Factors Influencing Willingness to Share Health Misinformation Videos on the Internet: Web-Based Survey.

BACKGROUND: The rapidly evolving digital environment of the social media era has increased the reach of both quality health information and misinformation. Platforms such as YouTube enable easy sharing of attractive, if not always evidence-based, videos with large personal networks and the public. Although much research has focused on characterizing health misinformation on the internet, it has not sufficiently focused on describing and measuring individuals' information competencies that build resilience. OBJECTIVE: This study aims to assess individuals' willingness to share a non-evidence-based YouTube video about strengthening the immune system; to describe types of evidence that individuals view as supportive of the claim by the video; and to relate information-sharing behavior to several information competencies, namely, information literacy, science literacy, knowledge of the immune system, interpersonal trust, and trust in health authority. METHODS: A web-based survey methodology with 150 individuals across the United States was used. Participants were asked to watch a YouTube excerpt from a morning TV show featuring a wellness pharmacy representative promoting an immunity-boosting dietary supplement produced by his company; answer questions about the video and report whether they would share it with a cousin who was frequently sick; and complete instruments pertaining to the information competencies outlined in the objectives. RESULTS: Most participants (105/150, 70%) said that they would share the video with their cousins. Their confidence in the supplement would be further boosted by a friend's recommendations, positive reviews on a crowdsourcing website, and statements of uncited effectiveness studies on the producer's website. Although all information literacy competencies analyzed in this study had a statistically significant relationship with the outcome, each competency was also highly correlated with the others. Information literacy and interpersonal trust independently predicted the largest amount of variance in the intention to share the video (17% and 16%, respectively). Interpersonal trust was negatively related to the willingness to share the video. Science literacy explained 7% of the variance. CONCLUSIONS: People are vulnerable to web-based misinformation and are likely to propagate it on the internet. Information literacy and science literacy are associated with less vulnerability to misinformation and a lower propensity to spread it. Of the two, information literacy holds a greater promise as an intervention target. Understanding the role of different kinds of trust in information sharing merits further research.

A micro-analytic approach to understanding electronic health record navigation paths.

Clinician task performance is significantly impacted by the navigational efficiency of the system interface. Here we propose and evaluate a navigational complexity framework useful for examining differences in electronic health record (EHR) interface systems and their impact on task performance. The methodological approach includes 1) expert-based methods-specifically, representational analysis (focused on interface elements), keystroke level modeling (KLM), and cognitive walkthrough; and 2) quantitative analysis of interactive behaviors based on video-captured observations. Medication administration record (MAR) tasks completed by nurses during preoperative (PreOp) patient assessment were studied across three Mayo Clinic regional campuses and three different EHR systems. By analyzing the steps executed within the interfaces involved to complete the MAR tasks, we characterized complexities in EHR navigation. These complexities were reflected in time spent on task, click counts, and screen transitions, and were found to potentially influence nurses' performance. Two of the EHR systems, employing a single screen format, required less time to complete (mean 101.5, range 106-97 s), respectively, compared to one system employing multiple screens (176 s, 73% increase). These complexities surfaced through trade-offs in cognitive processes that could potentially influence nurses' performance. Factors such as perceptual-motor activity, visual search, and memory load impacted navigational complexity. An implication of this work is that small tractable changes in interface design can substantially improve EHR navigation, overall usability, and workflow.

A Task-Analytic Framework Comparing Preoperative Electronic Health Record-Mediated Nursing Workflow in Different Settings.

