10/18/24, 9:15 PM Module 3

Module 3

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Module 3 Study Guide and Deliverables

Readings: Lecture Topics:

Lecture 05: The Cardiovascular System
Lecture 06: The Pulmonary System

Case Studies:

CS570 M3 CS01 McCormack pdf

Science Daily 2011 pdf

Carr Chest 2012 pdf

Recommended Reading:

Anatomy and Physiology (Biga et. al., 2019)

Chapter 18, 19, and 20: The Cardiovascular System

Chapter 22: The Respiratory System

Hacking Healthcare (Trotter and Uhlman, 2011)

Chapter 4 - The bandwidth of paper

Additional Resources:

Preventable adverse drug events and their causes and contributing factors: the
analysis of register data. Jylhä V, Saranto K, Bates DW.. Int J Qual Health Care.
2011 Apr;23(2):187-97. (Jylha IJQHC pdf).

Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory

event reports from 30 health care organizations. Snydman LK, Harubin B, Kumar
S, Chen J, Lopez RE, Salem DN. Am J Med Qual. 2012 Mar-Apr;27(2):147-53.
(Snydman AJMQ pdf) (BU library material)

Role of computerized physician order entry systems in facilitating medication

errors. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom
BL. JAMA. 2005 Mar 9;293(10):1197-203. (Koppel JAMA 2005 pdf)

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National study on the frequency, types, causes, and consequences of voluntarily
reported emergency department medication errors. Pham JC, Story JL, Hicks RW,
Shore AD, Morlock LL, Cheung DS, Kelen GD, Pronovost PJ. J Emerg Med. 2011
May;40(5):485-92. (Pham JEmMed 2011 pdf) (BU library material)

Discussions: Discussion 3

Initial posts due by Saturday, September 21 at 11:59 PM ET

Comments on other students' posts due by Tuesday, September 24 at 6:00
PM ET

Assignments: Assignment 3 due Tuesday, September 24 at 6:00 PM ET

Assessments: Graded Quiz 3 due Tuesday, October 1 at 6:00 PM ET

Live Classroom: Tuesday, September 17 from 7:00-8:30 pm ET
Friday, September 20 from 7:00-8:30 pm ET

Learning Objectives

After completing this module, you will cover the basics of the physiology of human cardiovascular and respiratory systems. You
will be able to identify major types of clinical information systems and understand the benefits that can be achieved through their
interoperability. The analysis of a case study will focus on medical error, analysis of sources, and the role of health informatics in
minimizing medical errors. You will be introduced to the strengths and weaknesses of paper-based records and healthcare
managements and business office operations. You will develop understanding of specific points:

Basic understanding of the structure, function and interdependency of the heart and the lung functions.
Basic comprehension of the multiple cardiovascular and respiratory regulatory checkpoints and how aberrations in a
single functionality can cascade to generate a complex pathology.
Appreciation of imaging techniques and therapeutic options available for diagnosing and treatment of cardiovascular and
respiratory problems.
The role and limitation of paper records
Some considerations when implementing an IT system to replace paper forms
Basics of Health Information Systems

The Cardiovascular System

The Cardiovascular System

How is it possible that we can think? How is it possible that our arms can move? These achievements could not be made
without nutrients (sugar, proteins...) and oxygen being transported from one place to another via the circulatory system
cardiovascular system.

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The blood vessels form a closed system that carries blood from the heart to the tissues and from the tissues back to the heart
again. You have to think about it as a set of conduits (veins, arteries, and capillaries) interconnected that must carry blood
(which carries nutrients and oxygen, among other things) and that needs a pump to work: that pump is the heart.

Basic Cardiovascular Anatomy

The conduits in the cardiovascular system are veins, arteries, and capillaries. Veins and arteries are bigger vessels that may
have different sizes. Capillaries are the smaller vessels in our body that are just about one cell thick and are the connection
between arteries and veins. It is at the capillary system where nutrients and oxygen from the blood is distributed to the
peripheral tissues. On the other hand, we have the big vessels: arteries and veins. The basic idea is that we call artery any
conduit carrying blood away from the heart, and we call vein any conduit carrying blood to the heart. Also, it is important to say
that arteries have a different muscular tone and elasticity than veins do, and that this muscular tone and elasticity is of great
importance within the circulatory system.

The heart is a four-chamber muscular pump. The two upper chambers are called atria, and receive the blood coming from
the veins. “Upper” and “lower” are being used conceptually here. The actual orientation of the normal adult heart would be
somewhat tilted in these terms. The two lower chambers are called ventricles and are the stronger part of the heart because
their main function is to pump the blood to the arteries. The right ventricle pumps blood to the pulmonary artery, and it is less
thick—strong—than the left ventricle, which pumps blood to the aorta (artery). The peak or maximum pressure in the aorta is
normally higher than in the pulmonary artery. The aorta (artery) is the main artery in the body that will carry most of the blood to
all the tissues. That is the reason why a lesion affecting the aorta may result in death within seconds if nothing is done, because
the majority of the body’s blood circulates through this artery.

