Physician Executives Should Not Ignore How Smartphones Will Transform Healthcare

Physician executives who ignore smartphones and their healthcare applications will miss the most important disruptive technology trend in the next five years. Physician executives who understand how smartphones will transform the industry for providers, payers, patients, and employers will thrive in their careers.

Rajeev Kapoor, a former executive at Verizon, describes the smartphone-enabled transformation: “The paradigm of healthcare has changed. You used to bring the patient to the doctor. Now you take the doctor, hospital, and entire healthcare ecosystem to the patient.” (http://ow.ly/3GIir) Susannah Fox of the Pew Research Center’s Internet and American Life Project offers a specific example when she talks about the celiac disease patient who uses her smartphone to evaluate food products in the grocery store. “You cannot call your gastroenterologist every time you buy a new product.” (http://e-patients.net/index.php?s=fox) David Jacobson of Wellpoint notes that “The technology of telehealth is well ahead of the socialization of the telehealth idea and we are at a tipping point for utilization to begin taking off.” (http://ow.ly/3GIir)

The Global mHealth Developer Survey found that today 78% of respondents said that smartphones offer “the best business opportunities for mobile healthcare” in 2011; by 2015, 82% said smartphones would dominate the industry. Cell phones, tablets, and PDAs trailed smartphones in popularity according to the survey. (http://ow.ly/1aVf9V)

Smartphones run on a specific operating system and can download applications (apps) that run on the operating system. The most popular operating systems in the United States are iPhone, BlackBerry, Windows Mobile, Palm, Web, Symbian, and Android. (http://ow.ly/3GIwf) We are just beginning to discover how to harness the smartphone’s computing power, cameras, audio, video, motion sensors, and GPS functions to better manage health and wellness. (http://ow.ly/3gVzg)

In contrast to the rather slow adoption rate for both health information technology and personal health records, smartphone use is skyrocketing. In October 2006 15% of Americans owned a smartphone; by December 2009 that number was 42%. Surprisingly, one report noted that the smartphone market was “unfazed by the recession.” (http://ow.ly/3GIwf) In late January 2011 Apple reported that someone downloaded the 10 billionth app for the iPhone. (http://ow.ly/3IlLY) That lucky smartphone user received a $10,000 gift card to the iTunes store.

Why are smartphones so popular? The ability to carry around a handheld computer that is user-friendly and that allows users to do things anywhere at any time is attractive. One research whitepaper coined the term “care anywhere” for smartphone-enabled health care. (http://ow.ly/3GIir) But it has to be more than just that when people routinely say they “love their iPhone.”

MIT’s Sherry Turkle in her book Evocative Objects: Things We Think With writes “We think with the objects we love, and we love the objects we think with.” She also emphasizes how important it is that we carry this “second self” with us at all times. Mark Rolston, chief creative officer of Frog Design, observes that people grieve when they lose a personal electronic device. “You are leaving your brain behind,” he says (http://ow.ly/3jjCG).

Joseph Kvedar, MD, director of the Center for Connected Health at Partners HealthCare in Boston, states that humans find it easy and natural to anthropomorphize pet rocks and tomagotchis, and that we are truly forming trusting relationships with our smartphones. (http://e-patients.net/index.php?s=fox) In her new book, Alone Together: Why We Expect More from Technology and Less from Each Other, Turkle explores the positive and negative consequences of this love affair with smartphones and other forms of technology.

Demographics will also drive increased use of smartphones in health care. The first of the 78 million baby boomers will turn 65 in 2011 and as the sandwich generation who are concerned about the welfare of their children and their parents, they know the importance of health and wellness. Boomers also lead all generations in technology spending, and they will use smartphone technology to foster ongoing independence for themselves and to care for their relatives who live across the country. John Sherry, Director of User Experience Design for Intel, observes, “A number of economic, generational, and societal factors combine to make boomers likely early users of remote health monitoring and management products.” (http://ow.ly/3GIPJ)

Smartphones will transform healthcare by offering solutions in four classes of activities: communication, transactions, knowledge, and integration of information. (http://ow.ly/3GIir)

