Electronic Health Records and Physician Burnout

This assignment examines the effects of electronic health records (EHRs) on physicians, including burnout, job satisfaction, and clinical performance. It also discusses the use of medical scribes in healthcare settings and the potential benefits of EHRs in improving quality and efficiency. Additionally, it reviews studies on the impact of EHRs on exam room communication skills and patient care outcomes.

Impact of Electronic Health Record on Physician Productivity, Provider Burn Out and
solutions for the future
Paul Labeodan
University of Illinois at Chicago

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Abstract
One of the major technological advancements in the healthcare domain is Electronic
Health Records. In spite of the benefit of Electronic Health Records, there is an imbalance in
its implementation. Increased rates of documentation and regulatory requirements have led to
physician burnout and dissatisfaction. The aim of this paper is to analyze the impact of
electronic health records in practice management of physicians in hospital settings. The paper
will discuss strategies that will be helpful to address these issues while increasing quality of
care. In order to perform this research, the research will employ thematic analysis of data
and, based on the evolved theme, the research will try to draw the best possible conclusion.

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Table of Contents
Introduction................................................................................................................................3
Methodology..............................................................................................................................5
Literature Review.......................................................................................................................6
EHRs and its healthcare implications....................................................................................6
EHRs and physicians’ burnout...............................................................................................7
EHRs and physicians productivity.........................................................................................9
Barriers in acceptance and implementation of EHRs..........................................................10
Conclusion and Recommendation............................................................................................13
References................................................................................................................................15

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Introduction
Promotion, adoption and application of health information technology (HIT), is one of the
major priorities among the U.S. health policy makers. It is regarded as an important medium
of managing the healthcare costs and quality. The U.S. started adopting Electronic Health
Records (EHRs) during the challenging economic times in the U.S. hospitals (Jha, 2010).
During the tenure of 2008-2009, basic and comprehensive adoption of EHRs increased
substantially. The electronic medical record (EMR) or electronic health record (EHR) is
regarded as an integral part of hospital-based patient care (Babbott et al., 2013). EMR and
EHR implementation has significantly increased in the past years. A basic electronic health
record includes demographics of the patient, list of problems, clinical notes, medication list,
prescription printing, and laboratory test results and radiology reports. Comprehensive EHRs,
which are fully functional, also contain medical history of the patient, a detailed illustration
of the follow-up notes, ordering reports of medicines and laboratory tests, latest prescriptions,
electronic images and other clinical decision support tools (Babbott et al., 2013). The
majority of the hospitals, however, did not employ the required standards needed to
implement EHRs in the hospital setting in a comprehensive manner (Babbott et al., 2013).
According to Jha (2010), the EHR is beneficial, but imbalance in proper implementation has
led to physician burnout arising from increased regulatory requirements and documentation.
According to Shanafelt, Dyrbye, Sinsky, Hassan, and Satele (2016), EHRs have increased the
workload of the doctors as they are now forced to spend extra time in documenting the
information electronically under the strict scrutiny of hospital policies. This is turn
hasreduced the time in hands-on patient interaction.
The aim of this paper is to measure the impact of EHRs in administrative management
and physicians’ productivity under hospital settings. The paper will also try to shed light on

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possible recommendations in optimal implementation of the EHR for increasing physicians’
productivity and quality care to the patent.

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Methodology
The search of the literature was done in the databases PubMed, Medline and Embase
(from 2010 to 2018). The literature search was based on the use of broad keywords. The main
keywords used for the Boolean literature search include electronic health records (EHRs),
electronic medical records (EMRs), EHRs AND physician burnout OR physician
productivity, EHRs AND application, EHRs AND impact, EHRs AND barriers, EHRs AND
application, EHRs AND patient. The main inclusion criteria included for the search of the
research articles included studies that were published on or after 2010 and are available in
English. The search was not limited by size of the trial and type. The studies dealing with the
genetic studies in association with EMRs or EHRs, mobile-based encryption, role of
information technology in EMRs and EHRs were excluded from the search since those were
out of scope of the aim of the research. In the inclusion criteria, surveys, systematic reviews
and meta-analysis were chosen because aim of this review is to provide a comprehensive
picture of EMRs or EHRs in holistic patient care and physician burnout.