The heart pumping is called contraction. It is involuntarily and autonomously modulated by the autonomic nervous system and
coordinated by several regions of the heart—composed by a specific muscle type called myocytes—which have specialized
characteristics by themselves, such as automaticity (pacemaker capabilities). The reason for this
coordinated rhythmic contraction is logical: The blood has to move from the atria (upper chambers) to the ventricles (lower
chambers), and from the ventricles to the arteries, to go to the lungs and the rest of the body. If there is no coordination in the
contraction, the blood may not follow this direction and the heart function—pumping—will not be achieved. (Imagine the blood
pumping stops and interrupts the flow of blood coming from the veins to the atria; clearly, it would not be good for a person.)

The heart contains valves that normally limit regurgitation—blood going backwards—during heart functioning. Blood flowing
from the right atrium to the right ventricle flows through the tricuspid valve. Blood flowing from the right ventricle to the
pulmonary artery flows through the pulmonary valve. Blood flowing from the left atrium to the left ventricle flows through
the mitral valve. Blood flowing from the left ventricle to the aorta flows through the aortic valve. Heart valve pathology may result
in stenosis or narrowing of the opening of the valve. Heart valve pathology may result in valve insufficiency or regurgitation.
Heart valves open and close during normal functioning of the heart.

Heart valve pathology may result in turbulent blood flow. A sound known as a murmur and can be heard on physical examination
in this case.

Basic Physiology of the Cardiovascular System

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Tissues need oxygen to survive. But the oxygen we inhale must go from the lungs to the rest of our body. The way this is done
can be partially explained by exploring the anatomy of the heart. Further explanation will be provided when we discuss the
respiratory system. The transport of oxygen from the blood to a tissue is done at the microcirculation level that we
call capillaries.

The right part of the heart has one mission, which is different from the mission of the left part. The right atrium receives blood
from the superior vena cava and the inferior vena cava, which are the main veins that collect all the blood of the body to direct it
to the heart. Because this blood is coming from tissues, it has low oxygen in it and high carbon dioxide. This blood—with low
oxygen—is pumped into the pulmonary artery from the right ventricle. The pulmonary artery divides into smaller and smaller
arteries to go through the lungs and collect oxygen and release carbon dioxide from the lungs at the capillary level. Oxygenated
blood is transported by vessels that converge into the pulmonary veins to reach the left atrium. From the left atrium, the blood is
pumped to the left ventricle, which pumps the blood to the aorta to distribute the oxygenated blood to the tissues.

The heart itself needs oxygen to pump and the myocytes to survive. This is done by a complex circulatory system: the coronary
arteries. They arise at the root of the aorta and divide to supply blood to the heart. In general, there are three main coronary
arteries: the right coronary artery, and two branches of the left coronary artery known as the left anterior descending artery and
the left circumflex artery.

Coronary Circulation
Please click each image below to enlarge.

Coronary vessels that supply Coronary vessels portraying

the anterior surface of the the complexity and extent of
heart. coronary circulation.

Common Cardiovascular Pathophysiology

Heart Attack
We all have heard about heart attack. But what does it exactly mean, and what are its implications?

The word “heart attack” is commonly used; however, the medical term is myocardial infarction. In general, with a myocardial
infarction, the blood vessels that carry blood to one or more parts of the heart are obstructed. This results in limited blood

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passage. The muscle of the heart beyond this obstruction no longer receives adequate oxygen and nutrients, and starts a
process that will end with the death of the myocytes and necrosis—premature and not planned death of cells in a living tissue—
in that part of the muscle.

In general, the severity of a myocardial infarction mainly depends on: a) the level of the obstruction, as if it affects one of the
smaller subdivisions of the coronary arteries, the muscle affected will be smaller, say, than if it affects one of the three main
coronary arteries; and b) time until the obstruction is removed and blood is allowed again to re-oxygenate the ischemic tissue.
Ischemia is another term that indicates lack of oxygen supply.

The main cause of a heart attack is the existence of a clot in the coronary circulation that creates an obstruction to the
circulation of blood. Clots causing myocardial infarctions may come from different causes, but the most common are clots
associated with atherosclerosis. Also, clots may affect other blood vessels apart from those of the heart. For example, a clot
may be located in one of the arteries supplying blood to the brain and cause death—necrosis—of brain tissue. This is referred to
as a stroke.

The clinical manifestations of myocardial infarctions may vary. Characteristic signs and symptoms include pain and/or a weight
in the chest that radiates to the left arm or jaw, and excessive sweating (diaphoresis).

Angina
Angina pectoris is commonly caused by chronic coronary artery disease which is closely related to myocardial infarction.

Myocardial infarction (heart attack) and angina are different possible manifestations of coronary artery disease. In both cases,
the clinical manifestations due to insufficient delivery of oxygen to the heart muscle can be very similar. However, myocardial
infarction involves necrosis of cardiac tissue. It is common for a patient to have angina pectoris prior to having a myocardial
infarction. Both typically occur in the settings of coronary artery atherosclerosis.

Commonly, patients with stable angina will report that chest pain always occurs when doing a specific activity, such as using the
stairs instead of elevator, and that the pain disappears when they are able to rest. You might think of stable angina pectoris as
being caused by a fixed obstruction in a coronary artery. In this case, there is a reduced capacity to deliver oxygen/blood to
cardiac muscle “downstream” of the obstruction. The reduced capacity is sufficient to meet the oxygen demands of cardiac
muscle when the patient is at rest. With activity, the oxygen demand of cardiac muscle increases. Beyond a certain amount of
activity, the reduced capacity to deliver oxygen is not enough to meet the demand of cardiac muscle and symptoms may occur.
When the patient stops this activity and rests, the reduced capacity to deliver oxygen again becomes sufficient to meet the
demand of cardiac muscle.

