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Published on 08.11.12 in Vol 1, No 2 (2012): Jul-Dec

This paper is in the following e-collection/theme issue:

    Original Paper

    Physician Satisfaction Following Electronic Health Record Adoption in Three Massachusetts Communities

    1VA Boston Healthcare System, Section of General Internal Medicine, Jamaica Plain, MA, United States

    2Brigham and Women's Hospital, Division of General Internal Medicine, Boston, MA, United States

    3Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, United States

    4Massachusetts eHealth Collaborative, Waltham, MA, United States

    5Partners Health Care System, Wellesley, MA, United States

    6VA Boston Health Care, General Internal Medicine, Boston, MA, United States

    Corresponding Author:

    Leonie Heyworth, MD, MPH

    VA Boston Healthcare System

    Section of General Internal Medicine

    150 S. Huntington Ave, Suite 425

    Jamaica Plain, MA, 02130

    United States

    Phone: 1 857 364 5704

    Fax:1 857 364 6990



    Background: Despite mandates and incentives for electronic health record (EHR) adoption, little is known about factors predicting physicians’ satisfaction following EHR implementation.

    Objective: To measure predictors of physician satisfaction following EHR adoption.

    Methods: A total of 163 physicians completed a mailed survey before and after EHR implementation through a statewide pilot project in Massachusetts. Multivariable logistic regression identified predictors of physician satisfaction with their current practice situation in 2009 and generalized estimating equations accounted for clustering.

    Results: The response rate was 77% in 2005 and 68% in 2009. In 2005, prior to EHR adoption, 28% of physicians were very satisfied with their current practice situation compared to 25% in 2009, following EHR adoption (P < .001). In multivariate analysis, physician satisfaction following EHR adoption was correlated with self-reported ease of EHR implementation (adjusted odds ratio [OR] = 5.7, 95% CI 2.1 - 16), resources for practice improvement (adjusted OR = 2.6, 95% CI 1.2 - 6.1), pre-intervention satisfaction (adjusted OR = 4.8, 95% CI 1.5 - 15), and stress (adjusted OR = 5.3, 95% CI 1.1 - 25). Male physicians reported lower satisfaction following EHR adoption (adjusted OR = 0.3, 95% CI 0.2 - 0.6).

    Conclusions: Interventions to expand EHR use should consider additional support for practices with fewer resources for improvement and ensure ease of EHR implementation. EHR adoption may be a factor in alleviating physicians’ stress. Addressing physicians’ satisfaction prior to practice transformation and anticipating greater dissatisfaction among male physicians will be essential to retaining the physician workforce and ensuring the quality of care they deliver.

    Interact J Med Res 2012;1(2):e12




    Electronic health records (EHRs) have the potential to transform health care by improving the quality and safety of care delivered, particularly if adopted on a wide-scale basis. EHRs may also reduce the cost of providing ambulatory care [1,2]. Despite emerging evidence about these potential benefits, increasing public policy attention toward universal EHR adoption by legislative leaders, and financial incentives for EHR use, little is known about physician experience following EHR adoption.

    Successful EHR implementation generally requires users to be satisfied; therefore, defining predictors of satisfaction may increase the likelihood of a system’s success. Recent studies examining existing physician EHR users found that larger practices and younger physicians were more likely to adopt EHRs [3,4]. In addition, EHR users were found to be generally satisfied with their system [3]. Another cross-sectional study of physicians’ EHR-related satisfaction found that it was time-dependent and associated with use of a more robust EHR [5]. Prior studies have demonstrated physician satisfaction with new EHR adoption to be associated with the success of electronic implementation [6]; however, few prospective data are available regarding physicians’ overall satisfaction with their practice following EHR adoption.

