CME: The increased use — and risks — of social media in a health care setting

Objectives

Upon completion of this educational activity, the learner should be able to:

• identify and remediate the pitfalls for a medical practice using social media;
• describe HIPAA-compliant communication methods for online physician-patient interactions;
• discuss how COVID-19 has affected the physician-patient relationship via increased use of online communications; and
• apply risk management strategies when interacting with the public online.
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Course author

Roxanna Maiberger is a civil litigation attorney with Mayer LLP. She earned her undergraduate and graduate degrees from The University of Texas at Austin. She earned her law degree from St. Mary’s University School of Law in San Antonio. Before attending law school, she worked for Texas Medical Liability Trust as a risk management representative.
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Disclosure

Roxanna Maiberger has no relevant financial relationship(s) with ineligible companies to disclose. TMLT staff, planners, and reviewers have no relevant financial relationship(s) with ineligible companies to disclose.
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Target audience

This 1-hour activity is intended for physicians of all specialties who are interested in learning more about risks associated with communicating online with patients via social media and developing risk management skills to avoid potential liability when interacting with these platforms.
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CME credit statement

The Texas Medical Liability Trust is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
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The Texas Medical Liability Trust designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Ethics credit statement

This course has been designated by TMLT for 1 credit in medical ethics and/or professional responsibility.
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Test

To receive CME credit, physicians should complete the test questions that follow the activity. A passing score of 70% or better earns the physician 1 CME credit.
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Pricing

The following fee will be charged when accessing this CME course online at http://tmlt.inreachce.com.

Policyholders: $10

Non-policyholders: $75
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Instructions

CME test and evaluation forms must be completed online. After reading the article, go to http://tmlt.inreachce.com. Log in using your myPortal account information to take the course. Follow the online instructions to complete the forms and download your certificate. To create a myPortal account, go to www.tmlt.org, click the log in button, and follow the on-screen instructions.
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Release/review date

This activity is released on June 10, 2025 and will expire on June 10, 2028. Please note that this CME activity does not meet TMLT’s discount criteria. Physicians completing this CME activity will not receive a premium discount.

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Introduction: Defining social media

There is no question that social media is here to stay. Yet, questions persist around how intertwined social media should be in our daily — and professional — lives. Social media is often defined through its most popular and ubiquitous platforms: Facebook, LinkedIn, Instagram, and TikTok with more social media platforms seeming to pop up every day.
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But “social media” encompasses more than the traditional platforms used by everyday consumers. Merriam-Webster defines social media broadly as “forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content (such as videos)”. (1)
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This basic definition shows how expansive and potentially wide-ranging social media is,  even extending to the inclusion of online reviews or applications for capturing user data. (2) This broad definition surely encourages positive outcomes through information sharing, but social media is not without its own set of risks.
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Although outside the scope of this article, an important consideration in terms of social media’s increasing presence, is its intersection with “Big Data.” Big Data refers to large databases and the process of analyzing the information stored within these databases. (2) The information captured includes personal data harvested from use of electronic applications, such as fitness tracking applications or retail purchase receipts.
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In terms of health care, Big Data may consist of electronic health record (EHR) data and medical research data. When considering the intersection between physician-patient interactions within such applications as EHR interfaces and online patient reviews, the potential of Big Data exposures triggers HIPAA concerns and highlights the risks associated with the use of social media.
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This article focuses on health care professionals’ use of social media for professional purposes and does not center on their personal use of social media. However, when interacting with social media for personal use, especially if one’s platforms are available for public view, it is important to be aware of the associated safety and medical liability risks. (3)
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Unfortunately, we live in a world where patient dissatisfaction can escalate and become a threat to personal safety. So, it is good risk management practice to adopt the same or similar boundaries that you would use for in-person interactions when interacting online. It is important to approach social media use in terms of a security assessment from a virtual and physical risk assessment standpoint.
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For example, some social media platforms allow you to disable commenting on posts, which can curb unwarranted and unnecessary patient comments. If commenting or posts by patients are allowed on the social media platform, consider assessing the settings that allow individuals to comment or interact with a health care practice social media page. Further, assess your own personal social media security and privacy settings to ensure you are not leaving yourself open to unwanted negative interaction.
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This article emphasizes that the increasing presence of social media and technology is the “new normal” and needs to be faced and managed. This new normal also presents an opportunity for health care professionals to proactively consider all internet-based communication and information sharing when embarking on patient care and managing a health care practice.
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Ultimately, the goal of this article is to provide risk management considerations for health care professionals when facing the increasingly complex realm of social media. This article will discuss the following:

