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Kai Zheng • Johanna Westbrook
Thomas G. Kannampallil • Vimla L. Patel
Editors

Cognitive Informatics
Reengineering Clinical Workflow for Safer
and More Efficient Care
Editors
Kai Zheng Johanna Westbrook
Department of Informatics Australian Institute of Health Innovation
University of California, Irvine Macquarie University
Irvine, CA North Ryde, NSW
USA Australia

Thomas G. Kannampallil Vimla L. Patel

Department of Anesthesiology and Institute Center for Cognitive Studies in
for Informatics, School of Medicine Medicine and Public Health
Washington University in St Louis The New York Academy of Medicine
St Louis, MO New York, NY
USA USA

ISSN 1431-1917     ISSN 2197-3741 (electronic)

Health Informatics
ISBN 978-3-030-16915-2    ISBN 978-3-030-16916-9 (eBook)
https://doi.org/10.1007/978-3-030-16916-9

© Springer Nature Switzerland AG 2019

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Foreword

Clinical care problems today include inefficiency, errors, and applying best
evidence.
There is universal recognition that healthcare today is expensive and inefficient
and is plagued by failure to deliver high quality. Nowhere is this truer than the
United States, with its fragmented system of providers and payers and its singularly
huge health expenditures per capita as a proportion of gross domestic product. It is
hardly controversial to propose that part of the solution is to improve efficiency
through communication and coordination among all the stakeholders.
Current communication and coordination are largely related to financial matters,
especially payment to healthcare providers. Where “workflow” is addressed, it is
largely administrative in nature (admission, discharge, transfer, referral for clinical
procedures, and documentation for billing purposes). Yet the real workflow—mov-
ing the patient through the healthcare system to transform the sick patients to
healthy ones and keep them that way, what the administrative processes were cre-
ated for in the first place—often garners less study for process improvement. As a
result, clinical workflows take a back seat to administrative ones. By way of illustra-
tion, I once worked at a hospital where transfer of a patient from a medical or surgi-
cal service to the rehabilitation service required formally discharging the patient,
with attendant discharge summary and orders, and then readmitting them, with
attendant intake and admission orders—even though the patient might not physi-
cally move from one bed to another. The opportunity for degraded continuity of
care, such as order transcription errors, was only one of the problems that this pro-
cess imposed.
In the United States, the Affordable Care Act has led to rapid adoption of elec-
tronic health record (EHR) systems, largely commercial products, many of which
with serious flaws that had previously impeded their adoption. The unintended con-
sequences of this experience can inform similar efforts in other countries.
Nevertheless, EHR adoption has been held out as a way to improve healthcare effec-
tiveness and efficiency through automation of, in part, the communication and coor-
dination related to workflow processes.

v
vi Foreword

It is fair to say that the clinical (previously “medical”) informatics research com-
munity has been poised to help with information technology-based workflow for
decades, at least since the inception of the Symposium on Computer Applications in
Medical Care in 1977 (now renamed as the Annual Symposium of the American
Medical Informatics Association). The work presented at that conference alone,
over its 40-plus years, comprises many thousands of informatics projects, the major-
ity of which failed to find long-term adoption.
While early evaluation of informatics solutions consisted of demonstrating that
programs could run to completion without errors and could do so faster and more
accurately than previous attempts, current evaluations examine issues such as
usability and usefulness. Yet even systems that fair well in such assessments find
that enthusiasm for their use is underwhelming.
To a large extent, the lack of success of most of these projects has been related to
failure to integrate them into healthcare systems and, even where integrated, failure
to support workflow processes in natural, intuitive ways. For example, nurses and
physicians find work-arounds in using electronic clinician order entry systems to
the detriment of patients, while alerts and reminders are overridden more often than
not as being inappropriate and bothersome. In my own experience, I developed a
tool called the Medline Button, the first version of a class of applications called
infobuttons that attempt to anticipate and assist with clinician information needs,
which executed medical literature searches based on a patient’s ICD9 codes in the
pre-PubMed era. It was a technical success, making the retrieval of relevant infor-
mation possible with the touch of a button. However, it was a practical failure
because it used data generated at the time of hospital discharge that were no longer
relevant during a subsequent hospital admission.
What has largely been missing from efforts to health information technology-­
based efforts to improve clinical workflow, as evidenced by the Medline Button
experience, are studies of cognitive processes of patient care providers and their
impact on healthcare team communication and coordination. In subsequent infobut-
ton research, for example, successful adoption did not occur until I partnered with
Vimla Patel, one of this book’s editors, and her team of cognitive scientists at McGill
University to study clinicians’ information needs through formal observational
think-aloud studies in actual clinical settings.
This brings me to the purpose and place of this book. Its reviews, essays, and case
studies will, collectively, raise the reader’s awareness of the myriad issues that relate
health information technology to clinical workflow, not from the perspective of admin-
istrative processes but based on cognitive processes that such systems are intended to
support. Once enlightened with that perspective, the reader should consider the sys-
tems present (or needed) in his or her own institution and how they should be studied.
Hopefully, some of these readers will be decision-makers at their institutions, who will
be able to include cognitive researchers in the task of putting the findings of their
research into practice. This book will then be at the right place at the right time to
provide insight into the types of tools and evaluation expertise that will be needed to
better match workflow systems to intended, rather than unintended, consequences.

