Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care

321 Pages·2019·6.825 MB·English

by  Kai Zheng, Johanna Westbrook, Thomas G. Kannampallil, Vimla L. Patel

Health Informatics
Kai Zheng
Johanna Westbrook
Thomas G. Kannampallil
Vimla L. Patel Editors
Cognitive
Informatics
Reengineering Clinical Workfl ow for
Safer and More Effi cient Care
Health Informatics
This series is directed to healthcare professionals leading the transformation of
healthcare by using information and knowledge. For over 20 years, Health
Informatics has offered a broad range of titles: some address specific professions
such as nursing, medicine, and health administration; others cover special areas of
practice such as trauma and radiology; still other books in the series focus on
interdisciplinary issues, such as the computer based patient record, electronic health
records, and networked healthcare systems. Editors and authors, eminent experts in
their fields, offer their accounts of innovations in health informatics. Increasingly,
these accounts go beyond hardware and software to address the role of information
in influencing the transformation of healthcare delivery systems around the world.
The series also increasingly focuses on the users of the information and systems: the
organizational, behavioral, and societal changes that accompany the diffusion of
information technology in health services environments.
Developments in healthcare delivery are constant; in recent years, bioinformatics
has emerged as a new field in health informatics to support emerging and ongoing
developments in molecular biology. At the same time, further evolution of the field
of health informatics is reflected in the introduction of concepts at the macro or
health systems delivery level with major national initiatives related to electronic
health records (EHR), data standards, and public health informatics.
These changes will continue to shape health services in the twenty-first century.
By making full and creative use of the technology to tame data and to transform
information, Health Informatics will foster the development and use of new
knowledge in healthcare.
More information about this series at http://www.springer.com/series/1114
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
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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 C linical 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 T he 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