10/18/24, 9:16 PM Module 4

Module 4

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Module 4 Study Guide and Deliverables

Readings: Lecture Topics:

Lecture 07: The Nervous System
Lecture 08: The Immune System

Case Study:

D1 Case Study Chapter 11 pdf

Recommended Reading:

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

Chapter 12: The Nervous System and Nervous Tissue

Chapter 13 and 14: Nervous System Organization
Chapter 15: The Special Senses
Chapter 18: The Blood
Chapter 21: The Lymphatic and Immune Systems

Hacking Healthcare (Trotter and Uhlman, 2011)

Chapter 6 - Patient-facing software

Additional Resources

Health Informatics:

R1 Inst Med reportbrief pdf

R2 nationalqualitystrategy 032011 pdf
R3 EightSuccessStories 092810 pdf

Nervous system:

L3 SC570 04 Maranhao Filho ArqNeuro 2009 pdf

Immune system:

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NIH Immune System Research

Assignment Readings:

A1 Todays Hospitalist Diagnostic imaging stroke

A2 telestroke care
A3 Telestroke Networks Can be Cost-Effective for Hospitals
A4 Telestroke Program Participation and Improvement in Door-To-Needle
Times
A5 Is telestroke more effective than conventional treatment for acute
ischemic stroke?
A6 The clinical effectiveness of telehealth
A7 The State of Telehealth Before and After the COVID-19 Pandemic

Exercises:

E1 Vaccines Vac Gen How Vaccines Prevent Disease pdf

E2 CDC Influenza Vaccine Safety pdf
E3 wer8730 vaccine safety pdf
E4 Thiomersal controversy pdf

Discussions: Discussion 4

Initial posts due by Saturday, September 28 at 11:59 PM ET

Comments on other students' posts due by Tuesday, October 1 at 6:00 PM
ET

Assignments: Assignment 4 due Tuesday, October 1 at 6:00 PM ET

Assessments: Graded Quiz 4 due Tuesday, October 8 at 6:00 PM ET

Live Classroom: Tuesday, September 24 from 7:00-8:30 pm ET
Friday, September 27 from 7:00-8:30 pm ET

Module Overview

Our central and peripheral nervous systems will be examined from a functional point of view rather than a strict
anatomical description. The Central and Peripheral Nervous systems are geographically defined but a useful
differentiation is between the Somatic system, controlling functions of which we are mostly aware, and the Autonomic
Nervous system that is primarily involved in maintaining homeostasis through control of internal organ function.
Nervous system pathologies and their consequences will be examined. In particular, we will examine the association
of behavioral traits, skills, physiological functions with particular parts of the central nervous system (CNS) and how

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this can be monitored. In particular, we will examine the various biophysical techniques used to image the CNS and
how software analysis can maximize interpretation.

Our immune systems will be examined from a functional point of view rather than a strict anatomical description. A
healthy immune system will flawlessly distinguish between self and non-self where non-self most of the time being a
pathogen that cause disease. The immune system pathologies, such as autoimmune and immune-deficiency
diseases, and their consequences will be addressed. We will define the basic responses to infectious diseases, and
how the body has to maintain a balance between too little reactivity, that will increase likelihood of infection or even
tumor development, while not expressing too much activity that could lead to autoimmune disease. The importance of
immune cell mobility through the circulatory system will be described as well as the varying functions of the different
types of immune (white blood) cells that circulate. This will lead to an overview of the importance of vaccination.

Learning Objectives

After completing this module, you will have a basic understanding of the physiology of human nervous and immune
systems. You will also understand key concepts related to clinical information systems management of change and
related challenges for health informatics. This module will cover types of organizational change, strategies for change
management and the role of IT. It will also introduce patient-facing software applications, such as personal health
record (PHR). The analysis of a case study will focus on management of change due to relocation of a clinic, and the
role of health informatics in facilitating such events.