Unstable angina is said to exist when there is a change in the usual pattern of this chest pain (e.g., pain occurs every time the
patient moves around over the last few days, instead of just when using the stairs) and/or there is chest pain at rest. The
development of unstable angina pectoris may precede a myocardial infarction.

Heart Failure
Heart failure may be thought of as a condition in which the pumping capacity of the heart is insufficient. The pumping capacity of
the heart is measured as the cardiac output. The cardiac output need to meet the oxygen demands of all body tissues. Heart
failure may be caused by a number of different medical conditions, including myocardial infarction and alcoholic
cardiomyopathy. Alcoholic cardiomyopathy is a condition that may occur if large amounts of alcohol are consumed over an
extended period of time.

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Heart failure may be thought of in terms of left-sided failure and right-sided failure. Left-sided failure is inadequate pumping
function of the left side of the heart (left atrium and left ventricle), and right-sided failure is inadequate pumping function of the
right side of the heart (right atrium and right ventricle).

Heart failure can vary in manifestations, but typical clinical signs and symptoms include shortness of breath (dyspnea), edema in
legs (abnormal accumulation of fluid under the skin in legs), and pulmonary edema (fluid accumulated in the lungs). Patients
with heart failure may complain of shortness of breath on lying down that is relieved by sitting up or standing. This is referred to
asorthopnea.

Arrhythmia
Heartbeats are typically rhythmic. As we have previously explained, the myocytes (muscle cells of the heart) are typically under
pacemaker-like control and after a starting stimulus (typically done by the sinoatrial node; group of self firing neurons located at
one side of the right atrium), in a synchronized way, contract, propelling the blood form the atria to the ventricles, and from
ventricles to the arteries. Another nerve node is present between the atrium and the ventricle and is called atrioventricular node,
it also contribute to the propagation and regulation of the nerve impulse that stimulates the heart muscle. Therefore, we say
there is rhythmic heart beating.

An arrhythmia is a condition in which there is a lack of rhythm or abnormal rhythm of the heartbeat. There are a number of
different types of arrhythmias. Bradycardia is a condition in which the heart beats at a slower rate than normal. Tachycardia is a
condition in which the heart beats at a faster rate than normal. The normal heart rate is ideally between 50-70 beats/minute for a
resting individual. Athletes have lower heart rate than normal individuals. Miguel Indurain, an Olympic gold medalist recorded a
resting heart rate of 28 beats/min (National Geographic).

Atrial fibrillation is a common arrhythmia. In this condition, there is uncoordinated atrial activity. This results in a lack of effective
atrial pumping function. A clot may form from blood in the atrium in this condition; a clot formed in the left atrium may travel out
of the heart and cause a stroke. Where as a clot in the right atrium may travel to the right ventricle and cause pulmonary
embolism (Blood clot in the arteries supplying the lungs.)

Hypertension
A patient that has had multiple arterial blood pressure readings above a specified level may be said to have hypertension.
“Blood pressure” (arterial) readings are generally expressed with two numbers. These are the systolic and diastolic pressures.
Systolic pressure is with the pressure exerted on the arteries during the contraction of the left ventricle. Diastolic pressure is the
pressure exerted on the arteries during the relaxation of the left ventricle.

There are many possible causes of hypertension. Often, the cause of hypertension in a particular patient is unknown. A person
may have elevated blood pressure and not be aware of it. Hypertension seems to be inherited from the parents. Hypertension
may contribute to a number of pathologic conditions. These include cardiac hypertrophy (increase in the mass of the heart
muscle), myocardial infarction and stroke.

Common Cardiovascular Diagnostic Tests

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EKG
Also called an electrocardiogram, an EKG is a noninvasively obtained recording of the electrical activity of the heart. EKGs have
involved representations of the electrical activity of the heart being printed on a piece of recording paper moving at a
standardized speed.

An EKG involves the placement of multiple electrodes on the chest. This study allows clinicians to see anomalies in the
electrical activity of the heart from different perspectives (electrode positions). These anomalies may have specific meaning
within a medical context.

EKGs are widely used in hospital emergency departments and clinician offices to help diagnose myocardial
infarctions and arrhythmias. EKGs may show characteristic changes in a number of conditions, such as hypertension and a
blood clot in the pulmonary circulation. EKGs have been done manually, with nurses attaching the electrodes to a patient’s body,
and physicians reading the electrocardiogram results. However, there are current options that: a) display the results through a
PC; and b) are able to provide an interpretation of results.

Echocardiogram
An echocardiogram is essentially an ultrasound of the heart, and is also referred to as a “cardiac ECHO.” As mentioned in
Module 2 regarding ultrasonography, this test uses sound waves to construct a visual representation of its diagnostic target.
A transthoracic echocardiogram is performed by placing an ultrasound transducer on the chest wall. A transesophageal
echocardiogram is performed by placing an ultrasound transducer in the esophagus.

Echocardiograms may be useful in detecting multiple heart disorders. These include abnormal ventricular function, abnormal
heart valve function, and clots in the heart.

