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peer review

The social Media Revolution

CHERYL DuBOsE, Eds, R.T.(R)(MR)(CT)(QM)
Background The growing popularity and use of social media tools such as Facebook, YouTube, Twitter, blogging, and wikis have led

to a social media revolution. Given this widespread influence, it is important for educators, administrators, and technologists to understand the risks of using social media in the classroom and workplace. Objective To investigate popular social media sites and their effect on radiologic technology education and business practices. Method A comprehensive search of literature was performed to examine social media and its applications in education, health care, and business. results Social media use is on the rise, affecting all aspects of mainstream society. Leaders in the radiologic sciences should be familiar with social media and cognizant of its risks. Conclusion Future studies regarding social media use in the radiologic sciences are necessary to determine its effect on the radiologic science community.

he world has progressed beyond the marvels of the cordless telephone and pager, and we now enjoy instant communication and feedback via the Internet, smartphones, and other wireless technologies. The growing user participation in these technologies has led to an explosion in Web-based user-generated content that has been termed the social media revolution. Social media websites such as Facebook (Palo Alto, California), MySpace (Specific Media, Los Angeles, California), and Twitter (San Francisco, California) allow individuals to share information about any topic at any time, and wikis and blogs promote ongoing information sharing within interested user communities. Web cameras and audio/ video computer applications, such as Skype (Microsoft, Redmond, Washington) and Ventrilo (Flagship Industries, Inc, Vancouver, British Columbia, Canada), enable face-to-face communication via the Internet. Video websites such as YouTube (San Bruno, California) provide a platform where individuals can share their digital videos instantly with anyone in the world. The proliferation in the number of social media websites and users is viewed by many as a boon to society. For others, the ease of information access and sharing is a concern. Modern technology has ushered in an age of instant information and gratification, and profound effects have been seen in business, health care, and education environments. Thus, educators, administrators,
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and radiologic technologists should be aware of the risks associated with social media use before deciding whether to incorporate social media into classroom curricula or work environments. This comprehensive literature review provides an overview of the history of social media, examines the most popular social media sites today, and explores how social media is used in the classroom and workplace. It is hoped that this information will help educators, administrators, and radiologic technologists make more informed decisions regarding best practices when using social media.

Literature review
Social media networking would not be possible without the evolution of the original Bulletin Board System, a dial-up computer system that allowed users to exchange information such as software, text files, and news. The system was developed in the 1970s and is considered the precursor to the Web. Although the information exchange was slow by todays standards, the system marked the beginning of the social media revolution.1 According to Kaplan and Haenlein, social media is a collection of Internet-based applications that build on the ideological and technological foundations of Web 2.0 and allow the creation and exchange of usergenerated content.1 However, to truly understand the definition of social media, individuals must be aware

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of 2 related terms that make it possible for social media to exist. The terms Web 2.0 and user-generated content are typically used synonymously regarding social media, but they are not a part of social media. Although the Web originated with Web 1.0, Web 2.0 is not a technical update of Web 1.0; rather, it is a set of basic functionalities necessary for many social media websites to survive.1 Web 2.0 components necessary for social media functionality include Adobe Flash Player (Adobe Systems Inc, San Jose, California), Really Simple Syndication (RSS), and asynchronous JavaScript and XML (AJAX). Adobe Flash Player is a program that plays animations and audio/video streams and allows interactivity. RSS enables users to publish frequently updated works (eg, blogs) in a standardized format. AJAX is a technique to retrieve data from Web servers without interfering with the display and behavior of the page. Social media also requires user-generated content, the sum of all the ways people use social media. Content must meet 3 criteria to be considered usergenerated: It must be published on a publicly accessible website or social networking site accessible to a selected group of people. It must show a certain amount of creative effort. It must have been created outside of professional routines and practices.1 The social media revolution may be described as a time when we get as much information from each other as we do from media.2 The most significant strides in information sharing have been achieved in the past decade, leading to the development of numerous innovative websites and social media applications. Called the new norm, conversation mechanisms have evolved from 1-to-1 (phone call) to 1-to-many or many-to-many (eg, blogs, Facebook walls, and tweets).3 This rapid exchange of information affects society on many different levels and in many different environments, including education, health care, and business. A variety of social media websites are finding their way into traditional settings, and the outcomes are surprising.