(A) Nervous System

Recognition and understanding of the basic structure and functionality of the nervous system.
Understanding of the pathophysiology of the nervous system together with common diagnostic methods and
treatments

(B) Immune System

An understanding of the development of the various cells of the blood, their relation to immunity, and to the
established lymphoid structures including the lymphatics, lymph nodes, spleen, tonsils and thymus. The
integration of the immune system with the barriers to the outside world: the skin, gut and respiratory epithelial
tissues.
The immune response to infection
An understanding of the pathophysiology of the immune system together with common diagnostic methods and
treatments

The Nervous System

The Nervous System

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The nervous system can be classified into two parts, which are the central nervous system and the peripheral nervous
system. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes
nerves that have a path outside of the brain and spinal cord.

The nervous system may be thought of as a decision and control system for the body. Control may be exerted
voluntarily or involuntarily. An example of voluntary control is moving your hand to wave to someone. An example of
involuntary control is peristalsis.

Something to think about

The same action may be controlled voluntarily or involuntarily. An example of this is blinking your
eyes. You may voluntarily blink or wink with one eye. Blinking occurs involuntarily on a regular basis
and also occurs as reflex such as when a drop of water hits your eye. Breathing is another example.

Nervous system disorders may be diagnosed or treated by physicians of different specialties. A neurologist is a
physician that specializes in diagnosis and treatment of nervous system disorders. A neurosurgeon is a physician that
specializes in surgical treatment of disorders of the nervous system.

A psychiatrist is a physician that specializes in diagnosis and treatment of mental disorders. A psychologist is a
scientist that has studied the science dealing with mental processes and behavior. These two terms may sometimes
be confused. Both a psychiatrist and a psychologist may be involved in the care of a patient with a mental disorder.

Basic Nervous System Anatomy

The brain sits inside of the skull and has different parts. Different parts of the brain have different functions. Patients
with disorders in different parts of the brain may present with very different signs and symptoms. In this context, a sign
is something that is found on examination of a patient. A symptom is something that a patient reports or complains
about such as pain or difficulty doing something. The different signs and symptoms may help determine the location of
a problem in the nervous system.

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The Major Regions of the Brain

Drag and drop each
label to their correct
location on the
diagram

Diencephalon

Hypothalamus

Corpus callosum

Spinal cord

Pineal body
Pons

Medulla oblongata

Third ventricle
Median apeture
(Foramen of Magendle)

Fourth ventricle
Cerebellum

Cerebrum

Thalamus

Midbrain

Pituitary

Brain stem

The cerebrum is the largest part of the human brain and is divided into two halves the right and the left hemispheres.
It is responsible for conscious thoughts. Specialized centers are localized to different parts of the cerebrum and are
responsible for different specific functions. Some centers are responsible for sending a signal to the muscle to move
certain body parts and other centers of the cerebrum function in receiving sensory stimulations from specific body
parts. Essentially, the cerebrum is the top, front, sides, and back of the human brain. It normally has grooves
or sulci that give it the appearance that may be considered characteristic of the brain.

The cerebrum is divided into major areas known as lobes. The frontal lobe is involved with motor control.
The parietal lobe is involved in receiving sensory information from other parts of the body. The temporal lobe is
involved with language and speech. The occipital lobe is involved with vision.

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The brain, its lobes, and principal sulci. The location of certain sensory and motor areas are
shown.
Rice, J. (2003). The terminology of health & medicine (2nd ed.). Upper Saddle River, NJ: Pearson Education Inc.

The cerebellum essentially lies under the posterior or rear aspect of the cerebrum. The Functions of the cerebellum
contributes to certain aspects of coordination and gait.

The brainstem is at the inferior or lower aspect of the brain where it connects to the spinal cord. The brainstem is
involved with breathing and staying awake.

The spinal cord extends inferiorly from the brain. You might think of the spinal cord as a massive collection of wires
that conduct control/motor information from the brain to different parts of the body and sensory information from
different parts of the body to the brain.

The spinal cord lies within the spinal canal. The spinal canal runs through vertebrae or backbones. Vertebrae provide
protection for the spinal cord. Nerves extend out of the spinal canal to make connections with other parts of the body.

