Research Analysis

This is an exercise to help you identify the major parts of a research study as well as preparing you to present on this study for the Research Study Analysis assignment. This assignment is adapted from the document “University of Guelph Student Worksheet: Analyzing a Journal Article” for the purposes of the Social Informatics course.

Using the study assigned, write up a document answering the following questions:

· What is the exact statement in which the authors of your study describe what they were testing. (Hint: This information may be provided in the article as a hypothesis or a research question(s). Include quotation marks around the exact wording and indicate page number(s).

· Describe the purpose of the study in your own words.

· What was the “gap” in the research that the authors were trying to fill by doing their study? How many sources do the authors cite?

· What are some of the authors’ major conclusions or findings as written in the article? Include quotation marks wherever you are quoting from the article and indicate page numbers.

· What is your understanding of these findings in your own words?

· Briefly summarize the main steps or measurements the authors used in their methods. Explain these methods in your own words as much as possible.

· Do the authors suggest any problems with their methods? Do you see any problems or limitations with their methodology?

· How did the authors analyze their data? Describe their tests in your own words.

· Do the authors suggest any problems with the study that could lead to unreliable results?

· Do the conclusions about the nature of the study results discussed by the authors make sense to you? Do the claims seem in proportion to the size or the nature of the study?

· Based on the accuracy of the methodology and the reliability of the results, do you think the conclusions can be believed?

· Based on what you’ve discussed in this exercise, how could the findings of your study be applied in new software development or implementation of existing tools?

Information you need to do well:

· This is a draft of an essay, so I strongly suggest answering all of the questions in more detail than you think you might need and write it up as paragraphs of prose not bulleted points.

· Cite the assigned study in a correctly formatted APA citation at the end of the essay.

· No additional sources need to be cited for this essay beyond the assigned research study. Use APA in-text citations to indicate the page number of where any direct quotes from the study appear in your essay.

· If you encounter qualitative or quantitative methods of analysis in your study, be prepared to briefly explain what they are (a sentence or two is sufficient) and refer to the method(s) by the names used by the authors of the study.

Revisions of this assignment will be expected for the Research Study Analysis/Presentation assignment. It’s OK to discuss your answers with other members of your Class Meeting group, but it’s not OK to use the same language as other members of your group unless it is directly quoting from the research study and appropriately cited.

Research

Exploring the Effects of Clinical
Exam Room Design o

n

Communication, Technology
Interaction, and Satisfaction

Zahra Zamani, PhD, EDAC1 , and Esperanza C. Harper, EDAC

2

Abstrac

t

Objective: This article evaluates the effects of technology integration and design features in clinical exam
rooms on examination experiences, communication, and satisfaction. Background: Exam room fea-
tures can affect the delivery of patient-centered care and enhance the level of communication, which
has been shown to directly impact clinical outcomes. Although there has been an increasing body of
literature examining design and patient-centered care, little research has evaluated the extent to which
information sharing and electronic health record (EHR) interaction are impacted. Method: The
research randomly allocated 22 patients, 28

caregivers, and 59 clinicians to simulated clinical

encounters in four exam room mock-ups with semi-inclusive, exclusive, and inclusive layouts (12

8

sessions in 32 scenarios). Video recordings of the simulations were coded for clinician gazing, talking,
and EHR-interaction behaviors. Participants also completed surveys and answered open-ended
questions after experiencing each scenario (N ¼ 362). Results: Semi-inclusive rooms with a trian-
gular arrangement of consultation table, sharable screens, exam table, and caregiver chair were highly
preferred as they supported conversation, gazing, and information sharing. The inclusive layout had highe

r

durations of EHR interactions and enhanced viewing and sharing of EHR information. However, this
layout was criticized for the lack of clinician-shared information. The exclusive layouts impeded infor-
mation sharing, eye contact, and constrained simultaneous data entry and eye contact for clinicians. The
distance and orientation between chair, exam table, curtain, and door were important for protecting
patient and family comfort and privacy. Conclusion: Characteristics and configurations of design
qualities and strategies have a key role on examination experiences, communication, and satisfaction

.

Keywords
clinical exam rooms, information sharing, technology integration, patient-centered care, exam room
furniture, eye contact, furniture orientation, satisfaction

Patient-centered treatment can be defined as care

that recognizes the patient’s requirement and

health outcome as the primary influence for

healthcare choices and quality dimensions

(Ajiboye, Dong, Moore, Kallail, & Baughman,

2015; Gorawara-Bhat & Cook, 2011). The quality

1 Design Researcher, EwingCole,

Raleigh, NC, USA

2 Six Sigma Green Belt, Healthcare Planner, EwingCole,

Raleigh, NC, USA

Corresponding Author:

Zahra Zamani, PhD, EDAC, Design Researcher, EwingCole,

8208 Brownleigh Dr #200, Raleigh, NC 27617, USA.

Email: zzamani@ewingcole.com

Health Environments Research
& Design Journal

2019, Vol. 12(4) 99-1

15

ª The Author(s) 20

19

Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/19375867198260

55

journals.sagepub.com/home/her

https://orcid.org/

0000-0003-0536-245X

https://orcid.org/0000-0003-0536-245X

mailto:zzamani@ewingcole.com

https://sagepub.com/journals-permissions

https://doi.org/10.1177/1937586719826055

http://journals.sagepub.com/home/her

http://crossmark.crossref.org/dialog/?doi=10.1177%2F1937586719826055&domain=pdf&date_stamp=2019-02-05

of collaborative, coordinated, and accessible care

is substantial for patient-centered care delivery

and affected by the patient–physician communi-

cation experience (Ajiboye et al., 2015; Lee,

2011). Communication is defined as the act of

transferring information by different means: ver-

bal (talking), nonverbal (gazing), or visualized

(electronic health record [EHR] information

shared and viewed by monitors; Asan, Young,

Chewning, & Montague, 2015; Kazmi, 2014

).