Communication

Communication between all players in the healthcare space will be changed by the use of smartphones. The most obvious arena to examine is the patient/doctor relationship. People who access scientifically sound advice through their smartphones wherever they find themselves can become more independent, empowered, self-managing patients as the above celiac example shows. Smartphones also make patients more likely to participate in online conversations with other patients on social media websites like PatientsLikeMe and DiabetesMine. Patients want to communicate with their physicians via email, but physicians have been slow to accommodate this desire. Although many consumers have not been able to use smartphones for communication with their provider, 85% of those that have connected with their doctor by means other than face-to-face were satisfied with their discussion. (http://ow.ly/3GIir)

Physicians worry about patient compliance, and 88% would like their patients to be able to monitor their weight, blood sugars, and vital signs on their own. 66% of physicians said they would like to use email for administrative communications like appointment reminders, but only 23% of consumers preferred communication by email for such simple communications. (http://ow.ly/3GIir) Forty percent of physicians said 30 percent of office visits could be avoided with the use of remote monitoring, email or text messaging with patients. (http://ow.ly/3GIPJ) A Mayo Clinic two-year study found that e-visits could replace in-office visits in 40 percent of 2,531 cases. (http://ow.ly/3GIir)

The Good Shepherd Health System developed their own iPhone app to help physicians access medical records, track vital signs, order medication, and coordinate care with other team members. Physicians from Duke, Harvard, and the John Theurer Cancer Center have worked with Zibbel, a health solutions technology company, to create a smartphone enabled virtual network for mobile cardiology and oncology consults between experts. (http://ow.ly/3GIir)

Smartphone technology can also change and improve communication between consumers and their pharmaceutical companies, health plans, employer, and health system. Michael Mathias, Aetna’s chief technology officer comments, “The days of mass communication are over. We can now deliver customized communications through mobile apps, online, telephonically, or through mail based on our understanding of how each member wants to be communicated with.” (http://ow.ly/3GIir)

Kaiser and Mayo are both developing smartphone apps to help patients managing chronic conditions and healthy consumers who want to stay fit. Scott Eising of Mayo Clinic says, “We’re a very content-oriented organization. In our research into the mobile health consumer, we found that people are looking for very action-oriented information.” Mayo Clinic has launched Mayo Clinic Meditation and Symptom Checker iPhone apps so that we can “take care of patients here and ‘there,’ whether at home or at work.” (http://ow.ly/3GIwf)

Qualcomm is creating “the clinic without walls” to take care of its 12,000 employees in the San Diego area. Using the Myca Health platform, Qualcomm’s health staff can consult remotely with mobile employees via smartphones. “People are so connected to phones, they’re an extension of themselves. You can’t have your doctor with you all the time but the phone can keep you on the right path toward health and wellness,” states Dr. Marion Zabinski. (http://ow.ly/3GIwf)

Merck Serono has developed a smart electronic injection device with two-way Bluetooth communication functions that track all injections made by the patient. When an injection is missed, nurses contact the patient to remind them to adhere to the treatment plan. (http://ow.ly/3GIir)

Transactions

The ability of consumers to use smartphones to book a flight or make a hotel reservation has revolutionized the travel industry, and many predict health care will soon follow suit.

The first area in healthcare that has utilized smartphones for transactions is e-prescribing. The most common prescription orders that a doctor uses can be automatically populated on their smartphone. Donald Burt, MD, chief medical officer of PatientKeeper, says their 25,000 physician users spend 20 percent of their time on their smartphone. Trusted nurses can post prescription order request on smartphones, and the physician can modify or approve the order no matter where they are located physically. A PricewaterhouseCoopers 2010 survey found that over 80 percent of both specialists and primary care doctors were interested in e-prescribing using their smartphones. (http://ow.ly/3GIir)

Aetna has made transaction functions such as physician finder and claims check available on smartphones. CVS Caremark has iPhone apps for prescription drug information and patient management of drug refills as well as for retail location finder functions. (http://ow.ly/3GIir)

Knowledge

Allowing physicians to have access to the latest evidence-based medicine knowledge at the point of care may be the most exciting and important application of smartphone technology. In a national survey, one third of physicians responded they make decisions based on incomplete information in nearly 70 percent of the patients they see. (http://ow.ly/3GIir) Lay people are also utilizing this technology to become wiser consumers of health care.

