Social Media and Unprofessional Pharmacist Conduct: A Cross-Sectional Survey of Boards of Pharmacy

Purpose: To determine how often boards of pharmacy (BOPs) receive complaints related to licensee’s online behavior, and what types of online behaviors may prompt an investigation of a licensee. Methods: A survey (consisting of questions related to BOP’s management of complaints against licensee online behavior and 10 case vignettes) was adapted from a previous survey of United States medical boards. Vignettes encompassed themes such as patient confidentiality, derogatory language, alcohol use, false or misleading product claims, and others. Following institutional review board approval, survey materials were distributed via email by the National Association of Boards of Pharmacy to 63 domestic and international boards of pharmacy. Completed surveys were analyzed using descriptive statistics. The proportion of respondents who indicated that the vignette would “very likely” or “likely” result in an investigation was used to determine consensus. Proportions of >75%, 50%-75% and <50% were classified as high, moderate and low consensus, respectively. Results: Fourteen completed surveys (22.2%) were received. Sixty percent of respondents stated that their board has been involved in managing a complaint regarding the online behavior of a licensee, and that disciplinary actions including revocation or suspension of license, letter of reprimand, and monetary fines have been enacted. While 79% of responding BOPs have a policy regarding Internet usage, 36% are unsure whether the policies are sufficient to cover online professionalism. One vignette, where a pharmacist made misleading claims regarding a compounded product, achieved high consensus for likelihood to prompt an investigation. Moderate consensus was achieved for a breach of patient confidentiality, inappropriate alcohol use, and misrepresentation of professional credentials. Conclusion: Boards of pharmacy are widely varied in what types of online behaviors may prompt an investigation. Additional dialogue is needed among pharmacy leaders to determine best practices. Introduction Social media is defined as an online platform whereby individuals can interact with one another. 1 Some social media sites, such as Facebook, MySpace and Twitter are primarily used for personal social interactions, whereas others such as LinkedIn and ASHP Connect are primarily used to build a professional network. 1,2 As social media use increases, so too does the intersection between private and personal life. 3-6 Questionable content on an individual’s social network site may affect both personal and professional relationships, as well as potentially affect employment status or opportunities. 4,5,7-10 Some organizations recommend that pharmacists maintain distinct personal and professional personas online, Corresponding author: Jessica Skelley, PharmD Assistant Professor of Pharmacy Practice McWhorter School of Pharmacy Samford University 800 Lakeshore Drive, Birmingham, AL 35229 office:205-726-4338; fax: 205-726-2669 [email protected] but the line where these meet is vague and difficult to define. 1 Using social media, pharmacists may easily publish statuses, photos, and videos directly into the public domain; and there is increased need for education and informed guidance for both pharmacy practitioners and students on what constitutes professional and appropriate behavior. 4,11,12 In 2012, the American Society of Health-System Pharmacists (ASHP) published recommendations for the use of social media by health systems, pharmacists and pharmacy technicians. ASHP recommends that health systems weigh the benefits of social media with the potential liability it creates, and develop and adhere to best practices. For the individual, ASHP recommends: that medical advice provided be in accordance with the highest level of professional practice including legal and ethical requirements; that social media be used to receive drug information and to counterdetail false or misleading information; that pharmacists recognize when alternative communication methods (phone, face-to-face) with patients are more appropriate; and that Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 2 pharmacists ensure that privacy settings are sufficient to protect patient identity. 1 Additionally, pharmacists who use social media should present an image that will positively influence students and residents, and at all times should avoid complaining about or disparaging patients. 1 These guidelines may not always be met, as an analysis of pharmacy themed blogs revealed that the majority of material published presents a negative view of the profession and/or pharmacists. 13 Furthermore, pharmacists writing blogs and microblogs (i.e. Twitter posts) may use unprofessional or explicit language, be critical of patients or other health care professionals, and may not always maintain anonymity in their writings. 