Recent literature indicates that clinician’s eye

contact (gaze) with patients is a significant pre-

dictor for perceptions of enhanced patient-

centered communication and patient satisfaction

(Gorawara-Bhat & Cook, 2011). Furthermore,

establishing eye contact between the clinician and

patient is linked to patients’ perception of higher

levels of clinician communication, empathy,

attention, and warmth (Asan, Xu, & Montague,

2013; Bonner, Simons, Parker, Yano, & Kirchner,

2010).

The increased integration of the EHR in

healthcare practice suggests the importance of

understanding how technology-mediated clinical

exam rooms impact patient–caregiver–clinician

communication and behavioral dynamics

(Ajiboye et al., 2015; Asan et al., 2013; Asan

et al., 2015; Bonner et al., 2010; Gorawara-Bhat

& Cook, 2011). There is some controversy

regarding the impact of EHR on clinical exami-

nation experiences. Several studies found that

EHR integration inhibits clinician’s continuous

attention on patients, delays communication, and

impairs patient–clinician relationships (Ajiboye

et al., 2015; Asan, D Smith, & Montague, 2014;

Bonner et al., 2010). On the other hand, other

literature suggests that opportunities for EHR

information sharing promotes patient engage-

ment, satisfaction, interaction, and attention for

shared decision-making (Ajiboye et al., 2015;

Almquist et al., 2009; Asan et al., 2013, 2014,

2015; Chen, Ngo, Harrison, & Duong, 2011;

Unruh, Skeels, Civan-Hartzler, & Pratt, 2010).

For example, Ajiboye, Dong, Moore, Kallail,

and Baughman (2015) evaluated a traditional

exam room with an experimental room that pro-

vided equal access to the laptop computer screen.

Findings showed that patients were more likely to

have an excellent encounter and were more

satisfied with the seating position of the physician

in the experimental room versus the traditional

room setup. In the experimental condition,

participants perceived enhanced computer acces-

sibility, interpersonal interaction, provider infor-

mation sharing, and more time engaged in a

conversation with the provider. Asan, Xu, and

Montague (2013) research indicated the

technology-centered rooms with physicians over-

relying on technology had the shortest gaze

between patients and physicians by a significant

margin (p < .05).

Kumarapeli and de Lusignan (2012) classified

consultation room layouts into four categories:

(a) inclusive: Clinicians and patients share com-

puter screens; (b) semi-inclusive patient con-

trolled: Patients have control and can view

screen comfortably; (c) semi-inclusive clinician

controlled: Clinician has control over screen

access, and patients must turn or move, or screen

must be rotated for content sharing; and (d) exclu-

sive: Patients are located at the opposite position

without screen access. Findings showed that a

combination of room layout and the physi-

cians’ actions influenced patients’ gaze towa

rd

the EHR. In the semi-inclusive-clinician-

controlled layouts, screen sharing was not

noticed and clinicians were less likely to look

at the computer versus the semi-inclusive-

patient-controlled layout.

Age and level of clinical experience variations

may also impact perceptions and competence with

the EHR-interaction and patient-centered commu-

nication. For instance, Piper and Hollan (2013)

observational prototype tests indicated that view-

ing charts and images from the EHR improved

communication and data interpretation for older

patients. Literature also suggests that physician

EHR training improves EHR-associated commu-

nication skills, physician–patient relationship, and

provider confidence (Lanier, Cerutti, Dao, Hudel-

son, & Perron, 2018).

Clinical patients spend most of their time and

interaction within the exam room. Therefore, the

physical environment and design of exam rooms

is an important factor for the overall satisfaction

and delivery of care. Typical examination room

layout is clinician centered and mostly lacks

design features for successful patient–physician

100 Health Environments Research & Design Journal 12(4)

communication (Ajiboye et al., 2015; Almquist

et al., 2009). Despite the increasing amount of

research in the wider scope of technology-

integrated exam rooms, there has been litt

le

exploration of the role of room design and furni-

ture configuration’s impact on communication,

EHR interaction, and satisfaction to inform

design decisions. Therefore, this explorative

study aims to address the following questions:

Q1: Do the exam room’s layout and technology

arrangements affect communication behaviors

and EHR interactions? Q2: What, if any, is the

relationship between satisfaction levels of exam-

ination experience, communication, information

sharing, and exam room features? Do satisfaction

levels vary by user type?

Method

This study deployed an exploratory mixed-

methods approach that included quantified obser-

vation of behaviors, surveys, and qualitative

analysis of open-ended responses. All research

protocols were designed and evaluated for com-

pliance with the institutional review board of the

hospital setting where the research occurred. The

researchers randomly allocated 22 patients, 28

caregivers, and 59 clinicians to simulated clinical

encounters in four exam room architectural

mock-ups. Participation was voluntarily, and

patients, families, and clinicians were recruited

by an e-mail that explained the study purpose,

approach, and data confidentiality.

The researchers placed video cameras in unob-

trusive locations in each examination room,

recorded each simulation, and later analyzed

video recordings to determine the duration and

frequency of examination stages, communication

patterns (gazing and talking), and EHR interac-

tion. The observational method followed a

within-subject experimental design in which the

participants were randomly assigned to exam

rooms. Sessions were performed on four consec-

utive days and in eight different time slots. To

address carryover effects, the study employed a

counterbalancing approach in which the orders of

experiencing exam rooms differed in each day

and were randomly distributed. The randomiza-

tion design schedule consisted of four room

orders within four days for each patient type (16

pediatrics or 16 geriatrics), resulting in 32 total

scenarios and 128 session

s.

Participants also completed surveys and

answered open-ended questions after experien-

cing the clinical scenario in each mock-up. The

pilot survey was tested before the actual scenario

and refined. The survey explored levels of satis-

faction in four categories: (a) examination stages,

(b) communication with medical doctor (MD) or

medical assistant (MA), (c) information sharing

and viewing of monitors (visual communication),

and (d) room features. Examples of survey ques-

tions are presented in Table 1. Questions were on

a 7-point Likert-type scale, with anchors at 1 ¼
very dissatisfied, 4 ¼ neither satisfied nor dissa-

tisfied, and 7 ¼ very satisfied. Additionally,

open-ended questions explored participants’ per-

spectives of liked or disliked exam room features.

