Ethical Considerations Regarding Internet Searches for Patient Information

The quality of data that one obtains via the Internet is highly variable. Anyone seeking information on the Internet needs to be aware that information can be posted by almost anyone and under such multitudinous circumstances that each item of information needs to be assessed carefully for its reliability and authorship (14). Most physicians are aware that negative reviews can be posted about them by people who are not patients associated with their practice.

Nonetheless, there are some potential benefits from seeking out information via the Internet. Appelbaum and Kopelman (16) and others (4, 15) have noted that it may be a useful source of collateral information. For example, evidence suggests that many individuals (particularly adolescents and young adults) are remarkably open about mental health symptoms on social media (17, 18). Appelbaum and Kopelman (16) also endorsed the possibility that research might be conducted via the Internet, although concerns about informed consent and protection of human subjects (12), as well as the quality of data utilized for research, remain prominent.

DeJong et al. (19) have noted several problems with data acquired via the Internet, including lack of nonverbal cues, the context of the narrative, the fact that the context may be fluid or changing, the fact that Internet data are often posted with little reflection and represent impulsive communications, that people may be using the Internet to role-play (also noted by Appelbaum and Kopelman [16]), and that other important information may be totally lacking. Another concern is the possibility that Internet data linked to a particular name may be related to an individual other than the patient (20). If the patient’s name is common, searching for additional identifiers (e.g., a unique e-mail address) may be helpful (21).

If the psychiatrist keeps in mind the limitations of Internet- and social networking–based data, this information can be useful in supplementing traditional sources of clinical information, provided it is gathered and interpreted with the patient’s best interests at heart.

Special considerations may arise in the context of a forensic evaluation (4, 21, 22). Researchers have noted the existence of Web sites containing mug shots and sex offender registries (15). Finding an evaluee’s name on such a list may help to establish important areas for inquiry in the forensic assessment or further research. Similarly, checking a criminal database, such as ordering a Bureau of Criminal Investigation search, may be appropriate in forensic evaluations in which the psychiatrist needs more information to inform an assessment of dangerousness.

Before relying on any information obtained through a targeted Internet search, however, the psychiatrist should make reasonable attempts to corroborate the information (11).

The Internet and social media have contributed to a “blurring of boundaries between social and professional spheres” (16) that can pose special ethical challenges for psychiatrists and other mental health professionals. In the traditional setting of care, evaluation and treatment occur within the confines and context of a private conversation between the psychiatrist and the patient. In some circumstances, a patient may allow the physician to exchange information with important third parties, such as close relatives. However, boundary issues may arise when communication with third parties is conducted through electronic means (e.g., via instant messaging software or videoconferencing chats). Providers should be extremely careful in those circumstances with respect to HIPAA rules and technological safeguards (23).

Many individuals use privacy tools on social networking sites, such that only one’s “friends” or persons categorized as “friends of friends” may view content posted on a person’s profile. Sending a patient a “friend request” in order to gain access to this more personal information arguably represents a departure from traditional clinical ethics and should be avoided unless compelling circumstances justify such a drastic boundary crossing.

People may embrace different values with regard to an investigation of their presence in social media and on the Internet (24, 25). Some patients might assume that a treating psychiatrist will review their Facebook page and other Internet presence, whereas others may be quite offended by such an action. In the absence of an emergency, it would likely be inappropriate for a treating physician to conduct an Internet search on a patient without the patient’s informed consent to the search. Asay and Lal (26) and Tumolo (5) have opined that it might be extremely useful in building a therapeutic relationship with the therapist or physician to inquire about Internet and social media activity, particularly with adolescents. Others have cautioned that pecuniary motivations, voyeurism (12, 20), clinician bias development (20, 27), and other negative motivations need to be examined (28). Among graduate students in counseling and psychology, trainees who performed targeted online searches for client information indicated that curiosity was the most common reason for the search (29). Other studies have found that psychiatrists and other mental health professionals have also participated in Internet searches of their patients motivated by curiosity.

When an Internet search on a patient is unnecessary, such a search may lead to unforeseen boundary problems that may adversely affect the psychiatrist-patient relationship (30, 31).

Clinton et al. (12) have provided an illustrative clinical vignette involving a psychiatrist whose patient claims to be unable to pay his bill. The psychiatrist looks up the patient’s address on Google Maps, discovers it to be a mansion in a wealthy neighborhood, and confronts the patient about it. As it turns out, the patient is renting a small room in the building in exchange for performing manual labor on the property, and the confrontation severely damages the doctor-patient relationship. The vignette illustrates the complexity of boundary problems that might arise in relation to Googling a patient or researching the patient online.

Kolmes and Taube (7) suggest that patient-targeted research on social media could help mental health professionals to determine the social proximity of a patient without compromising the patient’s privacy or confidentiality. Through tools such as Facebook, for example, it may be possible to find reassurance that one’s patient is not within one’s own social circle without, for example, mentioning the patient’s name to a colleagues or friends. In this respect, patient-targeted Internet searches could be used to identify potential future boundary problems. This does not, however, address the problem of what happens should the mental health professional come across sensitive information about the patient in the course of the search.

