Posted: February 26th, 2023
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
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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)
T
a
b
le
5
.
E
x
am
p
le
s
o
f
O
p
en
-E
n
d
ed
R
es
p
o
n
se
s
o
n
Li
ke
d
o
r
D
is
lik
ed
E
x
am
R
o
o
m
A
tt
ri
b
u
te
s.
A
tt
ri
b
u
te
Lo
ca
ti
o
n
Fa
ce
-t
o
-F
ac
e
C
o
m
m
u
n
ic
at
io
n
In
fo
rm
at
io
n
Sh
a
r
in
g
C
o
m
fo
rt
an
d
Sa
fe
ty
Im
p
ac
ti
n
g
Fl
o
w
C
o
m
p
u
te
r
m
o
n
it
o
r
O
ri
en
ta
ti
o
n
o
f
th
e
co
m
p
u
te
r
to
t
h
e
p
at
ie
n
t
an
d
gu
es
t
ch
ai
rs
w
as
n
ic
e
(R
D
;
M
D
).
A
b
le
to
fa
c
e
p
at
ie
n
t
w
h
ile
d
o
in
g
E
M
R
(R
B
,
M
D
).
T
h
e
co
m
p
u
te
r
an
d
m
o
n
it
o
r
ar
e
st
ill
ai
m
ed
at
p
h
ys
ic
ia
n
an
d
n
o
t
th
at
ea
si
ly
sh
ar
ed
(R
B
,
M
D
).
I
th
in
k
w
ir
es
h
an
gi
n
g
b
y
th
e
co
m
p
u
te
rs
co
u
ld
b
e
a
p
ro
b
le
m
(R
A
,p
at
ie
n
t)
.
T
h
e
ab
ili
ty
to
ty
p
e
an
d
se
e
th
e
p
at
ie
n
t—
lo
ts
o
f
tw
is
ti
n
g
b
ac
k
an
d
fo
rt
h
(R
B
,
M
A
).
W
al
l-
m
o
u
n
te
d
m
o
n
it
o
r
T
h
e
d
ir
ec
t
sp
at
ia
l
r
e
la
ti
o
n
sh
ip
b
et
w
ee
n
m
ys
el
f
(p
at
ie
n
t)
an
d
p
h
ys
ic
ia
n
an
d
w
al
l
m
o
n
it
o
r
(R
A
,
P
at
ie
n
t)
.
T
h
e
d
is
cu
ss
io
n
b
et
w
ee
n
p
at
ie
n
t
an
d
ca
re
gi
ve
r
h
in
d
er
ed
b
y
th
e
th
re
e
la
rg
e
m
o
n
it
o
rs
an
d
in
ab
ili
ty
to
lo
o
k
at
th
e
p
at
ie
n
t
d
ir
ec
tl
y
(R
C
,
M
A
).
I
lik
e
d
th
e
w
al
l
m
o
n
it
o
r/
in
fo
rm
at
io
n
sh
ar
in
g
(R
C
,
p
at
ie
n
t)
.
It
w
as
d
iff
ic
u
lt
to
ch
ar
t,
as
I
h
ad
to
lo
o
k
u
p
t
o
th
e
w
al
l
m
o
n
it
o
r
(R
C
,
M
D
).
I
d
o
n
o
t
lik
e
th
e
m
o
n
it
o
r
o
n
th
e
w
al
l,
h
ar
d
fo
r
m
e
to
lo
o
k
an
d
ty
p
e
(R
C
,
M
D
).
M
D
w
o
rk
st
at
io
n
Lo
ve
d
th
e
se
tu
p
o
ft
h
e
ta
b
le
/
co
m
p
u
te
r
in
re
la
ti
o
n
to
th
e
p
at
ie
n
t
an
d
gu
es
t
(R
A
,
M
D
).
T
h
e
w
o
rk
st
at
io
n
d
id
n
o
t
al
lo
w
fo
r
th
e
M
A
o
r
p
ro
vi
d
er
to
se
e
th
e
p
at
ie
n
t
(R
B
,
M
A
).
Il
ik
ed
p
o
si
ti
o
n
in
g
o
fc
o
m
p
u
te
r
st
at
io
n
w
it
h
fa
m
ily
an
d
p
at
ie
n
t—
ea
sy
to
in
te
rv
ie
w
b
o
th
an
d
d
o
d
o
cu
m
en
ta
ti
o
n
-s
h
o
w
in
fo
rm
at
io
n
o
n
th
e
sc
re
en
(R
A
,
M
D
).
Lo
ca
ti
o
n
o
f
w
o
rk
st
at
io
n
w
as
u
n
co
m
fo
rt
ab
le
fo
r
m
e
to
vi
ew
(R
C
,
M
D
).