Preoperative care is a critical, yet complex, time-sensitive process. Optimization of workflow is challenging for many reasons, including a lack of standard workflow analysis methods. We sought to comprehensively characterize electronic health record-mediated preoperative nursing workflow. We employed a structured methodological framework to investigate and explain variations in the workflow. Video recording software captured 10 preoperative cases at Arizona and Florida regional referral centers. We compared the distribution of work for electronic health record tasks and off-screen tasks through quantitative analysis. Suboptimal patterns and reasons for variation were explored through qualitative analysis. Although both settings used the same electronic health record system, electronic health record tasks and off-screen tasks time distribution and patterns were notably different across two sites. Arizona nurses spent a longer time completing preoperative assessment. Electronic health record tasks occupied a higher proportion of time in Arizona, while off-screen tasks occupied a higher proportion in Florida. The contextual analysis helped to identify the variation associated with the documentation workload, preparation of the patient, and regional differences. These findings should seed hypotheses for future optimization efforts and research supporting standardization and harmonization of workflow across settings, post-electronic health record conversion.

Evaluating the Quality of Health Information in a Changing Digital Ecosystem.

BACKGROUND: Critical evaluation of online health information has always been central to consumer health informatics. However, with the emergence of new Web media platforms and the ubiquity of social media, the issue has taken on a new dimension and urgency. At the same time, many established existing information quality evaluation guidelines address information characteristics other than the content (eg, authority and currency), target information creators rather than users as their main audience, or do not address information presented via novel Web technologies. OBJECTIVE: The aim of this formative study was to (1) develop a methodological approach for analyzing health-related Web pages and (2) apply it to a set of relevant Web pages. METHODS: This qualitative study analyzed 25 type 2 diabetes pages, which were derived from the results of a Google search with the keywords "diabetes," "reversal," and "natural." The coding scheme, developed via a combination of theory- and data-driven approaches, includes 5 categories from existing guidelines (resource type, information authority, validity of background information sources, objectivity, and currency) and 7 novel categories (treatment or reversal method, promises and certainty, criticisms of establishment, emotional appeal, vocabulary, rhetoric and presentation, and use of science in argumentation). The coding involves both categorical judgment and in-depth narrative characterization. On establishing satisfactory level of agreement on the narrative coding, the team coded the complete dataset of 25 pages. RESULTS: The results set included "traditional" static pages, videos, and digitized versions of printed newspapers or magazine articles. Treatments proposed by the pages included a mixture of conventional evidence-based treatments (eg, healthy balanced diet exercise) and unconventional treatments (eg, dietary supplements, optimizing gut flora). Most pages either promised or strongly implied high likelihood of complete recovery. Pages varied greatly with respect to the authors' stated background and credentials as well as the information sources they referenced or mentioned. The majority included criticisms of the traditional health care establishment. Many sold commercial products ranging from dietary supplements to books. The pages frequently used colloquial language. A significant number included emotional personal anecdotes, made positive mentions of the word cure, and included references to nature as a positive healing force. Most pages presented some biological explanations of their proposed treatments. Some of the explanations involved the level of complexity well beyond the level of an educated layperson. CONCLUSIONS: Both traditional and data-driven categories of codes used in this work yielded insights about the resources and highlighted challenges faced by their users. This exploratory study underscores the challenges of consumer health information seeking and the importance of developing support tools that would help users seek, evaluate, and analyze information in the changing digital ecosystem.

Impact of an electronic handoff documentation tool on team shared mental models in pediatric critical care.

OBJECTIVE: To examine the impact of the implementation of an electronic handoff tool (the Handoff Tool) on shared mental models (SMM) within patient care teams as measured by content overlap and discrepancies in verbal handoff presentations given by different clinicians caring for the same patient. MATERIALS AND METHODS: Researchers observed, recorded, and transcribed verbal handoffs given by different members of patient care teams in a pediatric intensive care unit. The transcripts were qualitatively coded and analyzed for content overlap scores and the number of discrepancies in handoffs of different team members before and after the implementation of the tool. RESULTS: Content overlap scores did not change post-implementation. The average number of discrepancies nearly doubled following the implementation (from 0.76 discrepancies per handoff group pre-implementation to 1.17 discrepancies per handoff group post-implementation); however, this change was not statistically significant (p=0.37). Discrepancies classified as related to dosage of treatment or procedure and to patients' symptoms increased in frequency post-implementation. DISCUSSION: The results suggest that the Handoff Tool did not have the desired positive impact on SMM within patient care teams. Future electronic tools for facilitating team handoff may need longer implementation times, complementary changes to handoff process and structure, and improved designs that integrate a common core of shared information with discipline-specific records. CONCLUSION: While electronic handoff tools provide great opportunities to improve communication and facilitate the formation of shared mental models within patient care teams, further work is necessary to realize their full potential.

