EHR and Other IT Adoption
Results of a Large-Scale
Nir Menachemi, PhD, MPH; and Robert G. Brooks, MD
A B S T R A C T
Despite a national push toward the adoption of health information technologies, much is
still unknown about the use of IT in physician’s offices.We surveyed all primary care
physicians and a 25 percent stratified random sample of other specialists (total n= 14,921)
in Florida to better understand current trends and factors related to the use of IT in the
ambulatory setting. Data was analyzed using logistic regression modeling techniques to
compute adjusted odds ratios. Covariates included practice size, medical training, practice
type, age, race, and gender. Routine office computer use (80 percent) was found to be very
common for administrative functions. The use of quality enhancing technologies such as
PDAs (37.5 percent), use of e-mail with patients (16.6 percent) and EHR (23.7 percent) was
less common. Overall, large practice size, specialty practice, physician age and gender, and
multi-specialty practice affiliation were significantly related to the use of many, but not all,
of these IT applications in the ambulatory setting.
K E Y W O R D S
■ Ambulatory physician office practice ■ Information technology ■ Electronic health records
Adoption of health information technologies (IT) has would accrue through a variety of mechanisms, which
been heralded as a critical goal of a 21st-century healthcare include ready access to medical records, more efficient test
system. Toward that goal, a national strategic plan for and drug ordering, fewer errors, and improved communica-
accomplishing broad IT adoption has been recently tion between providers. However, before the maximum
outlined.1 benefits can be realized, electronic data will need to be
The goal of broad-scale IT adoption is partly based on pervasively available in all healthcare settings representing
evidence that suggests that IT in healthcare can improve the full continuum of care.
quality2,3,4,5,6 and potentially save money.7,8,9 These benefits Numerous studies in the scholarly literature have
Journal of Healthcare Information Management — Vol. 20, No. 3 79
examined IT utilization in healthcare. These studies, for clarity and readability.
however, have typically focused on the inpatient The most recent list of all physicians (allopathic and
setting,3,10,11,12 where IT has been generally adopted more osteopathic) with a clear and active medical license in
rapidly. Fewer academic studies exist of the ambulatory Florida was obtained from the State Department of Health
setting, where most healthcare is delivered.13,14 Studies of IT for 2004. Those physicians with a practice address outside
use in ambulatory settings that do exist tend to be limited of Florida were excluded.
by relatively small sample sizes,15,16,17,18,19,20,21,22 have a narrow A cover letter and questionnaire was mailed to every
scope,23 for example, by focusing on only one application primary care physician—family medicine, internal medicine,
or technology,15,17,24,25,26,27,28,29 or have a focus on a limited pediatrics, and obstetrics and gynecology—as well as a 25
population, such as physician preceptors,30 members of percent stratified random sample of other specialists.
research networks20 or physicians in a managed care Because the focus of this study was the ambulatory setting,
environment.21 One notable exception is a recent study31 physicians that do not traditionally practice in this setting,
that examined a national representative sample of physi- such as radiologists, pathologists, anesthesiologists, and
cians and their use of IT in 2003, before the recent emergency physicians, were excluded. The cover letter
increased national attention on health IT.1 indicated the purpose of the study and encouraged
While research has identified many trends worth individual physicians to participate. After the first mailing,
monitoring, much is still not understood about the factors surveys that were returned as undeliverable, primarily
that are associated with the use of IT in the ambulatory
setting. To better understand current trends in IT use and
specifically EHR adoption, we conducted a large-scale study
“…much is still not understood
of physicians in Florida. In particular, the study focused on
practice-related computer use, available Internet access, use about the factors that are associated
of personal digital assistants (PDAs), use of e-mail to
communicate with patients, and the use of electronic health with the use of IT in the
records (EHRs). It is believed that this study represents the
largest study of U.S. physician IT use of its kind.