Foundation Inc, San Francisco, California), WikiLeaks (The Sunshine Press), Skype, and Ventrilo. The following key search terms were used in various combinations: social media revolution, social media, socionomics, Twitter, Facebook, MySpace, Skype, Ventrilo, YouTube, HIPAA, FERPA, and social networking. The literature review was limited to articles published within the past 5 years because of rapid advancements in social media and social networking and was further limited to studies or scholarly papers related to the use or presence of social media in education, health care, and business. Of the articles found, 19 were deemed appropriate.

results
The ease of contact and the ability to connect with friends over many miles and after many years has led to the popularity of social networking websites. Social networking appeals to many personality types and has been described as an essential component for todays youth. In an article by Neal, students remarked that social networking websites allow them to be left alone and to connect with others simultaneously.4 The appearance of social networking websites MySpace and Facebook, launched in 2003 and 2004, respectively, led to the moniker social media. MySpace allows users to create a personal Web page within the software application and individualize their page with various backgrounds and links to photos and music. Friends may visit a persons MySpace page and leave messages. Similar to MySpace, Facebook allows users to create an individual page, post a profile, offer likes on posts, and comment on events in their everyday life. According to the latest statistics, Facebook has more than 800 million followers, and 50% of active users log into Facebook daily.5 MySpace also saw comparable growth. In 2007, MySpace had more U.S. Web users than Google (Mountain View California).6 MySpace and Facebook users frequently post videos or links to videos hosted on the website YouTube. Developed in 2005 by former PayPal (eBay, San Jose, California) employees, YouTube hosts numerous videos ranging from family reunion footage to news-driven media and important consumer updates. Berg stated that approximately 20 hours of new material is downloaded to YouTube every minute.7 The popularity of social media literally has no boundaries. In fact, up to three-fourths of YouTube participants are predominantly outside the United States, indicating that social media is a global phenomenon.7
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Methods
A search of the literature was conducted using the research database EBSCOhost (EBSCO Publishing, Ipswich, Massachusetts). A separate search yielded the most recent statistics and usage rules and regulations from social media websites and platforms, including MySpace, Facebook, Twitter, Wikipedia (Wikimedia

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Adding to global communication is the instant messaging phenomenon of Twitter. Twitter is an Internet-based social media tool that allows users to share thoughts throughout the day with members of a group.8 Users tweet messages to members of their social group and can search for tweets by entering specific key words or phrases. Hashtags (eg, #radiology) can be added to tweets to help individuals interested in a topic find and participate in the discussion. Similar to a blog post, tweets are intended to reach several people at once, are limited to 140 characters,3 and are accessible from a device with Internet capabilities. Wikis and blogs are changing the world of news media and information sharing. Launched in 2001, Wikipedia is an online encyclopedia that allows users to collaboratively edit content.2 Individuals are allowed to contribute, review, and revise entries, but businesses are excluded from this online community.1 Individuals can peruse the extensive library of facts and discover information beyond that recorded in a published text. For example, someone interested in the toy company Hasbro (Pawtucket, Rhode Island) can find information not only about the history and founders but also about the recalls of a poorly designed Easy Bake Oven door.1,9 Another wiki receiving recent media attention is WikiLeaks, a nonprofit media organization established in 2007 that publishes original source material reported by investigative journalists.10 The advantage of posting, editing, and revising wikis and blogs is also its disadvantage; material in wikis and blogs may be posted and edited by anyone who believes he or she has useful information. Thus, information in wikis or blogs should be verified prior to academic or personal use. Audio/Visual Stimulation Powered by voice-over Internet protocol technology, Skype and Ventrilo are personal computer (PC)based programs that enable voice and video communication over the Internet. Developed in 2003, Skype allows PC-to-PC, PC-to-landline, PC-to-mobile device, and mobile-to-mobile interactions. Skype can be used for voice or video calls and instant messaging, and it has the capability of recording conversations for later reference.11 One of the most popular aspects of Skype is that it is free, as long as the communication is from 1 Skype user to another, and Skype videoconferencing allows up to 25 participants at a time.12 PC-to-landline and PC-to-mobile phone communication entails a connection fee and charges per minute.
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Ventrilo is another PC-based communications software package. Although not as versatile as Skype, Ventrilo is still widely popular with the public especially with role-playing gamers. The Ventrilo download is free, but users must purchase an account before they can communicate with friends and family. Accounts may accommodate up to 400 individuals; however, as the number of potential connections rise, so does the cost.13,14 Applications of Social Media According to a 2008 survey by the Pew Internet & American Life Project, 35% of adults have a profile on a social media website.3 The popularity of social media among adults has prompted businesses to use social media websites as marketing tools to increase visibility and sales. Health care also is entering the social media frenzy, with the goal to improve overall communication between caregivers and patients.3 Education, too, is quickly assessing and implementing the advantages of virtual worlds, simulations, and audio capabilities now available through social media companies.11
Business Marketing