Driven to distraction: The nature and apparent purpose of interruptions in critical care and implications for HIT.

OBJECTIVES: To examine the apparent purpose of interruptions in a Pediatric Intensive Care Unit and opportunities to reduce their burden with informatics solutions. MATERIALS AND METHODS: In this prospective observational study, researchers shadowed clinicians in the unit for one hour at a time, recording all interruptions participating clinicians experienced or initiated, their starting time, duration, and a short description that could help to infer their apparent purpose. All captured interruptions were classified inductively on their source and apparent purpose and on the optimal representational media for fulfilling their apparent purpose. RESULTS: The researchers observed thirty-four one-hour sessions with clinicians in the unit, including 21 nurses and 13 residents and house physicians. The physicians were interrupted on average 11.9 times per hour and interrupted others 8.8 times per hour. Nurses were interrupted 8.6 times per hour and interrupted others 5.1 times per hour. The apparent purpose of interruptions included Information Seeking and Sharing (n=259, 46.3%), Directives and Requests (n=70, 12%), Shared Decision-Making (n=49, 8.8%), Direct Patient Care (n=36, 6.4%), Social (n=71, 12.7%), Device Alarms (n=28, 5%), and Non-Clinical (n=10, 1.8%); 6.6% were not classified due to insufficient description. Of all captured interruptions, 29.5% were classified as being better served with informational displays or computer-mediated communication. CONCLUSIONS: Deeper understanding of the purpose of interruptions in critical care can help to distinguish between interruptions that require face-to-face conversation and those that can be eliminated with informatics solutions. The proposed taxonomy of interruptions and representational analysis can be used to further advance the science of interruptions in clinical care.

Longitudinal requirement for CD4+ T cell help for adenovirus vector-elicited CD8+ T cell responses.

Despite the widespread use of replication-incompetent recombinant adenovirus (Ad) vectors as candidate vaccine platforms, the mechanism by which these vectors elicit CD8(+) T cell responses remains poorly understood. Our data demonstrate that induction and maintenance of CD8(+) T cell responses by Ad vector immunization is longitudinally dependent on CD4(+) T cell help for a prolonged period. Depletion of CD4(+) T cells in wild type mice within the first 8 d following Ad immunization resulted in dramatically reduced induction of Ag-specific CD8(+) T cells, decreased T-bet and eomesodermin expression, impaired KLRG1(+) effector differentiation, and atypical expression of the memory markers CD127, CD27, and CD62L. Moreover, these CD8(+) T cells failed to protect against a lethal recombinant Listeria monocytogenes challenge. Depletion of CD4(+) T cells between weeks 1 and 4 following immunization resulted in increased contraction of memory CD8(+) T cells. These data demonstrate a prolonged temporal requirement for CD4(+) T cell help for vaccine-elicited CD8(+) T cell responses in mice. These findings have important implications in the design of vaccines aimed at eliciting CD8(+) T cell responses and may provide insight into the impaired immunogenicity of vaccines in the context of AIDS and other CD4(+) T cell immune deficiencies.

Revealing structures in narratives: A mixed-methods approach to studying interdisciplinary handoff in critical care.