Fl
o
w
(d
es
k
in
th
e
w
ay
),
(R
A
,
M
D
).
E
x
am
ta
b
le
C
h
ai
rs
p
o
si
ti
o
n
ed
w
el
lt
o
b
e
n
ea
r
p
h
ys
ic
ia
n
w
h
ile
at
co
m
p
u
te
r
(R
B
,
M
D
).
I
co
u
ld
fa
ce
th
e
p
at
ie
n
t
an
d
ad
d
re
ss
b
o
th
w
it
h
o
u
t
h
av
in
g
to
tu
rn
ar
o
u
n
d
o
r
h
av
e
m
y
b
ac
k
to
w
ar
d
th
em
(R
C
,
M
A
).
I
lik
ed
th
e
o
p
p
o
rt
u
n
it
y
fo
r
th
e
p
at
ie
n
t
to
se
e
m
u
lt
ip
le
sc
re
en
s
(R
C
,
M
A
).
I
d
id
n
o
t
lik
e
th
e
w
in
d
o
w
b
ei
n
g
w
h
er
e
th
e
p
at
ie
n
t
w
as
b
ei
n
g
ex
am
in
ed
o
r
ch
an
gi
n
g
(R
D
,
P
at
ie
n
t)
.
W
it
h
th
e
ex
am
ta
b
le
i
n
th
e
p
re
se
n
t
o
ri
en
ta
ti
o
n
,
o
n
ly
u
se
d
7
5
%
o
f
th
e
ex
am
ro
o
m
’s
ca
p
ac
it
y
(R
A
,
M
D
).
C
ar
eg
iv
er
ch
ai
r
T
h
e
p
ro
x
im
it
y
(m
ay
b
e
to
o
cl
o
se
al
m
o
st
)
b
et
w
ee
n
th
e
p
at
ie
n
t–
p
h
ys
ic
ia
n
–
ca
re
gi
ve
r
tr
ia
n
gl
e
(R
A
,
fa
m
ily
).
V
ie
w
in
g
o
f
p
at
ie
n
t
an
d
p
ar
en
t
w
o
rk
ed
w
el
l
(R
A
,
M
A
).
C
o
u
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
co
rn
er
o
f
th
e
ro
o
m
(R
D
,
Fa
m
ily
).
E
ve
ry
o
n
e
w
as
ve
ry
cl
o
se
an
d
M
D
w
as
ve
ry
cl
o
se
to
co
m
p
an
io
n
s
d
u
ri
n
g
ex
am
(R
D
,
M
D
).
T
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
T
ab
le
M
D
W
or
ks
ta
�o
n
Ch
ai
r
W
al
l M
on
ito
r
Co
m
pu
te
r M
on
ito
r
Ex
am
T
ab
le
M
D
W
or
ks
ta
�o
n
Ch
ai
r
Si
nk
Cu
rt
ai
n
Ex
am
T
ab
le
M
D
W
or
ks
ta
�o
n
Ch
ai
r
W
al
l M
on
ito
r
M
ed
ic
al
E
qu
ip
m
en
t
Ex
am
T
ab
le
M
D
W
or
ks
ta
�o
n
Ch
ai
r
W
al
l M
on
ito
r
Co
m
pu
te
r M
on
ito
r/
Ke
yb
oa
rd
W
in
do
w
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
19 15
55
16
11
22
15
7
31 27
2
7
16
11
21
8
18 16 18 14 18
20
8
17
2
25
2
1
2
4
6
4
8
8
2
8
3
5
5
8
9
1
10
2
15
7
1
2
7
1
14
8
1
4 2
8
3
10
5
4
1
12
20
1
1
3
18
19
3
1 2
3 7
1
3
2
1
2
3
1
7 3
2
2
11
3
4
2
2 1
0
20
40
60
80
100
120
Co
m
pu
te
r T
ab
le
Cu
rt
ai
n
Di
ag
no
s�
c
Se
t
Ex
am
T
ab
le
Ch
ai
r
Co
m
pu
te
r/
Ke
yb
oa
rd
Co
m
pu
te
r T
ab
le
Cu
rt
ai
n
Di
ag
no
s�
c
Se
t
Ex
am
T
ab
le
Ch
ai
r
Co
m
pu
te
r/
Ke
yb
oa
rd
Co
m
pu
te
r T
ab
le
Cu
rt
ai
n
Di
ag
no
s�
c
Se
t
Ex
am
T
ab
le
Go
w
n
W
al
l M
on
ito
r
Ch
ai
r
Co
m
pu
te
r T
ab
le
Di
ag
no
s�
c
Se
t
Ex
am
T
ab
le
Si
nk
W
in
do
w
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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