    It is estimated that 27% of practices in the United States were using a fully functional EHR in 2010 [7]. The mandate for universal EHR implementation and robust clinical data exchange by 2014 [8], and incentives in place for EHR adoption [7] mean that very large numbers of practices in the United States are, or likely soon will be, in the process of EHR implementation. EHR adoption may not only impact how a physician writes prescriptions and notes, but may also influence the overall practice environment by changing workflow and physician-patient interaction. In addition, the emerging patient-centered medical home as a model for health care delivery rewards practices for EHR adoption [9], even though the EHRs of today are variable at meeting the needs of medical homes [10,11]. It is likely that EHR implementation is occurring simultaneously with practice changes to fit the medical home model, further underscoring the need to assess physicians’ satisfaction with an EHR, but also with their practice overall.

    Using Konrad and Linzer’s framework for measuring physicians’ work-life satisfaction [12,13], we identified several key facets that would be relevant to physicians’ satisfaction with their practice post-EHR adoption. We speculated that intrinsic factors (eg, years in practice, gender, race, self-reported stress, computer literacy, and satisfaction prior to EHR implementation), pay (in the form of bonuses for EHR use), and availability of practice resources would predict physician satisfaction following EHR adoption. Therefore, we undertook the present study to identify correlates of physician satisfaction with their practice following EHR adoption, in the context of a pilot community-based collaborative model in Massachusetts.


    The methods of survey development and administration have been described elsewhere and are summarized subsequently [14]. The survey and research protocol were approved by the Partners HealthCare Human Research Committee.

    Setting: The Massachusetts eHealth Collaborative

    The Massachusetts eHealth Collaborative (MAeHC) is a not-for-profit consortium established in 2004 as a pilot demonstration project to facilitate the adoption and implementation of EHRs. Following a competitive application process involving 35 eligible communities, three communities were selected as demonstration sites in March 2005: North Adams/Williamstown, Brockton, and Newburyport. Physicians and practices within these communities were found to be generally representative of Massachusetts [14]. A total of 548 physicians (97.7%) in 159 practices (95.2%) accepted the offer to participate. A select group of EHR vendors were identified through a comprehensive process and agreed to competitive EHR pricing. The EHR vendors Allscripts, eClinicalWorks, NextGen Healthcare Information Systems, and GE Healthcare were selected (all of whom were subsequently certified by the Certification Commission for Health Information Technology). As of the pilot’s completion date [15], overall participation was 84.0% for physicians in 134 practices in the pilot’s three communities. EHRs were implemented in 97.9% of practices between March 2006 and March 2008.

    The Massachusetts eHealth Collaborative Survey

    The MAeHC physicians were surveyed using the same survey instrument developed for a Massachusetts statewide survey of EHR use, described elsewhere [4] and available from the corresponding author upon request. The survey included demographic information about the physician, including age, gender, and self-reported race (physicians had the option to select one or more of the following categories: Asian, American Indian or Alaskan Native, black or African American, Native Hawaiian or other Pacific Islander, white, or “other”). Race data were collected in order to compare survey data with census figures about population distributions. The baseline MAeHC survey was delivered to participating physicians between September and October 2005. Between January and February 2009, a similar follow-up survey was delivered after physicians had been using a new EHR for at least one year. Surveys were mailed to all physicians who had signed agreements to participate in the MAeHC. Physicians were instructed to complete the survey and return the survey by mail or to an MAeHC staff member visiting their practice site. No cash incentive was offered for survey completion because participation in the evaluations was a condition for MAeHC involvement. Between 2005 and 2009, some practices dissolved, some physicians departed, and new physicians entered the communities. A total of 163 physicians from 134 practices completed both the 2005 and 2009 survey questionnaires [16].