Vertebral column

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_Vertebral_column-coloured.png

The vertebrae are divided into 5 segments. These are cervical, thoracic, lumbar, sacral, and coccyx. It is common to
refer to levels of the spinal canal with a letter and number. For instance, L3 would be at the level of the third lumbar
vertebrae. T6 would be at the level of the sixth thoracic vertebrae.

The spinal cord does not extend through the entire length of the spinal canal. It ends at about the level of L2. Below
this level nerves continue inferiorly as the cauda equina.

Both the brain and the spinal cord are enclosed by membranes known as meninges. The meninges consist of three
membranes known as the dura mater, arachnoid, and pia mater. A fluid known as cerebrospinal fluid is contained the
space between the arachnoid and the pia mater. Cerebrospinal fluid is also contained in the ventricles of the brain and
can be important in diagnosing certain disorders.

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The brain, spinal cord, and spinal nerves. An expanded view of a spinal nerve is
shown.
Rice, J. (2003). The terminology of health & medicine (2nd ed.). Upper Saddle River, NJ: Pearson Education
Inc.

The peripheral nervous system includes nerves that connect at the spinal cord and run to distal parts of the body. The
peripheral nervous system also includes nerves that connect in or to the brain. These are referred to as cranial
nerves. Cranial nerves are involved in a variety of functions including; vision, hearing, taste, and voluntary muscle
control.

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Cranial Nerves and Functions

Basic Nervous System Physiology

Neurons or nerve cells can conduct a signal along their length electrically. This is accomplished through the
movement of chemical ions with a charge across cell membranes. Examples of these ions are Na+ (Sodium), K+
(Potassium) and Cl- (Chloride). The difference in ions concentrations across the plasma membrane results in un-even
charge distribution, which is mostly positive charges outside and negative charges inside the cell. The difference in
charge distribution creates a potential difference. A voltage difference or “potential” between the inside and outside of
the cell membrane can be established by pumping ions across the cell membrane. The analogy of nerves to electrical
wires may not be as far-fetched as some students might think.

A nerve “signal” is transmitted from a neuron to another neuron or its target tissue such as muscle across a synapse.
This is an area where neurons meet or a neuron meets its target tissue. The electrical nerve impulse “signal” are
transmitted across the synapse by chemicals known as a neurotransmitters. The body uses different
neurotransmitters to communicate signals. The side of the synapse that the signal is coming from is referred to as
presynaptic. The side of the synapse that the signal is going to is referred to as postsynaptic. Neurotransmitter is
released and re-absorbed by presynaptic neurons. Neurotransmitters released from pre-synaptic neurons bind to
receptors on the post-synaptic neurons to propagate the neuronal stimuli.

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The axon is a part of the neuron that carries a signal to another neuron or a neuron’s target tissue. Some axons are
lined by other cells of the nervous system and are called myelinated. These myelinated axons can generally conduct
impulses faster than unmyelinated axons. Essentially, this is because the signal jumps to nodes between myelinated
areas. This is referred to as saltatory conduction. There are disorders that can affect myelinated axons.

The path conducting the “signal” for voluntary movement of muscle from the brain to the body generally crosses the
midline (left to right or right to left) high up in the pathway at or near the level of the brainstem. You may hear the
terms upper motor neuron and lower motor neuron associated with this path. In this case, the upper motor neuron
path would run from the cerebrum to a level at or near where the path leaves the spinal cord. The lower motor neuron
would continue from this level to the synapse (neuro-muscular junction) with the target muscle.

Regarding the path for conducting sensory information from the body to the brain, the paths for conducting some
types of sensation generally cross the midline near the vertebral level where the path enters the spinal canal. The
paths for other types of sensation generally cross the midline at or near the level of the brainstem. These distinctions
can become important in diagnosing the location of a problem of the nervous system.

The path conducting nerve impulses associated with vision is similar in concept. Photoreceptive cells from
the retina layer of the eyeball initiate nerve impulses corresponding to visual stimuli. Some of these impulses cross
the midline and some do not. Generally, impulses originating from medial photoreceptive cells cross the midline, while
those originating from lateral photoreceptive cells do not cross the midline. Midline crossing occurs at the optic
chiasm.