OBJECTIVE: To examine a novel mixed-methods approach for studying patterns of clinical communication that could inform future informatics solutions, with a specific focus on handoff within interdisciplinary teams. MATERIALS AND METHODS: Researchers observed, recorded, and transcribed verbal handoff discussions of different members of critical care teams. The transcripts were coded qualitatively, and then analyzed quantitatively for emerging structural patterns using categorical cluster analysis, and for degree of shared mental models (SMM) using the modified Pyramid method. RESULTS: An empirical study using the proposed mixed-methods approach suggested emerging patterns of communication among clinicians. For example, the temporal focus of handoff was often determined by the role of the clinician giving the handoff; the clinical content of handoff was consistent between clinicians, but varied between patients. The SMM index ranged from 0.065 (with the maximum possible overlap score of 1) to 0.007 with a median of 0.026; the overlap was higher in statements concerned with patient presentation (23.6% of these had overlap) and referring to the past (24% overlapped). This calculated SMM index was correlated with the assessment of coherence within the participating teams by independent physicians (r=0.63, p=0.038). CONCLUSIONS: The proposed novel mixed-methods approach helped to reveal emerging patterns in content and structure of handoff communication and highlight differences due to the clinical context, and to the different priorities of clinicians on interdisciplinary patient care teams. The approach for calculating SMM is more ecologically sensitive as it relies on naturally occurring discourse and less intrusive than traditional ways of assessing SMM, and takes initial steps toward establishing empirical foundation for the design of electronic tools to support handoff in interdisciplinary teams.

Survey of Potential Disparity Issues Among Minority Stroke Survivors in Central Brooklyn.

Medical data and information are ubiquitous due to internet availability. However, most people persist in using and trusting their healthcare professionals for health information. They are increasingly flooded with health information from diverse sources such as the internet, community-based organizations, and family or friends. It is crucial to understand where stroke patients vary in the use and trust of health information to improve their conditions. This pilot study aimed to better understand the nature of the problems confronted by stroke patients, such as the source of reliable health information, trust in the healthcare system, and technology trend awareness. African American and Afro-Caribbean stroke patients (n=64) residing in Central Brooklyn, New York, participated in a survey. The results showed that physicians remained the most highly trusted information sources for stroke patients, particularly among patients with higher education, irrespective of the available communication sources.

Vitamin A deficiency impairs vaccine-elicited gastrointestinal immunity.

Vitamin A deficiency is highly prevalent in much of the developing world, where vaccination programs are of paramount importance to public health. However, the impact of vitamin A deficiency on the immunogenicity and protective efficacy of vaccines has not been defined previously. In this article, we show that the vitamin A metabolite retinoic acid is critical for trafficking of vaccine-elicited T lymphocytes to the gastrointestinal mucosa and for vaccine protective efficacy in mice. Moderate vitamin A deficiency abrogated Ag-specific T lymphocyte trafficking to the gastrointestinal tract, gastrointestinal cellular immune responses, and protection against a mucosal challenge following immunization with a recombinant adenovirus vaccine vector. Oral vitamin A supplementation as well as retinoic acid administration fully restored the mucosal immune responses and vaccine protective efficacy. These data suggest that oral vitamin A supplementation may be important for optimizing the success of vaccines against HIV-1 and other mucosal pathogens in the developing world, highlighting a critical relationship between host nutritional status and vaccine efficacy.

Navigating Infection Control Processes in a COVID-19 Only Safety-Net Hospital at the Height of the Pandemic.

Hospitals faced extraordinary challenges during the pandemic. Some of these were directly related to patient care-expanding capacities, adjusting services, and using new knowledge to save lives in a dynamically changing situation. Other challenges were regulatory. The COVID-19 pandemic significantly disrupted routine hospital infection control practices. We report the results of an interview study with 13 individuals associated with infection control in a small independent hospital. We employed the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework and as a basis to analyze data. The findings revealed how routine practices and protocols were displaced in notable ways. Due to COVID-19, clinical activities were modified, and the increased demands of regulatory reporting became laborious, and punitive if reports were late. Strategies are needed to mitigate increases in healthcare-associated infections. Our examination of the information flows, transformation, and needs shows areas in which digital tool creation and the use of a trained informatics workforce could ameliorate and automate many processes.

Multiple innate immune pathways contribute to the immunogenicity of recombinant adenovirus vaccine vectors.