Epocrates is perhaps the best example of a mobile reference resource that physicians turn to in real time for information about the patients they are seeing right now. Epocrates’ drug reference app is the most popular free medical download for iPhones, and one study documented that 60 percent of Epocrates users avoided three or more medical errors a month. More than 125,000 doctors use Epocrates on iPhone and iPod touch devices. (http://ow.ly/3GIwf)

UpToDate is another evidence-based, peer-reviewed information resource available via smartphones. Over 400,000 providers use UpToDate for their synthesis of the medical literature, the latest studies, and treatment recommendations. (http://www.uptodate.com/home/index.html)

Skyscape has put together the largest library of medical resources that is available for smartphones, and the Medical Encyclopedia from the University of Maryland was one of the top ten free apps in the iTunes Store in December 2009. FDA Recalls is a free app for iPhones that keeps clinicians on top of which products have recalled by the manufacturer. (http://ow.ly/3GIwf)

Diagnostic tools for clinicians are too numerous to catalog. Examples include Diagnosaurs for general diagnosis, ARUP Consult for laboratory, OsiriX for digital imaging, Instant ECG for ECG interpretation, Vigilance for Emergency room situations, AirStrip OB for obstetrics, and American Well for remote physician consultations. (http://ow.ly/3GIwf)

Consumers are also using smartphones apps to keep abreast of medical knowledge. The Evincii app matches symptoms to over the counter medications, and the Mayo Clinic Symptom Checker iPhone app became available in early 2010. (http://ow.ly/3GIwf) Consumer interest has been highest in fitness and weight control apps (Tap & Track, iTreadmill, Walk It! And Pedometer-Widget), Diabetes Management (Glucose Buddy, Handylogs Sugar), High Blood Pressure Management (HeartWise, My Blood Pressure and Heart Rate), sleep hygiene (Sleep Cycle Alarm Clock, Smart Alarm Clock), Stress Reduction (Stress Free with Deepak Chopra, Rage Eraser), and First Aid (Pocket First Aid & CPR). (http://ow.ly/3gVzg)

Integration of Information from Diverse Sources

Perhaps the biggest challenge for both consumer and physician is how to integrate all of this information that is available via smartphones. It truly is like drinking from a fire hose, and the amount of information can be overwhelming.

Health systems have been focused on implementation of the electronic medical records, and the Patient Protection and Affordable Care Act has provided billions of dollars to support rapid adoption. Unfortunately both the hospital systems and the Office of National Coordinator have largely ignored the importance of integrating mobile health into other health information technology efforts. For example, two thirds of physicians in a national survey said they were using smartphones in their practice that are not connected to either their office or hospital HIT systems. Thirty percent of physicians said their health systems or medical group would not provide support for smartphones. (http://ow.ly/3GIir)

Many physicians and hospital administrators, tired of wearing multiple devices on their belts, have wanted their IT Departments to consolidate all messaging functions to smartphones. Most hospitals already have invested in pagers, cell phones, Vocera badges, SpectraLink Wi-Fi phones, and two-way radios, and what works for maintenance staff may not work for ICU nurses. A research white paper reporting on the experience of smartphone early adopter hospitals recommends supporting a variety of devices at the present time, but it also warns against being too slow to adopt smartphones. It also points out that work processes have been designed around the currently employed technologies and replacement by smartphones will necessitate work process redesign which may result in cost-savings. (http://ow.ly/3HalT)

Smartphones in health care will not live up to their full potential if integration is not successful. No matter how many readmissions for congestive heart failure remote weight monitoring at home could avoid, such programs will fail if the information does not appear in the office or hospital medical record.

Joseph Kevdar, MD, director of the Center for Connected Health at Partners HealthCare, stated that while “sensor technology may be rapidly becoming commoditized, integration with EMR and data aggregation systems is not something we have done well. We need to get better at gathering information, adding logistical software to get to the intersection of all the data and population health management.” (http://ow.ly/3GIir)

There are technological advances that are promising, according to Kvedar. Emotional sensors predict the patient’s mood by analyzing their voice (Cogito) or by facial recognition (Affectiva). Bodytrace’s wireless weight scale, Telecare’s wireless glucometer, and Vitality’s GlowCaps device all can find mobile networks when the sensor is triggered and so transmission of clinical data does not require the patient to do anything. (http://ow.ly/3K2FR)

Conclusion

Smartphone technology is already transforming the healthcare industry, but many physician and hospital leaders have not thought through the implications of their widespread adoption by both consumers and physicians. By understanding the implications of smartphones for communication, transactions, knowledge, and integration, leaders can begin to map successful strategies and tactics during a time of delivery system and payment reform. As John Mattison, MD, of Kaiser Permanente states, “The new wellness delivery channel for ubiquitous care will be the smartphone, and it will happen sooner than you think.” (http://ow.ly/3GIwf)

Who Should Manage Your Social Media Strategy [Accepted for publication in The Physician Executive]

By Kent Bottles, M.D., and Tom Sherlock

Hospital and medical group leaders are facing the most challenging healthcare environment in recent memory. The need to decrease per-capita cost and increase quality to respond to federal healthcare reform and the global economy is a daunting task that requires two-way communication with a broad range of stakeholders. As reform unfolds, hospitals and medical groups of all sizes are embracing social media tools as soon as they realize that they're no longer optional.