    Statistical Analysis

    For all statistical analyses, SAS version 9.2 software (SAS Institute Inc, Cary, NC, USA) was used. Logistic regression was used to analyze predictors of self-reported physician satisfaction following EHR implementation, and Chi-square analysis was used to examine the association between physician satisfaction and perceived EHR vendor characteristics. The dependent variable in these analyses was the response to the 2009 survey item: “Overall, how satisfied are you with your current practice situation?” Physicians were asked to check 1 of 4 possible responses: very satisfied, generally satisfied, somewhat dissatisfied, or very dissatisfied. These responses were dichotomized in the analyses to “very satisfied” versus “generally satisfied, somewhat dissatisfied, or very dissatisfied.” In this logistic regression model, physician satisfaction was examined as a function of exogenous and perceptual predictor variables modeled after Konrad and Linzer’s 10 facets of measuring physician satisfaction [12,13]. Exogenous predictor variables included were whether the practice had financial incentives for EHR adoption, the level of financial resources available for practice improvement or expansion, size of practice (1-4 vs 5+ physicians or nurse practitioners and physician assistants), practice specialty (primary care vs specialty practice), and whether the practice experienced difficulty with EHR implementation (self-reported). Perceptual variables included physicians’ views of whether personal or professional stress was a problem in their practice and how comfortable they felt with the use of computers prior to EHR implementation and their daily patient volume in 2009. Physician characteristics, including age, gender, self-reported satisfaction in 2005, and practice ownership, were also included a priori in the final logistic regression model. Generalized estimating equations were used for the logistic regression to account for the correlations within each practice [17,18].


    Respondent Characteristics

    A total of 163 surveys were returned from the same physicians in 2005 and 2009. The response rate in 2005 was 76.5% and was 68.2% in 2009. Respondents and non-respondents were similar with respect to specialty and practice size [14]. Of the 163 respondents to both surveys, 147 responded to the question, “Overall, how satisfied are you with your current practice situation?” in both the 2005 and 2009 surveys. Of the respondents to both surveys, 44 had missing responses to questions used as explanatory variables, resulting in 119 respondents’ surveys eligible for subsequent analysis.

    Physician Satisfaction

    Physicians responding to both the 2005 and the 2009 MAeHC surveys had adopted an EHR for at least one year, and were primarily white (79.1%) men (73.6%) in practice for more than 15 years (89.0%). Overall, 26.4% reported feeling very satisfied with their current practice situation in 2005, compared to 23.9% in 2009 (P < .001). Approximately half (46.6%) of responding physicians worked in practices with > 5 physicians or nurse practitioners (NPs) or physician assistants (PAs), and 60.7% worked in specialty (non-primary care) practices. A majority (61.4%) reported incentives for health information technology (HIT) use. A total of 20.2% reported that their practices had financial resources available for practice improvement or expansion. A minority of physicians (16.6%) post-EHR adoption reported that they would prefer to give up their EHR and return to paper records (Table 1).

    Predictors of Physician Satisfaction with Current Practice

    In logistic regression analyses, ease of EHR implementation and male gender were the strongest independent predictors of physician satisfaction among physicians adopting a new EHR (Table 2). Physicians who found that their EHR implementation process was not very difficult were much more likely to report feeling satisfied in their current practice in 2009 (adjusted odds ratio [OR] = 5.7, 95% CI 2.1 - 16). Male physicians were much less likely to be satisfied following EHR adoption (adjusted OR = 0.3, 95% CI 0.2 - 0.6), whereas physicians who reported higher personal or professional stress before EHR adoption were more satisfied following implementation (adjusted OR = 5.3, 95% CI 1.1 - 25). Physicians’ report of feeling very satisfied in their current practice at the time of their baseline survey in 2005 was also strongly correlated with satisfaction in 2009 (adjusted OR = 4.8, 95% CI 1.5 - 15). Physicians in practices with financial resources available for practice improvement or expansion also were more likely to report feeling satisfied in their current practice in 2009 (adjusted OR = 2.6, 95% CI 1.2 - 6.1).

    In the Chi-square analysis, we found that baseline levels of satisfaction were not related to post-intervention (2009) reports of easy EHR implementation (P = .62). This analysis provided evidence that the observed relationship between ease of EHR implementation and 2009 satisfaction was not likely to be confounded by baseline levels of satisfaction. We also confirmed that satisfaction post-EHR adoption was strongly associated with the physician-reported training level of the EHR vendor (P = .002) and the quality of assistance provided by MAeHC senior leadership (< .001) and staff (= .002), but found that prompt support from the information technology (IT) support team for problems related to the EHR application, or for hardware or network connectivity, did not impact practice satisfaction (Table 3).