MRI
Magnetic Resonance Imaging or “MRI” is a medical imaging technology that may be used to study a patient’s heart. A magnetic
resonance angiogram or “MRA” is a study that combines the technology of an MRI with the use of contrast material that can be
visualized in blood vessels on MRI results.

Magnetic resonance imaging will be explored further in Module 4.

Catheterization
Cardiac Catheterization is an invasive procedure that allows the introduction of a catheter through an artery (mostly the femoral
artery) and into the heart for the purpose of: a) diagnosing coronary artery disease by demonstrating narrowing or obstruction of
a coronary artery or arteries; and b) treating narrowing or obstruction by introducing stents (a metallic tube similar to a small
spring) that can expand to widen narrowed segments of a coronary artery.

Cardiac catheterization is commonly used to diagnose and treat coronary artery disease. X-ray images can be reviewed after
the procedure and can be discussed and used in clinical sessions with other physicians or trainees.

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Common Cardiovascular Treatments

There are many medical treatments that are used alone or in combination to treat one or multiple cardiovascular conditions.
Currently, with the use of medications and non-surgical procedures targeting different problems, many patients with
cardiovascular disease can continue their lives using medication instead of needing surgery.

Some commonly used cardiac-related medication types are:

Antihypertensive medications: lowering the blood pressure

Medications treating lipid disorders: a well-known type of medication commonly used for this purpose is an HMG-CoA
reductase inhibitor, which are commonly referred to as “statins”
Antiplatelet/Anticoagulant medications: widely used in patients with multiple kinds of heart conditions; the objective is to
avoid clots

Summary of Concepts of the Cardiovascular System

This is a list of concepts/names that the student should be able to recognize:

1. Artery, vein, and capillary

2. Heart: atria and ventricles, left and right chambers
3. Concept of heart as a pump
4. Pathophysiology: understand the concept of angina, heart attack, arrhythmia, and hypertension
5. Diagnostic tests: understand the use of EKG, echocardiography, and catheterization
6. Treatments: stent placement and the fact that many cardiovascular diseases have a medical treatment

The Bandwidth of Paper

A custom paper form record system is hard to beat, from the perspective of the doctor who designed it. The strength of paper
form system includes fast, durable, extensible, intuitive, convenient, forgiving, and cheap. A paper form can be very fast by
proper use of check boxes, which support infinite extensibility. There is no limitation of the type or content of data that can be
added to a paper form. Instructions, diagrams, complaints, questions, answers, tables, pictures, reports, receipts, faxes, and
post-it notes can all be added to a paper form. Paper forms are far more potent in healthcare industry than in most other
industries. Multiple studies reported improved care quality through the use of checklists. Pitcher et al. reported that the use of a
checklist during surgical ward rounds makes significant improvement in the consideration of most key aspects of care and
education in the completion of a structured progress form substantially improved documentation (Pitcher et al., 2015). Simpson
and co-authors reported that their medical intensive care team developed a checklist of care issues that must be addressed
daily in the intensive care unit. The checklist enabled improvement of their daily, multidisciplinary quality rounds and informed all
personnel when important items have been missed (Simpson et al., 2007).

Individual paper forms are tokens in a complex clinical workflow. The paper chart is a whole bundle of paper forms, not just a
single form. It is not just a paper record of a patient’s healthcare history and current status, it is also a token in a clinical
workflow. Health IT specialists often make the simple mistake of considering paper forms without considering the workflow.

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Often a paper form was designed so long ago that no current employee remember why it was designed that way. When Health
IT specialists design a software application to replace the paper form, they need to carefully consider all the workflows that
involve this paper form as they may discover that what they consider an incidental aspect of the form’s design was actually
solving some problem in another workflow (Trotter and Uhlman, 2011).

Paper forms are good at keeping record of clinical care when data does not need to move. Paper records could cause medical
errors due to illegible handwriting, unclear abbreviations, and not having capacity to support fast data movement. Also the data
in paper forms are trapped, inactive, and difficult to study en masse (Trotter and Uhlman, 2011).

When implementing a health IT system, health IT specialists first need to get rid of the idea that computers are the solution to
information flow in a clinical environment. They need to understand the paper form based workflow and respect the ways in
which a paper based information system handles something well. Secondly, health IT specialists need to be careful not to
attempt to replicate the paper chart in software as software and paper are both amazingly capable information systems that are
good at different information tasks. Paper handles ambiguity extremely well. For example, when filling up a paper form
containing a checklist, a nurse can repurpose the form to communicate a complex ambiguity by adding a note or even just a
question mark. In an EHR, a check box must be either checked or unchecked and no further information can be communicated.
When replacing a paper chart, one must understand how the old and new systems work. It is important to understand the two
basic approaches to record health data, liberally formatted input and usefully bounded input, when developing an EHR system
(Trotter and Uhlman, 2011).

Some data storing software such as relational databases use a concept named normalization. In our context, we use the term
normalization to refer to data that is (Trotter and Uhlman, 2011):

Well bounded: the potential values in the data are usefully constrained;
Well linked: the relationships between different data points are well understood;
Flexible: only violate the first two rules when need to do something faster, better, or different.