• the intersection of social media with the physician-patient relationship;
• the pitfalls of and the risk management considerations for social media and the physician-patient relationship, including ethical dilemmas, informed decision making, and when to call your professional liability insurer or seek legal advice;
• HIPAA concerns associated with the risks of social media;
• the ongoing impact of COVID-19 and the increased use of telemedicine and social media; and
• future considerations for social media use and the virtual reality for physicians.
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This article will also help you plan ahead and address unanticipated social media and patient interaction concerns. Specifically, we will explore guidelines for creating general policies and procedures on social media for physicians and their staff members.  
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The information in this article should not be used or referred to as a primary legal source. Instead, it is a best practice to consult with your attorney to create policies and procedures that ensures your practice complies with your state’s health care laws and medical board rules.

Social media meets the physician-patient relationship
Social media maintains an ongoing, permanent presence in health care because we live in an “online world.” Specifically, social media intersects health care in:

• physician practice advertisements and promotions;
• communications through EHR systems; and
• the ability of patients to leave their thoughts and/or comments online for public consumption. (4).
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Patients have the right to express their positive feelings or frustrations following an experience with a health care provider or practice. The danger is that these (one-sided) posts often describe events out of context or bypass the nuances of the interaction (i.e. body language, tone of voice, patient history unknown to the public) or of the physician-patient relationship (a long history of patient noncompliance or one of deep trust).  
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There are certainly positive aspects of social media use in health care, such as patient education and increased communication between patients and their respective health care teams. However, the negative experiences of social media often remain top of mind because of the headaches they can cause.
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One negative outcome of social media is that it can contribute significantly to stress and burnout for physicians and other health care professionals. (5) It is undeniable that health care rules and regulations set in motion by the increased presence of social media can seem impossible to comply with, especially for smaller health care practices already stretched thin. (4)
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However, the good news is that with the proper tools and information, many of these social media concerns can be planned for appropriately. (4) Taking the time to think through possible scenarios can lessen the stress caused when a negative interaction between patients and health care professionals occurs. Just as negative interactions may occur with patients in-person, the same is true for interactions with patients online. (6)