14 According to published literature, community pharmacy practitioners may be more likely than other pharmacists to display these types of online behaviors. 14 Furthermore, the repercussions of unprofessional behavior online may be severe. The National Association of Boards of Pharmacy (NABP) requires that pharmacists who are applying for licensure be of good moral character. 15 However what exactly encompasses good moral character is more difficult to describe, and application of this rule varies from state to state. 16 Therefore online behavior that is deemed as reflective of a bad moral character by a board of pharmacy may prevent pharmacy graduates from obtaining licensure. A survey of 454 predominantly hospital residency program directors indicates unprofessional online behavior may impede applicant’s ability to find a residency position. 9 For example, 76% of respondents strongly agree or agree that it is appropriate to review social media profiles of residency candidates; and 77% of respondents strongly agree or agree that if they review a candidate’s social media interactions it is acceptable to consider this information in determining the suitability of the candidate and when making judgments on professionalism, character, and attitudes. About 20% of program directors surveyed regularly reviewed social media behavior of applicants. 9 On the contrary, only 6% of pharmacy students think that online behaviors should be used to judge professionalism and aptitude. 7 Several cases regarding the use of social media have brought into question the balance between professionalism and the right to free speech. In Yoder v University of Louisville, a nursing student was dismissed from school after making offensive remarks regarding a patient’s birth process in a blog on MySpace. The decision of the school was upheld in district court as well as at the level of the U.S. Court of Appeals because of the honor code in place at the school of nursing. In Snyder v Millersville University, a student teacher posted a photograph on MySpace of herself dressed as a pirate and apparently intoxicated with the caption “drunken pirate.” Another student reported seeing the photograph to the school district, and the student teacher was barred from the classroom immediately, which prevented her from graduating with an education degree. Following a non-jury trial, a judge ruled on behalf of the university. 17 Without guidance on what types of online behavior may be deemed inappropriate and prompt boards of pharmacy to investigate conduct, pharmacy professionals do not have sufficient guidance on how to achieve best online practices. The objective of this study was to determine boards of pharmacy’s current involvement in managing complaints regarding online behaviors of licensees, and to assess what types of online behaviors could potentially lead to investigations by state pharmacy boards. Methods A survey instrument published by Greysen et al used to survey state medical boards was identified and adapted with permission of the authors to make the content applicable to the pharmacy profession. 3 Changes were limited to only necessary vocabulary and situational adjustments to preserve the intent of the original instrument. The survey contained assessment questions on the involvement of boards of pharmacy with online content and social media, as well as several vignettes developed by Greysen et al based on actual incidents experienced by investigators and described in national media. Respondents were asked to rank likelihood of further investigation of the incidents depicted in the vignettes, assuming that the occurrence of the hypothetical situation resulted in a complaint to the board. Like with the Greysen study, response choices used a 4-point incremental scale ranging from “very unlikely” to “very likely” with an additional option of “I don’t know”. Respondents were allowed to enter free-text comments as after choosing a response. In partnership with the National Associations of Boards of Pharmacy (NABP), the survey was distributed electronically to all active and affiliate boards of pharmacy (N=63) through the NABP electronic mailing list, including boards of pharmacy in all 50 states, Guam, Puerto Rico, US Virgin Islands, Canada, Australia, and New Zealand. Surveys were directed to the executive director of each board, although responses were also accepted from others in positions of leadership at the board who served as the proxy to the executive director. Only one survey was collected from each board. The survey Internet link was re-distributed electronically after 2 weeks as a reminder e-mail, and remained open for responses for a Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 3 total of one month. Data collection occurred during March 2013. No incentives were offered to complete the survey. Responses were analyzed, with only fully completed surveys being included for data analysis. Due to the nature of the information and the paucity of literature that exists on this topic, descriptive statistics were used