The innate immune pathways that contribute to the potent immunogenicity of recombinant adenovirus (rAd) vaccine vectors remain largely undefined. Previous studies assessing innate immunity triggered by vaccine vectors have largely focused on in vitro studies involving antigen-presenting cells and on early in vivo inflammatory responses. Here, we systematically explore the Toll-like receptor (TLR) signaling requirements for the generation of cellular immune responses by intramuscular immunization with common and alternative serotype rAd vectors in mice. Antigen-specific CD8(+) T-lymphocyte responses elicited by these rAd vectors were significantly diminished in MyD88(-/-) mice but not in TRIF(-/-) or TLR3(-/-) mice, suggesting the importance of MyD88-dependent TLR signaling. However, the absence of each individual TLR resulted in minimal to no effect on vaccine-elicited cellular immune responses. Moreover, responses were not diminished in IL-1R(-/-) or IL-18R(-/-) mice. These data suggest that rAd vectors engage multiple MyD88-dependent signaling pathways, none of which are individually critical; rather, they are integrated to contribute to the potent immunogenicity of rAd vectors. Stimulation of multiple innate immune mechanisms may prove a generalizable property of potent vaccines, and this strategy could be harnessed in the development of next-generation vaccine vectors and adjuvants.

Cognitive and Cultural Factors That Affect General Vaccination and COVID-19 Vaccination Attitudes.

The development of COVID-19 vaccines is a major scientific accomplishment that has armed communities worldwide with powerful epidemic control tools. Yet, COVID-19 vaccination efforts in the US have been marred by persistent vaccine hesitancy. We used survey methodology to explore the impact of different cognitive and cultural factors on the public's general vaccination attitudes, attitudes towards COVID-19 vaccines, and COVID-19 vaccination status. The factors include information literacy, science literacy, attitudes towards science, interpersonal trust, public health trust, political ideology, and religiosity. The analysis suggests that attitudes towards vaccination are influenced by a multitude of factors that operate in a complex manner. General vaccination attitude was most affected by attitudes towards science and public health trust and to a lesser degree by information literacy, science literacy, and religiosity. Attitudes towards COVID-19 vaccines were most affected by public health trust and to a lesser extent by general trust, ideology and attitudes towards science. Vaccination status was most influenced by public health trust. Possible mediating effects of correlated variables in the model need to be further explored. The study underscores the importance of understanding the relationship between public health trust, literacies, and sociocultural factors.

Route of adenovirus-based HIV-1 vaccine delivery impacts the phenotype and trafficking of vaccine-elicited CD8+ T lymphocytes.

Candidate HIV-1 vaccine regimens utilizing intramuscularly (i.m.) administered recombinant adenovirus (rAd)-based vectors can induce potent mucosal cellular immunity. However, the degree to which mucosal rAd vaccine routing might alter the quality and anatomic distribution of vaccine-elicited CD8(+) T lymphocytes remains unclear. We show that the route of vaccination critically impacts not only the magnitude but also the phenotype and trafficking of antigen-specific CD8(+) T lymphocytes in mice. I.m. rAd immunization induced robust local transgene expression and elicited high-frequency, polyfunctional CD8(+) T lymphocytes that trafficked broadly to both systemic and mucosal compartments. In contrast, intranasal (i.n.) rAd immunization led to similarly robust local transgene expression but generated low-frequency, monofunctional CD8(+) T lymphocytes with restricted anatomic trafficking patterns. Respiratory rAd immunization elicited systemic and mucosal CD8(+) T lymphocytes with phenotypes and trafficking properties distinct from those elicited by i.m. or i.n. rAd immunization. Our findings indicate that the anatomic microenvironment of antigen expression critically impacts the phenotype and trafficking of antigen-specific CD8(+) T lymphocytes.

Efficient generation of mucosal and systemic antigen-specific CD8+ T-cell responses following pulmonary DNA immunization.