Pitfalls and areas of concern
‍Although the definition for social media technically could include patient and health care professional interactions and/or communications within a practice’s respective EHR system, the main focus of these interactions center on the pitfalls stemming from public-facing social media channels. This typically manifests itself in the form of a patient leaving a negative comment or feedback in an online review. (6)
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As previously discussed, social media is an important tool for health care professionals as they progress through their careers. Notably, the use of social media to promote health care practices cuts both ways, because an overwhelming majority of patients likely consult online reviews before choosing a physician and/or heath care professional to meet. (6) As a result, a negative review may carry significant weight to a health care professional’s reputation, especially for residents and physicians beginning their careers. This creates a vulnerable situation for physicians because it, understandably, places them in the defensive position of protecting and maintaining their reputations. (6)
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However, it is important to point out that one bad review, while possibly a temporary setback, is unlikely to tarnish one’s medical career long term. Perspective is key here. Most people look at the totality of online reviews when choosing a health care professional and may even take a few negative comments with a grain of salt. (7)
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Many patients don’t look at online reviews or comments at all. A recent study from the Journal of Patient Experience shows that patients give more credence to recommendations from family or friends (55 percent “important” vs. 36 percent “not important”) than to online reviews (43 percent “important” vs. 47 percent “not important”) when seeking a physician. (8)
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Also, it is important to consider that according to research, 50 percent of negative online reviews left by patients stem from “poor communication.” (6) Poor communication is introduced in quotes because this complaint can be hard to define and could cover a host of scenarios. “Poor communication” is a subjective phrase, and will undoubtedly mean something different to each patient. Another subjective reason could be “poor staff interactions.” This could refer to anything from not getting a preferred appointment time to perceived rudeness from a receptionist.  
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When coming across negative online reviews for you or your practice, it is important to first pause and to not respond. (6) Treat it as you would treat an email from an angry or frustrated patient. Walk away and give yourself time to think about a warranted response, if any. Consider the following in managing a negative online review.
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Though it is frustrating for physicians, patients are entitled to share their feedback online. (6) Accepting this reality opens the opportunity for health care professionals to focus on handling and mitigating the impacts of a negative review as opposed to being stuck on whether it’s fundamentally fair or not.
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An equally important consideration is to be honest and assess whether there is any truth or validity to the patient’s comments. Although this may be uncomfortable, thinking this through can serve as a critical strategy in mitigating the aftermath of a negative online patient review. (7)
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Assessing the validity of a patient’s comments may lead to a re-evaluation of systems in place for a health care practice. Rather than allowing the patient’s negative comment to serve as an indicator of being right or wrong, let it serve as a check and balance to the overall functioning of practice systems. It could create an opportunity for change, even if it is uncomfortable in the moment.
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When deciding how to respond to an online comment or post, the most critical consideration is to maintain patient privacy and HIPAA compliance. (Because of HIPAA’s importance and complexity, it is discussed at length in the next section.) The best practice is to avoid responding. However, consider the possibility of seeking clarity from the patient through private (offline) one-on-one communication.  
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If the patient is identifiable, seeking an individualized, non-public, one-on-one interaction with the frustrated patient will likely de-escalate the situation. Even if the patient is frustrated, they will likely remember a physician, health care provider, or a member of the health care team who picked up the phone and tried to understand their frustration and find a solution to prevent it in the future to the extent it is feasible. This action removes most HIPAA concerns about direct responses to the patient’s online comment.
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Should a health care professional choose to reach out to a patient, avoid making excuses or blaming the patient. Instead, take ownership of the situation that created the patient’s frustration. From a risk management perspective, this can allow the patient to feel heard, understood, and validated. Listening to understand as opposed to listening to be right about the situation will likely lead to a more productive dialogue. It is also inappropriate to ask a patient to remove their negative online comment. (6)
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If the patient’s comment alludes to an ongoing medical emergency, it may become necessary to call the patient and direct them to emergency health services or to call 911. Document these efforts accordingly.
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HIPAA and social media
Significant privacy protections for patients were added after passage of HIPAA. (9) The act was also passed partly in response to technology advancement and the potential “erosion” of health information privacy. (9) Although well intended, the application of HIPAA’s privacy rule undoubtedly complicates day-to-day activities for physicians and staff. For example, even corresponding with another member of the health care team about a patient’s care is under the microscope to ensure the interactions were “HIPAA compliant.”
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Even then, assessing whether a communication platform is truly “HIPAA compliant” raises questions outside the scope of this article. When issues arise related to HIPAA and the use of protected health information (PHI), reach out to your medical professional liability insurance insurer, your state’s medical association, and/or your health care attorney for guidance.
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Because HIPAA consists of federal rules and regulations, state law may vary from the HIPAA rules and regulations. In some instances, state laws governing patient privacy and data may have even more stringent requirements.
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In the event a health care professional chooses to respond publicly to a patient’s online comment, whether it be a negative or positive comment, each response should use a general, uniform statement as a means of ensuring HIPAA compliance. For instance, general statements could be:

• “Thank you for your comment. We value feedback. Due to patient privacy regulations, we cannot discuss details mentioned in your comment. If you are a patient, please contact our office at [insert your office’s contact information] to discuss this further should you have additional comments or suggestions.”
• “In order to protect our patients’ privacy, all patient concerns and complaints are resolved directly by our practice and not through social media. If you are a patient, please contact us at [office contact information]. Thank you.”
• “Thank you for your comment. At our medical practice, we strive to provide the highest levels of patient satisfaction. Due to federal privacy laws, it is not the policy of [insert practice name] to substantively respond to negative reviews on ratings websites. If you are a patient and have a concern, please contact us at [phone number].” (10)
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These uniform responses can help you plan ahead if and when a patient leaves a negative comment on a social media page. When planning these uniform responses, the response from a health care professional should always be respectful. It is also good practice to thank them for their feedback. Additionally, if you are ever unsure whether a comment complies with HIPAA, it is best to consult your health care attorney.
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The response should never allude to or state that the patient received care from the physician, health care professional, or practice, as this reveals PHI. Lastly, the comment should include contact information so the patient can speak with the health care practice directly. This effectively provides the patient a way to voice their complaints without expressly identifying them as a patient of the health care practice. (7).
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Remember that HIPAA is not a two-way street. While a patient can state publicly that they are a patient of the physician or health care practice, the physician or health care practice cannot do the same in return. Doing so is a HIPAA violation. (7) Further, health care practices are required to provide HIPAA training to all staff.
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Consider these general guidelines when responding to a patient’s online comment.