Demographic characteristics were not col-

lected due to hospital policies; however, gender

information was later retrieved from the videos

(detailed findings are reported in supplementary

Table 1. Example of Survey Questions.

Category Scaled Questions

On a scale of 1–7, with 1 being
very unsatisfied and 7 being very
satisfied, overall how satisfied
were you with:

Examination stages
(6 items)

Intake with medical assistant?
Gowning?
Physical examination?
Prescription of medications?
Tele-visit/consult?
Immunization?

Communication
(4 items)

Communication between the
medical assistant and patient?

Communication between the
doctor and patient?

Information
sharing (2 items)

Sharing of information on the
monitor

Viewing information on the
monitor

Room features
(30 items)

Wall-mounted monitor?
Computer monitor?
Exam table?
Family chairs?
Curtain?

Zamani and Harper 101

files). Participants included patients (n ¼ 11),

patient actors (n ¼ 11), caregivers (n ¼ 12), care-

giver actors (n ¼ 16), MDs (n ¼ 22), and MAs

(n¼ 37). Actors were hospital staff members who

played various roles, defined by the scenario

simulation script in case of patient or family una-

vailability. These role assignments did not impact

the validity of results, as any healthcare staff

member could be or have been a patient or family

in real life.

Setting

Four exam room prototypes were approved and

developed for full-scale construction on a vacated

floor of an existing hospital building. As illu-

strated in Figure 1, each exam room had a differ-

ent taxonomy, configuration, and somewhat

similar furniture. Room A (RA) and Room D

(RD) had a semi-inclusive clinician-controlled

setup, Room B (RB) an exclusive, and Room C

(RC) an inclusive configuration. The exam room

designs were owner/designer preference for this

exploration. Each design was evaluated and

selected based on the owner’s criteria including

but limited to the inclusion of current design stan-

dards, projected budget, designation of clinical

practices to be present in the actual setting, and

current and future EHR technology.

Analysis

The Behavioral Observation Research Interactive

Software (BORIS, version 7.4.2) was implemen-

ted for event logging and video coding of obser-

vations. Behaviors were defined as state events

(with durations) or point events (no duration).

Exported codes included these segments: subject,

examination stage, behavior, and modifier (point

events linked to behaviors). Subjects coded dur-

ing the video analysis included physician (MD)

and MA. Sessions were coded for the following

clinical examination stages of interest: (1) MA

intake: MA initiates questions and enters data in

the computer (excluding blood pressure and

examination); (2) MD information gathering:

physician conversation with patient or family

about the patient’s health status; (3) MD physical

examination: MD starts adjusting the exam table,

performs examination, and rearranges the exam

Figure 1. The four exam room layouts. Floor plans of full-scale mock-ups highlighting various physical features.
Image authorship: author.

102 Health Environments Research & Design Journal 12(4)

table; and (4) MD diagnosis-patient education:

MD enters exam results in EHR system, explains

the examination results, educates the patient, and

discusses future care.

Observed behaviors were classified into the

following categories: (a) gazing: mutual gaze

between the clinician, patients, families, or both

as an indication of attention and communication

(Asan et al., 2014; Montague & Asan, 2014); (b)

EHR interaction: clinician application of key-

board, mouse, or monitor screens to read or enter

data; and (c) talking: the duration of clinician

engaging in a conversation with the patient or

family. Researchers also coded if the patient,

family, or both were the point of focus for clin-

ician gazing or conversation (as a point data

described as a modifier in the BORIS software).

For instance, when the provider (MA or MD) and

patient mutually gazed at each other, the interac-

tion was coded as follows: provider as the subject,

behavior as eye contact, and modifier as patient.

Training in the instrument implementation

occurred to ensure the reliability of findings. The

proportion of agreements and Cohen’s k coeffi-

cients were employed to analyze reliability values

until interrater reliability scores reached .67.

Due to time restraints for coding the entire

videos, sessions were divided into examination

stages, and stages were randomly selected to rep-

resent different patients and exam stage across

rooms. Researchers separately coded the three

defined behaviors within the examination stages,

with the ability to start and stop recording when

the behavior was paused or interrupted for

instance by another person, searching behaviors,

or starting vitals. These pauses created behavioral

segments. That is, if within an examination stage

the observed behavior was stopped, one beha-

vioral segment was created. The total number of

behavioral segments was representative of beha-

vior disconnection.

The resulting sample after data randomization

sampling included nine geriatrics and 12 pediatric

sessions that ranged in different rooms (RA n ¼
16, RB n ¼ 15, RC n ¼ 16, and RD n ¼ 13). The

sample represented the following stages (N ¼
258): MA intake (n ¼ 67, 26%); physician

diagnosis-education referral (n ¼ 73, 28.3%),

physician information gathering (n ¼ 77,

29.8%), and physician physical exam (n ¼ 41,

15.9%). The data included 53.1% (n ¼ 137)

adults and 46.9% (n¼ 121) pediatrics data values

performed by physicians (n ¼ 191, 74%) and

MAs (n ¼ 67, 26.0%).

To evaluate the nature of examination stages

per observed behaviors, codes were structured

into three categories: (a) behavioral duration per

examination stage (BDS): total duration of a

behavior (talking, gazing, or EHR interaction) for

each examination stage; (b) behavioral segments

per examination stage (BSS): Resulting from dis-

continuity of the behavior, this number presented

the total number of behavior segments (start–stop

units) observed in an examination stage; and (c)

total behavior duration per session (TBS): total

duration of the three coded behaviors across the

four examination stages of a session. Addition-

ally, gazing and talking behavior durations were

merged to identify patient–clinician or family–

clinician interactions.

All statistical analysis was conducted using the

SPSS Statistics 24 software. Descriptive statistics

are presented as means and standard deviations

(in parenthesis next to average values) for contin-

uous variables, frequencies, and proportions for

categorical variables. One-way analysis of var-

iance (ANOVA) and post hoc tests analysis were

performed to understand significant differences

between rooms.

The open-ended responses were content ana-

lyzed and audited using standard content analysis

techniques. A minor difference between the

coders was resolved by collective reviewing.