Unlike smaller-scale national studies, the study enabled
an in-depth look at the use of ambulatory IT in a single because of unknown or changed addresses or incorrect
state where regulatory, reimbursement, and medico-legal practice locations, were re-mailed if updated information
issues do not vary. Research identified pertinent was obtained. New addresses could not be obtained for 7.2
demographic and practice characteristics of physicians that percent of the sample, and these individuals were excluded
are related to use of these IT applications. Specifically, from participating in the survey.
building on the previous literature,31,32,33,34 researchers Each questionnaire was tracked by a six digit identifying
examined typical categories of practice configurations code. After four weeks, non-responders were mailed a
(practice size, type, specialty, and so on) and physician second cover letter and questionnaire. A small number of
characteristics (age, race, and gender) that may influence physicians—fewer than one percent—who indicated that
the adoption of IT. Moreover, researchers examined the they were no longer actively treating patients were
relationships between IT adoption and satisfaction with the excluded. Data from completed questionnaires were
level of computerization and with the status of medical entered into a computer database and was subjected to
practice among responding physicians. data verification and cross-check methodologies. The appro-
priate institutional review board approved the protocol that
Methods was used.
A survey instrument was developed and administered to
a large sample of 14,921 physicians in Florida. The survey Statistical Analysis
instrument was developed using multiple methods. First, a Analyses included standard descriptive statistics and
comprehensive literature review identified gaps in binary logistic regression models to compute adjusted odds
published data regarding IT use in the ambulatory setting. ratios. Dependent variables included in the regression
Then, a list of questions was crafted to build on previously models included routine office computer use, routine PDA
published work. Next, content and face validity were estab- use, use of e-mail with patients and routine EHR use.
lished by soliciting expert advice. Individuals with expertise Covariates included practice size, medical training, practice
in health policy or medical informatics were asked to advise type, age, race, and gender. All analyses were computed in
and recommend additional content areas to include in the SPSS version 13.0 and significance was considered at the
survey. Numerous iterations resulted in a first draft instru- P<.05 level.
ment that was cognitively tested with a panel of physicians To examine practice size, categories were based on the
80 Journal of Healthcare Information Management — Vol. 20, No. 3
number of physicians practicing at a given practice location. with respect to attributes of the survey that would likely
Medical training was dichotomized to facilitate comparison influence participation.
between primary care physicians with other specialists. For
the purpose of this analysis, primary care included family Results
physicians, general practitioners, pediatricians, and general A total of 4,203 surveys were returned, representing a
internists. Physician age was categorized by decade and 28.2 percent participation rate. Demographic and practice
included categories of those younger than 40 years, 41 to characteristics of the respondents are shown in Table 1.
50, 51 to 60, and 61 and older. Briefly, the average age of respondents was 50.6 years with
Lastly, as recommended by survey research experts,35 the a total age range of 30 to 86. Most of the responding physi-
potential for response bias was studied by comparing cians were Caucasian (68.4 percent), male (75.9 percent),
respondents and non-respondents with respect to known and worked in a single specialty practice (66.3 percent). A
demographics and compared early and late respondents great number of respondents were in either solo practice
Journal of Healthcare Information Management — Vol. 20, No. 3 81
(30.9 percent) or had two to nine physicians in their group computer functions most commonly reported by respon-
(54.2 percent). An additional 9.7 percent and 5.2 percent dents included billing and charge capacity (80.6 percent),
were in groups of 10 to 49 physicians, or in groups with scheduling of patients appointments (78.6 percent), claims
more than 50 physicians, respectively. submission (65.6 percent), and patient registration (64.2
Access to a computer (96 percent) and Internet access percent).
(96.4 percent) were almost universally available in the Routine office computer use among physicians was
physician office practices surveyed. Of those with available related to practice size, medical training, practice type, age,
Internet access, roughly three-quarters (74.5 percent) and gender (see Table 2). For example, respondents from
indicated the availability of high-speed connections. Only practices with 50 or more physicians were significantly
10.6 percent indicated currently using a connection via more likely to indicate routine use of the office computer
dial-up service. Additionally, almost one in 10 physicians (compared with those in solo practice, OR=4.18, p=.021), as
(9.7 percent) indicated the availability of wireless were specialist physicians (compared with primary care,
networking capability in tandem with Internet access in OR=1.47, p<.001) and those working in a multi-specialty
their medical practice. practice (OR=1.64, p=.012).