At least since the first quarter of 2010, analysts have been reporting that websites and search engines no longer dominate online communication.[i] Deloitte's Social Networks in Health Care[ii] recently concluded that healthcare executives “who do not consider how to incorporate social networks into their future strategies risk being run over on the super-highway of health information sharing.”

Your social media strategy will work more smoothly when no one department has control, because it's likely that before long employees in many of your departments will be using social media to do their jobs. It's time for your Internet strategy to be managed by a qualified person — definitely one of your best-and-brightest — who reports directly to senior management and works with all department heads as an equal colleague.[iii]

You no longer have the opportunity to be an early adopter, but you can give yourself a big advantage by having people in every department who've been trained how to use social media intelligently, and who follow the lead of your social media manager. It's essential that you understand that each of these tools is designed to nurture personal relationships and thereby strengthen loyalty to your institution:

• We use Twitter as our principal example because it's a more important business tool for hospitals and medical groups than Facebook.
• If your organization isn't already on Facebook, you should wait until you have a specific strategic reason for using it.
• Blogs can be particularly effective business tools if they let readers get to know and understand the blogger. Paul Levy’s "Running a Hospital" blog[iv] has shown how a CEO blog can be a powerful communication and branding tool.
• Many of your people should be listed on LinkedIn. Each person's profile will be unique, but a certain amount of coordination is necessary to make sure your institution is identified accurately and consistently, for example.
• Your YouTube channel can present videos that let people get to know some of your key physicians and nurses, for example. Your social media manager can see to it that the content, style, and production values of your videos will send the right message about your organization.

You might conclude that you need to hire someone new to manage your website and your social media strategy. But don't rush into a decision to bring in someone new to be your social media manager just because they have experience with these tools. It would be far better to find someone who is already thoroughly familiar with and personally committed to your institution.[v]

Note right away that social media is not something you use for advertising or marketing, and that it doesn't duplicate or replace any of the functions of your website. When you reduce it to its fundamentals, social media strategy isn't complicated. It's social. It's about establishing and nurturing authentic relationships in ways that will build loyalty to your institution. Your social media manager will:

• Listen to what's being said about you anywhere on the Internet, with special attention to your own social media channels.
• Respond by engaging those who are talking to or about your organization.
• Establish relationships by showing people respect, honesty, and enthusiasm, and then nurture those relationships by authentic personal interaction. Your social media manager will gradually get a feel for how much time to put into each of the relationships that are established.
• Bring to your attention the insights and opinions he's hearing and the facts he's learning so that with his help, you can evaluate any implications for what you do and how you do it. Not all feedback is valuable, but some of it certainly will be. Senior management should balance a healthy skepticism with openness to input from people who use social media to tell you something.

There really are no social media experts, because we're all still trying to find the best ways to use these tools.[vi] One of us has been on Twitter since June 2008, and one of us is among the most influential physician twitters according to several metrics. We each spend at least two hours a day on Twitter, and yet we cannot claim to be an expert on how you should use Twitter or the other tools — because your social media strategy will have to take into account a unique combination of goals, strengths, target audiences, and local concerns.

Adopting an effective social media strategy involves a challenging but rewarding process of discovery that must be done in-house. A smart, creative consultant with significant experience in healthcare social media can fast-track the process by explaining the basics and best practices, and by helping your social media manager learn how to consistently create content that interests your target audiences.

Social Media Does Not Belong in the IT Department

It's surprising that anything that has to do with the Internet is sometimes still assigned to the IT department. Websites and social media aren't primarily technical matters, and social media may eventually take 50% or more of your social media manager's time (your social media manager should have responsibility for your website too). The rest of his or her time might be spent on content development for your website and keeping up with the literature.