Birmingham, AL, USA  James J. Cimino

Contents

Part I Clinical Workflow and Health Information Technologies

1 Clinical Workflow in the Health IT Era������������������������������������������������    3
Kai Zheng, Johanna Westbrook, Thomas G. Kannampallil,
and Vimla L. Patel
2 Cognitive Behavior and Clinical Workflows�����������������������������������������    9
Jan Horsky
3 Unintended Adverse Consequences of
Health IT Implementation: Workflow
Issues and Their Cascading Effects��������������������������������������������������������   31
Elizabeth V. Eikey, Yunan Chen, and Kai Zheng

Part II The State of the Art of Workflow Research

4 A Review of Clinical Workflow Studies and Methods��������������������������   47
Philip Payne, Marcelo Lopetegui, and Sean Yu
5 A Workflow Perspective in Aviation ������������������������������������������������������   63
Guy André Boy
6 Characterizing Collaborative Workflow and
Health Information Technology��������������������������������������������������������������   81
Craig E. Kuziemsky, Joanna Abraham, and Madhu C. Reddy
7 Interruptions and Multitasking in Clinical Work:
A Summary of the Evidence�������������������������������������������������������������������� 103
Johanna I. Westbrook, Magdalena Z. Raban, and Scott R. Walter
8 Reengineering Approaches for Learning Health Systems:
Applications in Nursing Research to Learn from Safety
Information Gaps and Workarounds to Overcome
Electronic Health Record Silos �������������������������������������������������������������� 115
Sarah Collins Rossetti, Po-Yin Yen, Patricia C. Dykes,
Kumiko Schnock, and Kenrick Cato
vii
viii Contents

9 Patient-Oriented Workflow Approach �������������������������������������������������� 149

Mustafa Ozkaynak, Siddarth Ponnala, and Nicole E. Werner
10 Workflow at the Edges of Care �������������������������������������������������������������� 165
Bradley N. Doebbeling and Pooja Paode

Part III Research Methods for Studying Clinical Workflow

11 Computer-Based Tools for Recording Time and
Motion Data for Assessing Clinical Workflow�������������������������������������� 181
Danny Tzu-Yu Wu
12 Understanding Clinical Workflow Through Direct
Continuous Observation: Addressing the
Unique Statistical Challenges����������������������������������������������������������������� 191
Scott R. Walter, William T. M. Dunsmuir, Magdalena Z. Raban,
and Johanna I. Westbrook
13 Clinical Workflow and Human Factors ������������������������������������������������ 211
Aaron Zachary Hettinger, Emilie M. Roth, Rollin J. Fairbanks,
and Ann Bisantz
14 Automated Location Tracking in Clinical Environments:
A Review of Systems and Impact on Workflow Analysis �������������������� 235
Akshay Vankipuram and Vimla L. Patel