Responses were analyzed to identify perspectives

and underlying reasons for satisfaction ratings on

examination stages, room features, communica-

tion, or information sharing.

Results

Observational Findings

The average duration of the examination sessions,

including MA vital intake, waiting, and gowning

times, was 540.67 s (aggregated data across all

room types). Average duration of all four exam

stages was 377.93 (aggregated data across all

room types). This number excludes MA vital

Zamani and Harper 103

intake, waiting, and gowning times. Average

durations of each exam stage for adult patients

were: MA intake ¼ 91.05 (55.80), MD info gath-

ering ¼ 89.99 (36.90), MD exam ¼ 158.4

3

(96.41), MD education and referral ¼ 96.4

1

(14.67), and total ¼ 435.86. For pediatric physi-

cal exam, average durations of examination

stages were as follows: MA intake ¼ 76.75

(35.00), MD info gathering ¼ 56.50 (27.27),

MD exam ¼ 127.52 (50.95), MD education and

referral ¼ 55.75 (35.39), and total ¼ 316.52.

Durations of MD info gathering and MD educa-

tion significantly differed between patient types,

F(1, 22) ¼ 6.39, p ¼ .019, F(1, 21) ¼ 14.17,

p ¼ .001.

Aggregated data across all room types showed

talking duration (M ¼ 104.7), and eye contact

(M ¼ 83.39) were longer than EHR interaction

(M ¼ 35.59), and this difference was significant,

F(2, 136) ¼ 18.078, p < .001. The ANOVA indi-

cated significant difference between room types

and average BDS, F(3, 251)¼ 3.44, p¼ .017, RA

M ¼ 37.75 (28.79); RB M ¼ 39.75 (29.98); RC

M ¼ 53.79 (36.43); RD M ¼ 37.55 (33.38). RC

had significantly higher duration of behaviors

than RA and RD (p < .05). There were no signif-

icant variations across rooms in the average BSS

or TBS values. The results showed no significant

difference comparing the average BDS, BSS, and

TBS values for the two patient types in rooms.

Rooms did not significantly differ in the

average TBS or BSS for talking, gazing, or

EHR-interaction values. Average BDS values for

talking or gazing were not significantly different

across rooms. However, statistical analysis

showed significant variations among BDS values

for EHR interaction across rooms F(3, 55) ¼
4.80, p ¼ .005, RA M ¼ 18.37 (13.17); RB

M ¼ 22.46 (13.58); RC M ¼ 49.84 (49.32); RD

M ¼ 16.95, (15.25). Tukey HSD comparisons

indicated that RC had longer EHR-interaction

BDS than RA, RB, and RD (p < .05).

Data analysis explored BDS values for talking,

gazing, and EHR interaction per the four exam-

ination stages across rooms. ANOVA indicated

no significant difference across rooms, except the

average duration of EHR interaction during MA

intake, F(3, 17)¼ 5.034, p¼ .01. Tukey HSD test

indicated that RC had significantly longer EHR

interactions during MA intake, in comparison to

RA and RB (p < .05). Descriptive results showed

that clinician interactions occurred mainly with

patients, subsequently patient–caregiver, and

then caregiver (59.6%, n ¼ 115; 21.24%, n ¼
41; 19.17%, n ¼ 37, respectively). BDS and BSS

values during interactions were not significantly

different across rooms.

Survey Findings

Average time for survey completion was 15 min

and 13 s (MD n ¼ 123, 34.0%; MA n ¼ 89,

24.6%; family n ¼ 89; 24.6%; and patient n ¼
61, 16.8%, N ¼ 362). Overall satisfaction with

examination stages and communication levels

was high (5 and above), with no significant dif-

ference between rooms.

The findings show that satisfaction with mon-

itor sharing and viewing information on the

monitor significantly differed across rooms:

monitor-sharing RA M ¼ 4.03 (2.83); RB M ¼
2.66 (2.5); RC M ¼ 4.96 (2.47); RD M ¼ 4.22

(2.86); F(3, 348) ¼ 14.19, p > .001; viewing

information on monitor RA M ¼ 4.95 (2.6); RB

M ¼ 3.54 (2.7); RC M ¼ 4.84 (2.44); RD M ¼
4.76 (2.68); F(3, 346) ¼ 6.58, p > .001. Tukey’s

test showed that RB had significantly the lowest

ratings for sharing and viewing information on

the monitor (p < .001).

Satisfaction ratings for MA or MD communi-

cation with patient or family were not signifi-

cantly different across rooms. Table 2 displays

significant predictors of satisfaction with commu-

nication between MD, patient, and family mem-

bers across rooms. As displayed, satisfaction with

the MD examination was affected by perception

of communication level and exam room features

such as the MD workstation, wall monitor, and

computer monitor.

Table 3 displays room features with significant

satisfaction ratings. Tukey’s analysis indicated

that average ratings for the computer monitor in

RB were significantly lower compared to RA

(p ¼ .002) and RD (p ¼ .001). Also, RC repre-

sented significantly lower ratings for computer

monitor, compared to RA (p < .001) and RD

(p < .001). RB had significantly lower mean

ratings for satisfaction with the wall monitor

104 Health Environments Research & Design Journal 12(4)

(p < .001) and exam table (p < .05), compared to

other rooms. Post hoc tests showed that RD rep-

resented the highest satisfaction ratings for the

physician workstation table, compared to other

rooms (p < .01). Satisfaction with the curtain con-

figuration ranged significantly in exam rooms.

RD had significantly higher ratings for the

curtain configuration compared to other

rooms (p < .05). Further RA had significantly

lower curtain configuration ratings compared

to RB or RD (p < .05).

Table 4 displays descriptive values for vari-

ables that significantly differed across rooms by

user type for examination stages, communication,

information sharing, and room features. (For this

study, only relevant features are disused.) For

MDs, the following attributes significantly dif-

fered: RC and RB the least favored for the com-

puter monitor and wall-mounted monitors,

respectively, compared to other rooms. MD

workstation in RD was more favored than in

RC. The curtain configuration in RD was rated

higher than in RA and RC.