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Results
The keyword search identified 100 papers. These papers were again scrutinized based
on the title of the research and 50 articles were found to be significant. These 50 papers were
again reviewed based on their abstract and out of those, 30 were found relevant. These 30
research papers were read thoroughly and only 20 papers coincided with the scope of the
review. Study of the research papers led to the generation of four themes. These themes will
help to generate a comprehensive scenario of EMRs or EHRs.
EHRs and their Healthcare Implications
The Health Information Technology for Economic and Clinical Health (HITECH) Act
of 2009 was passed in order to support the diffusion of health information technology
towards improvement of patient care. HITECH then established national EHRs certification
campaign to certify the capacity of EHRs to satisfy the meaningful use requirements of
healthcare systems (King, Patel, Jamoom & Furukawa, 2014).EHRS are now increasingly
becoming a popular medium for accessing patient’s health-related information (Haas,
Wohlgemuth, Echizen, Sonehara, & Müller, 2011). The survey conducted by King et al.
(2014) showed that 8 out of 10 physicians were satisfied with the application of EHRs
towards enhanced care. The majority of the physician who took part in the survey (81%)
reported that use of EHRs helped them to access the detailed health history of the patients
remotely. Nearly 65% physicians opined that application of EHRs alerted them to potential
medical error. Of the physicians surveyed, 62% believed that EHRs helped alert them to
critical laboratory values while providing clinical benefits (King, et al., 2014).Bowman
(2013) opined that clinical decision-making supported by EHRs results in errors. These errors
arise out of system performance issues, software design flaws, poor decision support rules
and inadequate user training. Application of decision support systems may generate errors of

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omission, as individuals might overlook crucial information because the automated system
does not allow them to notice the same. It may also cause errors of commission; for example.
Individuals act as per the commands of the system even when it goes against their training or
other available source of information. This type of error is known as “automation bias”
(Bowman, 2013). According to Silow-Carroll, Edwards, and Rodin (2012), EHR systems
helped healthcare professionals to store and retrieve patient information in detail. This
information is useful for the both the healthcare professionals and patients during the time of
patient’s hospitalization, over the time of hospital stay, and across care settings; however,
Haas et al., (2011) is of the opinion that the remote access of patient data by numerous
healthcare professionals, including hospitals administration, signifies that patient's medical
data can lose confidentiality. This loss of data is caused via inappropriate handling of EHRs
by the non-medical staffs (maintenance staffs) of EHRs (Haas et al., 2011). Embedded
clinical decision support and other tools of EHRs have the significant potential to assist the
physicians to procure safe and effective care plans, which are otherwise not possible relying
on the human memory and paper-based systems. Moreover, EHRs also help hospitals to
monitor, improve, and report information on healthcare safety and quality (Silow-Carroll et
al., 2012).
EHRs and Physician Burnout
According to Shanafelt et al. (2012) and Shanafelt et al. (2015)., more than half of the
physicians in US are now suffering from physician burnout and this rate of burnout is higher
than in any other profession in U.S. Shanafelt et al. (2012) has cited both organizational and
individual factors responsible for this burnout. According to O’Malley, Grossman, Cohen,
Kemper, & Pham (2010) and Holden (2011), the majority of doctors have highlighted that the
maintenance of electronic patient portals, prescribing medicines and computerized physician
order entry (CPOE) are few of the leading cause of work overload, concentration distraction,