Social media is of great interest to established businesses and new business ventures. Although social media platforms provide excellent opportunities for marketing and growth, businesses are discovering they have less control over information about their products.1,15 For businesses following the ideology of integrated marketing communications (IMC), this lack of control is concerning. The goal of IMC is to maintain a unified customer-focused message by controlling promotional elements (ie, advertising, public relations, and sales).16 The rapid exchange of negative and positive information on various social media websites requires companies to update IMC paradigms developed nearly 100 years ago. The business world refers to social media as consumer-generated media.16 Some businesses, including health care and educational institutions, have MySpace and Facebook profiles to increase visibility and recruit new customers to their patron lists. Twitter and blogs are used to send promotional offers and news to interested customers, and they allow customers to communicate with each other. This extension of the traditional word-of-mouth approach is gaining in popularity. By offering consumers a forum to complain, businesses may control negative publicity. If a business is notified of a complaint quickly, then

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rectification of the problem may begin before the news spreads and causes a major loss in revenue. According to current business dogma, a dissatisfied customer tells not 10 people, but 10 million. Of course, satisfied customers also have major marketing power.16
Patient Care

The benefits of social media are seen not only in business practice, but also in health care business. Hello Health (Brooklyn, New York) offers a unique spin on the traditional practice of medicine. Patients can follow the activities of the organizations physicians via Facebook. E-mail, instant messaging, and video chat are available on the companys website, where patients can participate in a cyber visit, which may be free or cost up to $100 (depending on the time commitment). Clinical office visits are still scheduled, but most patients seem content to remain a cyber patient for a mere $35 a month, which includes getting answers to most basic clinical questions and receiving generic prescriptions. Hello Health has done so well that a second office opened in Manhattan, New York, a year after the opening of the Brooklyn office. Hello Health plans to share the information platform with physicians across the country for a modest percentage of their fees.3 Hello Health is not an anomaly in health care. Patients and physicians across the country use social media websites to communicate about diseases and treatments. My Health Manager (Kaiser Permanente, San Francisco, California) allows patients to read physician-authored blogs a digital diary used for sharing news, commentary, and about their experiences. PatientsLikeMe (Cambridge, Massachusetts) is a social media platform that allows individuals with similar diseases to communicate and compare health care options and outcomes. Sermo (Cambridge, Massachusetts) is an online physician community where doctors can share insights about medicine and specific cases or diseases.3
Health Care Communities

educators use Twitter in the classroom, asking students to post comments and questions to the website weekly. From this, discussions are held and assessments made. During a nursing conference, attendees were encouraged to use Twitter throughout the 3-day weekend. The result was a conference-wide discussion. For individuals interested in nursing, at least 5 Twitter feeds are available.7 The health care community is embracing the enormous potential of Twitter and other social media websites to stay connected and enhance professional knowledge and overall patient care.
Education

As the use of social media becomes the norm, students become more adept and comfortable with communicating thoughts and ideas through the written word. This comfort level paves the way for increasing educational benefits through various collaborative techniques. The increasing availability and use of technology has allowed online education and hybrid courses (ie, classroom courses with an online component) to experience tremendous growth in recent years. Termed the Silent Revolution by London and Draper, the use of emerging technologies such as simulations, virtual environments, digital libraries, and personal intelligent tutors (computer-based interactive tutorial programs) allow students to reach higher levels of academic achievement at less cost.17 Electronic learning, also known as e-learning, provides online collaboration and access to reusable and sharable resources.18 Although e-learning may be described as missing the audio/visual and interactive experiences of the classroom, modern technology and social media are drastically changing this perception.
Simulated Work Environments