The software check box is strongly bound by limiting the choice to only two possibilities. Another general principle of bounding is
to store only one copy of a specific data in the database. When the data is needed in multiple workflows, link the data from one
part of the system to the other instead of keeping multiple copies of the data. Normalized data allows a physician to study
patient data as a population. To facilitate information exchange, data need to be normalized and well-structured. We will learn
data standards and interoperability in several other health informatics courses, CS580, CS581, and CS781. For more
information on this topic, refer to the textbook (Trotter and Uhlman, 2011) Chapter 4 The bandwidth of paper.

Health Information Systems

Health information systems are central applications of health informatics. Clinical information systems support health care
providers in delivering health care, principally diagnostics, treatment, and health monitoring functions. Administrative information
systems are used by managers and administrators at health care institutions to support general operations, as well as financial
and management functions of health care organizations. Electronic Health Record (EHR) plays a central role in the provision of
health care. Early applications were electronic records managed by health care practitioners and their organizations – electronic
medical records (EMRs). The EHR is a patient record whose content is shared between multiple health care organizations.
Current trends show shift towards health data stored Personal Health Records (PHR) that are managed, and controlled by
individuals. The content, functionality, and interoperability of EHRs and PHRs conform to national interoperability standards to
enable sharing and consultation across multiple health care organizations.

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An electronic health record (EHR) is a digital record that contains health information of an individual patient gathered over time.
The EHR is generated through encounters in health care delivery settings. The patient information includes demographics, vital
signs, problems, medication, progress notes, medical history, immunization record, laboratory data, radiology reports, and billing
information.
Other types of health information systems include:

Computerized provider order entry (CPOE) that support ordering diagnostic tests and therapy plans
Medication administration systems (MAS) that support medication dispensation that typically use bar coding.
Clinical decision support systems that assist healthcare professionals to make decisions of clinical relevance such as
diagnosis or therapy.
Telemedicine systems that transfer health data at distance.
Electronic error reporting systems where various institutions report errors that occurred during health care delivery.

The key goals of health information systems are the improvement of the quality of health care and improve productivity to lower
the cost. The important elements of these goals include improved safety of patients and improved medical outcomes and, at the
same time, the reduction of costs of health care delivery.

Use of health information systems generally improves outcomes of health care and improves patient safety. Patient safety is a
key measure of quality of health care. For example timely access to EHR in emergency departments and use of CPOE systems
reduce medical errors. Medical error is an adverse effect of health care mainly due to incorrect, inaccurate, incomplete, or
untimely diagnosis or treatment of illness or injury. Some estimates (see Wager, p 121) indicate that nearly 100,000 patients die
every year in the US hospitals due to medical error. The main causes of medical error are medication errors and adverse drug
reaction. Medication errors arise during the process of ordering, dispensing, and administration of drugs. CPOEs offer significant
advantages as compared to paper-based systems and help reduces the total number of medication error by 80%, but CPOE
systems were found to facilitate the risk of medical errors (see Koppel et al 2005, recommended reading material). Twenty-two
types of risks that introduce medication errors through the use of CPOEs have been identified (Koppel et al, 2005). Similarly,
twenty-six types of preventable adverse drug reactions originating from information management have been identified (Yuhla et
al., 2011, recommended reading material).

Laboratory testing, is an essential part of medical process, and itself can be a source of medical error, estimated to cause nearly
15% of medical errors. Approximately 40% of laboratory testing errors are due to defective labeling of specimens (Snydman et
al., 2011, recommended reading). Fortunately, the vast majority of medical errors result in no harm to the patient. Snydman et al.
(2011) studied 37,532 cases of laboratory testing errors across 30 hospitals over the period of 5 years. They found that
approximately 8% of laboratory testing errors resulted in temporary harm to the patient, while permanent harm or death
happened in 0.08% of the cases. These numbers translate into 30 cases of death or serious harm, and 3,000 cases where
additional health care needed to be provided.

Medical errors happen due the failures in the medical system, often at multiple points. Typically, the blame is placed on person
who was the last participant in the chain of events, such as the nurse who administered the drug to the patient. Other steps in
the chain of events include production of drug, labeling, storage, prescribing, dispensing, and monitoring. Different information
systems are accessed throughout the health care delivery process involving multiple quality control and quality assurance steps.
Prevention of medical error must address the whole process of health care delivery where health informatics plays an
increasingly important role. There is an ample space for health informaticians to study and optimize the design and
implementation of health information systems, particularly EHRs, CPOEs, and MASs to help further minimize the number and
severity of medical errors.

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References

Pitcher M, Lin JT, Thompson G, Tayaran A, Chan S (2015) Implementation and evaluation of a checklist to improve patient care
on surgical ward rounds. ANZ J Surg.

Simpson S, Peterson DA, O'Brien-Ladner AR (2007) Development and implementation of an ICU quality improvement checklist.
AACN Adv Crit Care, 18(2):183-9.

Trotter F and Uhlman D (2011). Hacking healthcare: A guide to standards, workflows, and meaningful use. Chapter 4 The
bandwidth of paper.

The Pulmonary System

The Respiratory System

Breathing provides oxygen to oxygenate the blood as discussed in the previous lecture. The act of breathing can be controlled
or modified voluntarily, but it is typically carried out involuntarily.