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which ultimately leads to burnout. Zhou, Kanter, Wang, and Garrido (2010)have opined that
the concept of EHRs has been introduced in order to bring technological advancement in
quality of care and patient safety; however, implementation of EHRs has increase the clerical
burden on the physicians (Dyrbye,West, Burriss, & Shanafelt, 2012; Palen, Ross, Powers,
&Xu, 2012). Dyrbye et al. (2012) have further opined that application of EHRs has created a
huge change in the patient-physician interaction along with potential distraction of the
physicians from more meaningful aspects of medical practice. In the majority of hospitals,
EHRs have been implemented in order to eliminate transcription services, while introducing
physician self-entry of notes via typing or voice recognition software. All these changes have
paved the way towards an increase in burnout among the physicians, as they are now forced
to spend more time in clerical documentation in comparison to critical analysis of patient’s
condition (Shanafelt et al., 2013). The study undertaken by Shanafeltet al. (2016) revealed
that physician satisfaction with EHRs is significantly low. . While a later study conducted by
Shanafeltet al. (2016) further revealed that physicians reported widespread dissatisfaction
with the clerical burden associated with EHRs,, studies conducted by Black et al. (2011),
showed that EHRs help in improving patient outcomes, but the evidence is inconclusive. The
systematic review conducted by Shultz and Holmstrom (2015) revealed that application of
EHRs help in the improvement of patient outcome, along with increase in the hourly volume
of patients attended. Shultz and Holmstrom (2015) further highlight that the implementation
of EHRs and subsequent usage must be done under the active support of trained nurses who
clear the messages of the patient's portal and perform other electronic communication. The
research undertaken by Taft, Lenert, Sakaguchi, Stoddard, and Milne(2014) have reported
that younger physicians are generally more flexible with adapting to the new technologies in
the work system and provide a satisfactory grade towards the comprehensive implementation
of the EHRs in comparison to the older physicians. Nonetheless, younger physicians have

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also reported the increase in the clerical workload while implementing EHRs in association
with its advantage to the overall patient outcome (Taft et al., 2014). The research conducted
by Heyworth et al. (2012) revealed that interventions that are employed to expand EHRs
should consider additional support for practices and ensure ease of optimal implementation of
EHRs. Heyworth et al. (2012) have further opined that adoption of EHRs may be an
alleviating factor for physician stress and hence, addressing physicians’ satisfaction before
the implementation of the practice transformation, while anticipating greater dissatisfaction
among the physicians, will be crucial. This will help in retaining the physician workforce,
while ensuring the quality of care they deliver to their patients (Heyworth et al., 2012).
According to the reports published by Babbott et al. (2013), an increase in stress associated
with moderate use of EHRs is the principal reason behind the physician burnout. Their first
findings indicate that primary care doctors who are employing a moderate number of
applications with EHRs suffer from more job stress and less percentage of job satisfaction in
comparison to that of the physician with a low number of EHR functions. Babbott et al.
(2013) cited that hybrid systems made up of EHRs and paper require physicians to handle
two different processes, leading to confusion in tracking the orders and patient summaries.
Moreover, handling two workflows simultaneously makes it difficult for the physician to
manage time (Babbott et al., 2013).
EHRs and Physician Productivity
Physician productivity is an important yet understudied factor in the U.S. healthcare
system. The productivity of physicians critically affects numerous aspects of healthcare
starting from patient access to care, the cost of care, patient and physician satisfaction and
quality of care (Bank & Gage, 2015). Numerous factors adversely affects physician
productivity including overwhelming applications of EHRs. EHRs increase the volume of
data collected from the patient such that the doctors in the emergency department are required

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to spent significant amount of time in data entry. This results in physician burnout, which
ultimately hampers the physician's productivity (Bank & Gage, 2015). Bank and Gage (2015)
proposed some strategies that might be considered to be helpful to improve the productivity
of the physician, and this includes recruitment of physician extenders like nurses or
physician's assistants and optimal implementation of clinical pathways. As an example,
physicians using scribes saw a rise in productivity, as it was found that they were able to see
10% more patients within their eight hours of scheduled clinic time. The survey conducted by
Farooq, Landi, Rahmanian and Rao (2017) showed that seven out of ten physicians believed
that EHRs reduce their productivity. Deloitte 2016 survey further revealed that the majority
of the physicians are of the opinion that EHRs are useful in the domain of analytics and
reporting capabilities in comparison to other attributes like improvements towards the clinical
outcomes and supporting value-based care. Deloitte's survey also stated that the satisfaction
of the physicians in the domain of EHRs varies with the practice characteristics. The
employed physicians in comparison to independent physicians are more likely to ascertain
that EHRs support the exchange of the clinical data, thereby assisting to improve the overall
clinical outcomes (Farooq, Landi, Rahmanian & Rao 2017). The survey also revealed that
physicians who practiced independently are more likely to ascertain that EHRs reduce the
productivity in comparison to the employed physicians. Moreover, independent physicians
think that EHRs increase the cost of practice in comparison to employed physicians (Farooq,
Landi, Rahmanian & Rao 2017).
Barriers in Acceptance and Implementation of EHRs
Silow-Carroll et al.(2012)are of the opinion that despite of the overwhelming utility of
EHRs, the hospitals and the healthcare units were initially reluctant to adopt them. A survey
conducted by American Hospital Association (AHA) members in the year 2009 found that
only 1.5%of the hospitals had installed a comprehensive EHR system. Comprehensive EHRs