Radiologic technologists, nurses, and other health care professionals use Twitter to connect to their professional community and to stay abreast of current topics. Accreditation organizations such as the Joint Commission on Accreditation of Hospitals and Organizations regularly tweet about policy changes and other items of interest to followers. Twitter was used during the 2010 earthquake disaster in Haiti for people to stay abreast of health care needs. Some nurses tweet about clinical best practices, and health care

Technology is expensive, and some educational institutions are finding creative ways to pay for it. Mesalands Community College in Tucumcari, New Mexico, has formed a partnership with Sandia National Laboratories (Albuquerque, New Mexico) to develop wind energy technology. This collaboration has not only supplemented the curriculum with real-time, hands-on training, but also has encouraged voters to approve $7 million toward the development of a new building with multimedia simulation capabilities.19 These simulations and collaborations give students the chance to experience building wind turbines valuable knowledge difficult to achieve by field experience alone. One of the primary advantages of
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using simulated work environments is that it provides a low-stress transition into real-world work.17 Another example of incorporating simulation equipment into the curriculum is the recent implementation of magnetic resonance (MR) imaging software at Arkansas State University (Jonesboro, Arkansas). Although purchasing and maintaining an MR scanner is outside the current fiscal budget, supplying simulation equipment for students to use in the classroom provides students with hands-on software manipulation prior to entering clinical rotation. Familiarity with the software gives students the opportunity to ask university faculty questions and appears to improve students confidence.20
Informal Education

Although Twitter, simulation equipment, and group communications are being integrated into formal education, it is important to recognize what is being called the informal learning of digital networks.21 According to Freishtat and Sandlin, students who use Facebook experience learning activities within a modernist mediafacilitated public pedagogy. Facebook creates norms and expectations of digital behavior, lulling students to conform to a predetermined culture that reduces individuality and promotes consumer conformity.21 Social Media Concerns
Liability

of inappropriate social media use by implementing social media policies and procedures. Arkansas State University drafted social networking guidelines that explain in detail what the university considers to be appropriate use of online social networks.24 The guidelines specify official use of social networking websites, use of university logos and images, and the intended audiences for posted messages. Employees of Arkansas State University are encouraged to check spelling and grammar prior to publishing messages on social networking sites. Scripps Health, which manages 4 hospitals in San Diego, California, has an unofficial social media policy that advises users to attempt new things, be nice, and dont say anything that the health systems legal department would object to.15 According to the Scripps Health Web technology director, the easiest method for hospital organizations to avoid trouble is to stay clear of anything clinical in nature.
Consumer Privacy

Social media is debated in law classes and courtrooms, and many of these debates address issues of privacy, Facebook, and employment. Individuals across the country have been fired for offensive comments made on their Facebook pages. Reasons for termination range from criticisms against a supervisor to the approval of a rival companys Facebook page. Whether these reasons for termination are legal remains to be seen. The National Labors Relations Board (NLRB) recently filed a suit in the defense of an ambulance company employee who was fired after posting negative comments about a supervisor on her Facebook page. According to the board, criticisms on social networking websites are protected activity and are not considered a legal firing offense.22 In February 2011, the NLRB negotiated a settlement with the employer. Although the settlement results are unknown, social media users should be cognizant of the risks of posting debasing or defamatory comments on any social media platform.23 Many organizations and educational institutions have started to address the potential dangers
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As more individuals participate in social media venues, the risk of information being compromised rises exponentially. The use of electronic medical and educational records by health care organizations and educational institutions has led to regulations that protect consumer privacy. The Health Insurance Portability and Accountability Act (HIPAA) is designed to protect the confidentiality of a patients medical records, and the Family Educational Rights and Privacy Act (FERPA) is designed to protect the confidentiality of a students educational records. HIPAA compliance is a concern for employees and physicians of any health care organization. Discussing a patient or providing enough descriptors to identify a patient to any individual not directly involved in the patients care is in direct violation of HIPAA regulations. The widespread acceptance of social media use provides multiple opportunities to break this medical confidence. Not only should confidential information remain estranged from MySpace or Facebook pages, but care should be taken when using e-mail, Twitter, or instant messaging. According to Dinh, encryption usually is not enabled on instant messaging devices. Therefore, transmissions can be intercepted easily, leading to breaches, inappropriate disclosures, and medical identity theft.25 Similar to HIPAA, FERPA is designed to protect the privacy of student records, including the entire student file, electronic and paper. The distribution of student information by educational institutions is