For MAs, the computer monitor configuration

in RB had lower ratings than in RA and RD. RB

was the least favored for wall-monitor

configuration, compared to other rooms. For fam-

ily members, RC had higher ratings than RB for

information sharing on monitor, with RB the least

favored across all rooms for information viewing,

wall-monitor configuration, and exam table. The

curtain in RD was rated more satisfactory than in

RA. For patients, RB was the least favored for

information sharing, information viewing, com-

puter monitor, wall-mounted monitor, and exam

table across all rooms. Also, patients favored RD

more than RA for curtain configuration and the

MD workstation. Overall, all participants had

higher satisfaction with RD and low satisfaction

ratings for RB.

Open-Ended Findings

Table 5 presents examples of liked or disliked

physical features, associated attributes, and possi-

ble outcomes. Table 6 displays total frequency of

negative or positive comments based on room type

and associated outcomes. Figures 2 and 3 display

findings based on room type, physical features,

and associated outcomes (Figures 2 and 3).

The triangular setup in RA and RD was the

most preferred because it supported eye contact,

communication, and monitor information-sharing

opportunities. Physicians favored the ability to

maintain eye contact while entering EHR informa-

tion in RA and RD. The clinicians favored the

shape of the MD workstation and its orientation

toward the exam table that provided minimal dis-

tance between the provider and patient, facilitating

conversation and monitor sharing. The exam table

position was the most favored feature in RB, as it

provided adequate room for examination, was near

the caregiver chair, and afforded eye-contact

opportunities when the provider entered the room.

The triangular setup in RA and RD was

the most preferred because it supported

eye contact, communication, and monitor

information-sharing opportunities.

In RC, the multiple wall-mounted monitors

were a preferred feature. Comments inferred that

information sharing was enhanced by the

“readable fonts.” Additionally, the monitors were

considered a positive distraction in the exam

Table 2. Analysis of Variance Results of Significant
Predictors for MD Communication With Patients or
Family.

b F

Satisfaction With MD Communication With Patient
RB MD workstation 0.30** 7.91**
RC Wall-mounted monitor 0.29* 11.68***

Sharing information on
monitor

0.27*

RD MD workstation 0.51*** 23.39***
Viewing information on

monitor
0.32**

Satisfaction With MD Communication With Family
RA Sharing information on

monitor
0.23* 4.28*

RC Wall-mounted monitor 0.29** 9.73***
MD workstation 0.26*

RD Physician workstation 0.54*** 22.04***
Viewing information on the

monitor
0.24**

Note. MD ¼ medical doctor; RA ¼ Room A; RB ¼ Room B;
RC ¼ Room C; RD ¼ Room D.
* indicates p < .05; ** indicates p < .01; *** indicates p < .001

Zamani and Harper 105

room. Conversely, some participants disliked the

wall-mounted monitor information sharing in

RC who perceived it as “overwhelming,”

“expensive,” or “unnecessary.” The clinicians

were concerned about liability issues for sharing

sensitive information and violating Health Insur-

ance Portability and Accountability Act of 1996

(HIPPA) policies (n ¼ 10). Physicians also

favored the mobile workstation and wireless

keyboard in RC that enhanced maneuvering and

flexibility during EHR entry.

The inadequate distance between clinician

workstation and exam table in RA resulted in the

most negative comments on furniture positioning,

indicating that it resulted in uncomfortable man-

euvering, tripping hazards, furniture movements,

and inefficiency. The exclusive layout of RB had

the highest number of negative comments on

face-to-face communication, information shar-

ing, and patient comfort. Participants criticized

the location of provider workstation in RC in

relation to the monitors. Providers needed to

Table 3. One-Way Analysis of Variance on Satisfaction With Exam Room Features.

Satisfaction Rating RA Mean (SD) RB Mean (SD) RC Mean (SD) RD Mean (SD) F

Monitor sharing 4.03 (2.83) 2.66 (2.5) 4.96 (2.47) 4.22 (2.86) 14.19***
Monitor information viewing 4.95 (2.6) 3.54 (2.7) 4.84 (2.44) 4.76 (2.68) 6.58***
Computer monitors 5.72 (1.61) 4.90 (2.13) 4.35 (2.59) 5.86 (1.49) 10.16***
Wall-mounted monitor 4.58 (2.7) 0.63 (1.8) 4.81 (2.42) 4.71 (2.73) 76.48***
Exam table 4.83 (2.16) 4.30 (2.1) 5.61 (1.60) 5.65 (1.52) 12.13***
Physician workstation 4.48 (2.36) 4.50 (2.14) 4.31 (2.39) 5.60 (1.83) 6.61***

Note. RA ¼ Room A; RB ¼ Room B; RC ¼ Room C; RD ¼ Room D.
***p < .001.

Table 4. Significant Satisfaction Average (M) and Standard Deviation (SD) Variations Across Rooms by User
Type.

A B C D
FM (SD) M (SD) M (SD) M (SD)

MD Computer monitor 6.10 (1.03) 5.33 (1.69) 3.81 (2.39) 6.32 (0.77) 14.91***
Wall-mounted monitor 4.29 (3.04) 0.39 (1.41) 5.03 (2.01) 4.93 (2.56) 28.78***
Physician workstation 5.29 (2.04) 4.94 (1.87) 4.55 (1.86) 6.07 (1.04) 3.87*
Curtain 1.48 (2.13) 3.00 (2.87) 1.68 (2.27) 4.07 (2.65) 6.94***

MA Computer monitor 5.91 (1.28) 5.37 (2.11) 4.16 (2.41) 5.77 (1.57) 4.24**
Wall-mounted monitor 4.05 (2.79) 1.00 (2.13) 3.60 (2.63) 3.59 (3.00) 5.35**
Curtain 2.22 (2.61) 2.26 (2.88) 2.38 (2.84) 5.73 (1.67) 10.07***