to characterize the findings. This study was granted approval by the Institutional Review Board for Samford University, Birmingham, Alabama. Results Demographics and characteristics of reported cases Of the 63 surveys distributed to the population, 14 completed surveys were returned for analysis (22.2% response rate). Two additional partially-completed surveys were returned but were excluded from data analysis according to protocol. Respondents were classified by NABP district (Appendix A, question 1) and licensee population size (see Table 1). The responding boards of pharmacy represent approximately anywhere between 29,000 to greater than 76,000 practicing pharmacists in the US and other foreign nations. Over 85% of respondents (12/14) occupied an executive role at their respective boards of pharmacy and were in positions of knowledge regarding matters surveyed. Overall, 40% of responding boards indicate that they have not had to deal with incidents of unprofessional online behavior of licensed pharmacists in their states or territories. Of the various types of online professional behavior, the most commonly encountered complaints received by boards responding affirmatively dealt with inappropriate use of the Internet for clinical practice (e.g., unapproved online pharmacy activity) (range = 4-14 reported cases per board responding affirmatively) and inappropriate communication or contact with patients online in a sexual or other inappropriate context (range = 2-6 reported cases per board responding affirmatively). These same boards indicated that the outcomes of these investigations varied but most commonly resulted in revocation of license (21%), monetary fines (14%) and other less punitive measures such as temporary restriction of license (14%) or issuance of a letter of reprimand (7%). Methods of reporting inappropriate events varied and most commonly were discovered through the examination of other complaints against the same licensee (20%). Direct reporting of inappropriate online behavior by another pharmacist, trainee (e.g., resident, student extern or technician), or non-clinical staff was uncommon among responding boards (all 7%, respectively). When asked whether similar events of inappropriate online conduct have been reported by other licensees of their boards of pharmacy (i.e., technicians), 33% answered affirmatively, whereas 47% and 20% of respondents indicated “no” or were unsure. Perceptions of boards toward unprofessional online activity Perceptions of the gravity of unprofessional online behavior of pharmacists varied among responding boards of pharmacy. When it comes to First Amendment or “free speech” rights prohibiting boards of pharmacy from acting on complaints, 57% of respondents disagreed or strongly disagreed that such individual or Constitutional rights would prevent their board from pursuing warranted charges of unprofessional conduct, whereas 43% were generally unsure. When asked to rank level of concern on a 5 point Likert scale (range: not concerned – very concerned), the majority of responding boards indicated that they were not concerned (46%) or moderately concerned (46%), whereas only one responding board indicated “very concerned” about incidents of unprofessional online behavior by pharmacists in their jurisdiction. Responding boards indicated mixed certainty as to whether current statutes in their states or territories are broad enough to encompass pharmacist professionalism in the context of online behavior, with 57%, 7% and 36% of responding boards indicating “yes”, “no” and “not sure”, respectively. In a similar line of questioning, 79% of responding boards indicated that current rules and statutes are in force that specifically addresses issues of Internet use and online unprofessional behavior. Furthermore, 93% of respondents indicated that no plans are currently in place for their board to develop policies to address the issues of Internet use and online unprofessional behavior. Conceivably, some boards that do not have current statutes in place do not have plans to address issues of Internet use and online unprofessional behavior of pharmacists. Along the lines of enforcement of existent or nonexistent statutes, there was general uncertainty among responding boards, with 50%, 21% and 29% indicating “yes”, “no” and “not sure,” respectively to the question of whether their board was able to effectively deal with future cases of pharmacist unprofessional online behavior. There was also large variability with respect to responding board’s adoption of social media, with 36%, 50% and 14% of respondents answering “yes”, “no” or “not sure”, respectively, as to whether their board uses such means to communicate with licensees, patients or other parties. However, the majority of responding boards do utilize publically accessible websites for a variety of purposes (see Table 2). Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 4 Board perceptions of professionalism vignettes Responding boards were exposed to 10 case vignettes (created around professionalism themes) to illustrate online content or behaviors that may or may not be exemplative of unprofessional pharmacist online behavior. Respondents were asked to imagine that these dramatized cases and photos were actually real cases brought to their attention by a concerned individual within the profession or the community. Themes included in the vignettes depicted potential violations of patient confidentiality (print and photographic media) (n=3), use of insensitive and stereotypical language about individuals or groups of people (n=2), inappropriate use of alcohol in workplace and nonworkplace settings (n=2), inappropriate Internet communication with patients that is sexual in nature (n=1), misrepresentation of board certification credentials (n=1) and posting false or misleading product claims (n=1). Respondents were given a 5-item Likert scale (“very likely”, “likely”, “don’t know”, “unlikely”, “very unlikely”) to indicate level of certainty as to whether a vignette would elicit an investigation by their board. Consensus among responding boards was calculated for all 10 vignettes. Consensus was determined by calculating sum and overall proportion of respondents who indicated that the given vignette would “very likely” or “likely” result in a formal board investigation (see Table 3). 3 Cumulative proportions of >75%, 50%-75% and <50% were classified as vignettes generating high, moderate and low consensus, respectively. 3 Discussion This international survey of boards of pharmacy has varied levels of consensus about the likelihood of an investigation following specific online behaviors. While some specific examples of online behavior, such as using the internet for false or misleading claims for a product or service, can be considered universally prohibited behaviors for pharmacists to avoid possible investigation by pharmacy boards due to high level of consensus among responders, other vignettes had responses of low to moderate consensus. Similar to the results of the Greysen study, likelihood of investigation in “gray areas” such as derogatory speech and alcohol use are varied and may depend on context, as explained by responder comments on the vignettes. In the Greysen study, >75% of boards of medicine were likely or very likely to investigate social media practices whereby a physician misrepresents his or her credentials, uses a patient’s image without permission, cites misleading information about clinical outcomes, or contacts a patient inappropriately. 3 Similarly, our study identified that 78% of boards of pharmacy were likely or very likely to investigate misleading claims in social media. However, a significant difference between the studies was that only 57% of boards of pharmacy would investigate a situation where a patient’s image was used without permission, and 28% would investigate a complaint of a patient being contacted inappropriately. This difference may be due to the sensitive nature of the photograph used in the Greysen study, which depicted a non-explicit view of a woman giving birth. While the breach of patient confidentiality is the same, the context of the two situations may carry a different weight with the survey respondents. In the Greysen study, between 50-75% of respondents were likely or very likely to investigate photos of alcohol intoxication, while 64% of pharmacy boards indicated an investigation would occur. 3 The survey data suggests that investigation was less likely with photos that evidence alcohol consumption without intoxication, although still at a slightly higher rate than identified by the medical board respondents. Comments suggested that respondents were likely to be unconcerned with the use of alcohol unless it directly interferes with patient care or is part of a pattern of abuse. Only 23% of medical board respondents had written policies on physician conduct on the internet, but 73% report being very concerned or moderately concerned about online professionalism. 3 Interestingly, 79% of pharmacy board respondents indicate the existence of written policies on pharmacist conduct on the Internet which is a much higher rate than their physician counterparts, with varied responses on their level of concern about online professionalism. Compared to Greysen, in which respondents indicated that only 12% of medical boards use social media to communicate with physicians or patients, 36% of pharmacy boards selected that they utilize social media platforms. While these results may initially indicate a higher level of policy utilization and overall familiarity with social media by pharmacy boards than medical boards, many clinical vignettes had a wide range of responses, with only one scenario resulting in high consensus for investigation. This suggests that although policies may exist, they vary widely between pharmacy boards, with many boards also selecting “I don’t know” in many scenarios. The frequency of “I don’t know” responses may be reflective of the lack of specific guidance on social media interactions both by national licensing boards and national pharmacy organizations. Dialogue on online professionalism should continue to be expanded in an effort to obtain a broader consensus, or best practices, on what specific behaviors are considered appropriate versus inappropriate, rather than leaving it to an individual’s best judgment. Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 5 Another result of note is the low rate of direct reporting of inappropriate online behavior by another pharmacist, trainee (e.g., resident, student extern), technician, or non-clinical staff (all 7%, respectively). While some inappropriate online behaviors (such as contacting a patient) may be private in nature and therefore unlikely to be reported by anyone other than the patient, many are potentially public actions that colleagues may be cognizant of. Pharmacists and other medical professionals should be reminded of the responsibility to hold both themselves and their colleagues accountable for actions that may negatively impact both patient health and the profession. Similarly some scenarios, such as potential breaches of patient confidentiality, use of insensitive and stereotypical speech, and inappropriate use of social media for communication with patients in a sexual nature resulted in low consensus for likelihood of investigation. Such practices are specifically discouraged by existing policy statements on social media based on how they may negatively impact public perception of the pharmacy profession and fail to advance dignity of both the patient and profession. 1 While the survey identifies what types of scenarios may be likely to result in investigations by boards of pharmacy, it does not account for other potential legal consequences, such as those from employers, hospitals, or lawsuits filed based on violations of patient privacy that could be prosecuted by the Department of Health and Human Services. The survey does identify several scenarios where consensus was low on how best to approach resolution, suggesting that these examples should be further considered, debated and addressed by national organizations. Our study has several limitations. While the response rate to the survey was low (22.2%) compared to the Greysen study, this may be attributed to the current increase in workload many boards of pharmacy in the United States are experiencing due to the compounding sterility issues. However, based on the wide range of responses and geographic location of responders in both the US and select international boards, the authors feel that the sample is reflective of current board of pharmacy policies both nationally in the US and internationally. Additionally, as with the Greysen study these vignettes are all considered hypothetical and not comprehensive of all types of potential violations of online professionalism. Conclusion A survey was conducted of all 63 boards of pharmacy that are members of the NABP assessing the involvement of boards of pharmacy with online content and social media, as well the likelihood of investigation of several examples of potential violations of online professionalism depicted through ten different vignettes. A high consensus of investigation was identified for a scenario of false or misleading claims through social media for a compounded product, with moderate consensus for a potential breach of patient confidentiality, inappropriate alcohol use, and misrepresentation of professional credentials. Consensus was widely varied on other vignettes, suggesting that dialogue on online professionalism should continue to be expanded in an effort to obtain a broader consensus and best practices on what specific behaviors are considered appropriate versus inappropriate by the pharmacy profession. References 1. ASHP Statement on the Use of Social Media by Pharmacy Professionals. Am J Health-Syst Pharm. 2012; 69:2095-7. 2. Alkhateeb FM, Clauson KA, Latif DA. Pharmacist use of social media. Int J Pharm Pract. 2011;19(2):140-2. 3. Greysen SR, Johnson D, Kind K, Chretien KC, et al. Online Professionalism Investigations by State Medical Boards. Ann Intern Med. 2013; 158:124130. 4. Mattingly II TJ, Cain J, Fink III JL. Pharmacists and Facebook: Online social networking and the profession. J Am Pharm Assoc. 2010; 50(3): 424-427. 5. Kukreja P, Sheehan AH, Riggins J. Use of Social Media by Pharmacy Preceptors. Am J Pharm Educ. 2011; 75(9): Article 176 6. Thompson LA, Dawson K, Ferdig R, Black EW, Boyer J, Coutts J, Black NP. The intersection of online social networking with medical professionalism. J Gen Intern Med. 2008;23(7):954-957. 7. Cain J, Scott DR, Akers P. Pharmacy students’ Facebook activity and opinions regarding accountability and e-professionalism. Am J Pharm Educ. 2009; 73(6): Article 104. 8. Metzger AH, Finley KN, Ulbrich TR, et al. Pharmacy faculty members’ perspectives on the student/faculty relationship in online social networks. Am J Pharm Educ. 2010;74(10):Article 188. 