    Characteristicn (%)

    Male120 (73.6%)

    Female38 (23.3%)

    Missing response5 (3.1%)
    Years in practice

    15 or greater145 (89.0%)

    Less than 1518 (11.0%)

    White129 (79.1%)

    Asian15 (9.2%)

    American Indian or Alaskan Native1 (0.6%)

    Black or African American4 (2.5%)

    Native Hawaiian or other Pacific Islander0

    Other4 (2.5%)

    Missing response10 (6.1%)
    Practice size

    Solo or partner practice47 (28.8%)

    3-5 physicians or NPs/PAs24 (14.7%)

    > 5 physicians or NPs/PAs76 (46.6%)

    Missing response16 (9.8%)
    Practice typeb

    Primary care63 (38.7%)

    Specialty99 (60.7%)

    Missing response1 (0.6%)
    Moderate or extensive financial resources
    available for practice improvement or expansion
    33 (20.2%)
    Incentives for HIT100 (61.4%)
    Satisfaction with current practice

    Very satisfied in 200543 (26.4%)

    Very satisfied in 200939 (23.9%)
    Personal/professional stress

    A moderate or serious problem in 200557 (35.0%)

    A moderate or serious problem in 200961 (37.4%)
    Comfort with computers

    Very comfortable in 200574 (45.4%)

    Very comfortable in 200987 (53.4%)

    EHR implementationc

    Very difficult54 (33.1%)

    Somewhat or not difficult102 (62.6%)

    Missing response7 (4.3%)
    Preference to return to paper records in 2009d

    Yes27 (16.6%)

    No136 (83.4%)
    Table 1. Sample characteristics and demographics of physician respondents to both the 2005 and the 2009 Massachusetts eHealth Collaborative (MAeHC) surveys (n = 163).a
    View this table
    CharacteristicAdjusted OR95% CIP value

    Male0.30.2 - 0.6< .001
    Years in practice

    15 or greater2.30.7 - 7.2.17

    White2.10.8 - 5.5.14
    Practice ownership3.00.3 - 28.33
    Practice size

    Solo or partner practice (reference)----

    3-5 physicians or NPs/PAs

    > 5 physicians or NPs/PAs2.50.8 - 7.9.11
    Practice typeb

    Primary care1.30.4 - 0.6.73
    Daily patient volume

    ≤ 15 (reference)----

    > 160.50.1 - 2.5.40
    Moderate or extensive financial resources available for practice improvement or expansion2.61.2 - 6.1.02
    Incentives for HIT c1.70.2 - 10.50
    Physician perceptions

    Very satisfied with current practice (2005)4.81.5 - 15.007

    Personal/professional stress a moderate or serious problem (2005)5.31.1 - 25.04

    Very comfortable with computers (2005)1.60.3 - 10.60

    No difficulty with EHR implementation (2009)5.72.1 - 16< .001
    Table 2. Multivariate relationship between practice characteristics and physician perceptions of practices and physician satisfaction (n = 119).a
    View this table
    CharacteristicP value
    Excellent or very good EHR vendor quality.002
    Excellent or very good help provided by MAeHC

    Senior leadership< .001

    Senior staff< .001
    Prompt support from information technology team

    For hardware/ network connectivity.82

    For EHR application issues.74
    Table 3. Bivariate relationship between physicians feeling very satisfied with their practice following EHR adoption and their perceptions of EHR vendor characteristics (n = 159).
    View this table


    We examined physicians’ satisfaction with their practice in the context of new EHR adoption through a pilot community-based collaborative model in Massachusetts (MAeHC) and found that physician satisfaction declined modestly overall after EHR adoption. We found that one of the strongest predictors of physicians reportingsatisfaction post-EHR adoption was the ease with which the EHR implementation occurred. In subsequent analyses, we found that satisfaction was related to physician-perceived EHR vendor training and the quality of assistance provided by MAeHC senior leadership and staff. There was no association with availability of prompt support from the IT team for hardware or connectivity issues, or for problems related to the EHR application. This finding emphasizes the importance of site-specific experience and potentially explains why physicians within the MAeHC may have reported varying experiences with ease of EHR implementation.

