{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T17:19:21Z","timestamp":1778692761588,"version":"3.51.4"},"reference-count":40,"publisher":"SAGE Publications","issue":"1","license":[{"start":{"date-parts":[[2013,10,8]],"date-time":"2013-10-08T00:00:00Z","timestamp":1381190400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Health Informatics J"],"published-print":{"date-parts":[[2014,3]]},"abstract":"<jats:p>This article identifies sources of variation in clinical workflow and implications for the design and implementation of electronic clinical decision support. Sources of variation in workflow were identified via rapid ethnographic observation, focus groups, and interviews across a total of eight medical centers in both the Veterans Health Administration and academic medical centers nationally regarded as leaders in developing and using clinical decision support. Data were reviewed for types of variability within the social and technical subsystems and the external environment as described in the sociotechnical systems theory. Two researchers independently identified examples of variation and their sources, and then met with each other to discuss them until consensus was reached. Sources of variation were categorized as environmental (clinic staffing and clinic pace), social (perception of health information technology and real-time use with patients), or technical (computer access and information access). Examples of sources of variation within each of the categories are described and discussed in terms of impact on clinical workflow. As technologies are implemented, barriers to use become visible over time as users struggle to adapt workflow and work practices to accommodate new technologies. Each source of variability identified has implications for the effective design and implementation of useful health information technology. Accommodating moderate variability in workflow is anticipated to avoid brittle and inflexible workflow designs, while also avoiding unnecessary complexity for implementers and users.<\/jats:p>","DOI":"10.1177\/1460458213476968","type":"journal-article","created":{"date-parts":[[2013,10,8]],"date-time":"2013-10-08T22:50:54Z","timestamp":1381272654000},"page":"35-49","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":34,"title":["Sources of variation in primary care clinical workflow: Implications for the design of cognitive support"],"prefix":"10.1177","volume":"20","author":[{"given":"Laura G","family":"Militello","sequence":"first","affiliation":[{"name":"Applied Decision Science, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicole B","family":"Arbuckle","sequence":"additional","affiliation":[{"name":"University of Dayton Research Institute, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jason J","family":"Saleem","sequence":"additional","affiliation":[{"name":"Roudebush VAMC, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emily","family":"Patterson","sequence":"additional","affiliation":[{"name":"The Ohio State University, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mindy","family":"Flanagan","sequence":"additional","affiliation":[{"name":"Regenstrief Institute, Inc., USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Haggstrom","sequence":"additional","affiliation":[{"name":"Roudebush VAMC, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bradley N","family":"Doebbeling","sequence":"additional","affiliation":[{"name":"Roudebush VAMC, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2013,10,8]]},"reference":[{"key":"bibr1-1460458213476968","first-page":"174","volume":"107","author":"Tu SW","year":"2004","journal-title":"Medinfo"},{"key":"bibr2-1460458213476968","first-page":"797","volume":"1994","author":"Shiffman RN","year":"1994","journal-title":"AMIA Annu Symp Proc"},{"key":"bibr3-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-006-0275-9"},{"key":"bibr4-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.24.5.1180"},{"key":"bibr5-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1200\/JOP.091098"},{"issue":"5","key":"bibr6-1460458213476968","first-page":"1","volume":"3","author":"Thakkar M","year":"2006","journal-title":"Perspect Health Inf Manag"},{"key":"bibr7-1460458213476968","unstructured":"Karsh B-T. Clinical practice improvement and redesign: how change in workflow can be supported by clinical decision support. AHRQ Publication No. 09-0054-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2009."},{"key":"bibr8-1460458213476968","volume-title":"Computational technology for effective health care: immediate steps and strategic directions","author":"Stead WW","year":"2009"},{"key":"bibr9-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1136\/jamia.2010.004333"},{"key":"bibr10-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1177\/001872678203501207"},{"issue":"1","key":"bibr11-1460458213476968","first-page":"37","volume":"41","author":"Trist EL","year":"1951","journal-title":"Hum Relat"},{"key":"bibr12-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1518\/001872008X288501"},{"key":"bibr13-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1201\/b12477"},{"key":"bibr14-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1197\/jamia.M1471"},{"key":"bibr15-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijmedinf.2009.06.008"},{"key":"bibr16-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijmedinf.2008.04.001"},{"key":"bibr17-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1197\/jamia.M2462"},{"key":"bibr18-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1177\/001872677602900806"},{"key":"bibr19-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1177\/001872678704000303"},{"key":"bibr20-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2011.237"},{"key":"bibr21-1460458213476968","first-page":"203","volume-title":"Naturalistic decision making and macrocognition","author":"Militello LG","year":"2008"},{"key":"bibr22-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6947-11-74"},{"key":"bibr23-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1197\/jamia.M2163"},{"key":"bibr24-1460458213476968","doi-asserted-by":"publisher","DOI":"10.4324\/9780203809877"},{"key":"bibr25-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1197\/jamia.M2170"},{"key":"bibr26-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.38398.500764.8F"},{"key":"bibr27-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1197\/jamia.M1370"},{"key":"bibr28-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2004.11.015"},{"key":"bibr29-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1197\/jamia.M1777"},{"key":"bibr30-1460458213476968","first-page":"223","volume":"2009","author":"Haggstrom DA","year":"2009","journal-title":"AMIA Annu Symp Proc"},{"key":"bibr31-1460458213476968","first-page":"558","volume":"2009","author":"Saleem JJ","year":"2009","journal-title":"AMIA Annu Symp Proc"},{"key":"bibr32-1460458213476968","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-144-10-200605160-00125"},{"key":"bibr33-1460458213476968","first-page":"311","volume-title":"Inside interviewing: new lenses, new concerns","author":"Charmaz K","year":"2003"},{"key":"bibr34-1460458213476968","first-page":"295","volume-title":"Informed by knowledge: expert performance in complex situations","author":"Militello LG","year":"2011"},{"key":"bibr35-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMsa0802005"},{"key":"bibr36-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1016\/B978-0-08-052029-2.50007-3"},{"key":"bibr37-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2007-3005"},{"key":"bibr38-1460458213476968","doi-asserted-by":"publisher","DOI":"10.4018\/978-1-61520-733-6.ch005"},{"key":"bibr39-1460458213476968","first-page":"1","volume":"2009","author":"Ludwick DA","year":"2009","journal-title":"Int J Telemed Appl"},{"key":"bibr40-1460458213476968","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijmedinf.2009.04.001"}],"container-title":["Health Informatics Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1460458213476968","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/1460458213476968","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1460458213476968","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T22:29:50Z","timestamp":1777501790000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/1460458213476968"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2013,10,8]]},"references-count":40,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2014,3]]}},"alternative-id":["10.1177\/1460458213476968"],"URL":"https:\/\/doi.org\/10.1177\/1460458213476968","relation":{},"ISSN":["1460-4582","1741-2811"],"issn-type":[{"value":"1460-4582","type":"print"},{"value":"1741-2811","type":"electronic"}],"subject":[],"published":{"date-parts":[[2013,10,8]]}}}