Part IV Applications and Case Studies

15 Health IT-Enabled Care Coordination and
Redesign in Ambulatory Care���������������������������������������������������������������� 257
Jonathan S. Wald and Laurie Novak
16 Turning “Night into Day”: Challenges, Strategies, and
Effectiveness of Re-engineering the Workflow to
Enable Continuous Electronic Intensive Care
Unit Collaboration Between Australia and U.S.������������������������������������ 281
Cheryl Hiddleson, Timothy Buchman, and Enrico Coiera
17 Encoding Clinical Pathways: The Impact Beyond the Target ������������ 289
Edward H. Suh and Gina T. Waight
18 Cognitive Disconnect and Information Overload:
Electronic Health Record Use for Rounding and Handover
Communications in a Pediatric Intensive Care Unit���������������������������� 297
R. Stanley Hum
19 Clinical Workflow: The Past, Present, and Future ������������������������������ 307
Kai Zheng, Johanna Westbrook, Thomas G. Kannampallil,
and Vimla L. Patel
Index������������������������������������������������������������������������������������������������������������������ 313
Contributors

Joanna Abraham, PhD Department of Anesthesiology and Institute for

Informatics, School of Medicine, Washington University in St. Louis, St. Louis,
MO, USA
Ann Bisantz, PhD University at Buffalo, Buffalo, NY, USA
Guy André Boy, PhD FlexTech Chair, CentraleSupélec (Paris Saclay University)
and ESTIA Institute of Technology, Bidart, France
Timothy Buchman, PhD, MD Emory University, Atlanta, GA, USA
Kenrick Cato, RN, PhD School of Nursing, Columbia University, New York, NY,
USA
Yunan Chen, PhD Department of Informatics, Donald Bren School of Information
and Computer Sciences, University of California, Irvine, Irvine, CA, USA
Enrico Coiera, MB, PhD, FACMI, FACHI Macquarie University, Sydney, NSW,
Australia
Sarah Collins Rossetti, RN, PhD, FACMI Department of Biomedical Informatics,
School of Nursing, Columbia University, New York, NY, USA
Bradley N. Doebbeling, MD, MSc College of Health Solutions, Arizona State
University, Phoenix, AZ, USA
William T. M. Dunsmuir, PhD Department of Statistics, School of Mathematics
and Statistics, University of New South Wales, Sydney, NSW, Australia
Patricia C. Dykes, RN, PhD, FACMI Division of General Internal Medicine and
Primary Care, Department of Medicine, Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA
Elizabeth V. Eikey, PhD Department of Informatics, Donald Bren School of
Information and Computer Sciences, University of California, Irvine, Irvine, CA,
USA

ix
x Contributors

Rollin J. Fairbanks, MD, MS MedStar Health, Columbia, MD, USA

Georgetown University, Washington, DC, USA
Aaron Zachary Hettinger, PhD MedStar Health, Columbia, MD, USA
Georgetown University, Washington, DC, USA
Cheryl Hiddleson, MSN, RN, CENP, CCRN-E Emory University, Emory eICU
Center, Atlanta, GA, USA
Jan Horsky, PhD Center for Research Informatics, Northwell Health, Manhasset,
NY, USA
R. Stanley Hum, MD, FRCPC Columbia University, New York, NY, USA
Thomas G. Kannampallil, PhD Department of Anesthesiology and Institute for
Informatics, School of Medicine, Washington University in St Louis, St Louis, MO,
USA
Craig E. Kuziemsky, PhD Telfer School of Management, University of Ottawa,
Ottawa, ON, Canada
Marcelo Lopetegui, MD, MSc Centro de Informática Biomédica, Facultad de
Medicina Clínica Alemana, Universidad del Desarrollo, Concepción, Región del
Bío Bío, Chile
Laurie Novak, PhD, MHSA Vanderbilt University, Nashville, TN, USA
Mustafa Ozkaynak, PhD, MS College of Nursing, University of Colorado—
Denver, Aurora, CO, USA
Pooja Paode College of Health Solutions, Arizona State University, Phoenix,
AZ, USA
Vimla L. Patel, PhD, FRSC, FACMI Department of Biomedical Informatics,
Arizona State University, Scottsdale, AZ, USA
Center for Cognitive Studies in Medicine and Public Health, The New York
Academy of Medicine, New York, NY, USA
Philip Payne, PhD, FACMI Institute for Informatics, School of Medicine,
Washington University in St. Louis, St. Louis, MO, USA
Siddarth Ponnala, PhD Cand. Department of Industrial and Systems Engineering,
College of Engineering, University of Wisconsin-Madison, Madison, WI, USA
Magdalena Z. Raban, PhD, MIPH Faculty of Medicine and Health Sciences,
Centre for Health Systems and Safety Research, Australian Institute of Health
Innovation, Macquarie University, North Ryde, NSW, Australia
Madhu C. Reddy, PhD, FACMI Department of Communication Studies, School
of Communication, Northwestern University, Evanston, IL, USA
Contributors xi