Breathing has two clear movements: inhalation and exhalation. When inhaling, oxygen is allowed to get into the lungs and from
there, through the flow of oxygenated blood, it travels to the rest of our tissues. The air we exhale, though, contains a smaller
quantity of oxygen and more of CO2 (carbon dioxide), which is produced by our bodies. These two movements are done by a

set of muscles and two very specific organs: the lungs.

Basic Respiratory System Anatomy

The main components in the respiratory system are the lungs, which contain the alveoli (alveolus in singular), small air sacs
lined with highly specialized epithelial cells that allow the O2 to go to the bloodstream and the CO2 from the bloodstream to the
exhaled air.

The lungs are the two big respiratory organs located in the chest, protected by an “armor” of ribs and involuntarily (although, it is
possible to voluntarily modify an involuntary breathing pattern, such as when swimming underwater) inflated by respiratory
muscles. The lungs are covered by a fine membrane called pleura, which plays a role in respiration movement. There is a
visceral layer of pleura that lies on the lungs, and there is a parietal layer of pleura that is associated with the rib cage.

The alveoli are the part of the respiratory system where the gas exchange occurs. The alveolar sac is wrapped with the blood
capillary bed that contains blood flowing from the pulmonary artery to the pulmonary veins. Gas exchange occurs across the
microscopic space between the capillary and the alveoli.

The alveoli are at the end of the different subdivisions of the respiratory tree. The respiratory tree starts at the nose and mouth
openings. The nasal passages and the bucal cavity meet at the pharynx (mentioned in module 2). The pharynx bi-furcates at
into the esophagus and the trachea. The trachea is also referred to as the wind pipe. The trachea branches like a tree to yield
the bronchii and the bronchioles. The bronchioles connects directly to the alveoli.

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Respiratory tree

http://en.wikipedia.org/wiki/File:Gray961.png

Basic Physiology of the Respiratory System

The mechanics of breathing are complex. This lecture provides a general overview.

The major function of the lungs and the whole respiratory system is to provide oxygen to the tissues for metabolism and
removing a major byproduct of normal metabolism, CO2 (carbon dioxide).

This is done by breathing, the act of inhaling and exhaling air, an autonomous movement (although can be voluntary at times)
executed thanks to respiratory muscles. In order to “breathe,” lungs should be able to expand during inhalation and gradually
diminish in size to exhale the air; this means that they have a certain degree of elasticity.

Also, there is a special component in the alveoli called surfactant that allows the alveoli to expand easily and more
efficiently. Surfactant is a substance containing different proteins and specific fats (lipids) that are key to preventing the alveoli
from collapsing, as well as facilitating inhaling. Surfactant reduces surface tension.

In order to understand the need for surfactant, we can make an easy exercise. Take a balloon in your mouth, and try to inflate it.
At the very beginning, we have to make a lot of effort to start inflating the balloon. The more we inflate it, the easier it is. Also, at
the end, the balloon usually collapses, almost leaving no space inside of it. Alveoli are very similar to a balloon, although: a) they
do not need this initial effort to be expanded, they expand on a regular basis, being more efficient; and b) they do not collapse
when exhaling, because there is something that prevents them from fully collapsing. Both a) and b) properties are facilitated by
the surfactant.

The other major accomplishment that occurs in the alveoli is the gas exchange. This is done thanks to a complex system of
balancing pressure and concentration of gases in the bloodstream and in the hollow cavity of the alveoli. Summarizing it, gases
flow (diffuse) from a place where they exist in higher concentration (higher pressure) to a place where they exist in lower

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concentration (lower pressure) if those places are properly functionally connected. As previously mentioned, the thickness of the
walls separating blood and air in the pulmonary capillary system is very thin, allowing this trespass and flow of gases from a
place with a higher concentration to a place with a lower concentration. When inhaling, the lungs and alveoli are full of air, with
oxygen in a relatively higher concentration than it is in the blood flowing to the lungs in the pulmonary circulation. Also, during
this time, carbon dioxide migrates from the blood, where it is found in higher concentration, to the alveoli where it is found in
lower concentration. After a small period of time, when the exchange is done, the blood now has higher oxygen concentration
than when it arrived, and it is moved away to the tissues. Another factor is the erythrocytes (red cells in blood that can carry
oxygen and some carbon dioxide). Erythrocytes carry oxygen combined with the erythrocyte protein hemoglobin. Hemoglobin
contains iron and that’s where the term heme=iron comes from.

The Larynx, Bronchii, Trachea and Lungs

Drop each label to the
correct location on the
diagram

Capillaries

Left bronchus

Cardiac depression
Superior lobe (right)

Superior lobe (left)

Right bronchus

Alveolar sacs

Middle lobe

Pulmonary artery
Right lung

Larynx

Trachea

Inferior lobe (right)

Pulmoinary vein
Left lung

Inferior lobe (left)

Alveolus

Common Respiratory Pathophysiology

Asthma
A very common chronic disease characterized by airflow obstruction (reversible and within different levels of severity) and
bronchospasms (constriction of smooth muscle surrounding airways). Its symptoms may vary, but patients may have wheezing,

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shortness of breath, cough, and a feeling of chest tightness.

The cause of asthma may not be fully understood. It may be a mix of environmental factors (such as pollen) and genetic factors.
Treatment may include inhaled corticosteroids taken on a regular basis. Treatment may also include an inhaled bronchodilator
used during an acute episode. Evaluation of a patient with asthma may involve spirometry, which will be discussed later.
Commonly, a limited form of spirometry testing—consisting of measuring peak expiratory flow—is utilized. The concept is to
provide a measurement of flow of air with exhalation. A small handheld device can be used for this. This study or test is
commonly referred to as a “peak flow.”