Something to think about

Photoreceptive cells in the medial aspect of the right eye and lateral aspect of the left eye generally
receive visual stimuli from in front of and to the right of a person. Photoreceptive cells in the lateral
aspect of the right eye and medial aspect of the left eye generally receive visual stimuli from in front
of and to the left of a person. Combining impulses from the medial right eye and the lateral left eye
can group together impulses related to something to the right of a person. Combining impulses from
the medial left eye and the lateral right eye can group together impulses related to something to the
left of a person.

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Image credits:
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The ear is another specialized sensory device or organ. In addition to the function in hearing, the ear has important
functioning related to balance.

Structures of the ear respond to sound, which in normal functioning, results in nerve impulse conduction to the brain.
Under normal conditions, the tympanic membrane can respond to sound by vibrating. Sound impulses would then
normally be conducted through the middle ear with movement of three small bones in the middle ear. These bones
are the malleus, the incus, and the stapes. Collectively, these are known as ossicles. Sound impulses transmitted
through the middle ear would then arrive at the inner ear. Sound impulses are converted to nerve impulses in the
inner ear at the site of the cochlea.

The inner ear also contains three semicircular canals. These are involved in maintaining balance or equilibrium.

The Ear
Drag and drop each
label to their correct
location on the
diagram

Incus

Tympanic membrane

Acoustic nerve

Stapes

Semicircular canals

External auditory
meatus
Malleus

Round window

Cochelea

Voluntary control of skeletal muscle has been discussed. Movement due to involuntary contraction of skeletal muscle
is also possible. One example of this is a stretch reflex. The stretch reflex involves a sensory nerve impulse due to
muscle stretch and an involuntary lower motor neuron impulse triggering muscle contraction. Evaluation of patellar
stretch reflexes is common during physical examination. You may have witnessed this being done by tapping just
below the patella or knee cap with a small rubber hammer. The concept behind this is that tapping on the patella
tendon causes a stretch reflex of muscle that extends or straightens the knee.

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Common Nervous System Pathophysiology

A herniated disk or herniated nucleus pulposus is a common disorder. Between cervical, thoracic and lumbar
vertebrae are softer tissue areas known as intervertebral disks. The inner component of the disk is the nucleus
pulposus. The nucleus pulposus protruding through the outer disk layer, the annulus fibrosis, is by definition a
herniated nucleus pulposus.

A herniated nucleus pulposus may push on the spinal cord or on nerves that enter the spinal canal. Pain that occurs
may be localized to the area of the herniated disk. Pain may also be perceived in areas that are innervated by the
nerves that enter the spinal canal in the area of the disk herniation. For example, a herniated lumbar disk may cause
leg pain. A herniated disk may cause only minimal discomfort. It may also cause significant pain accompanied by
neurologic findings on physical examination such as a change in a muscle stretch reflex.

Sciatica refers to symptoms characterized by pain in the back or side of the leg. The term sciatica may be used to
describe symptoms in the gluteal region and leg that include tingling and numbness. The sciatic nerve runs from the
lower back, through the gluteal region, and down the leg. Sciatica may be caused by a herniated disk in the lower
back, but does not have to be.

Normal Situation and Spinal Disk Herniation in Cervical Vertebra

Please click each image below to enlarge.

A disorder that has some similarities to herniated disk is lumbar stenosis. Lumbar stenosis involves a narrowing of the
spinal canal. There is less room for nerves to pass through. If space decreases enough symptoms may occur. Lumbar
stenosis is associated with osteoarthritis of the lower back seen in older individuals, but also has other causes.

Characteristic symptoms of Lumbar stenosis include leg pain with standing and walking relieved by sitting. There may
be leg numbness or weakness. The symptoms of this disorder may be confused with peripheral vascular disease or
claudication. You may hear lumbar stenosis referred to as pseudoclaudication.