• When in doubt, do not respond.
• Consider whether a general online response is even warranted — specifically, consider whether a response may be better received by the patient offline. 
• f you feel strongly that you must respond online, keep any response general and non-specific. Provide information for the patient to call the office if they so choose.
• Never disclose any of the patient’s information or acknowledge that they are a patient of your practice.
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In the event of an alleged HIPAA violation, it is important to immediately contact your medical professional liability insurance insurer, as they may have resources to help you navigate the reporting requirements and associated bureaucracy.
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Moreover, because state laws vary, keep in mind that HIPAA violations may have different implications in the event of a lawsuit by a patient affected by the wrongful disclosures of information. Certain state laws may even vary by certain medical conditions. In addition to varying rules by state, within each state, certain courts may vary in their interpretation of the rules. This highlights the importance of consulting an attorney who is well-versed in HIPAA compliance and state-based patient privacy laws. (11)
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The complexity of HIPAA and state-based patient privacy laws supports the recommendation to proactively and consistently train health care staff and consider the supervisory protocols for the practice. In addition, privacy and security protocols are required by federal law. These protocols should be clear and understandable. It is more than simply drafting protocols once and never reviewing them again. At a minimum, the protocols should be reviewed annually and updated in accordance with the health care practice’s growth and changes over time.
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Additionally, working with your EHR and/or IT vendors to better understand how your patients’ data is being used could be beneficial and provide an increased sense of control over your practice’s electronic resources and assets. It may be beneficial to speak with your medical professional liability insurer to understand its expectations and steps to take in the event of a data breach.  Certain notification timelines may apply to ensure you are covered or qualify for assistance in remedying the breach.
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Examples of data breaches for PHI in the context of social media could be:

• responding to an online review with specific information that identifies the writer as a patient;
• posting photos to a practice website without the patient’s consent that includes potentially identifying information, such as a patient’s face, tattoos, or other unique physical identifier. If a patient consents to posting of photos on a website or social media, written consent should be obtained after review by the patient of each specific photo to be posted;
• posting photos to a practice website in which the metadata (12) has not been properly removed, resulting in the file name identifying the patient’s information when hovering a cursor over the image (please see case study below); and
• improperly disposing of PHI (i.e. throwing papers with PHI in a trash can without properly shredding the documents). (13)
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The following case study illustrates how a patient’s PHI was breached online
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Case study — Patient identified on surgeon’s website
A plastic surgeon’s website featured “before and after” photos of patients. The patients’ consent to post photographs was obtained, names were not used, and the photos were posted in a way that preserved patient anonymity.

However, unknown to the plastic surgeon and his staff, the patients’ names had not been properly removed from the meta tags associated with the photos. Meta tags are content descriptors that describe web page content to search engines. Meta tags do not appear on the page, but are found in the HTML code for the page.
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The issue was discovered when a patient performed a Google search on herself and her images from the plastic surgeon’s site appeared in the search results. Although he was told about the meta tag issue, the plastic surgeon did not immediately remove the photos.
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Fifteen patients filed lawsuits against the plastic surgeon. The Office of Civil Rights also investigated the plastic surgeon for possible HIPAA violations.
 