Although mucosal CD8(+) T-cell responses are important in combating mucosal infections, the generation of such immune responses by vaccination remains problematic. In the present study, we evaluated the ability of plasmid DNA to induce local and systemic antigen-specific CD8(+) T-cell responses after pulmonary administration. We show that the pulmonary delivery of plasmid DNA formulated with polyethyleneimine (PEI-DNA) induced robust systemic CD8(+) T-cell responses that were comparable in magnitude to those generated by intramuscular (i.m.) immunization. Most importantly, we observed that the pulmonary delivery of PEI-DNA elicited a 10-fold-greater antigen-specific CD8(+) T-cell response in lungs and draining lymph nodes of mice than that of i.m. immunization. The functional evaluation of these pulmonary CD8(+) T cells revealed that they produced type I cytokines, and pulmonary immunization with PEI-DNA induced lung-associated antigen-specific CD4(+) T cells that produced higher levels of interleukin-2 than those induced by i.m. immunization. Pulmonary PEI-DNA immunization also induced CD8(+) T-cell responses in the gut and vaginal mucosa. Finally, pulmonary, but not i.m., plasmid DNA vaccination protected mice from a lethal recombinant vaccinia virus challenge. These findings suggest that pulmonary PEI-DNA immunization might be a useful approach for immunizing against pulmonary pathogens and might also protect against infections initiated at other mucosal sites.

A framework for characterizing eHealth literacy demands and barriers.

BACKGROUND: Consumer eHealth interventions are of a growing importance in the individual management of health and health behaviors. However, a range of access, resources, and skills barriers prevent health care consumers from fully engaging in and benefiting from the spectrum of eHealth interventions. Consumers may engage in a range of eHealth tasks, such as participating in health discussion forums and entering information into a personal health record. eHealth literacy names a set of skills and knowledge that are essential for productive interactions with technology-based health tools, such as proficiency in information retrieval strategies, and communicating health concepts effectively. OBJECTIVE: We propose a theoretical and methodological framework for characterizing complexity of eHealth tasks, which can be used to diagnose and describe literacy barriers and inform the development of solution strategies. METHODS: We adapted and integrated two existing theoretical models relevant to the analysis of eHealth literacy into a single framework to systematically categorize and describe task demands and user performance on tasks needed by health care consumers in the information age. The method derived from the framework is applied to (1) code task demands using a cognitive task analysis, and (2) code user performance on tasks. The framework and method are applied to the analysis of a Web-based consumer eHealth task with information-seeking and decision-making demands. We present the results from the in-depth analysis of the task performance of a single user as well as of 20 users on the same task to illustrate both the detailed analysis and the aggregate measures obtained and potential analyses that can be performed using this method. RESULTS: The analysis shows that the framework can be used to classify task demands as well as the barriers encountered in user performance of the tasks. Our approach can be used to (1) characterize the challenges confronted by participants in performing the tasks, (2) determine the extent to which application of the framework to the cognitive task analysis can predict and explain the problems encountered by participants, and (3) inform revisions to the framework to increase accuracy of predictions. CONCLUSIONS: The results of this illustrative application suggest that the framework is useful for characterizing task complexity and for diagnosing and explaining barriers encountered in task completion. The framework and analytic approach can be a potentially powerful generative research platform to inform development of rigorous eHealth examination and design instruments, such as to assess eHealth competence, to design and evaluate consumer eHealth tools, and to develop an eHealth curriculum.

A new adaptive testing algorithm for shortening health literacy assessments.

BACKGROUND: Low health literacy has a detrimental effect on health outcomes, as well as ability to use online health resources. Good health literacy assessment tools must be brief to be adopted in practice; test development from the perspective of item-response theory requires pretesting on large participant populations. Our objective was to develop a novel classification method for developing brief assessment instruments that does not require pretesting on large numbers of research participants, and that would be suitable for computerized adaptive testing. METHODS: We present a new algorithm that uses principles of measurement decision theory (MDT) and Shannon's information theory. As a demonstration, we applied it to a secondary analysis of data sets from two assessment tests: a study that measured patients' familiarity with health terms (52 participants, 60 items) and a study that assessed health numeracy (165 participants, 8 items). RESULTS: In the familiarity data set, the method correctly classified 88.5% of the subjects, and the average length of test was reduced by about 50%. In the numeracy data set, for a two-class classification scheme, 96.9% of the subjects were correctly classified with a more modest reduction in test length of 35.7%; a three-class scheme correctly classified 93.8% with a 17.7% reduction in test length. CONCLUSIONS: MDT-based approaches are a promising alternative to approaches based on item-response theory, and are well-suited for computerized adaptive testing in the health domain.