While some IT people may enjoy doing web design, website maintenance, and now social media, one may presume that they were hired to do something quite different. The skills required for IT are a world away from those needed for social media.

Nearly a decade ago, a technical headhunting firm was trying to determine why the Web developers they sent to their clients were striking out so often. The problem turned out to be that they were requiring that a web developer have at least three years' experience with the C++ programming language. They were sending programmers to do a communicator's job. Programmers (and graphic designers) aren't usually the people who have the combination of writing, communication, and relationship skills that are needed to ensure that your Internet strategy supports your overall business strategy.

Social Media Does Not Belong in the Marketing Department

One of your marketing people may be best qualified to be your social media manager:

• if she's a creative, energetic, and enthusiastic person who is not the least bit cynical or world-weary;
• if she's enthusiastic about social media, is already using it on her own, and talks about it every day to anyone who will listen; and
• if she understands that Twitter and Facebook are not marketing platforms. As recently as just a couple of years ago we spoke of “social media marketing” — but no more, because that phrase sends the wrong message.

Because developing and nurturing relationships is the whole point, social media can't be effective if it's automated in any way, and for the same reason outsourcing your social media strategy and execution to a marketing agency or other vendor is almost always a bad idea. Agencies may try to persuade you to entrust social media to them, but that's calculated to meet their needs, not yours.

Studies suggest that people like brands with an authentic personality, and your social media manager is going to be out there on the front lines every day, using his or her own name, showing people who you are — and doing and saying things that give people reasons to be loyal to your organization. That's got to be done in-house by someone who understands your organization and is personally committed to it.

You might find that someone in your marketing department is the person best qualified to be your social media manager. If that's the case, that person should begin reporting directly to senior management, and should be relieved of his or her duties in the department. As already mentioned, many people in your organization are going to be using social media as part of their jobs, and you can eliminate potential obstacles by keeping responsibility for your Internet strategy independent of any one department.

What to Look for When You're Selecting a Social Media Manager

Your social media manager should have easy, informal access to senior management, and should attend top-level meetings at least once a month. The position is that important, and you do need to be personally involved at least to this extent.[vii] If the person you're considering as your social media manager is not someone you would look forward to meeting with, then he or she isn't the right person.

Many hospitals and larger medical groups will already have a person with the qualifications to be social media manager somewhere on staff, but he or she may not immediately come to mind. Don't assume that social media is something that's best suited for women — or that it's just something the kids are doing these days.

You're looking for a remarkably intelligent person with the following qualifications and characteristics, a person who might be male or female, younger or older:

1. Someone You Can Trust. You want someone you can trust without hesitation, someone to whom you're willing to give everything — including confidential information about current challenges and future plans — that will enable him or her to do the job. Social media tools can be used to build trust in your institution, but the process must begin with your trusting your social media manager.

2. An Accomplished Writer. You want someone who welcomes the opportunity to write all day every day. This rules out many of your people, but it's essential. You might even initiate your search by asking everyone who works for you to identify themselves if they really enjoy writing.

3. Creative Imagination. A successful social media manager will have the ability to see possibilities and connections in everything he sees, hears, and reads. To build a list of followers, he has to give them a reason to follow — and interesting, informative tweets are what that's about.

4. Organizational Skills. Twitter's constant barrage of facts, opinions, and ideas must be tamed if it's going to benefit your organization. Managing social media for an organization involves coordinating social media strategy throughout the departments, and it means keeping databases or lists of followers, people being followed, and contacts made, for example. These can take Twitter's free-flowing stream and turn it into an organized system.

5. A Charming Personality. You want a genuinely nice person with an outgoing personality — a good listener who finds it easy to establish professional relationships with people, and who can respond to people who are annoying or idiotic without becoming hostile or sarcastic.

6. Generosity. You want someone who can tweet generously about other healthcare institutions and organizations in your community, including your competitors when they do something worth noting or congratulating. This is social media, and promoting your community in this way will enhance your reputation (and confound your competitors).

7. Empathetic Listening Skills. You want someone who can interact honestly and ask and answer questions with genuine empathy — because if people feel that their concerns have been validated, their respect for your organization will grow.

8. Honesty and Diplomacy. You want someone who will speak truthfully because she feels a deep sense of responsibility to the people who follow her on Twitter. You need someone who will be able — after consultation with senior management when that's called for — to deal unflinchingly with controversial matters, as part of crisis management, for example, or when a hot topic that might impact your organization — like the role of the physician vis-à-vis the role of the nurse — is being discussed.