COPD
The term “Chronic Obstructive Pulmonary Disease” or “COPD” encompasses both chronic bronchitis and emphysema. One
might think of chronic bronchitis as a chronic condition of airway inflammation. The symptoms of a patient with chronic bronchitis
may be similar to the symptoms of a patient with asthma. One might think of emphysema as a chronic condition of lung tissue
destruction that results in air trapping in the lung and decreased gas exchange capacity.

A patient may have elements of both emphysema and chronic bronchitis. Both of these are associated with cigarette smoking.
Some treatment options for COPD are also commonly used to treat asthma.

Pneumonia
Inflammation of the lung caused by infection from a microorganism is referred to as pneumonia. Pneumonia is commonly
caused by bacteria that are able to stay in a particular site of the lung and reproduce. Other causes of pneumonia are fungi,
parasites, and viruses.

Patients with pneumonia commonly experience fever and cough. Treatment for bacterial pneumonia typically includes an
antibiotic regimen. Some patients may be treated as an inpatient in a hospital. Prognosis may vary depending on preexisting
conditions. (Prognosis for pneumonia may be different in a 25-year-old healthy person than in an already sick 95-year-old
person.)

Common Respiratory Diagnostic Tests

X-Ray
X-ray imaging is commonly used in the evaluation of patients with respiratory disorders. You may see an X-ray study of the
lungs referred to as a chest radiograph, chest X-ray, or as a “CXR.” Chest radiographs may be helpful in diagnosing multiple
medical disorders, including pneumonia and COPD.

You may encounter different study options for chest radiographs. A commonly used study consists of two “views” referred to as
“PA” and lateral. A PA “view” means that the X-rays are directed from the back (posterior) of the patient to the front (anterior) of
the patient. X-rays are directed from one side of a patient with a lateral “view.” Posterior/Dorsal and anterior Ventral are used
interchangeably. See the following figure:

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Posterior/Dorsal and anterior Ventral are used interchangeably

From section 27.2 of the Openstax Biology book, cc-by-4.0

MRI and CT scan

MRI and CT scan results may provide more information than chest radiographs in the evaluation and diagnosis of patients with
pulmonary disorders. Both MRI and CT scanning will be discussed in Module 4.

Spirometry
Spirometry is used to obtain values for certain volumes and parameters associated with breathing. You may hear these volumes
and parameters referred to as “Pulmonary Function Tests” or “PFTs.” Examples of these are FEV1 and FVC. FEV1 (Forced
Expiratory Volume 1) is the amount of air that a particular person exhales in the first second of exhaling following a set of
instructions. FVC (Forced Vital Capacity) is the total volume exhaled in a single exhalation by a particular person following a set
of instructions. Spirometry may be used in the evaluation of multiple lung disorders, such as asthma and COPD.

Common Respiratory System Treatments

One might consider prevention as treating a population for a particular disease. Lowering the incidence of smoking may
decrease the incidence of a number of lung disorders, including COPD.

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Lung transplantation may be a treatment option for patients with a number of pulmonary disorders. One example may be a
patient with end-stage COPD. A lung transplant could possibly consist of one lung or two lungs. Also, a section of a lung known
as a lobe may be transplanted from a living donor. A recipient may receive a lobe to replace each lung with a lobe coming from a
different living donor.

Summary of Concepts of the Respiratory System

This is a list of concepts/names that the student should be able to recognize:

1. Anatomy: lungs, alveoli, pleura, and respiratory tree

2. Physiology: the concept of gas exchange and the effect of surfactant in alveoli
3. Disease: asthma, COPD, and pneumonia
4. Tests: The use of X-ray and spirometry

Major Software Applications and Commercial Vendors

Patient Registration
A patient registration application may be a standalone application or part of an ERP (Enterprise Resource Planning) or
enterprise level system. It provides capabilities to accept, modify, or delete patient demographic information. Patient
demographic information may include first name, last name, date of birth, social security number, parental information, all
insurances, guarantor, next of kin, etc. Usually, at the time of the patient registration, every patient is given a unique medical
record number (MRN). The MRN should remain the same for all the visits of a particular patient. Applications are capable of
merging two or many MRNs into single MRN when a patient is assigned more than one MRN by mistake. This occurs commonly
as patients may not remember their MRN or names may be changed—such as when a name is decided upon for a newborn
baby. Epic, eCW (e Clinical Works), and Cerner Millennium are major healthcare ERP application vendors in the market.
Registration data may also include emergency contact and other information such as chief complaint, language, race, ethnicity,
any document information, etc. Insurance coverage for patients and insurance information is also included.

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Applications should function according to business rules and government laws. All these rules should be considered at the time
of application design or customization—e.g., if the patient is less than 18 years old there must be a warning message if there is
no guarantor. Another consideration is that there could be family registration rather than a patient registration. Family registration
becomes useful when there are two or more patients from the same family.