Among those with a computer available, almost all (97.4 Approximately half (50.8 percent) of respondent physi-
percent) indicated the computer was used within the scope cians indicated that they own a PDA. Of those, 68 percent
of their practice. However, non-physician staff (92.6 reported that they routinely using a PDA in their office
percent) typically used the available computer more often practice. The most common PDA functions included drug
than physicians (81.1 percent). Specific office-based referencing (83.7 percent), calendar and organizer functions
82 Journal of Healthcare Information Management — Vol. 20, No. 3
(75.4 percent), and checking for medication interactions 68 physicians (1.6 percent) suggested that their office
(73.3 percent). practice location currently had an EHR available but that
Overall, routine use of PDAs among physicians was they did not personally use the system.
systematically related to practice size, age, race, and gender Overall, routine EHR use was significantly related to
(see Table 2). For example, physicians who were older than practice size, medical training, practice type, and age of the
61 were significantly less likely to routinely use a PDA than physician (see Table 2). Specifically, practices with 50 or
their younger counterparts who were younger than 40 more physicians (OR=19.6, p<.001), those with 10 to 49
(OR=0.43, p<.001). Furthermore, females were less likely physicians (OR=4.44, p<.001), and those with two to nine
to use PDAs (OR= 0.60, p<.001), while African American physicians (OR=1.40, p<.011) were more likely than solo
(OR=2.28, p=.002) and Hispanic (OR=1.46, p=.004) physi- practices to have physicians who routinely use an EHR.
cians were more likely than Caucasian to indicate routine Additionally, specialist physicians were significantly more
PDA use. likely to use EHRs than primary care physicians (OR=1.27,
Of the 4,015 physicians who indicated having an office- p=.037) and those in a multi-specialty group were more
based computer, 17.2 percent suggested personally using likely than those in a single specialty practice (OR= 1.47,
email to communicate with patients. Physicians who p=.021) to routinely use EHRs.
personally used email with patients (n=683) reported doing When asked to indicate how satisfied they were with the
so rarely (45.1 percent) or occasionally (37.5 percent). Only level of computerization in their current office practice,
117 physicians (17.4 percent) reported using email with most physicians indicated being satisfied (67.2 percent). The
their patients often. remaining physicians were either dissatisfied (16.5 percent)
Respondents from the largest practices (50 or greater or neutral (16.3 percent). Being satisfied with the level of
physicians) were significantly more likely than those in solo computerization in their office was significantly and
practice to use email to communicate with patients positively associated with routine computer use, routine
(OR=1.94, p=.05) (see Table 2). Moreover, only Asian physi- EHR use and email use with patients, but negatively corre-
cians reported using email with patients significantly less lated with routine PDA use (Table 3).
frequently than their Caucasian counterparts (OR=0.26, Physicians also were asked to respond on a Likert scale
p<.001). to how computer-savvy they considered themselves and
For the current study, an EHR was defined as a paperless overall how satisfied they were with the current medical
form of the medical record that requires the provider to practice. Findings indicated that sophisticated computer
enter patient information, such as clinical notes, into a users were significantly more likely to be using all
computer system instead of doing so on paper. Among examined IT applications when compared with their
responding physicians, 995 (23.7 percent) reported personal “neutral” or “unsophisticated” counterparts (Table 3).
routine use of an EHR in their office practice. An additional Additionally, overall satisfaction with the status of one’s
Journal of Healthcare Information Management — Vol. 20, No. 3 83
medical practice was positively and significantly associated all other confounding factors in statistical models. This trend
with routine use of an EHR (Table 3). is influenced by the fact that worthy EHR software is more
complex to develop for the variety of clinical situations
Comment encountered by primary care physicians.42,43 As the products
The Institute of Medicine36,37,38 and others7,39,40 have in this market segment mature, additional features will
described the important clinical and financial benefits hopefully encourage adoption of EHRs among primary care
associated with the use of IT, particularly in the ambulatory practices. Alternatively, if this trend continues, the digital
setting. The extent to which physicians have been using divide between primary care and other specialty physicians
key IT applications, including general computer use, PDAs, may widen.