Family Sharing information on monitor 4.00 (2.76) 2.20 (2.21) 5.50 (2.47) 3.75 (3.06) 5.73**
Viewing information on monitor 4.90 (2.57) 1.90 (1.74) 5.80 (2.38) 4.63 (2.77) 10.49***
Wall-mounted monitor 5.68 (1.39) 0.41 (1.53) 5.48 (2.40) 4.95 (2.48) 34.18***
Curtain 2.23 (2.56) 3.73 (2.57) 2.64 (2.63) 4.45 (2.21) 3.50*
Exam table 5.14 (2.38) 3.10 (1.87) 5.84 (1.70) 5.70 (2.05) 8.61***

Patient Sharing information on monitor 4.15 (2.91) 1.50 (1.91) 5.75 (1.95) 4.53 (2.85) 7.84***
Viewing information on monitor 5.15 (2.64) 1.64 (1.98) 5.75 (1.95) 5.12 (2.71) 9.12***
Computer monitor 6.21 (0.89) 3.29 (2.27) 5.63 (2.31) 5.82 (1.85) 6.72**
Wall-mounted monitor 5.69 (1.89) 0 5.69 (2.15) 5.82 (2.30) 33.57***
Curtain 2.29 (2.46) 4.07 (2.76) 3.06 (2.74) 5.00 (2.32) 3.28*
Physician workstation 3.21 (2.15) 4.57 (1.16) 4.38 (2.78) 5.94 (1.78) 4.53**
Exam table 6.14 (1.35) 4.14 (2.11) 5.81 (1.52) 6.41 (1.12) 6.35**

Note. MD ¼ medical doctor; MA ¼ medical assistant.
* indicates p < .05; ** indicates p < .01; *** indicates p < .001

106 Health Environments Research & Design Journal 12(4)

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ly

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th

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tr

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(R

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fa
m

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).

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ie

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o
f
p
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n
t

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d

p
ar

en
t

w
o
rk

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w

el
l
(R

A
,
M

A
).

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o
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ld

n
o
t

re
al

ly
se

e
th

e
m

o
n
it
o
r

o
n

ta
b
le

o
r

o
n

w
al

l,
fe

lt
lik

e
as

a
p
ar

en
t

tu
ck

ed
in

th
e

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rn

er
o
f
th

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ro

o
m

(R
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,
Fa

m
ily

).

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ve

ry
o
n
e

w
as

ve
ry

cl
o
se

an
d

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as

ve
ry

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o
se

to
co

m
p
an

io
n
s

d
u
ri

n
g

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am

(R
D

,
M

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).

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h
e

lo
ca

ti
o
n

o
ft

h
e

si
d
e

ch
ai

rs
.

T
h
ey

se
em

in
th

e
w

ay
o
ft

h
e

p
h
ys

ic
ia

n
;t

ig
h
t

o
n

th
e

se
tu

p
in

re
la

ti
o
n

to
ex

am
ch

ai
r

an
d

o
th

er
ch

ai
rs

(R
C

,
fa

m
ily

).

N
ot

e.
M

D
¼

m
ed

ic
al

d
o
ct

o
r;

M

A
¼

m
ed

ic
al

as
si

st
an

t;
R

A
¼

R
o
o
m

A
;
R

B
¼

R
o
o
m

B
;
R

C
¼

R
o
o
m

C
;
R

D
¼

R
o
o
m

D
.

107

Table 6. Total Frequency of Negative and Positive Open-Ended Comments Based on Room Type and Associated
Outcomes.

Position Flow
Patient

Comfort Gazing
Info

Sharing
Staff Safety
Comfort

Total frequency of positive comments
Room A 128 44 28 2 1

0

Room B 102 9 32 40 9 6
Room C 110 36 36 16 11 26
Room D 94 30 42 6 3

12

Total frequency of negative comments
Room A 128 44 28 2 1 0
Room B 102 9 32 40 9 6
Room C 110 36 36 16 11 26
Room D 94 30 42 6 3 12

31.00

3

0.00

2

1.00

11.00

6.00

30.00

17.00
21.00

8.00 7.00

16.00

6.00 7.00

2.00

6.00

28
31.00

27.00

10.00

7.00

1.00

11.00

1.00

1.00

3.00

1.00 2.00

4.00

1.00

5.00

5
2.00

4.00

15.00

18.00

13.00

2.00

2.00

5.00

5.00

4.00

5.00

5.00 4.00

14 18.00

13.00

1.00

1.00

11.00

3.00

2.00

3.00

4.00

2.00

1.00

18.00

7 4.00

3.00

11.00

4.00

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Ex
am

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ab

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RA RB RC RD

Frequency of Posi�ve Comments on Exam Room Physical
Features and Percevied Outcomes

Posi�on Impac�ng Flow Pa�ent Safety-Comfort Face-to-Face Communica�on Info Sharing

Figure 2. Open-ended comments content analysis results. The diagram displays frequency of positive comments
on exam room features and associated outcomes. Image authorship: author.

108 Health Environments Research & Design Journal 12(4)

continually turn around to read the screens. Fur-

ther, providers found that facing the wall-

mounted monitors was an “inconvenience.”

RC was also disliked for the caregiver chair

location as it was uncomfortably close to the

door, curtain, and exam table. Its location also

restricted eye contact opportunities with clini-

cians during the examination. RD had the high-

est frequency of negative comments impacting

patient safety and comfort due to the opposite

positioning of caregiver chairs in relation to the

exam table, which was criticized for impeding

patient privacy and safety.

Discussion

This article underscores the salience of physical

attributes of exam rooms in supporting patient-

centered care by impacting communication, EHR

interaction, and satisfaction outcomes. Total

behavior duration of EHR interaction was less

than talking or gazing. This may be due to

39

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ROOM A Room B Room C RD

Frequency of Nega�ve Comments on Exam Room
Physical Features and Percevied Outcomes

Posi�on Impac�ng Flow Pa�ent Safety-Comfort

Face-to-Face Communica�on Info Sharing Staff Safety-Comfort

Figure 3. Open-ended comments content analysis results. The diagram displays frequency of negative comments
on exam room features and associated outcomes. Image authorship: author.