    In the context of Konrad and Linzer’s framework of the necessary facets for physician job satisfaction [13], our results support the collective presence of a practice’s resources (financial resources for improvement or expansion), community (MAeHC, a community-wide pilot project), and administrative features (ease of EHR implementation) in nurturing physician satisfaction during a period of EHR adoption. Other predictors of satisfaction included physician’s satisfaction with their practice prior to EHR implementation. We also found that increased self-reported physician stress before EHR adoption was a predictor of satisfaction following EHR implementation. Although little research exists on the issue of physician stress and workflow, our results raise the intriguing possibility that physicians with higher stress levels may perceive a greater benefit from EHR implementation, perhaps by improving workflow, efficiency, and care coordination, resulting in higher levels of satisfaction. We did not find any associations between satisfaction following EHR adoption and physician age, practice size or ownership, physicians’ patient volume, or number of years in practice. The presence of financial incentives for EHR adoption was not associated with post-adoption satisfaction in this study.

    Our finding that male physicians were much less likely to report being satisfied following EHR implementation adds to the existing mixed literature on gender differences in physician career satisfaction. The largest study of female physicians, the Women Physicians’ Health Study [19], found that 84% of respondents reported being “usually,” “almost always,” or “always” satisfied. Another study demonstrated that male physicians report greater job dissatisfaction, work-life stress, and isolation in their work environment [20]. Existing social science literature has proposed several potential explanations for the higher reported satisfaction rates among professional women, including lower job expectations, socialization not to express discontent, and appreciation of different career characteristics compared with men [21-23]. The Physician Work Life Study, a large, nationally representative, randomly stratified sample, showed similar global satisfaction scores for men and women, although researchers found that women were more satisfied with their specialty and patient relationships than their levels of autonomy, relationships with the community, pay, and resources [24]. In the context of this literature, greater male dissatisfaction, particularly following practice transformation, is not an unexpected finding.

    Our finding that overall physician satisfaction decreased between 2005 and 2009 may be explained by a possible ceiling effect within our study sample. We observed that 92% of physicians reported feeling very satisfied or satisfied in 2005, and 75% reported feeling very satisfied or satisfied in 2009, The physicians in our study may have been more satisfied at baseline than average physicians in Massachusetts, where the proportion of physicians reporting that they felt either very satisfied or satisfied remained approximately the same (39% in 2006 and 38% in 2009) [25]. The Massachusetts health care insurance reform law in October 2006, pressure from pay-for-performance measures, or the economic climate may have contributed toward the observed trends in our sample.

    Few studies have examined physicians’ satisfaction with their practices in the context of community-based EHR adoption. One strength of this study was that EHR adoption was facilitated through the same pilot program among all surveyed physicians in three communities. This pilot was specifically designed to streamline robust EHR implementation, which has been found previously to be correlated with physician satisfaction [5]. Since participation in evaluation was a condition for MAeHC involvement, we were fortunate to have robust survey response rates for both the 2005 and 2009 surveys [15]. Surveys conducted before and after EHR implementation also allowed us to account for baseline satisfaction—our outcome of interest—in our analysis.

    This study has several limitations. Despite high response rates, the sample size (n = 119) restricted the number of independent variables that could be examined as correlates of physician satisfaction. In addition, as in any observational study, unmeasured confounders may exist, although our models included a number of covariates to control for confounding to the extent possible. A 2010 study found that satisfaction with EHR use seems to increase over time, but this study was limited by a low response rate (28%) [5]. It is possible that the physicians in our study, with relatively recent EHR implementation (at least 1 year, but many less than 2 years) would have reported higher levels of overall satisfaction with their practice if surveyed at a later date [26]. Since meaningful use criteria were established after these surveys were conducted, clinician experience in the context of meaningful use and EHR implementation was not captured in this study. The study’s setting and participants, generally comparable to physicians practicing within Massachusetts [4], may have limited generalizability to other states or communities, and these results may not generalize outside the United States. In addition, because all physicians were members of practices assisted by MAeHC with EHR implementation, physicians’ experiences with EHR implementation in other communities by alternate EHR vendors may differ.