and EHRs, as well as patient email has been previously
However, existing understanding of adoption of IT appli-
“Primary care physicians were less
cations has been limited by small or narrowly focused likely than others to be utilizing
studies. In light of the patient safety and healthcare quality
implications associated with the use of IT, updated informa- computer and EHR technologies.”
tion on adoption will need to be continually evaluated in
all healthcare settings, especially the ambulatory care The literature has mixed results regarding the relation-
environment. ship of age and IT adoption among ambulatory care physi-
The current study found a large percentage of physicians cians. Some studies find no relationship between IT
in Florida who are routinely using office-based computers adoption and physician age31,34,44 while others report a
to support administrative functions of their medical positive45 but not necessarily linear30,46 relationship. Most of
practices. However, fewer physicians have embraced these previous studies were limited to a specific specialty or
clinical and quality-enhancing technologies such as EHRs, other narrowly defined group. Furthermore, all of these
PDAs, and patient email. When compared with other indus- previous studies relied on univariate statistical methods that
trialized nations studied in a recent Harris Interactive poll,41 failed to control for potential confounders. In the current
this study’s data suggests that EHR and other IT use among study after using multivariate methods, younger age is
physicians in Florida lags considerably behind Sweden, The significantly associated with higher routine use of EHR
Netherlands, Denmark, Great Britain, Finland, and Austria. systems. The same is true for routine office computer use
In Florida, the decision to adopt some of these technolo- and, to some degree, PDA use, but not for physician-patient
gies appears to be related to both practice and individual email. While these trends are important, they are likely to
characteristics. For example, physicians who practice in weaken over time as younger physicians, and those
larger groups were significantly more likely than those in currently in the education pipeline, begin replacing older
solo practice to indicate routine office computer use, PDA physicians who retire.
and EHR use, and use of patient email. With respect to gender and race, the current study found,
With respect to EHRs, this relationship was not only the with a few caveats, that race does not seem to be systemati-
strongest but also had a significant dose-response relation- cally related to ambulatory IT adoption in Florida. For
ship. That is, the larger the group practice in Florida, the example, both African American and Hispanic physicians
more likely it is to routinely use EHRs. This trend, also are more likely to report routine PDA use, a trend that may
noted elsewhere,31 is probably attributable to the economies be the result of a project in Florida that equipped
of scale that larger practices have in terms of increased thousands of high-volume Medicaid physicians with hot-
access to both financial and human resources. Likewise, synching PDAs to help improve quality outcomes and
membership in a multi-specialty practice is potentially decrease rising state Medicaid costs. If African American
associated with similarly available resources. In addition, it and Hispanic physicians disproportionately participated in
may be more important to foster enhanced communication that Florida Medicaid project, this specific trend may not be
between physicians of differing specialties seeing common generalizable outside of Florida.
patients within a group. As such, physicians in multi- Additionally, only physicians of Asian descent, when
specialty groups were significantly more likely to indicate compared with their colleagues, were less likely to report
routine use of an office-based computer and a greater likeli- using email with patients. One potential explanation may
hood of using an EHR. be that perhaps these Florida physicians, many of whom
Primary care physicians were less likely than others to be are international medical graduates,47 find it challenging to
utilizing computer and EHR technologies. This seems to communicate via email in a language other than their
confirm a previous study comparing primary care providers native tongue.
and specialists.31 The current study in Florida found that Lastly, current study findings seem to conflict with
these relationships were still significant after controlling for previous work31,34,44 that suggested no differences exist
84 Journal of Healthcare Information Management — Vol. 20, No. 3
among the genders with respect to IT adoption in health- tions associated with survey research. This includes, but is
care. The current study found that males were proportion- not limited to, participants’ willingness and ability to partici-
ally more likely to routinely use a PDA in the scope of their pate, and be accurate with their responses. The response
practice. These findings were statistically significant even rate, while adequate,49,50 may be a limiting factor because
after controlling for other factors. It is yet uncertain if these bias is always a possibility. Nevertheless, no significant
different findings are attributable to more sophisticated evidence of bias was detected even after employing
statistical methods employed in the current study or if common techniques51,52,53,54,55 used to identify response bias.