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Carpal tunnel syndrome is another common disorder. It has multiple possible causes including excessive activity of
the wrist or hand and pregnancy. It is caused by compression of a nerve at the wrist. There is a location where this
nerve, known as the median nerve, passes through an anatomic opening that normally has enough room for the
nerve. The opening may have little extra clearance and a relatively small amount of swelling could result in median
nerve compression. Patients may complain of pain. Findings on physical examination may include loss of sensation
and weakness. Symptoms are typically in the hand. Pain may occur more proximally, such as in the shoulder.

You may be surprised that a nerve compression in the wrist could cause the perception of pain in the shoulder. The
location of the pain may vary for a given location of a nerve problem.

Pain may even be “felt” in a part of the body that is not present. There is a syndrome called phantom limb syndrome.
In this syndrome a patient “feels” pain in a part of an arm or leg that is missing or has been amputated.

Multiple sclerosis is an example of a demyelinating disorder. In multiple sclerosis, the myelin surrounding central
nervous system axons is injured or destroyed by an autoimmune process. An autoimmune process in one in which a
body or body part is essentially attacked by the body’s own immune system. Loss of myelin from a myelinated axon
may result in inability or decreased ability to conduct nerve impulses.

Signs and symptoms of multiple sclerosis may include weakness, fatigue, loss of sensation, and visual problems.
Progression of the disease may vary. There may be periods of better and worse symptoms. Signs and symptoms may
vary with a patient’s body temperature.

Meningitis is an inflammation of the meninges. Meningitis may be infectious or noninfectious. Causes of infectious
meningitis include bacteria and viruses. You may hear the term “aseptic meningitis”. This does not mean noninfectious
meningitis. Aseptic meningitis is a term that may be used to describe meningitis caused by a virus or viral meningitis.
Treatment of meningitis may vary greatly depending on the cause.

A patient with meningitis may present with headache, stiff neck, fever, and photophobia. Photophobia is an avoidance
of or sensitivity to light exposure.

A stroke may be caused by insufficient blood supply to the central nervous system or bleeding within the central
nervous system. A stroke may be referred to as a CVA or cerebrovascular accident. A stroke due to insufficient blood
supply is referred to as an ischemic stroke. A stroke due to bleeding is referred to as a hemorrhagic stroke.

Signs and symptoms of a stroke can vary depending on the location of the problem within the central nervous system.
For example, an occlusion or blockage of the anterior cerebral artery on one side may result in a partial paralysis of
the leg on the other side of the body among other problems.

Transient ischemic attacks are temporary periods of existence of signs and symptoms of stroke due to ischemia.
Transient Ischemic attacks may be referred to as TIAs or “Mini strokes”.

A seizure is characterized by a period of non-isolated abnormal brain neuron activity. There are multiple possible
causes of seizures. Sometimes the specific cause of a seizure may not be known. A seizure disorder may be referred
to as epilepsy.

A generalized seizure is one in which the abnormal activity is spread across the cerebrum. A partial seizure is one in
which the abnormal activity is localized. There are many different possible manifestations of seizures. Manifestations

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of seizures may range from loss of consciousness with abnormal movements to no symptoms at all. A patient may
experience hallucinations with partial seizures.

There are a number of different types of psychiatric or mental disorders. Sometimes a patient may have signs and
symptoms of a psychiatric disorder that are due to a non-psychiatric problem. For example, hypothyroidism or a state
of having a low level of thyroid hormone may cause depression. Medications may also cause manifestations of
psychiatric disorders. For example, propranolol, which is one of a type of medication commonly referred to as beta
blocker, may cause depression.

An example of a psychiatric disorder is bipolar disorder. You may hear this referred to as manic depression. This
disease is characterized by periods of extreme energy and activity alternating with periods of depression. However,
patients with this disorder may not have a history of depression.

Common Nervous System Diagnostic Tests

MRI or magnetic resonance imaging is helpful in diagnosing many disorders of the nervous system. MRI involves
placing a subject in a magnetic field and capturing response emissions from the body to radio waves. MRI has
become more accessible over recent years.