Zamani and Harper 109

participants entering scenario-scripted informa-

tion in computers, whereas in real-life instances

more focus, experience with EHR technology,

and attention are required to enter data and

prevent possible errors (Kazmi, 2014). Clini-

cians had to continually look back-and-forth

between the EHR screen and the patient and

caregiver, resulting in longer BDS durations

in RC. Further, the lack of dedicated computer

monitors was an obstacle toward simultaneous

eye contact and EHR entry, reducing satisfac-

tion and efficiency.

The results of this study indicate the active

role of computer monitors, and more specifi-

cally wall-mounted screens, in information shar-

ing and decision-making during clinical visits.

RA and RD were highly favored for the posi-

tioning of the wall monitor, clinician worksta-

tion, and the exam table. This triangular

arrangement promoted face-to-face communica-

tion, active information sharing, and simulta-

neous

EHR entry. It also enabled concurrent

data entry and eye contact for the

clinician.

This triangular arrangement promoted

face-to-face communication, active

information sharing, and simultaneous

EHR entry. It also enabled concurrent

data entry and eye contact for the

clinician.

Similar to previous studies (Ajiboye et al.,

2015; Almquist et al., 2009; Asan et al., 2015;

Kumarapeli & de Lusignan, 2012; Unruh et al.,

2010), the inclusive layout of RC was highly pre-

ferred for information sharing and interaction

facilitated by the size and quantity of wall moni-

tors in the room. Nevertheless, clinicians were

concerned about inability to control what infor-

mation is shared on the monitors, which could

jeopardize patient privacy, as found in prior stud-

ies (Asan et al., 2015; Bonner et al., 2010; Dow-

ell, Stubbe, Scott-Dowell, Macdonald, & Dew,

2013; Margalit, Roter, Dunevant, Larson, & Reis,

2006). Consistent with prior studies on exclusive

layouts (Asan et al., 2015; Milne et al., 2016;

Unruh et al., 2010), the lack of wall monitors for

information sharing with patients and families in

RB resulted in promoted passive patients and was

highly disliked by all participants.

. . . the inclusive layout of RC was highly

preferred for information sharing and

interaction facilitated by the size and

quantity of wall monitors in the room.

Sharing and viewing information on monitors,

as well as the orientation of MD workstation and

wall monitors, were predictors for communication

between MD, patient, and families. The findings

showed that across all rooms, designing opportuni-

ties for patient interactions through room layout

should be prioritized for achieving a patient-

centered experience. Studies show that physician

gaze highly impacts patient gaze, and thus focusing

on EHR information decreases potential eye con-

tact with patients (Almquist et al., 2009; Asan et al.,

2013; Montague & Asan, 2014). When clinicians in

RB focused on EHR entry with their back toward

the patient, eye contact was reduced. This exclusive

layout was identified as “impersonal” as it discour-

aged patient-centered communication, eye contact,

and information sharing. This corroborates previ-

ous literature (Gorawara-Bhat & Cook, 2011;

Kazmi, 2014; Kumarapeli & de Lusignan, 2012;

Milne et al., 2016; Montague & Asan, 2014).

Sharing and viewing information on

monitors, as well as the orientation of MD

workstation and wall monitors, were

predictors for communication between MD,

patient, and families.

In RC, computer screens were defined as dis-

tractions. In contrast, the semi-inclusive rooms

(RA and RD) were highly preferred as they facili-

tated provider–computer–patient–family commu-

nication and information sharing. In this room,

the clinician controlled the extent of data sharing

displayed on the wall monitor and could position

their keyboard workstation in various ways for

data entry. In RA, some participants, especially

patients, mentioned that the close distance

between workstation and exam table felt uncom-

fortable during the examination. In RC, the work-

station was portable but not positioned for

optimum wall-monitor viewing, and in RB, the

110 Health Environments Research & Design Journal 12(4)

workstation was at the corner of room limiting

EHR sharing and eye contact. This result shows

the importance of the workstation orientation for

enhanced gazing and monitor sharing.

Satisfaction with exam tables has been linked

to satisfaction with the facility, perceived quality

of care, and approach behaviors (Lee, 2011). The

results of this study offer new empirical insight

on how the orientation and usability of exam

tables also had major impacts on satisfaction. In

RA, participants were dissatisfied about the posi-

tioning of the exam table in the midsection of the

wall as it resulted in space redundancies. Further,

the exam table located at the front of the consult

table yielded a tight space for maneuvering dur-

ing examination thus reduced throughput. For

families and patients, the exam table in RB was

the least favored, compared to other rooms.

Reflecting on usability issues, families of pedia-

tric patients and older patients complained about

the difficulty of getting onto the exam table due to

its high positioning. Participants were unable to

alter the exam table configuration, and in RB, the

exam table was armless with manual adjustments.

Also, during pelvic exams, the stirrups were too

close to family chairs. The orientation in relation

to MD workstation impeded eye contact between

providers and patients and was unfavorable.

Integrating positive distractions in healthcare

environments is associated with enhancing

patient mood and satisfaction, as well as reducing

anxiety, pain, and the perception of waiting time

(Nanda et al., 2012; Schneider, Ellis, Coombs,

Shonkwiler, & Folsom, 2003). In line with prior

literature (Corsano, Majorano, Vignola, Guidotti,

& Izzi, 2015; Schneider et al., 2003), participants

mentioned that multiple monitors in RC facilitated

“the passing of time” and provided a “positive dis-

traction.” This underlines the importance of incor-

porating dynamic, interactive, and informative

technology components as a positive distraction.

During the clinical exam, triangulation

changes as patients, family, and clinicians move

through different stages. Figure 4 demonstrates

Figure 4. Triangulation diagram. This diagram shows the change in triangulation angles at start and information
sharing stages of the exam visit. Image authorship: author.

Figure 5. Ideal exam room layout. This diagram dis-
plays a revised configuration of Room D based on the
empirical findings. Image authorship: author.

Zamani and Harper 111

the how triangulation in each room is altered from

the starting stage of the exam (handwashing upon

clinician’s entry) to information gathering.