9. Cain J, Scott DR, Smith K. Use of social media by residency program directors for resident selection. Am J Health-Syst Pharm. 2010;67(19):1635-1639. 10. Elzweig B, Peeples DK. Using social networking web sites in hiring and retention decisions. SAM Advanced Manag J. Autumn 2009:27-35. 11. Cain J, Romanelli F, Fox B. Pharmacy, social media, and health: Opportunity for impact. J Am Pharm Assoc. 2010;50:745-751. Original Research http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3 Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 6 12. Williams J, Feild C, James K. The effects of a social media policy on pharmacy students’ Facebook security settings. Am J Pharm Educ. 2011; 75 (9) Article 177. 13. Cain J and Dillon G. Analysis of Pharmacy Centric Blogs: Types, discourse themes, and issues. J Am Pharm Assoc. 2010;50:714-719. 14. Clauson KA, Elkins J, Goncz C. Use of blogs by Pharmacists. Am J Health-Syst Pharm. 2010; 67:2043-8. 15. NABP Model Act §302(a)(3). 16. NABP Model Act §302(a)(3). Comment. 17. Cain J and Fink III J. Legal and Ethical Issues Regarding Social Media and Pharmacy Education. Am J of Pharm Ed. 2010; 74 (10) Article 184. Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 7 Appendix Vignette with High Consensus for Investigation: Misleading Claims of Treatment Outcomes of a Product on Pharmacist Web Site “Maybe considered unprofessional conduct by making false claims.” Vignettes with Moderate Consensus for Investigation: Depicted Alcohol Intoxication Online: Image of Pharmacist Intoxicated with Alcohol Posted to SNS “Possible impairment issue.” “At a minimum a request to the PharmAssist committee to look into it.” “Would investigate for possible substance abuse and his ability to perform his duties as a pharmacist after "partying".” Depicted Use of Alcohol Without Intoxication Online: Image of Pharmacist Holding Alcoholic Beverages Posted to Social Networking Site “It even appears to be in the pharmacy.” “They are "drinking" in the pharmacy, very inappropriate, would be considered unprofessional and we would investigate the pharmacist-in-charge for allowing this activity in the pharmacy area.” Patient Confidentiality (Online Images): Images of Patient Posted to Web Site Without Explicit Consent “Possible violations of patient confidentiality as it may be construed that patient is receiving "medical treatment" and therefore is considered confidential.” Misrepresenting Board Certification on Pharmacist Web Site “He would have had to have represented himself with those credentials on an official Board Licensure Document.” “We had one of these where the pharmacist had let it drop and no longer kept up the CE.” “Although board certification is not a license requirement, may still refer for investigation to determine if pharmacist aware of his "false" credentials and that it may be considered "unprofessional conduct' to "advertise" false information.” Vignettes with Low Consensus for Investigation: Discriminatory Speech Online: Narrative Expressing Discrimination Posted to Social Networking Site “Would need more information.” “Just checking as all patients deserve respect.” “Does not clearly identify a specific patient.” Discriminatory Speech Online: Narrative Expressing Disrespect for Patients “General bad behavior, but perhaps not actionable.” “Does not clearly identify a specific patient.” Patient Confidentiality: Narrative of Patient Encounter with Potential Identifiers “Possible confidentiality concern.” “Confidentiality Regulation in our state.” “Although it appears to be "unprofessional" for a pharmacist to "blog" about his/her patients, it is unlikely that this would trigger an investigation only because the pharmacist does not clearly identify the patient. Patient assumes pharmacist is referring to her.” Patient Confidentiality: Narrative of Patient Encounter with No Identifiers “As in the first case, appears that "confidentiality" may be an issue, however, again, since the pharmacist did not specifically identify the patient, unlike it would trigger an investigation.” Inappropriate Communication with Patients: Use of Online Dating Site to “Chat” With Patient “Need more information.” “Possible abuse of the patient pharmacist relationship.” “Appears to be inappropriate, would refer for investigation for possible unprofessional conduct since I'm not sure how many other persons are able to read this "chat" so pharmacist disclosing possible confidential information.” Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 8 Figure 1. Vignette with high consensus for investigation. Misinformation on Pharmacist Web Site: Misleading Claims of Treatment Outcomes of a Product on Pharmacist Web Site “The daughter of a cancer patient contacts your board regarding statements made by her mother’s pharmacist on his business website. She claims the pharmacist misled her mother about the potential benefits of his products. On the pharmacist’s website, you discover claims such as: “With my compounded products, I can cure your cancerguaranteed!” Figure 2. Vignettes with moderate consensus for investigation. Depicted Alcohol Intoxication Online A concerned patient reports her pharmacist frequently describes “partying” on his MySpace page which is accompanied by images of himself intoxicated such as the one below: Depicted Use of Alcohol Without Intoxication Online A concerned patient reports that her pharmacist posted pictures of herself drinking at a hospital pharmacy holiday party on Facebook: Misinformation on Pharmacist Web Site: Misrepresenting Credentials A concerned hospital administrator contacts your board about credentials of a pharmacist requesting privileges at his hospital. He reports that the pharmacist’s business website claims that the pharmacist is a “Board Certified Pharmacotherapy Specialist”, even though the pharmacist has only been practicing for one year. You decide to check and discover that he is NOT board certified. Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 9 Patient ConfidentialityOnline Images A patient reports that images of him receiving a vaccine were posted on his pharmacist’s website, in a promotional manner for the pharmacy, without his consent: Figure 3. Vignettes with low consensus for investigation. Derogatory Speech Online: Narrative Expressing Disrespect for Patients A concerned patient reports disrespectful language on a pharmacist’s blog: “I can’t believe how stupid my patients are sometimes. For example, I saw this guya real jerkwho keeps coming back to the ER over and OVER again with high blood sugar levels. He refuses to take his insulin, watch his diet, or take care of himself. I guess he feels entitled to emergency care at someone else’s expense just because he’s lazy and ignorant. In the last month, he’s been to the Emergency Room EIGHT times which has led to FIVE inpatient admissions. How stupid can you be? And the worst part is I know he’ll be back next week with the same problem and I’ll have to smile and go through the same motions with him!” Discriminatory Speech Online: Narrative Expressing Discrimination A concerned staff member at a local hospital reports discriminatory language on a pharmacist’s Facebook page: “I saw this homosexual patient at the pharmacy today who came in complaining of dysuria and wants me to help. Well... that’s what you get for being gay. I really don’t feel any compassion for these peoplethey don’t deserve antibiotics, they need to change their behaviors.” Patient Confidentiality: Narrative of Patient Encounter with Potential Identifiers A concerned patient reports content posted on a pharmacist’s blog describing clinical encounters: “Yesterday I saw my patient, Mrs. S, a silver-haired woman in her 40’s who came to my pharmacy complaining of burning urination. After further questioning, it turns out Mrs. S has been having an affair but, unfortunately, she doesn’t want to have HIV testing. This really frustrates me as a pharmacist because Mrs. S is a healthcare worker at our local hospital, so her husband and those patients could be affected by her HIV status.” Patient Confidentiality: Narrative of Patient Encounter with No Identifiers A concerned patient reports content on a pharmacist’s blog describing clinical encounters: “Sometimes I see patients who make decisions that adversely can affect both their health and the health of others. For example, I had a patient once who was concerned about STD’s but would not consent to HIV testing. He was married and also a healthcare worker so his decision to refuse testing frustrated me as a pharmacist.” Inappropriate Communication with Patients Online A concerned patient reports possibly inappropriate contact initiated by a pharmacist through a “chat” feature of an online dating site: “RPh1971: Hi there, remember me? I took care of you at Gooden Pharmacy a few weeks ago. SuzieQ: Oh, hiof course I remember you! RPh1971: Well we don’t need to wait for your next refill to see each other again. What are you doing this weekend? Want to meet up for a drink?” Original Research PHARMACY PRACTICE http://z.umn.edu/INNOVATIONS 2013, Vol. 4, No. 3, Article 125 INNOVATIONS in pharmacy 10 Table 1: Board of Pharmacy Demographics (n=14) Characteristic Response Rate (n) % NABP District / State or Territory District 1 Connecticut, Maine, Massachusetts, New Brunswick, New Hampshire, Nova Scotia, Quebec, Rhode Island, Vermont District 2 Delaware, District of Columbia, Maryland, New Jersey, New York, Ontario, Pennsylvania, Virginia, West Virginia District 3 Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, Puerto Rico, South Carolina, Tennessee, US Virgin Islands District 4 Australia, Illinois, Indiana, Michigan, Ohio, Wisconsin District 5 Iowa, Manitoba, Minnesota, Nebraska, North Dakota, Saskatchewan, South Dakota District 6 Arkansas, Kansas, Louisiana, Missouri, Oklahoma, Texas District 7 Alaska, Alberta, British Columbia, Idaho, Montana, Oregon, Washington, Wyoming District 8 Arizona, California, Colorado, Guam, Hawaii, Nevada, New Mexico, New Zealand, Utah 0