    EHR adoption and meaningful use of health information exchange represent a national health care priority in the United States. Before implementation of the American Recovery and Reinvestment Act of 2009, EHR adoption rates had been sluggish in the United States. This has led policy makers to implement broad national incentives for providers, and policy makers have also actively sought successful programs as models for EHR design and implementation in order to meet the national goal of universal EHR implementation and robust clinical data exchange by 2014 [8]. Demonstration projects, such as the MAeHC, have great potential to play a transformative role in the quest for widespread EHR adoption when partnered with on-site effective leadership and staff support. Importantly, our finding of ease of EHR implementation being strongly associated with physicians’ satisfaction is particularly noteworthy because sustained usage of EHR and physician promotion of EHR use within professional networks is fundamentally dependent on physicians’ satisfaction. Despite relatively widespread use of incentives for EHR use and physicians’ reports of comfort with computer use, neither of these was found to be associated with satisfaction in practice following EHR implementation. Our data, in-line with prior literature, underscore the need to adequately support practices with fewer financial resources for improvement and ensure physician’s practice satisfaction even before embarking on EHR implementation.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    MAeHC survey 2005.

    PDF File (Adobe PDF File), 186KB

    Multimedia Appendix 2

    MAeHC survey 2009.

    PDF File (Adobe PDF File), 318KB


    1. Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood) 2005 Oct;24(5):1103-1117. [CrossRef] [Medline]
    2. Miller RH, West C, Brown TM, Sim I, Ganchoff C. The value of electronic health records in solo or small group practices. Health Aff (Millwood) 2005 Oct;24(5):1127-1137. [CrossRef] [Medline]
    3. DesRoches CM, Campbell EG, Rao SR, Donelan K, Ferris TG, Jha A, et al. Electronic health records in ambulatory care--a national survey of physicians. N Engl J Med 2008 Jul 3;359(1):50-60. [CrossRef] [Medline]
    4. Simon SR, Kaushal R, Cleary PD, Jenter CA, Volk LA, Poon EG, et al. Correlates of electronic health record adoption in office practices: a statewide survey. J Am Med Inform Assoc 2007 Feb;14(1):110-117 [FREE Full text] [CrossRef] [Medline]
    5. Menachemi N, Powers T, Au DW, Brooks RG. Predictors of physician satisfaction among electronic health record system users. J Healthc Qual 2010;32(1):35-41. [Medline]
    6. Mazzoleni MC, Baiardi P, Giorgi I, Franchi G, Marconi R, Cortesi M. Assessing users' satisfaction through perception of usefulness and ease of use in the daily interaction with a hospital information system. In: Proc AMIA Annual Fall Symp. 1996 Presented at: Proc AMIA Annual Fall Symp; 1996; Washington, DC p. 752-756.
    7. Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med 2010 Aug 5;363(6):501-504. [CrossRef] [Medline]
    8. The White House. President George W. Bush. Transforming Health Care: The President's Health Information Technology Plan; 2006.
    9. Fisher ES. Building a medical neighborhood for the medical home. N Engl J Med 2008 Sep 18;359(12):1202-1205. [CrossRef] [Medline]
    10. Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood) 2010 Apr;29(4):614-621. [CrossRef] [Medline]
    11. Fernandopulle R, Patel N. How the electronic health record did not measure up to the demands of our medical home practice. Health Aff (Millwood) 2010 Apr;29(4):622-628. [CrossRef] [Medline]
    12. Linzer M, Konrad TR, Douglas J, McMurray JE, Pathman DE, Williams ES, et al. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med 2000 Jul;15(7):441-450. [Medline]