In the event of an emergency or other safety issue, the Internet may be a useful tool (32). One of the earliest reports in the literature about researching patients online described a case in which an undisclosed previous suicide attempt was discovered when the resident writing a clinical note decided to Google the patient and found a news item about the patient’s serious attempt several months earlier (15). In the case of an unresponsive or uncooperative patient (e.g., catatonia), searching the patient’s Internet presence or social media activity may enable clinical staff to locate the patient’s relatives for information about drug allergies and current medications (18). Internet and social media data may also allow the clinician to identify the need for emergency assessment or treatment, such as when the psychiatrist is informed that a patient has posted content online that suggests homicidal or suicidal ideation (30, 33). There may also be legitimate safety considerations for performing an Internet search for clinical data about a patient, such as when the psychiatrist hopes to confirm suspected relapse of substance abuse in a recalcitrant patient (20). In all emergency situations necessitating an online search, the psychiatrist must be aware of the limits of the search and should stop the search once the information being sought is obtained.

Information associated with the patient via social media may aid a physician in complying with a Tarasoff-type duty. For example, if the patient discloses an intention to harm his girlfriend, but the psychiatrist knows only the girlfriend’s first name, examining the patient’s Facebook profile might reveal her full name and possibly even her contact information.

Before conducting a search of social media or other Internet content for information about a patient, the psychiatrist should be familiar with all applicable laws regarding mandated reporting (14), such as for suspected child abuse or neglect.

Some types of searches may be expected from the standpoint of safety and liability. In many jurisdictions, physicians are required to check a state-sponsored database (prescription monitoring programs or prescription drug monitoring programs [PDMPs]) when prescribing certain controlled substances, so as to be aware of all controlled medications the patient is accessing through different physicians. Furthermore, in most jurisdictions with PDMPs, it is presumed that a physician will check the PDMP database regularly rather than relying solely on patient self-report.

Many areas have electronic health information exchange (HIE) programs that facilitate clinical information sharing among various treatment providers. HIEs are electronic networks accessible by health care professionals, and patients typically control which providers are able to access their health information through the HIE. In areas with centralized HIEs, conducting some patient-directed research through the exchange may be an expected step in prudent clinical practice, not a boundary violation. The central repositories in HIEs are often useful for medication reconciliation, among other clinical tasks.

Similarly, many patients have adopted electronic personal health records, which are often linked through secure patient portals to portions of the electronic health record or electronic medical records maintained by medical professionals (34).

If a psychiatrist locates information about a patient and needs to communicate with the patient or third parties (such as the patient’s family or other treating clinicians) about the content of this information, utmost caution should be exercised with respect to the patient’s privacy and confidentiality. For example, copying and forwarding a direct-link URL to a patient’s social media information in an unsecured e-mail message to the patient’s primary care physician would not be an ideal means of sharing clinical information about the patient. Similarly, if the psychiatrist is engaged in academic research and encounters relevant data online in personal information (e.g., disclosures of abuse or suicidal ideation), such data should be deidentified to the maximum extent possible in any publications and presentations, even if the individual who posted the material did not appear to make extensive use of the Web site’s (or application’s) privacy tools (24).

If the psychiatrist performs an Internet search on a patient and finds publicly available information that may subsequently harm the patient, such a discovery might warrant a discussion with the patient about the importance of protecting one’s privacy online. For example, an adolescent patient or an adult patient with bipolar disorder in a manic state might not exercise caution in protecting personal information through the use of a Web site’s privacy tools. Patients may not consider the likelihood that employers and others might easily access such information; in some cases, it might be appropriate for the psychiatrist to initiate such discussions with patients (20). An oft-cited study of bloggers found that individuals who post content online often have a very specific, limited audience in mind for the material (35). Those who post personal information online often assume, albeit wrongly, that they enjoy some measure of privacy for this material (36), even when privacy controls are not used.

McNary (33) noted the difficult ethical dilemmas that may arise, for example, if a psychiatrist’s search yields information suggesting that a patient receiving disability benefits is malingering. Similarly, if a psychiatrist finds a patient’s (or a patient’s friend’s) statements online to be acutely suicidal, does he or she have an ethical or moral obligation to attempt to help the patient or third party, even if it might increase his or her own risk of liability?

Several commentators have raised the question of whether data found through patient-targeted Googling should be added to the patient’s medical record (12, 33). It is also important to consider whether one should disclose the search to the patient, and if so, how to appropriately do so.

Psychiatrists should be aware that their own social media and Internet presence may become of interest to their patients. Maintaining a professional Internet presence requires skill and attention (28). Some have argued that patients should not be allowed to “friend” or “like” a physician’s personal Facebook account but that allowing patients and their families to follow the doctor’s professional account (e.g., the hospital’s Facebook feed) may be useful. However, the risk of befriending a patient on Facebook includes the temptation to subsequently explore or research the patient’s Facebook information and postings.

Speaking directly with patients is a standard aspect of most clinical medicine. Volpe et al. (37) suggested that conducting digital research on a patient could be used inappropriately as a means of bypassing the personal relationship and direct communication between the clinician and the patient. Several commentators have noted that using social networking sites to collect information about patients can undermine the patient’s trust in the physician and damage the physician-patient relationship in ways that may be harmful to the patient’s future well-being (12, 28, 29, 31, 38). Such searches may signify a psychiatrist’s lack of trust in the patient or a desire to find a shortcut or work-around for important clinical responsibilities, such as direct and open communication with the patient.