Emilie M. Roth, PhD Roth Cognitive Engineering, Stanford, CA, USA

Kumiko Schnock, RN, PhD Division of General Internal Medicine and Primary
Care, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical
School, Boston, MA, USA
Edward H. Suh, MD NewYork Presbyterian Hospital/Columbia University, New
York, NY, USA
Department of Emergency Medicine, Columbia University College of Physicians
and Surgeons, New York, NY, USA
Akshay Vankipuram, PhD Department of Biomedical Informatics, Arizona State
University, Scottsdale, AZ, USA
Gina T. Waight, MD NewYork Presbyterian Hospital/Columbia University, New
York, NY, USA
Department of Emergency Medicine, Columbia University College of Physicians
and Surgeons, New York, NY, USA
Jonathan S. Wald, MD, MPH, FACMI InterSystems Corporation, Cambridge,
MA, USA
Scott R. Walter, PhD, MBiostat Faculty of Medicine and Health Sciences, Centre
for Health Systems and Safety Research, Australian Institute of Health Innovation,
Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW,
Australia
Nicole E. Werner, PhD Department of Industrial and Systems Engineering,
College of Engineering, University of Wisconsin-Madison, Madison, WI, USA
Johanna I. Westbrook, PhD, MHA, FACMI Centre for Health Systems and
Safety Research, Australian Institute of Health Innovation, Faculty of Medicine and
Health Sciences, Macquarie University, Sydney, NSW, Australia
Danny Tzu-Yu Wu, PhD, MS Department of Biomedical Informatics and
Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
Po-Yin Yen, RN, PhD Institute for Informatics, School of Medicine, Washington
University School of Medicine in St. Louis, St. Louis, MO, USA
Goldfarb School of Nursing, Barnes-Jewish College, BJC HealthCare, St. Louis,
MO, USA
Sean Yu, ME Institute for Informatics, School of Medicine, Washington University
in St. Louis, St. Louis, MO, USA
Kai Zheng, PhD, FACMI Department of Informatics, Donald Bren School of
Information and Computer Sciences, University of California, Irvine, Irvine, CA,
USA
 Part I
Clinical Workflow and Health
Information Technologies
Chapter 1
Clinical Workflow in the Health IT Era

Kai Zheng, Johanna Westbrook, Thomas G. Kannampallil,

and Vimla L. Patel

Health information technology (IT) in general, and electronic health records (EHR)
in particular, hold great promise to cross the quality chasm of the healthcare system
and to bend the curve of ever-rising costs (Institute of Medicine (U.S.) 2001; Girosi
et al. 2005). However, health IT implementation projects globally have experienced
a wide range of issues, from rollout delays to budget overruns (Kaplan and Harris-­
Salamone 2009). Successfully deployed systems often fail to generate anticipated
results (Black et al. 2011; Kellermann and Jones 2013); some are even associated
with unintended adverse consequences (Ash et al. 2007; Campbell et al. 2006;
Koppel et al. 2005; Zheng et al. 2016).
In the U.S., for example, over $30 billion has been invested in accelerating EHR
adoption and promoting its “meaningful use” through the appropriation from the
Health Information Technology for Economic and Clinical Health (HITECH) Act
2009 (Blumenthal 2010; Blumenthal and Tavenner 2010). While the program has

K. Zheng (*)
Department of Informatics, Donald Bren School of Information and Computer Sciences,
University of California, Irvine, Irvine, CA, USA
e-mail: [email protected]
J. Westbrook
Faculty of Medicine and Health Sciences, Centre for Health Systems and Safety Research,
Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
e-mail: [email protected]
T. G. Kannampallil
Department of Anesthesiology and Institute for Informatics, School of Medicine,
Washington University in St Louis, St Louis, MO, USA
e-mail: [email protected]
V. L. Patel
Center for Cognitive Studies in Medicine and Public Health, The New York Academy
of Medicine, New York, NY, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 3

K. Zheng et al. (eds.), Cognitive Informatics, Health Informatics,
https://doi.org/10.1007/978-3-030-16916-9_1
4 K. Zheng et al.