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signifies that the system is capable of performing 24 different functions and was employed in
all clinical units. Silow-Carroll et al.(2012) also reported that another 7.6% of hospitals had
employed an EHR in at least one of its clinical unit. Two other hospital leaders highlighted
the startup and maintenance costs as the two principal barriers towards comprehensive
adoption of EHRs (Silow-Carroll et al.,(2012). The study conducted by King et al. (2014)
further hypothesized that the healthcare professionals who are more likely to perceive EHRs
as nurturing clinical benefits are more in favor of adopting optimal application of EHRs at an
earlier point of time. The research carried by Rao et al. (2011) revealed that among the
physicians who practice in small practices are less likely to adopt all the electronic functions
that are the integral part of the electronic health records. The main areas in which these
physicians lag include ordering radiologic tests, taking electronic clinical notes and electronic
prescribing. Moreover, the reports also revealed that the physicians who have adopted the
EHRs suffer from huge gaps in individual levels of understanding the EHR (Rao et al., 2011).
Another important barrier towards the successful adoption of the electronic health record is
the financial constraints. The comprehensive installation of the EHRs demands significant
amount of expenditure. According to Raoet al. (2011), physicians who practice in small
offices are likely to suffer from the lack of financial support and, hence, the EHRs sold to
them are lower in capability and, hence, devoid of required advanced program. Moreover, the
large vendors mostly target the larger hospital practices as their perspective customers; thus
the physicians in small offices are neglected, creating barriers towards spontaneous
acceptance. According to Raoet al. (2011), physicians who practice in small groups care the
majority of the Americans. Hence, lack of proper EHRs use among the physicians causes a
significant set back in quality of care and optimal implementation of EHRs. According to the
study published by McGinn et al. (2011), healthcare professionals and physicians suffer from
lack of adequate time, which is the prime barrier towards successful implementation of the

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EHRs. McGinn et al. (2011) further reported that application of EHRs lead to the change in
the mode of instruction among the physician and the patients. The majority of the clinicians
who took part in the survey conducted by McGinn et al. (2011) stated that EHRs demand
rigorous interaction with the technology and this hampers both physical and relational contact
with the patients. These change in the dimension of the relationship between the physician
and the patients’ acts as a barrier towards optimal implementation and acceptance of the
EHRs in the hospital setting. Other factors that create a barrier towards optimal
implementation and adoption of EHRs include absence of computer skills. According to
Ajami and Bagheri-Tadi (2013), the providers of EHRs tend to underestimate the bar of
computer skills required from the healthcare professionals, while the system is not only
viewed as, but in practice is actually, very complex to operate by the physician. Moreover, a
majority of the physicians also lack good typing skills, which eliminates much of their
valuable time documenting the data in the electronic setup, leading to burnout and barriers
towards acceptance.