    13. Konrad TR, Williams ES, Linzer M, McMurray J, Pathman DE, Gerrity M, et al. Measuring physician job satisfaction in a changing workplace and a challenging environment. SGIM Career Satisfaction Study Group. Society of General Internal Medicine. Med Care 1999 Nov;37(11):1174-1182. [Medline]
    14. Simon SR, Kaushal R, Jenter CA, Volk LA, Burdick E, Poon EG, et al. Readiness for electronic health records: comparison of characteristics of practices in a collaborative with the remainder of Massachusetts. Inform Prim Care 2008;16(2):129-137. [Medline]
    15. Goroll AH, Simon SR, Tripathi M, Ascenzo C, Bates DW. Community-wide implementation of health information technology: the Massachusetts eHealth Collaborative experience. J Am Med Inform Assoc 2009 Feb;16(1):132-139 [FREE Full text] [CrossRef] [Medline]
    16. Fleurant M, Kell R, Love J, Jenter C, Volk LA, Zhang F, et al. Massachusetts e-Health Project increased physicians' ability to use registries, and signals progress toward better care. Health Aff (Millwood) 2011 Jul;30(7):1256-1264. [CrossRef] [Medline]
    17. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986 Mar;42(1):121-130. [Medline]
    18. Zeger SL, Liang KY, Albert PS. Models for longitudinal data: a generalized estimating equation approach. Biometrics 1988 Dec;44(4):1049-1060. [Medline]
    19. Frank E, McMurray JE, Linzer M, Elon L. Career satisfaction of US women physicians: results from the Women Physicians' Health Study. Society of General Internal Medicine Career Satisfaction Study Group. Arch Intern Med 1999 Jul 12;159(13):1417-1426. [Medline]
    20. Quinn MA, Wilcox A, Orav EJ, Bates DW, Simon SR. The relationship between perceived practice quality and quality improvement activities and physician practice dissatisfaction, professional isolation, and work-life stress. Med Care 2009 Aug;47(8):924-928. [CrossRef] [Medline]
    21. Phelan J. The paradox of the contented female worker: an assessment of alternative explanations. Soc Psychol Q 1994;57:95-107.
    22. Robinson GE. STUDENTJAMA. Career satisfaction in female physicians. JAMA 2004 Feb 4;291(5):635. [CrossRef] [Medline]
    23. Chiu C. Do professional women have lower job satisfaction than professional men? Lawyers as a case study. Sex Roles 1998;38:521-536.
    24. McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K. The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group. J Gen Intern Med 2000 Jun;15(6):372-380. [Medline]
    25. Massachusetts Medical Society. Section 5: Physician Satisfaction, Attitudes Toward the Profession, And Future Career Plans. Physician Workforce Study 2011:34-50 [FREE Full text] [WebCite Cache]
    26. Zhou L, Soran CS, Jenter CA, Volk LA, Orav EJ, Bates DW, et al. The relationship between electronic health record use and quality of care over time. J Am Med Inform Assoc 2009 Aug;16(4):457-464 [FREE Full text] [CrossRef] [Medline]
    27. Ford EW, Menachemi N, Peterson LT, Huerta TR. Resistance is futile: but it is slowing the pace of EHR adoption nonetheless. J Am Med Inform Assoc 2009 Jun;16(3):274-281 [FREE Full text] [CrossRef] [Medline]


    EHR: electronic health record
    HIT: health information technology
    MAeHC: Massachusetts eHealth Collaborative
    NP: nurse practitioner
    OR: odds ratio
    PA: physician assistant

    Edited by G Eysenbach; submitted 26.02.12; peer-reviewed by D Burke, C Or, PY Yen, K Zheng, C Kuziemsky; comments to author 29.07.12; revised version received 04.09.12; accepted 21.09.12; published 08.11.12

    ©Leonie Heyworth, Fang Zhang, Chelsea A. Jenter, Rachel Kell, Lynn A. Volk, Micky Tripathi, David W. Bates, Steven R. Simon. Originally published in the Interactive Journal of Medical Research (, 08.11.2012.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Interactive Journal of Medical Research, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.