been largely successful in boosting EHR penetration rates across U.S. hospitals and
clinics (The Office of the National Coordinator for Health Information Technology
(ONC); Office of the Secretary, United States Department of Health and Human
Services (HHS) 2018), research on the effectiveness of the systems implemented
has showed mixed results (Jones et al. 2010; Romano and Stafford 2011). In their
Health Affair article entitled “What it will take to achieve the as-yet-unfulfilled
promises of health information technology,” Kellermann and Jones concluded that
despite the widespread adoption of health IT, the quality and efficiency of patient
care in the U.S. were only marginally better; and the annual aggregate expenditures
on healthcare continue to soar (Kellermann and Jones 2013).
Disruption to clinical workflow as a result of health IT implementation has been
repeatedly shown as a major cause for the under-realized value of health IT. A key
issue is that today’s health IT systems are often designed to simply mimic existing
paper-based forms, and thus provide little support for the cognitive tasks of clini-
cians or the workflow of the people who must actually use the system (National
Research Council 2009). Similarly, in a systematic review of the health IT evalua-
tion literature, Buntin and colleagues found that a considerable number of studies
reported negative or mixed findings, and that “most negative findings within these
articles relate to the work-flow implications of implementing health IT, such as
order entry, staff interaction, and provider-to-patient communication” (Buntin et al.
2011: 467).
“More/New Work” and “Unfavorable Workflow Change” are two workflow dis-
ruptions that have been most often discussed in the literature; both are directly
attributable to the radical changes to established clinical workflow associated with
introduction of health IT (Ash et al. 2007; Campbell et al. 2006; National Research
Council 2009; Niazkhani et al. 2009). While some changes are purposefully
planned—to reengineer existing processes to take full advantage of new capabilities
offered by health IT—some are manifestations of a wide range of problems such as
poor software usability, misaligned end-user incentives, rushed implementation
processes, and the lack of sociotechnical considerations to effectively integrate soft-
ware systems into their complex behavioral, organizational, and societal contexts
(Ash et al. 2007; Campbell et al. 2006; National Research Council 2009; Niazkhani
et al. 2009).
It is therefore critical to develop a comprehensive understanding of the impact of
health IT on clinical workflow, in addition to their root causes, mechanisms, and
consequences. Unfortunately, studies of these phenomena are still relatively scarce,
and available findings are often inconclusive or conflicting (Unertl et al. 2010;
Zheng et al. 2010; Carayon and Karsh 2010). Further, a consensus on the research
definition of “clinical workflow” remains elusive, especially in the context of assess-
ing workflow changes introduced by health IT (Unertl et al. 2010).
While conceptual models are available, e.g., (Unertl et al. 2010) many challenges
remain in the development and application of robust measures of changes to clinical
workflow (Zheng et al. 2010). Methods used in existing workflow studies vary to a
great extent (Unertl et al. 2010; Zheng et al. 2010; Carayon and Karsh 2010; Zheng
et al. 2011; Lopetegui et al. 2014). Even among studies using the same method, a
1 Clinical Workflow in the Health IT Era 5