An MRI study for a patient typically involves lying in a relatively narrow tube-like structure. Not all patients could
tolerate this easily. A patient may have claustrophobia or fear of enclosed spaces. Some newer MRI scanner models
may have “open” designs. This implies that the patient is not lying in an enclosed tube. Images obtained from an
“open” MRI may not be of the same quality as images obtained from a “non-open” design.

You may hear a reference to a “UBO” or “UBOs” as part of findings of an MRI of the brain. This stands for unidentified
bright object. It is not a flying saucer.

CT scan or Computerized tomography of the head results in images that are based on results of x-ray evaluation from
multiple angles. Ct scan may is helpful in diagnosing multiple neurologic conditions including brain infarct or
hemorrhage.

CT Scan of the Brain

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http://en.wikipedia.org/wiki/File:Computed_tomography_of_human_brain_-_large.png

Lumbar puncture is a procedure in which a needle is inserted in the lower back for the purpose of accessing and
withdrawing cerebrospinal fluid of the spinal canal. There are a number of tests that may be performed on
cerebrospinal fluid that is withdrawn. You may hear this procedure referred to as a “spinal tap”.

A lumbar puncture may be helpful in diagnosing or determining the cause of meningitis. In a case of bacterial
meningitis, examination of cerebrospinal fluid may reveal, among other findings, the presence of a certain type of
white blood cell and visualization of bacteria after appropriate staining of the fluid.

Electroencephalography is commonly used in evaluating patients with seizure disorders or with suspected seizure
disorders. Electroencephalography involves measuring brain electrical activity with electrodes placed on the head.
Electroencephalography may be referred to as “EEG”. Patients may be asked to hyperventilate and encouraged to
sleep during the evaluation.

Evoked potential testing may be used in diagnosing a number of neurological disorders. The general idea of evoked
potential testing is to evaluate brain electrical response to a stimulus. Similar to electroencephalography, this is done
by placing electrodes on the head. With visual evoked potential testing, electrical activity of the brain in response to
visual patterns is evaluated. This may be helpful in diagnosing multiple sclerosis. With auditory evoked potential
testing, electrical activity of the brain in response to sound stimuli is evaluated. This may be used in evaluating
hearing loss.

Nerve conduction studies, as described in module 2, may be helpful in diagnosing and/or evaluating a number of
neurologic disorders. These include carpal tunnel syndrome and lumbar stenosis.

Common Nervous System Treatments

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There are many medications that may be used in treating neurologic disorders. Some of these, such as ibuprofen,
may be commonly used in treating other types of disorders. Some, such as valproic acid, may be more limited to use
in neurologic and/or psychiatric disorders.

Some patients with ischemic stroke may be candidates for a type of treatment referred to as thrombolysis. The
general idea of this type of treatment is dissolving a blood clot that is blocking a blood vessel that delivers blood to the
central nervous system. You may hear this type of treatment referred to as “TPA”. Thrombolytic therapy for stroke is
characteristically given only within a certain number of hours of onset.

Treatment of individual stroke patients may depend on multiple factors. Aspirin is a medication commonly used in
patients that have had an ischemic stroke. The rationale for this treatment is similar to treating patients that have had
a myocardial infarction with aspirin. You can think of aspiring as a blood thinner and that’s why it causes bleeding from
the gastrointestinal tract as a side effect.

The treatment of meningitis can vary widely depending on the cause. Antibiotics may be life-saving in bacterial
meningitis. A patient diagnosed with viral meningitis may require little medical intervention.

A number of neurologic disorders may be treated with surgical interventions. As an example, patients with seizures
that cannot be treated successfully with medication may be treated with surgery. In this case different seizure
disorders may merit different surgical procedures.

Some patients with carotid stenosis or narrowing may be candidates for carotid endarterectomy. The carotid arteries
and the internal carotid arteries (which branch from the carotid arteries) supply blood to the brain. A carotid
endarterectomy essentially involves surgical removal of a plaque or blockage. Some patients with carotid stenosis
may undergo carotid artery stenting. This is similar to the procedure used in coronary artery stenting.