9. Good Judgment. Look for a person who will not embarrass your institution, his colleagues, or himself — or reveal confidential information of any kind. Interesting tweets will sometimes be provocative, but you want someone who understands the critical distinction between being intelligently provocative and being irresponsible — someone who is aware of the line and doesn't cross it.

Hiring the right person to be your first social media manager will ensure that your hospital or medical group will use these essential tools to compete effectively. Hiring the wrong person, or not embracing social media at all, is a recipe for failure in a rapidly changing healthcare environment.

Kent Bottles, M.D., is a former medical school professor, president and ceo, chief medical officer, and chief knowledge officer who is now an independent health care consultant, keynote speaker, and writer.

kentbottles@gmail.com and http://twitter.com/KentBottles

Tom Sherlock is an Internet strategist, Website producer, and content developer who has worked with businesses and healthcare professionals since 1994. tom@aicolorado.com and http://twitter.com/ColoradoHealth
Sidebar: Some Major Social Media Tools

Facebook — a social networking community originally for college students, then expanded to include high school students, and since September 2006 available to everyone; founded by Harvard student Mark Zuckerberg and friends in February 2004; in October 2007 Microsoft bought a 1.6% share of Facebook for about $240 million.

Jumo — a new social network for “people who want to change the world”; launched in a beta version on November 30, 2010; founded by Facebook co-founder Chris Hughes, who designed and managed the social networking systems used by the Obama campaign.[viii]

Linkedin — a business-oriented social network of more than 75 million professionals from around the world; founded by Reid Hoffman and former employees of Paypal and Socialnet.com; launched in May 2003.

Twitter — a social networking and micro-blogging service where updates are displayed on the user's profile page and instantly delivered to other users ("followers") who have signed up to receive them; founded by Jack Dorsey and Biz Stone; launched in October 2006.

YouTube — a video-sharing service founded in February 2005 by former PayPal employees Chad Hurley, Steve Chen and Jawed Karim; bought in November 2006 by Google for $1.65 billion in Google stock.

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[i] Jim Tobin notes in Mashable/Business that some major websites are starting to get more traffic from social networks than from Google http://mashable.com/2010/10/22/social-media-optimization/ Also see Justin Kistner: “Social is now dominating time spent online — and brands aren’t keeping up,” Useful Social Media Blog, Nov 2, 2010 http://bit.ly/cRG0HM

[ii] https://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/US_CHS_2010SocialNetworks_070710.pdf

[iii] Because of the focus of this article, we'll call this person your "social media manager," but you will actually want him or her to be your Internet strategy manager, with responsibility for coordinating all aspects of your institution's use of the Internet.

[iv] http://runningahospital.blogspot.com/

[v] During the 2008 political campaigns, many candidates simply hired to a college kid to "take care of" social media for the campaign. The results were often pathetic, and the campaigns were unable then or now to evaluate the lost opportunity. Many of these kids knew how to communicate with their friends, but actually interacting with voters and activists was not even on their radar. We strongly recommend that you reject suggestions that you hire an intern to "take care of" social media for your hospital or medical group.

[vi] Bill Sweetland at ragan.com is a teacher who knows how to use humor to make his points — by poking fun at social media "experts," for example. See “A short guide to the clichés of social-media speak” http://bit.ly/cfEeT5 and “The Don Draper guide to social media marketing” http://bit.ly/atBmQe

If you decide to hire a consultant to guide your organization, ask first to see a resume that includes information about his or her personal experience with blogs, Twitter accounts, Facebook pages, and other social media tools. Have one of your people follow applicants' Twitter timelines long enough to determine whether they're worth your time and money.

[vii] See Joe Stanganelli: “C-Suiters Out of Touch With Social Media,” Internet Evolution Oct 27, 2010 http://bit.ly/drrdIz and Leslie Gaines-Ross: “Why So Few Tweets from the C-Suite?” Harvard Business Review blog,” Oct 12, 2010 http://bit.ly/cF9NHu

[viii] “We’ll be matching people based on their skills and interests with organizations around the world that need their input,” Hughes said. “It’s a discovery process that first matches, then helps people build relationships, then lets people share their resources.” http://www.fastcompany.com/1587959/facebook-chris-hughes-jumocom See http://jumo.com and http://blog.jumo.com/