considerable degree of discrepancies exists in application of the method and

­interpretation of study results (Zheng et al. 2011; Lopetegui et al. 2014). For exam-
ple, time and motion is considered to be the “gold standard” approach for obtaining
quantitative assessments of clinical workflow; yet among the time and motion stud-
ies published to date, there has been a large degree of methodological inconsisten-
cies in the design, execution, and results reporting of those studies, such as how
inter-observer reliability is assessed and how multitasking is handled (Zheng et al.
2011; Lopetegui et al. 2014). This issue has significant implications for the rigor
and generalizability of time and motion studies, diminishing our ability to accumu-
late knowledge as a field. As commented by Carayon and Karsh in a comprehensive
literature survey report commissioned by the U.S. Agency for Healthcare Research
and Quality (AHRQ), the empirical evidence of health IT’s impact on clinical work-
flow has been “anecdotal, insufficiently supported, or otherwise deficient in terms
of scientific rigor” (Carayon and Karsh 2010: 7).
This book intends to address several of these knowledge gaps by bringing
together a team of experienced researchers and practitioners who have dedicated
their career to studying and improving clinical workflow. Several chapters included
in this book are results of a series of research or quality improvement efforts span-
ning multiple decades; some are syntheses of the research literature since early
1900s, bringing together what we know about clinical workflow, where gaps remain,
and how these gaps can be addressed in future research.
This book is organized into four Parts and 19 Chapters. Part I, Clinical Workflow
and Health Information Technologies, orientates readers to the problem domain,
basic concepts (e.g., cognitive behavior and workflow modeling), and consequences
of disrupted workflow due to health IT implementation.
Part II, the State of the Art of Workflow Research, summarizes workflow studies
conducted in healthcare in the past few decades. We purposefully include in this
section workflow research from a non-healthcare domain, aviation, to draw a com-
parison between how clinical workflow differs from workflows in other industries
and how they are conceptualized and studied differently. Part II also includes a
chapter specifically on multitasking and interruptions, which are two defining char-
acteristics of clinical workflow that have significant efficiency, care quality, and
patient safety implications; in addition to chapters that address nursing and patient
perspectives, and workflow-related issues during patient handoff and when patients
transition from one healthcare setting to another, i.e., workflow at the edges.
Part III, Research Methods for Studying Clinical Workflow, introduces research
methodologies that have been commonly used in clinical workflow studies, includ-
ing work sampling, time and motion, human factors engineering, and emerging
methods that leverage sensor technology for automated data collection and real-­
time workflow assessment. Part III also includes a chapter that discusses the unique
characteristics of quantitative workflow data and consequently unique challenges to
statistically analyzing such data.
Part IV, Applications and Case Studies, first presents one large clinical workflow
study supported by the U.S. Agency for Healthcare Research and Quality (AHRQ)
that looked into how health IT systems, introduced as part of ambulatory care prac-
6 K. Zheng et al.

tice redesign, impact clinical workflow. Part IV then presents three case studies each
focusing on a distinct perspective. These include effort in reengineering clinical
workflow to enable a cross-continental collaboration on creating continuously mon-
itored intensive care units, and efforts in enhancing clinical pathways, clinical
rounding, and patient handoff communications.
By compiling a collection of high-quality scholarly works that seeks to provide
clarity, consistency, and reproducibility in workflow research, we hope to create a
repository of knowledge to inform future studies on health IT design, implementa-
tion, and evaluation. In addition to a research reader, this book offers pragmatic
insights for practitioners in assessing workflow changes in the context of health IT
adoption, and in implementing remedial interventions when such strategies are war-
ranted. The book is also designed to present the state of the art on clinical workflow
research, providing an excellent reader for graduate students in all clinical disci-
plines as well as in biomedical and health informatics.

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Chapter 2
Cognitive Behavior and Clinical Workflows

Jan Horsky

2.1 Cognitive Work in a Complex Domain

The intrinsic complexity of evidence-based, technologically advanced modern

healthcare defines processes and affects work environments in ways that make them
difficult to describe with consistency and create models with highly predictable
outcomes. The healthcare industry comprises a wide array of organizational entities
that range in scale from small private practices and independent clinics to hospitals
and large healthcare delivery networks. They interact with a multitude of ancillary
and support service businesses, insurance and payer companies, public administra-
tive and regulatory bodies, private and public research centers and academic institu-
tions that together form one of the most complex organizational structures in society
(Begun et al. 2003; McDaniel et al. 2013). Individuals engaged directly or indirectly
in patient care, its management and administration routinely collaborate across pro-
fessional and institutional boundaries. The efficacy of their work and the safety of
patients are vitally dependent on technology support that allows collection, storage,
analysis and sharing of information and communication. Decision making and rea-
soning of clinicians in this highly interconnected environment is as often autono-
mous as it is interdependent and contingent on the expertise and decisions made in
parallel by others. This intricate combination of individual and collective responsi-
bilities, actions and decisions tends to generate many non-linear work processes that
account for much of the dynamism and elasticity of both personal and collaborative
workflows (Fig. 2.1).
Work characteristics that are specific and often unique to healthcare make pre-
dictive analyses of workflows in this domain problematic. The primary responsi-
bility of clinicians is to ensure that patients receive timely, appropriate and

J. Horsky (*)
Center for Research Informatics, Northwell Health, Manhasset, NY, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2019 9

K. Zheng et al. (eds.), Cognitive Informatics, Health Informatics,
https://doi.org/10.1007/978-3-030-16916-9_2