I got a message today from a midwife friend (ironically on Facebook) about an issue that is relevant to all professionals who use Facebook. Her dilemma was that her boss wanted her to delete all clients from her Facebook friends because there was a concern about possible HIPAA violations (http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html). She felt that there were many benefits to being Facebook friends with clients and did not want to set up a separate profile to be friends with clients (although that is an option, but will hamper sharing via mobile).

All birth professionals who use social media face the same dilemma – how to safely share not only our lives, but the experiences and resources we come across without violating patient privacy.

I support the argument for having a strong Facebook presence and will give insight for using it effectively by assigning Facebook friends so that you can keep your personal and professional lives separate without having to create separate accounts. I will also address ways to get around the new Facebook promotion that only allows a fraction of your business page fans to view your posts.

Becoming Friends with Clients: As midwives or doulas we create intimate relationships with clients and some of our clients become personal friends. It is always awkward when moving over that line from client to friend (almost like one of you asking the other out on a date), but these lines/boundaries have gotten much looser since the advent of social media.

I agree that being "friends" with clients on Facebook has many benefits and there are a few ways to use Facebook to get the most out of your new connection:

Being Accessible: Using Facebook messenger allows you to become much more accessible to your clients. Email has can be too formal. Paging seems too alarmist. It is nice for clients to be able to send you a message - "Hey, sorry to bother you, but this thing is happening that doesn't feel serious enough to page and I don't know how often the office email is checked, so when you get time, could you please let me know what you think." Important note: You must keep chat off at all times. If you leave chat open, you are too accessible and you will be bombarded with often inappropriate contacts and questions. If there are people in your life you want to chat with, use Skype or IM.

A Facebook message is the perfect middle ground between waiting days for a response to an email, a whole day for a response to a phone call to the office, versus the immediacy of paging for something that is not an emergency. However, some of this depends on the size of your practice. In a group practice, you all have to decide how you want to be contacted. Gonna leave the group dynamics aside for now.

Keeping in touch: The relationship you have with your patient builds during the pregnancy as you see them more frequently, culminating in the intensity of birth and immediately postpartum. Afterwards it often fades away and you both are left feeling a bit sad.

However, with Facebook, you can see their baby grow and maintain contact that continues the relationship even when they are not active clients. This helps with retaining clients for subsequent births and is important for both clients and midwives in maintaining a presence in each other’s lives.

It can also allow you to notice a problem that the client would not have brought to your attention and allow you to intervene. She might share that she is thinking of weaning, for example, and you can private message her and get more details and perhaps help her work through the difficulty and continue breastfeeding or make a plan for weaning. Either way, you can be there with clients even after they are no longer thinking of themselves as clients.

I also use FB to hook up clients with the same problems (with full permission, of course). I have friend suggested women with IGT, GDM, and HTN and they were all incredibly grateful to have others to lean on for support and resources without having to turn to anonymous internet sites.

Remaining compliant with HIPAA: Anything specific enough to identify a particular client cannot be posted without the client's permission. If you only have one client due for the month, then "baby on the way" will be a violation because people could reasonably deduce the mom's identity.

"If you wouldn’t say it in the elevator, don’t put it online.” This is a famous test, probably repeated by compliance departments and trainers at hospitals all over the US. If you wouldn’t say it in the elevator, don’t put it online. You can try speaking your post out loud before hitting the enter key. Take particular care when replying to people in real-time venues like Twitter. You don’t have to respond right away and if you have any doubt at all, ask a friend or colleague for their reaction before you post." (from: http://www.kevinmd.com/blog/2011/06/7-tips-avoid-hipaa-violations-social-media.html)

However, anything vague enough that no reasonable person can deduce the identity of the person or family or anything that you have permission to share is not a HIPAA violation. My FB peeps sometimes try to guess who I am posting about with an incoming baby. I only reveal if the family gives me permission.

Using Facebook Lists: My situation is a little different, because I am the owner of the business, but you can still maintain a separation between personal and professional by utilizing FB lists.

I actually friend request the local women who "fan" the business page. I put them in a list called "Baby Love BC fans" (had to create the list) and when I friend request, I make them "acquaintances" on FB (will get to the details of what list to put them in in a moment). You can do the same when clients friend request you.

I have the opposite problem as you do. I don't want to annoy old college friends with birth related status updates. For this reason I post those types of statuses only to “Baby Love BC Fans”.

If you put all of your real life friends into the list/category "close friends" and all clients into the list "acquaintances", you magically have the option to share a status with "friends except acquaintances".

I have my Facebook peeps divided into "close friends" and "acquaintances" and all of the "acquaintances" are also in the "Baby Love BC fans” list for clients. (This also includes colleagues/birth workers who are not also close friends in real life).

Here is where the magic happens:

I want to tell a funny story about something my husband did. It is not appropriate to share with clients/colleagues. So I share it with "friends except acquaintances". No one who has been placed in the "acquaintance" category will see the post. So no client will see the post.

I find a neat blog post about the dangers of early weaning. No reason to share it with my college buddies or next door neighbors, so I share it with "Baby Love BC fans". My "close friends" will not see the post. It just so happens that everyone who is a "Baby Love BC fan" is also an "acquaintance", but FB does not give you the option to share only with "acquaintances".

Same thing with "baby on the way" or "check in at Baby Love". I only share those with the “Baby Love BC fans”.

One thing to remember. Any post that goes to "friends" will also go to "acquaintances" aka your clients and colleagues who are not also close friends. Unless you choose to post to “friends who are not acquaintances”.

You do have to choose. A Facebook peep cannot be a close friend and also an acquaintance.

Please note that the same options may not be available on your phone. I cannot share with "friends except acquaintances" on my phone (Android), but I can share with “Baby Love BC fans” from my phone.

Business Pages & Promoting Posts: I am so glad that I took the time (set everyone up during one very long labor and now assign them as I add them) because then came the changes to business page postings. Business pages now have to pay to have all of their fans see posts.

I now simply share what I post on the Baby Love business page to "Baby Love BC fans" using my personal profile, increasing the number of fans/acquaintances who see that post.

All of the details about how to assign your current FB peeps to lists, how to create lists, and how to add new peeps to lists: https://www.facebook.com/help/204604196335128/