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Conclusion and Recommendation
It canbe summarized that the present study chronicles a widespread evolution of
electronic health records in the U.S. healthcare environment and its effect on the physician’s
productivity and burnout. The majority of the physicians reported dissatisfaction with the
clerical burden interlinked with the application of the EHRs. Increased documentation tasks
like data entry of patient health history, medicine order history, reviewing laboratory results
electronically and communicating with the patients online generate huge workloads.
Moreover, due to this increased workload, the physicians fail to practice main job role in a
comprehensive manner and this in turn hampers the physician-patient relationship, leading to
the development of physician burnout. Thus, numerous positive effects of EHRs in the
medical practices are overshadowed under the high rate of physician burnout and physician
dissatisfaction, and this prevents optimal adoption and implementation of the EHRs in the
hospital setting. For EHRs to have a positive impact on the safety of the patient and quality
care, the clinicians are required to use this system effectively after it is made available to
them. By considering the factors highlighted in the study, it should be possible to improve the
ability of the physicians to effectively adopt EHRs. Increases in the adoption and
implementation of EHRs can be achieved by providing proper training to doctors in the
domain of effective handling of EHRs. Other strategies that can be used to improve the
physician productivity include employment of physician extenders like nurse practitioners
and physician assistants. Other additional strategies that can be employed to increase the
physician productivity include application of medical scribes. Medical scribes are basically
trained assistants who are capable of performing multiple tasks under the constant
supervision of the physicians during the process of a patient’s care. Increasing the physician’s
productivity will help to decrease physician burnout, dissatisfaction, and this, in turn, will

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help to improve the quality of care. This drive towards substantial gains in the efficiency and
quality of the healthcare by simply adopting EHRs is likely to be inadequate. Instead, proper
policies are required to implemented that encourage the application of the EHRs under proper
training and guidance. This will lead to improvement in care.

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References
Ajami, S., & Bagheri-Tadi, T. (2013). Barriers for adopting electronic health records (EHRs)
by physicians.Acta Informatica Medica,21(2), 129. doi:10.5455/aim.2013.21.129-134.
Babbott, S., Manwell, L. B., Brown, R., Montague, E., Williams, E., Schwartz, M., ...&
Linzer, M. (2013). Electronic medical records and physician stress in primary care:
results from the MEMO Study.Journal of the American Medical Informatics
Association,21(e1), e100-e106.
Bank, A. J., & Gage, R. M. (2015).Annual impact of scribes on physician productivity and
revenue in a cardiology clinic.ClinicoEconomics and Outcomes Research: CEOR,7,
489.doi:10.2147/CEOR.S89329
Black, A. D., Car, J., Pagliari, C., Anandan, C., Cresswell, K., Bokun, T., ...& Sheikh, A.
(2011). The impact of eHealth on the quality and safety of healthcare: a systematic
overview.PLoS Medicine,8(1),
e1000387.https://doi.org/10.1371/journal.pmed.1000387
Bowman, S. (2013).Impact of electronic health record systems on information integrity:
quality and safety implications. Perspectives in Health Information
Management,10(5).
Deloitte 2016 Survey of US Physicians. Findings on health information technology and
electronic health records. Access date: 13th April. Retrieved from:
https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-
care/us-lshc-physician-survey-hit-factsheet.pdf

16
Dyrbye, L. N., West, C. P., Burriss, T. C., & Shanafelt, T. D. (2012). Providing primary care
in the United States: the work no one sees.Archives of Internal Medicine,172(18),
1420-1421.doi:10.1001/archinternmed.2012.3166
Farooq, F., Landi, W. A., Rahmanian, F., & Rao, B. (2017). System and Method for
Identifying Inconsistent and/or Duplicate Data in Health Records. U.S. Patent
Application No. 15/394,232.
Haas, S., Wohlgemuth, S., Echizen, I., Sonehara, N.,& Müller, G. (2011). Aspects of privacy
for electronic health records.International Journal of Medical Informatics,80(2),
pp.e26-e31.doi:10.1016/j.ijmedinf.2010.10.001
Heyworth, L., Zhang, F., Jenter, C. A., Kell, R., Volk, L. A., Tripathi, M., … Simon, S. R.
(2012).Physician satisfaction following electronic health record adoption in three
Massachusetts communities. Interactive Journal of Medical Research,1(2),
e12.http://doi.org/10.2196/ijmr.2064
Holden, R. J. (2011). Cognitive performance-altering effects of electronic medical records:
An application of the human factors paradigm for patient safety. Cognition,
Technology & Work,13(1), 11-29. doi:https://doi.org/10.1007/s10111-010-0141-8
Jha, A. K. (2010). Meaningful use of electronic health records: the road
ahead. Jama, 304(15), 1709-1710.
King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014). Clinical benefits of electronic
health record use: national findings.Health Services Research,49(1pt2), 392-404.doi:
10.1111/1475-6773.12135
Landi, H. (2016, October 3). Physician survey: EHRs increase practice costs, reduce
productivity. Annals of Internal Medicine. Retrieved from https://www.healthcare-