Florida physicians truly differ from their colleagues Finally, the current study depicts health IT applications
elsewhere in the country. used at a single point in time and in one state. Thus, gener-
Lastly, physicians who indicated that they were satisfied alizability to other locales and time periods must be done
with the level of computerization in their practice were with caution.
significantly more likely to have indicated using an EHR, In spite of these limitations, the present study represents
office-based computer, or email with their patients. This the largest evaluation of physician IT usage to date and
suggests that those who are using available technologies to demonstrates an overall positive trend in adoption of
enhance the safety and quality of the care they give tend to important IT applications in the outpatient practice of
be satisfied with the products they have chosen to use. medicine. As such, it offers hope that the vision of a
Moreover, those using an EHR system also were signifi- healthcare system wired for quality care is continuing to
cantly more likely to be satisfied with the overall state of materialize in tangible and measurable ways in the ambula-
their medical practice. This suggests that EHR systems may tory marketplace.
improve physician satisfaction in a variety of ways, in
addition to the clinical and organizational benefits they may About the Authors
provide. This may be important in light of the increasing Nir Menachemi, PhD, MPH, is an assistant professor and
number of physicians reporting dissatisfaction with director of the Center on Patient Safety at the Florida State
practicing medicine.48 More research may be required to University College of Medicine.
understand how IT can be used to increase satisfaction Robert G. Brooks, MD, is professor and associate dean
among physicians. for health affairs at the Florida State University College
The current study was susceptible to the common limita- of Medicine.
1. Brailer DJ. The Decade Of Health Information Technology: Delivering Consumer-Centric And Information-Rich Health Care. Washington, DC: Office
for the National Coordinator for Health Information Technology; 2004.
2. Berner ES, Maisiak RS, Cobbs CG, Taunton OD. Effects Of A Decision Support System On Physicians’ Diagnostic Performance. J Am Med Inform
Assoc. Sep-Oct 1999;6(5):420-427.
3. Bates DW. Using Information Technology To Reduce Rates Of Medication Errors In Hospitals. British Medical Journal. Mar 18 2000;320(7237):788-
4. Bates DW, Cohen M, Leape LL, Overhage JM, Shabot MM, Sheridan T. Reducing The Frequency Of Errors In Medicine Using Information
Technology. J Am Med Inform Assoc. Jul-Aug 2001;8(4):299-308.
5. Erstad T. Analyzing Computer Based Patient Records: A Review Of Literature. Journal of Healthcare Information Management. 2003;17(4):51-57.
6. Kaushal R, Shojania K, Bates DW. Effects of Computerized Physician Order Entry and Clinical Decision Support Systems on Medication Safety.
Archives of Internal Medicine. 2003;163:1409-1416.
7. Wang SJ, Middleton B, Prosser LA, et al. A Cost-Benefit Analysis Of Electronic Medical Records In Primary Care. Am J Med. Apr 1 2003;114(5):397-
8. Barlow S, Johnson J, Steck J. The Economic Effect Of Implementing An EMR In An Outpatient Clinical Setting. J Healthc Inf Manag. Winter
9. Cooper J. Organization, Management, Implementation and Value of EHR Implementation in a Solo Pediatric Practice. Journal of Healthcare
Information Management. 2004;18(3):51-55.
10. Teich JM, Glaser JP, Beckley RF, et al. The Brigham Integrated Computer System (BICS): Advanced Clinical Systems In An Academic Hospital
Environment. International Journal of Medical Informatics. 1999;54(3):197-208.
11. Menachemi N, Burke D, Brooks RG. Adoption Factors Associated With Patient Safety-Related Information Technology. J Healthc Qual. Nov-Dec
12. Burke D, Wang B, Wan T, Diana M. Exploring Hospitals’ Adoption of Information Technology. Journal of Medical Systems. 2002;26(4):349-355.