Facilitating the iterative design of informatics tools to advance the science of autism.

This paper describes a usability evaluation study of an innovative first generation system (Data Dig) designed to retrieve phenotypic data from the large SFARI data set of 2700 families each of which has one child affected with autism spectrum disorder. The usability methods included a cognitive walkthrough and usability testing. Although the subjects were able to learn to use the system, more than 50 usability problems of varying severity were noted. The problems with the greatest frequency resulted from users being unable to understand meanings of variables, filter categories correctly, use the Boolean filter, and correctly interpret the feedback provided by the system. Subjects had difficulty forming a mental model of the organizational system underlying the database. This precluded them from making informed navigation choices while formulating queries. Clinical research informatics is a new and immensely promising discipline. However in its nascent stage, it lacks a stable interaction paradigm to support a range of users on pertinent tasks. This presents great opportunity for researchers to further this science by harnessing the powers of user-centered iterative design.

Study of EHR-mediated workflows using ethnography and process mining methods.

Rapid ethnography and data mining approaches have been used individually to study clinical workflows, but have seldom been used together to overcome the limitations inherent in either type of method. For rapid ethnography, how reliable are the findings drawn from small samples? For data mining, how accurate are the discoveries drawn from automatic analysis of big data, when compared with observable data? This paper explores the combined use of rapid ethnography and process mining, aka ethno-mining, to study and compare metrics of a typical clinical documentation task, vital signs charting. The task was performed with different electronic health records (EHRs) used in three different hospital sites. The individual methods revealed substantial discrepancies in task duration between sites. Specifically, means of 159.6(78.55), 38.2(34.9), and 431.3(283.04) seconds were captured with rapid ethnography. When process mining was used, means of 518.6(3,808), 345.5(660.6), and 119.74(210.3) seconds were found. When ethno-mining was applied instead, outliers could be identified, explained and removed. Without outliers, mean task duration was similar between sites (78.1(66.7), 72.5(78.5), and 71.7(75) seconds). Results from this work suggest that integrating rapid ethnography and data mining into a single process may provide more meaningful results than a siloed approach when studying of workflow.

Trafficking of antigen-specific CD8+ T lymphocytes to mucosal surfaces following intramuscular vaccination.

A critical goal of vaccine development for a wide variety of pathogens is the induction of potent and durable mucosal immunity. However, it has been assumed that this goal would be difficult to achieve by systemic vaccination due to the anatomic and functional distinctness of the systemic and mucosal immune systems and the resultant compartmentalization of immune responses. In this study, we show that Ag-specific CD8(+) T lymphocytes traffic efficiently to mucosal surfaces following systemic vaccination. Intramuscular immunization with recombinant adenovirus (rAd) vector-based vaccines expressing SIV Gag resulted in potent, durable, and functional CD8(+) T lymphocyte responses at multiple mucosal effector sites in both mice and rhesus monkeys. In adoptive transfer studies in mice, vaccine-elicited systemic CD8(+) T lymphocytes exhibited phenotypic plasticity, up-regulated mucosal homing integrins and chemokine receptors, and trafficked rapidly to mucosal surfaces. Moreover, the migration of systemic CD8(+) T lymphocytes to mucosal compartments accounted for the vast majority of Ag-specific mucosal CD8(+) T lymphocytes induced by systemic vaccination. Thus, i.m. vaccination can overcome immune compartmentalization and generate robust mucosal CD8(+) T lymphocyte memory. These data demonstrate that the systemic and mucosal immune systems are highly coordinated following vaccination.