17
informatics.com/news-item/ehr/physician-survey-ehrs-increase-practice-costs-little-
improvement-clinical-outcomes
McGinn, C. A., Grenier, S., Duplantie, J., Shaw, N., Sicotte, C., Mathieu, L., ... & Gagnon,
M. P. (2011). Comparison of user groups' perspectives of barriers and facilitators to
implementing electronic health records: a systematic review.BMC Medicine,9(1), 46.
https://doi.org/10.1186/1741-7015-9-46
O’Malley, A. S., Grossman, J. M., Cohen, G. R., Kemper, N. M., & Pham, H. H. (2010). Are
electronic medical records helpful for care coordination? Experiences of physician
practices.Journal of General Internal Medicine,25(3), 177-
185.https://doi.org/10.1007/s11606-009-1195-2
Palen, T. E., Ross, C., Powers, J. D., &Xu, S. (2012). Association of online patient access to
clinicians and medical records with use of clinical
services.JAMA,308(19).doi:10.1001/jama.2012.14126
Rao, S. R., DesRoches, C. M., Donelan, K., Campbell, E. G., Miralles, P. D., &Jha, A. K.
(2011). Electronic health records in small physician practices: availability, use, and
perceived benefits.Journal of the American Medical Informatics Association,18(3),
271-275. doi:10.1136/amiajnl-2010-000010
Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., ...&Oreskovich, M.
R. (2012). Burnout and satisfaction with work-life balance among US physicians
relative to the general US population.Archives of Internal Medicine,172(18), 1377-
1385.doi:10.1001/archinternmed.2012.3199
Shanafelt, T. D., Gradishar, W., Kosty, M. P., Satele, D., Chew, H. K., Horn, L., ...& Pippen,
J. E. (2013). Burnout and career satisfaction among US oncologists: Results of the

18
2012 ASCO survey. Retrieved from:
http://ascopubs.org/doi/abs/10.1200/jco.2013.31.15_suppl.6533
Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P.
(2015, December).Changes in burnout and satisfaction with work-life balance in
physicians and the general US working population between 2011 and 2014.Mayo
Clinic Proceedings,90(12), 600-
1613.doi:https://doi.org/10.1016/j.mayocp.2015.08.023
Shanafelt, T., Dyrbye, L., Sinsky, C., HAssan, O., &Satele, D. (2016).Relationship between
clerical burden and characteristics of the electronic environment with physician burnout and
professional satisfaction.Mayo Clinic Proceedings,91(7), 836–848.
https://doi.org/10.1016/j.mayocp.2016.05.007
Shultz, C. G., &Holmstrom, H. L. (2015).The use of medical scribes in healthcare settings: A
systematic review and future directions.The Journal of the American Board of Family
Medicine,28(3), 371-381. Retrieved from:
http://www.jabfm.org/content/28/3/371.short
Silow-Carroll, S., Edwards, J. N., & Rodin, D. (2012). Using electronic health records to
improve quality and efficiency: The experiences of leading hospitals. Issue Brief
(Commonwealth Fund),17(1), 40.
Taft, T., Lenert, L., Sakaguchi, F., Stoddard, G., & Milne, C. (2014). Effects of electronic
health record use on the exam room communication skills of resident physicians: A
randomized within-subjects study. Journal of the American Medical Informatics
Association,22(1), 192-198. https://doi.org/10.1136/amiajnl-2014-002871

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Zhou, Y. Y., Kanter, M. H., Wang, J. J., & Garrido, T. (2010).Improved quality at Kaiser
Permanente through e-mail between physicians and patients. Health affairs,29(7),
1370-1375.https://doi.org/10.1377/hlthaff.2010.0048