13. Rittenhouse DR, Grumbach K, O’Neil EH, Dower C, Bindman A. Physician Organization And Care Management In California: From Cottage To
Kaiser. Health Aff (Millwood). Nov-Dec 2004;23(6):51-62.
Journal of Healthcare Information Management — Vol. 20, No. 3 85
14. Green LA, Fryer GE, Jr., Yawn BP, Lanier D, Dovey SM. The Ecology of Medical Care Revisited. N Engl J Med. Jun 28 2001;344(26):2021-2025.
15. Lee FW. Adoption Of Electronic Medical Records As A Technology Innovation For Ambulatory Care At The Medical University of South Carolina.
Top Health Inf Manage. Aug 2000;21(1):1-20.
16. Urkin J, Goldfarb D, Weintraub D. Introduction of Computerized Medical Records. A Survey of Primary Physicians. Int J Adolesc Med Health.
17. Dansky KH, Gamm LD, Vasey JJ, Barsukiewicz CK. Electronic Medical Records: Are Physicians Ready? J Healthc Manag. Nov-Dec 1999;44(6):
440-454; discussion 454-445.
18. Survey: Missouri Doctors Ready For E-Health Records. The Business Journal. January 24, 2005 2005.
19. Condon JV, Smith SP. An Analysis of Computerization in Primary Care Practices. Health Care Manag (Frederick). Dec 2002;21(2):60-71.
20. Andrews JE, Pearce KA, Sydney C, Ireson C, Love M. Current State Of Information Technology Use In A US Primary Care Practice-Based Research
Network. ]Inform Prim Care. 2004;12(1):11-18.
21. Johnson CE, Kralewski JE, Lemak CH, Cote MJ, Deane J. The Adoption of Computer-Based Information Systems by Medical Groups in a Managed
Care Environment. Journal of Ambulatory Care Management. 2002;25(1):40-51.
22. Zender A. Ready for the EHR? A New Survey Measures EHR Implementation And Individual Readiness. J Ahima. Mar 2005;76(3):54-55.
23. Burt CW, Hing E. Use of Computerized Clinical Support Systems in Medical Settings: United States, 2001-03. Adv Data. Mar 2 2005(353):1-8.
24. Galt K, Rich E, Young W. Impact of Hand-held Technologies On Medication Errors In Primary Care. Topics in Health Information Management.
Vol 23; 2002:71-81.
25. Chew F, Grant W, Tote R. Doctors On-line: Using Diffusion Of Innovations Theory To Understand Internet Use. Fam Med. Oct 2004;36(9):645-650.
26. Smithline N, Christenson E. Physicians and the Internet: Understanding Where We Are And Where We Are Going. J Ambul Care Manage.
27. Fischer S, Stewart TE, Mehta S, Wax R, Lapinsky SE. Handheld Computing in Medicine. Am Med Inform Assoc. Mar-Apr 2003;10(2):139-149.
28. Gaster B, Knight CL, DeWitt DE, Sheffield JV, Assefi NP, Buchwald D. Physicians’ Use of and Attitudes Toward Electronic Mail For Patient
Communication. J Gen Intern Med. May 2003;18(5):385-389.
29. Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors Who Are Using E-Mail With Their Patients: A Qualitative Exploration. J Med
Internet Res. Apr-Jun 2003;5(2):e9.
30. Carney PA, Poor DA, Schifferdecker KE, Gephart DS, Brooks WB, Nierenberg DW. Computer Use Among Community-Based Primary Care
Physician Preceptors. Acad Med. Jun 2004;79(6):580-590.
31. Audet AM, Doty MM, Peugh J, Shamasdin J, Zapert K, Schoenbaum S. Information Technologies: When Will They Make It Into Physicians’ Black
Bags? MedGenMed. Dec 6 2004;6(4):2.
32. Terry K. Doctors and EHRs. Med Econ. Jan 21 2005;82(2):72-74, 77-78, 80-74.
33. Miller RH, Hillman JM, Given RS. Physician Use of IT: Results from the Deloitte Research Survey. J Healthc Inf Manag. Winter 2004;18(1):72-80.