Risk management considerations

• Obtain written patient consent to take photographs. Specify how you plan to use the photos (i.e. medical records only, marketing, website, journal article) on the consent form. Have the patient review and approve the specific photos to be posted prior to signing the consent form.
• Do not name or save photo files with any of the identifiable information (described below) in any publicly accessible area. (Clearly, if you are just adding photos to medical records, they can contain identification.)
• Audit photos that have been added to your website. Check the site page for tags, meta tags, alt text, keywords, or anything that could be used to identify patients.
• Do not store photos of patients in an unencrypted device, such as a camera, cell phone, tablet, or personal laptop.

When it comes to publishing patient photos, certain HIPAA requirements must be met. If patient photos are completely de-identified, HIPAA requirements are satisfied. If patient photos are not de-identified, written authorization from the patient is required to post or share the photos. From a risk management standpoint, specific written authorization/consent is recommended for any posting of patient photographs.

The increased online presence for physicians in a post-COVID world
The COVID-19 pandemic fundamentally changed how people communicate because it required an increase in the use of virtual technology and the need for remote work. For physicians, COVID-19 solidified the increased need and use of telemedicine almost overnight. This led to the need to build an online presence, including social media. (14)

From HIPAA compliance and risk management perspectives, telemedicine further complicate patient privacy concerns.

The presence of virtual health visits and the general population’s reliance on telehealth technology persists. The “option” to communicate through online platforms or social media remains an acceptable alternative form of communication for many. This increases the need for physicians to be aware of the implications and pitfalls of online interactions to promote and advertise health care practices; using social media for health care educational means; and more.

In sum, increased presence means increased risk.

To be better prepared for this increased risk, it is important to accept the reality that technology will continue to progress faster than regulations and legislation will keep up. (2)

Effective planning requires anticipation of the risks and pitfalls of social media use discussed previously and promotes intentional and informed decision making. This planning can include the following items.

• Use state-based resources. For example, the Texas Medical Association (TMA) provides a wide array of resources from sample policies to useful articles to help you prepare your practice for HIPAA compliance and protect PHI. Consult your state medical association to inquire about the resources available to you.
• Consult with your health care liability insurer, as it may provide HIPAA consultation services or risk management resources.
• Remember that there is no need to reinvent the wheel when it comes to creating policies and procedures. There are numerous resources available with pre-templated policies. However, it is important to take the extra step of customizing these templates to suit the needs of your individual practice. Simply purchasing templated policies and keeping an electronic copy in your drive or placing them on your office shelf is not sufficient. It is critical you develop your policies into identifiable and verifiable action.
• Provide your patients with information on these topics. This may start with your patient intake forms and ensuring you have the proper Notice of Privacy Practices and other required information when it comes to PHI. Educating patients from the outset not only protects you, but it also sets expectations with your patients about the physician-patient relationship. Additionally, sharing this information encourages further communication with your patients and may prevent them from feeling unheard and without a sense of recourse — potentially eliminating a motive for negative online comments.
• Most importantly, remember that most situations can be resolved with intentional and thoughtful offline communication.

Personal social media use|
When it comes to personal social media use, it is important for physicians to remember that their online presence will never be completely personal or private. Patients, patients’ family members, or others in the community may conduct online searches to find out more about you, your role at work, or your friends and family.

When posting on social media platforms using your personal account, never disclose trade secrets, intellectual property, or other confidential information about your practice, organization, or yourself. If you comment online in support of your organization, including its products or services, be sure to clearly disclose your relationship with the organization. (15)

It is also important to consider not accepting “friend requests” on social media platforms from patients. If you do, you risk losing appropriate professional boundaries with patients. Also, if your professional relationship becomes unwittingly disclosed on social media, your patient’s privacy may be compromised, and you could be in violation of HIPAA. Although some shared banter on mutual interests can help build rapport between physicians and patients, excessive self-disclosure is unlikely to help in the clinical setting. Such disclosures could lead to boundary violations, legal, sexual, or otherwise. (16) The big takeaway is that the use of social media to communicate with patients can be a slippery slope.

In addition, make it a practice not to accept friend requests from anyone that you do not know personally, including friends of friends. When a friend request is accepted — unless privacy settings are specifically adjusted to restrict access — that person can view all your personal information, familiarizing themselves with your nearest friends, family members, and associates. (15) From a risk management perspective, consider reviewing your privacy and security settings regularly to ensure the settings are appropriate.