Rooms that maintain the relative angles between

the participants and between stages support tran-

sition as the clinician moves in the room and help

to keep the

continuity of the conversation, by

minimizing the disruption of repositioning. The

qualitative findings highlighted the importance of

furniture distances and adjacencies in exam

rooms to enhance performance and comfort. For

instance, participants in RD criticized that the

“too close” distance of furniture produces trip-

ping hazards for participants. Having the chair

at the corner of RD made some caregivers feel

“left out” of the examination process. Patients in

RC favored sitting next to caregivers while obser-

ving the wall-monitor information. However, the

location of caregiver chairs was the least favored

as it was proximate to the door swing, curtain, and

exam table and impacted flow and comfort.

Rooms that maintain the relative angles

between the participants and between

stages support transition as the clinician

moves in the room and help to keep the

continuity of the conversation, by

minimizing the disruption of

repositioning.

Adjustable and flexible furniture was an

important consideration for achieving satisfac-

tory evaluation. The fixed consult table in RD

was not favored and was perceived as a limitation

for monitor sharing and communication. How-

ever, being able to readjust computer monitors

using adjustable swivels diminished this barrier,

as suggested by prior studies (Chen et al., 2011).

RD had higher satisfaction ratings for the posi-

tioning of the curtain. RD’s curtain location

effectively separated the patient zone from family

or clinician zones and did not interfere with any

room furnishings. RA’s curtain had the lowest

rating across all participants as the family and

patient zone were on the same side forcing the

family to walk next to the door during the exam.

RA was perceived as not protecting patient pri-

vacy as patients were not shielded from the door

by a curtain.

Limitations and Directions for
Future Research

This study has limitations. In response to client

contracts, researchers were not able to test a semi-

inclusive patient-controlled layout. Further, due

to a lack of resources, researchers were unable

to code all the collected videos, so randomization

was employed to retrieve an acceptable sample.

Demographic data were not retrieved to ensure

Figure 6. Ideal exam room layout and triangulation. This diagram displays the revised configuration of Room D
clinical exam room that supports eye contact and information sharing by triangulating exam table, medical
doctor’s workstation, and family chairs, and wall-mounted monitor. Image authorship: author.

112 Health Environments Research & Design Journal 12(4)

patient, caregiver, and clinician privacy. It would

be interesting to explore the impact of age, gen-

der, and ethnicity in satisfaction and communica-

tion outcomes in relation to room layouts.

Although observer reliability was at an accepta-

ble level, modifying the methodology and coding

descriptions may enhance reliability in future

studies. In real-time clinic visits, interruptions

and distractions may impact examination and

behavioral durations or segmentation. Addition-

ally, clinicians from different areas of expertise

may use different examination methods from

those we explored. More research is needed to

explore different communication and satisfaction

outcomes in various medical specialty contexts

and with diverse layouts affected by design fea-

tures in exam rooms. In future research, diverse

patient types and demographics should be

explored. It would also be interesting to validate

the results obtained in this research through pre-

occupancy and postoccupancy assessments

through the design of new clinical exam rooms.

Conclusion

Exam room layout modification provides a great

capacity to increase communication, EHR inter-

action, and satisfaction in clinical exam rooms.

Semi-inclusive physician-controlled configura-

tions increased eye contact and encouraged

patient–caregiver involvement in discussions.

The computer in this layout was appreciated as

it supported patient privacy during information

sharing. Inclusive layouts promoted interactions

between clinicians, patient, and technology.

However, participants emphasized the value of

a balanced and effective technology integration

that is not overwhelming for the patients and pro-

tects patient privacy. The lack of opportunities for

viewing and sharing information in the exclusive

layout negatively affected the clinician’s capabil-

ity to establish eye contact and attentiveness

toward them.

In terms of furniture arrangement, the results

show that triangular configurations for the exam

table, clinician table, and caregiver chairs were

highly preferred. This orientation contributed to

comfortable encounters, efficiency, eye contact,

and effective information sharing. Patients

reflected the need for proper orientation of exam

table in relation to family chairs, curtains, or

doors to enhance perceptions of privacy and com-

fort. These findings suggest the importance of

comfortable and acceptable distance between fur-

niture (especially MD workstation, exam table,

and chairs) to reduce flow disruptions and

enhance comfort. The results of this study suggest

that RD had the best layout configuration for

patient-centered outcomes. Figure 5 suggests

changes to RD in response to the participant com-

ments. In the edited RD exam room, repositioning

the sink in the circulation path of the clinicians

promotes hand hygiene. An additional monitor

placed 90� from each other supports a triangular

relationship between patients, family, and clin-

icians as well as ease of maintaining eye contact

during information sharing (Figure 6). Further,

the revised position of the curtain and family

seating supports privacy and comfort. Overall,

this research contributes to the body of knowl-

edge and adds new perspectives regarding beha-

viors and preferences impacted by different

exam room layouts.

Implications for Practice

� Locate shared monitors directly in front of

patients, caregivers, and physician to

enhance information sharing, patient–fam-

ily engagement, and comfort.

� Configure appropriate distance for room

furniture positioning for comfortable man-

euvering, comfortable access to equipment,

and visibility of shared information.

� Triangular configuration of exam table,

caregiver chairs, and physician workstation

facilities eye contact, engagement, and

productivity.

� Providers prefer semi-inclusive exam room

configurations that include private and control-

lable computer screens on portable tables for

comfortable information sharing, simulta-

neous data entry, and enhanced face-to-face

communication.

� Exam table location, angle, and attributes are

essential factors for supporting patient pri-

vacy and comfort. Placing the exam table at

Zamani and Harper 113

the room corner with a 45� angle and reason-

able reach from provider chairs and curtain is

preferable.

Acknowledgment

The completion of this research could not have

been possible without the collaboration and assis-

tance of so many people. The authors sincerely

appreciate the inisght and contributions of Dr.

Nicholas Watkins and Alice Gittler.

Declaration of Conflicting Interests

The authors declared no potential conflicts of

interest with respect to the research, authorship,

and/or publication of this article.

Funding

The authors disclosed receipt of the following

financial support for the research, authorship,

and/or publication of this article: The authors

would like to thank EwingCole for funding this

research article.

ORCID iD

Zahra Zamani, PhD, EDAC https://orcid.org/

0000-0003-0536-245X

Supplemental Material

Supplemental material for this article is available

online.

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