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strictly monitored with few identifiers available for public view. Once again, caution should be used regarding the combination of social media and any type of student records. Comments regarding a students grades, activities, or any other information that could make it easy to find or contact the student should be avoided. Directory information, however, generally is not considered harmful or an invasion of privacy if disclosed.26
Educator Training

It is widely held that current generations are technologically savvy, but what about their educators? Instructors must be technologically proficient and must learn to incorporate this technology into the classroom in a way that maximizes learning.18 Many teachers realize the new social media platforms have surpassed their current proficiency and comfort levels. Some companies are making an effort to help teachers implement social media in the classroom. For example, Google sponsors the Google Geo Teachers Institute, a free seminar designed to teach educators how to use its various social media platforms in the classroom.27 As instructors become familiar with technology and social media options, student learning outcomes and student satisfaction can improve. The Power of Social Media Some authors suggest the emergence of social media may create an environment and generation ripe for checking the growing power of government.17,28 Unhindered by geographical boundaries, social media allows a rapid exchange of information, and as a result, individuals are more likely to be well informed about recent or upcoming governmental decisions. According to London et al, the growing centralization of government power makes it even more critical to have an educated citizenry, and thus, educational institutions need to prepare students using the latest social media and technology available.17 Although these social media avenues may be used to better educate the public and empower citizens, the reverse is also true. Freishtat and Sandlin fault Facebook with providing a breeding ground for cultural myopia, the eventual diminishment of the democratic voice, and the social conformity of younger generations.21 Social media also has been used as a campaign instrument in recent political elections. President Barack Obama used social media and online fundraising during his campaign, and both are believed to have contributed to his win.2

Although many embrace social media and its associated technology, Maxwell argued that technology has led to the degradation of the world, including intended and unintended negative consequences.28 The harmful consequences of modern technology include not only war and the horrific weapons of war, but also the unintended consequences of global warming and the spread of disease because of rapid travel capabilities. Maxwell also blamed the invention and use of television and the Internet for the trivialization of culture.28 Without television and the Internet, individuals and families would congregate to appreciate live music, theater, art, or poetry. However, technology now allows us to stream the arts into our living rooms, circumventing the traditional method of socialization and cultural appreciation that has existed for thousands of years. Maxwell warned readers of the need for an academic revolution a change of focus from knowledge to wisdom. In this aspect, wisdom is referred to as the ability to use modern technology without destroying the world in which we live. Maxwell believes we have more power than ever to wreak havoc on the planet and each other because of the far-reaching effects of technological advances. Global wisdom is not a luxury but a necessity, Maxwell claimed, and should be instilled in individuals by academe. Maxwell made a passionate argument, but most sources found in the literature search embrace the evolution of social media and encourage its use in the classroom and the workplace.

Conclusion
The social media revolution is upon us. Facebook, MySpace, Twitter, YouTube, wikis, and more have entered mainstream society, and thus, it may be advantageous for business, health care, and educational institutions to incorporate social media options into everyday life as much as possible. Social networking provides inexpensive marketing options and allows leaders to monitor the pulse of business. Many businesses are using Facebook and Twitter to update customers about new innovations and to receive customer feedback. Social media serves as a perpetual customer survey, allowing invested leaders access to the most recent consumer comments, complaints, and suggestions. Health care institutions are becoming more business and customer oriented. As a result, the health care culture is changing from The doctor is always right to a more patient-focused (or customer117

