional healthcare delivery systems is another trend. As consumers pay more for their healthcare, there is considerable dissatisfaction with rising healthcare and drug costs. Providers are no longer the gatekeepers to healthcare is the fourth trend. As noted by Sarasohn-Kahn (2018), “The new front door for health/care will be the patient’s home front door.” The increased focus on health, wellness, and preventative care is the fifth trend. The last trend relates to data and technology. As noted by Skiba (2018), “the more data that can be collected and shared, the more likelihood patients can get the right care at the right time and place. The more digital health tools, the more likely the consumer will be able to manage their health.” Other researchers refer to the five disruptors that will revolutionize healthcare: personalized medicine, consumerism, digital revolution, regulatory change, and the Amazon effect (Murphy & Jain, 2018). The “Amazon effect” refers to a consumer-centric organization that provides convenience and availability of services online. Murphy and Jain (May 2018) stated that “among the most important players in the healthcare’s disruption story are patients. After years of contending with limited options regarding where, when, how, and from when they get care, healthcare consumers now have choices. They can pick from a variety of delivery models, including telemedicine, concierge care, and online self-help.” Many believe that it is technology that is the disruptor but according to Manis (2018), the disruption is from consumer-centric organizations that allow more consumer-centric tools. Manis stated, “healthcare customers expect much more than access, quality and affordability. They expect exceptional, retail-like experience: ease of use and immediacy of service, how, when and where it is most convenient for them and not us” (meaning healthcare systems). Manis acknowledged that it is true that many consumer-centric organizations use digital tools, their driving force is exceptional consumer services. This notion is echoed in an AMIA (2017) White Paper in Redefining Our Picture of Health: Towards a Person-Centered Integrated Care, Research, Wellness and Community Ecosystem. In this report, the AMIA notes that over the last few years, new data types and technologies have provided us a more complete picture of an individual’s health. This is spearheaded by the abundance of available patient-generated health data (PGHD). “These trends are converging to deliver a more refined and complete picture of health, where personalized care can deliver treatments tailored to the individual, where a single patient can inform and improve the health of populations, and where the ‘n-of-many’ can be leveraged to better understand the ‘n-of-1’ and vice versa (AMIA, 2017, p. 4).” In the Connected Age, digital tools are primarily associated within the broad context of social media and mobile applications. Each year, We Are Social, a creative social media agency, prepares a global digital yearbook (https://wearesocial.com/global-digital-report-2019). The purpose of their report is to highlight the growth of the Internet and digital tools across countries including developing nations. For 2019, there were 4.338 billion Internet users (57% of the total global population) and 5.112 billion unique mobile users (67% of the global population). They report that the average user spends 6.5 h per day online, of which the greatest portion of that time is using social media tools. Although there has been a steady increase in the number of social media users, there have been some declines in the use of specific social media platforms. The Pew Research Center’s report on Social Media Use in 2018 (Smith & Anderson, 2018) noted that the majority of Americans used Facebook and YouTube but the younger generations gravitate toward Snapchat and Instagram. There has also been an increase in the use of Twitter. To better understand the tools being used in the Connected Age, it is important to define social media. In some cases, social media is used as the broad category that encompasses all of the Web 2.0 tools. Anthony Bradley (2010) in his blog (blogs.gartner.com/anthony_bradley/2010/01/07/anew-definition-of-social-media) offered a new definition, “social media is a set of technologies and channels targeted at forming and enabling a potentially massive community of participants to productively collaborate. … enable collaboration on a much grander scale and support tapping the power of the collective in ways previously unachievable.” According to Bradley (2010), there are six defining characteristics that distinguish social media from other collaboration and communication IT tools. These characteristics are Participation, Collective, Transparency, Independence, Persistence, and Emergence. Participation echoes the “wisdom of the crowds” concept, but note that there is no wisdom if the crowd does not participate. The term collective refers to the idea that people collect or congregate around content to contribute, rather than the way individuals create and distribute content in the Web 1.0 world. Transparency refers to the fact that everyone can see who is contributing and what contributions are made. Independence refers to the anytime, anyplace concept; people can participate regardless of geography or time. Persistence refers to the notion that information or content being exchanged is captured and not lost as in a synchronous chat room. Lastly, “the emergence principle embodies the recognition that you can’t predict, model, design and control all human collaborative interactions and optimize them as you would a fixed business process” (Bradley, 2010). Taken together these characteristics define the new world of social media. Social networking, a major social media platform, embraces many of the defining characteristics of the Connected Age and is a major component of connected care. First, participation and collaboration were two of the principal themes in Web 2.0 (Eysenbach, 2008) and are the driving forces behind the social media movement with continued relevance in the Connected Age. Eysenbach (2008) further noted, “Social networking … involves the explicit modeling of connections between people, forming a complex network of relations, which in turn enables and facilitates collaboration and collaborative filtering processes.” Another aspect of social networking is the ability to share user-generated content in the form of videos, stories, or photographs. In addition to adding and viewing content, consumers can also post comments to media someone else has contributed, thus adding another level of communication to these sites (Skiba, 2007). Of the available digital tools, social networking offers the most opportunity for peer support and consumer engagement. Users can make connections with people that they already know in person or may connect with others through associations that they create (Boyd & Ellison, 2007). Essentially, the social networking site serves as a powerful tool to engage and motivate consumers to share personal information, establish relationships, and communicate with others. With the driving force of consumerism and its use of digital tools, especially smartphones, it is important to examine how healthcare systems can use social media to engage patients in their health and becomes partners in their care. Healthcare institutions and consumers have already begun to capitalize on the limitless utility of social networking. Numerous hospitals and healthcare-related organizations have social networking sites where patients and visitors can explore details about the facility, learn more about available services, and find information about diseases and/or treatments (Sarasohn-Kahn, 2008). Of the available social networking sites, Facebook was considered one of the more popular sites and allowed for resource sharing, communication, and collaboration (Mazman & Usluel, 2010). One institution that was an early adopter of social media in healthcare was the Mayo Clinic. In 2010, the Mayo Clinic Center for Social Media was established and is still promoting the use of social media (https://socialmedia.mayoclinic.org/#).
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Social Media Tools in the Connected Age
INTRODUCTION
HISTORICAL PERSPECTIVE
Internet
World Wide Web
CONNECTED AGE
Social Media Digital Health Tools
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