‍Conclusion
Social media is here to stay — as is its intersection with health care practices and health care professionals. Although there are several positive aspects of social media in health care, there are also some potential pitfalls.  

These pitfalls primarily involve ensuring HIPAA compliance; state-based patient privacy laws; and wrongful disclosure of PHI. As a way to avoid these pitfalls, be proactive and plan for these scenarios.  

Effective planning consists of consulting state-based medical association resources, your medical professional liability insurer, and/or your health care attorney. Most importantly, personal communications with patients offline may be the best way to resolve patient complaints, prevent future ones, and protect against HIPAA compliance issues.
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Sources and notes

1. Social Media, Merriam Webster Dictionary online. Available at https://www.merriam-webster.com/dictionary/social%20media. Accessed May 2, 2025.
2. Parker DM, Pine SG, Ernst ZW. Privacy and Informed Consent for Research in the Age of Big Data. Penn State Law Review. Volume 123, Article 4. Spring 2019. Available at https://elibrary.law.psu.edu/pslr/vol123/iss3/4/. Accessed May 2, 2025.
3. Chipidza F, Wallwork RS, Adams TN, Stern TA. Evaluation and Treatment of the Angry Patient. Primary Care Companion for CNS Disorders. June 2016. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC5035812/.  Accessed May 2, 2025.
4. Gosfield AG, Shay DF. The physician’s electronic reality. Health Law Practice Guide § 38:9. March 2025 update. American Health Lawyers Association.
5. Singh R, Volner K, Marlowe D. Provider Burnout. Updated June 12, 2023. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. S025. Available at https://www.ncbi.nlm.nih.gov/books/NBK538330/. Accessed May 2, 2025.
6. Physician’s Weekly. How physicians can safely respond to negative online review. June 21, 2024. Available at https://www.physiciansweekly.com/how-physicians-can-safely-respond-to-negative-online-reviews/. Accessed May 2, 2025.
7. American Medical Association. Are physicians prohibited from responding to online patient reviews? April 26, 2022. Available at https://www.ama-assn.org/practice-management/hipaa/are-physicians-prohibited-responding-online-patient-reviews. Accessed May 2, 2025.
8. Kozikowski A, Morton-Rias D, Mauldin S, et. Al. Choosing a Provider: What Factors Matter Most to Consumers and Patients? Journal of Patient Experience. January 19, 2022. Available at https://pmc.ncbi.nlm.nih.gov/articles/PMC8785326/. Accessed May 14, 2025.
9. Tucci E. #NoFilter: A critical look at physicians sharing patient information on social media. Indiana Health Law Review. Volume 16. No 2. 2019. Available at https://journals.indianapolis.iu.edu/index.php/ihlr/article/view/23322/22619. Accessed on May 2, 2025.
10. Responding to online patient complaints. Texas Medical Liability Trust. Available at https://www.tmlt.org/articles/responding-to-online-patient-complaints-2. Accessed May 14, 2025.
11. Sanson CK. Cause of action against physician or other health care practitioner for wrongful disclosure of confidential patient information. Causes of Action Second Series. March 2025 updated. Clark Boardman Callaghan, publisher.
12. Metadata is information within a data point or data set that reveals information about authors, the creation of the data, or the file size. This can be found in items such as digital photos, documents, and other types of data being shared electronically. IBM. What is metadata? September 2024. Available at https://www.ibm.com/think/topics/metadata. Accessed May 13, 2025.
13. HIPAA Privacy Rule. Department of Health and Human Services. National Institutes of Health. Available at https://privacyruleandresearch.nih.gov/pr_08.asp. Accessed May 2, 2025.
14. Fowler LR. COVID-19 & the myth of health data privacy. Kansas Journal of Law & Public Policy. Summer 2022.
15. Social media and cyber risk management. Texas Medical Liability Trust. Available at https://www.tmlt.org/resource/social-media-and-cyber-risk-management. Accessed May 14, 2025.
16. Chang Chretian K. Should I Be “Friends” with My Patients on Social Networking Web Sites? American Family Physician. July 1, 2011. Available at https://www.aafp.org/pubs/afp/issues/2011/0701/p105.html. Accessed May 14, 2025.