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focused) entity. Both physicians and health care institutions are incorporating social media as a way to keep in contact with patients and to promote the physician-patient relationship. The purpose of educational institutions is unchanging: to educate those interested in learning. However, todays students are different from yesterdays, and more changes are coming. Access to instant feedback outside the classroom is pushing educators to incorporate instant feedback inside the classroom. The use of social media provides educators with the capability to incorporate instant feedback into lessons, improving student learning outcomes and satisfaction. However, these advantages are accompanied by certain risks. Businesses and educational institutions must be mindful of liability risks, with special care to avoid HIPAA and FERPA violations. With the incorporation of social media into mainstream society comes the need to protect individuals from unintended harm. The popularity of social media has exploded in recent years, lending credence to the term social media revolution. This literature review covered a mere fraction of the available social media platforms available. Because of its relatively recent popularity, few empirical studies have been performed on social media. However, social media has commanded our attention and new studies are being published monthly. Future research options are almost limitless. Very little research was found regarding the incorporation of social media into the radiologic sciences. Further research is needed to determine the methods and frequency of social media use, as well as reasons it is not being incorporated.

references
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7. Berg G. The listening gallery: YouTube.com. J Singing. 2010;66:623-626. 8. Bristol T. Twitter: Consider the possibilities for continuing nursing education. J Continuing Educ Nurs. 2010;41:199-200. 9. Wikipedia. Easy-Bake Oven. en.wikipedia.org/wiki/Easy -Bake_Oven. Accessed July 28, 2010. 10. WikiLeaks. http://wikileaks.ch/. Accessed on January 25, 2011. 11. Hargis J, Wilcox S. Ubiquitous, free, and efficient online collaboration tools for teaching and learning. Turk Online J Distance Educ. 2008;9(4):9-17. 12. Skype. www.skype.com/intl/en-us/home. Accessed July 29, 2010. 13. Ventrilo. Ventrilo: Surround Sound Voice Communication Software. www.ventrilo.com/purchase.php. Accessed July 29, 2010. 14. Typefrag. Ventrilo Hosting. www.typefrag.com/services /ventrilo-prices/. Accessed July 29, 2010. 15. AHC Media LLC. Are you Twittering, getting friends on Facebook, and YouTube? Same-Day Surg. 2009;33(11):105-108. 16. Mangold W, Faulds D. Social media: the new hybrid element of the promotion mix. Business Horiz. 2009;52:357-365. 17. London H, Draper M. The silent revolution in higher education. Academic Questions. 2008;21:221-225. 18. Gunga S, Ricketts I. The prospects for e-learning revolution in education: A philosophical analysis. Educ Philosophy Theory. 2008;40(2):294- 314. 19. Ullman E. Sustainability: ideas for training the next generation of American workers. Community Coll J. 2009;80(2):12-15. 20. Meacham K. MRI Simulator. www.iacionline.com/simula tors.da. Published 2011. Accessed September 9, 2011. 21. Freishtat R, Sandlin J. Shaping youth discourse about technology: Technological colonization, manifest destiny, and the frontier myth in Facebooks public pedagogy. Educ Stud. 2010;46:503-523. 22. Firing worker for Facebook rant: is it legal? HR Specialist. 2010;8(12):1-2. 23. Hyman J. NLRB ruling revisited: can employees really trash you on Facebook? HR Specialist website. www.the hrspecialist.com/article.aspx?artcleid=36570. Published April 5, 2011. Accessed September 9, 2011. 24. Arkansas State University. Social Networking Guidelines. www2.astate.edu/dotAsset/251526.pdf. Published March 29, 2010. Accessed July 6, 2010. 25. Dinh A. Privacy and security of social media in health care. J Health Care Compliance. 2011;13(1):45-72. 26. Rainsberger R. Make sure media announcements comply with FERPA. Successful Registrar. 2009;9(9):3. 27. Byrne R. Google geo teachers institute. Free Technology for Teachers. www.freetech4teachers.com/2010/05/google

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-geo-teachers-institute.html. Published May 10, 2010. Accessed July 29, 2010. 28. Maxwell N. From knowledge to wisdom: the need for an academic revolution. London Rev Educ. 2007;5(2): 97-115.

editors Note:
This article was accepted in February 2011 and sections have been updated to reflect information current as of October 2011; however, social media statistics quickly become out of date because of the rapidly changing nature of the Web. Please read this article as a guide to trends in and concerns for the radiologic sciences rather than an overview of cutting-edge technology.

Cheryl DuBose, EdS, R.T.(R)(MR)(CT)(QM), is the magnetic resonance imaging program director and an assistant professor at Arkansas State University in Jonesboro.

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