34. Loomis GA, Ries JS, Saywell RM, Jr., Thakker NR. If Electronic Medical Records Are So Great, Why Aren’t Family Physicians Using Them? J Fam
Pract. Jul 2002;51(7):636-641.
35. Asch DA, Jedrziewski MK, Christakis NA. Response Rates To Mail Surveys Published In Medical Journals. J Clin Epidemiol. Oct 1997;50(10):1129-
36. Kohn LT, Corrigan JM. To Err Is Human: Building A Safer Health System. Washington, DC: National Academy Press; 2000.
37. IOM. Crossing the Quality Chasm: A New Health System For The 21st Century. Washington, DC: Institute of Medicine; 2001.
38. Aspden P. Patient Safety Achieving A New Standard For Care. Washington, D.C.: National Academies Press; 2004.
39. Bates DW, Ebell M, Gotlieb E, Zapp J, Mullins HC. A Proposal For Electronic Medical Records In U.S. Primary Care. J Am Med Inform Assoc.
40. Frisse MC. The Business Value Of Health Care Information Technology. J Am Med Inform Assoc. Sep-Oct 1999;6(5):361-367.
41. Taylor H, Leitman R. European Physicians Especially in Sweden, Netherlands, and Denmark, Lead U.S. in Use of Electronic Medical Records.
Health Care News. 2002;2(16).
42. Crosson JC, Stroebel C, Scott JG, Stello B, Crabtree BF. Implementing an Electronic Medical Record In A Family Medicine Practice: Communication,
Decision Making, And Conflict. Ann Fam Med. Jul-Aug 2005;3(4):307-311.
43. Baron RJ, Fabens EL, Schiffman M, Wolf E. Electronic Health Records: Just Around The Corner? Or Over The Cliff? Ann Intern Med. Aug 2
44. Valdes I, Kibbe DC, Tolleson G, Kunik ME, Petersen LA. Barriers to Proliferation Of Electronic Medical Records. Inform Prim Care. 2004;12(1):3-9.
45. Younger Docs More Likely to Embrace Tech. iHealth Beat. September 15, 2004 2004.
46. Reed MC, Grossman JM. Limited Information Technology For Patient Care In Physician Offices. Issue Brief Cent Stud Health Syst Change. Sep
47. Brooks RG, Mardon R, Clawson A. The Rural Physician Workforce In Florida: A Survey Of US- And Foreign-Born Primary Care Physicians. J Rural
Health. Fall 2003;19(4):484-491.
48. Brooks RG, Menachemi N, Hughes C, Clawson A. Impact of the Medical Professional Liability Insurance Crisis On Access To Care In Florida. Arch
Intern Med. Nov 8 2004;164(20):2217-2222.
86 Journal of Healthcare Information Management — Vol. 20, No. 3
49. Goyder J. Nonresponse Effects on Relationships between Variables.
Public Opinion Quarterly. 1985;40(360-69).
50. Finlay J, Thistlethwaite PC. Applying Mail Response Enhancement
Techniques To Health Care Surveys: A Cost-Benefit Approach.
Health Mark Q. 1992;10(1-2):91-102.
51. Hansen MH, Hurwitz W. The Problem of Nonresponse in Sample
Surveys. JAMA. 1946;41(517-529).
52. Etter JF, Perneger TV. Analysis Of Non-Response Bias In A Mailed
Health Survey. J Clin Epidemiol. 1997;50(10):1123-1128.
53. Hikmet N, Chen SK. An Investigation Into Low Mail Survey
Response Rates Of Information Technology Users In Health Care
Organizations. ]Int J Med Inform. Dec 2003;72(1-3):29-34.
54. Siemiatycki J, Campbell S. Nonresponse Bias and Early Versus All
Responders In Mail And Telephone Surveys. Am J Epidemiol. Aug
55. Ferber R. The Problem Of Bias In Mail Returns: A Solution. Public
Opinion Quarterly. 1948;12(669-676).
Journal of Healthcare Information Management — Vol. 20, No. 3 87