Patient Scheduling
Patient scheduling is another vital business function for healthcare organizations. Once patient registration is complete, the
patient can be admitted as an emergency patient, inpatient, or outpatient in the system. There may be other patient
classes/categories based on the healthcare organization structure and function. Outpatient scheduling is done for office visits,
procedures, or other day-only patient services (not requiring an overnight stay). The patient scheduling chart may provide a lot
of information, such as patient demographics, patient location (within a healthcare facility), all past and future appointments, a
completed or no-show ratio, and reports. The application may also provide check in, check out, appointment info, canceled
appointments, and rescheduling functions.

Potential sub modules for scheduling are pictured below.

The application also allows for searching for a patient by MRN, name, DOB, and/or other criteria. The users may see the
appointments listed by department or provider level. In some applications, other business functions may be included, such as
account/visit maintenance, patient care, and billing. The application may be customizable at various levels, including that of an
individual user. It may provide a variety of tools, administration functions, and security. Administration and security modules of
systems control the access of user accounts within the system.

Patient registration and scheduling applications may also provide other sub-modules to cover patient transfers, discharges, bed
management, census inquiries, labor and delivery, patient query, and reports. If there are multiple applications, the patient
registration/scheduling application may “talk” to other applications via HL7 interfaces to accept or send patient
registration/scheduling data to other applications. Certain data may be sent to government agencies. The reports are also
customizable, configurable, and can be saved for future runs. An example of a user interface screen to run an admission report
is pictured below.

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Information systems used in a healthcare setting could vary from a few standalone applications to enterprise-level systems used
with multiple department-specific systems. An enterprise-level system covers most, but not all, business functions. Major
business functions that could be included in enterprise-level systems or department-specific systems range from patient
registration, scheduling, orders, pharmacy, lab, radiology and imaging, emergency, anesthesia, and billing to dashboards where
healthcare executives could see up to the minute patient flow, revenue generation, or multiple types of statistical information.

Cerner provides an ERP system called Millennium that includes almost every aspect of a healthcare organization. All the
modules in Millennium are customizable to fulfill an individual healthcare organization’s needs. The main modules of Millennium
are FirstNet for emergency, RadNet for radiology, PathNet for lab, and PowerChart. PowerChart is the central place to provide
patient-specific information such as flowsheet, orders, medication administration, medication list, tasks, plan of care, lab results,
blood bank, documents/notes, appointments, procedure information, and customized modules for other healthcare organization
needs.

Medication Administration: MAR (Medication Administration Record) displays order information with corresponding task and
result information. It is a single source for all of a patient’s medications and medications administered.

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Flowsheet provides information regarding vital signs, assessment, safety checks, ongoing care, etc.

The Orders module is for medical orders and related information.

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Medication List provides information regarding a patient’s medications. The view or the information displayed is customized
here.

The documents and notes module provides all functionalities needed for document management. A note could be typed in, sent
from other systems, or a scanned document. The notes/documents can be in any status, such as preliminary note, signed by a
provider, authenticated by attending, or final.

A scanned document is shown below.

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Below is the general look of PowerChart.

The module for emergency department admissions is FirstNet. A typical look (this is customizable) of this module may consist of
information related to registration, check in, check outs, beds, triage, patient transfers, orders, documentation, medical records,
etc. FirstNet consists of three major components: Triage and Tracking, ED (emergency department) Care and Management, and
Physician Documentation with Coding. FirstNet may be coupled with other applications provided by Cerner or by other vendors.
A clinician can input the data interactively using a touch screen, pen, or mouse and keyboard.

The other major modules within Millennium are RadNet for radiology, PathNet for laboratory orders and results, PharmNet for
pharmacy, and Discern Explorer. Discern Explorer is for developers to design and develop new modules where the built-in

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modules cannot provide the functionality a healthcare organization needs.
RadNet is a radiology information system for radiology departments. The main areas in RadNet are orders, imaging,
procedures, film evaluations, reports, and folder and notes management. PathNet may include laboratory activities such as
micro-organism, pathology, blood bank, general laboratory studies, transfusion, tissue typing, antibody screening, result history,
reports, etc. PharmNet functions include recommended medication dose ranges, prescription refills, insurance claims
processing, prescription tracking, drug utilization, pharmacy reporting, and adverse drug events, etc.

For a dental department, an enterprise application may provide patient registration, scheduling, and image storing capability
similar to that of a radiology department. However, the dental image size is usually much smaller than a radiology image. A
dental application may provide billing, referral tracking, clinical note functions including treatment plan templates, various kinds
of reporting, and a document/image center. Some functions, such as an image center, can be combined with the application
used by a radiology department. The application can be integrated with the imaging device so that the film/image could be
uploaded and stored by the application for medical analysis and charting purposes. A sample screen shot of a dental chart
follows. Nowadays, vendors have started providing mobile versions of these applications and modules.

A sample image of a dental X-ray is shown below.

An application may also provide periodontal (supporting or surrounding the teeth) charting function. A screen capture example of
this type of function follows. This part of the application may include tooth mobility, plaque, furcation grades (relates to defects
surrounding roots of teeth due to periodontal disease), bone loss (bone that holds teeth), pocket (a space between tooth and
gum tissue) depths, bleeding, gingival (gum) margins, etc. An application may also do the calculations to avoid manual errors.

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Once data is entered or calculated, it can be viewed either graphically or numerically. Other functions may include charting
reports, letters, insurance, or referring to other dental professionals.

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