Some patients with herniated nucleus pulposus or lumbar stenosis are treated surgically. One procedure that patients
with these diagnoses may undergo is laminectomy. During a laminectomy some or all of the lamina of a vertebra is
removed. There are a number of surgical procedures that patients with these diagnoses or other spine disorders may
undergo.

Lamina

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Patients with carpal tunnel syndrome may be treated with a surgical procedure referred to as a carpal tunnel release.
The concept behind the procedure is to relieve compression of the median nerve by giving it more room as it passes
through the wrist. This procedure may be performed endoscopically.

Wrist Surgery

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A treatment option that may be misunderstood is electroconvulsive therapy or ECT. You may hear this referred to as
electroshock therapy. ECT may be used to treat a number of psychiatric disorders such as major depression. The
treatment involves electrically inducing seizure activity. Anesthesia is administered prior to the procedure.

Case Study: the Nervous System

A 35 year old male presented to his physician for worsening, intermittent back and leg pain. The patient reported that
the pain started about one year prior to the time of presentation. The patient could remember occasional mild twinges
of pain in the back of his thighs while performing certain weight lifting exercises. Initially, the pain did not occur
consistently with these exercises. The patient described the discomfort as sharp, shooting pain that quickly resolved
on changing position. The frequency and severity of the pain steadily increased over the year prior to presentation.
The patient began to notice the pain when lying down. At times it would prevent him from sleeping. At that time, the
pain was relieved by getting out of bed and sitting.

As the pain severity and frequency continued to worsen, it became severe enough to cause the patient to jump out of
bed. The patient reports at this time the pain felt like electric shocks down the back of the legs. In the last few weeks
before presentation, there were times that the pain could only be relieved by assuming a crawling position on the floor.
The patient, thinking that he might have a herniated disk, went to see his physician.

On examination, the patient appeared to be in no apparent distress. Gait was normal. There was no fever. There was
no back or leg tenderness. There was no weakness or loss of sensation. Leg stretch reflexes were normal and the
same on both sides. Pain could not be elicited with back or leg movements. The remainder of the examination was
unremarkable. White blood cell count was normal. X-rays of the lower back were normal.

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The patient was sent for an MRI study of the lumbar and sacral spine. This showed a tumor in the cauda equina area
of the spinal canal.

The patient underwent surgical removal of the tumor. The tumor was found to be benign. Approximately 24 hours after
the procedure, the patient developed headache and neck pain on prolonged standing. This was attributed to mild
cerebrospinal fluid leaking following the procedure. Headache and neck pain gradually resolved over the next week.

The patient was seen by the neurosurgeon at a follow-up visit and reported no complaints or problems.

IT Workflow: the Nervous System

If the patient sees his physician in the hospital clinic, the MRI study is ordered using the HIS/CPOE system. The
HIS/CPOE system sends the order to the Radiology Information System (RIS) and PACS systems. RIS and PACS
may be parts of the same system or be separate systems. When the MRI study is completed, the resulting images are
stored in the PACS system for current interpretation and for any future reviews or comparisons to newer studies. The
resulting images are evaluated by a Radiologist at a radiology workstation. The Radiologist may retrieve or “pull”
previous procedure images from PACS to compare with the current MRI study result images. Upon evaluation
completion, the Radiologist’s interpretation and impression are recorded into the RIS.

The IT workflow associated with the MRI study is similar to that associated with an X-ray study as previously
described. Radiology may have an enterprise level RIS and PACS. There may be several steps where the information
flows from one location to another or several others in one or multiple systems.

After receiving an order, PACS notifies the archive server about the scheduled MRI study.
Previous imaging results stored by PACS for the same patient, if any, are retrieved and sent to the radiologist
workstation.
Patient arrives at the imaging modality (MRI area). The imaging modality queries PACS for the needed
information.
A technologist obtains MRI images and sends these new images to the PACS.
A technologist prepares PACS imaging exam results and sends these to a radiologist workstation.
PACS imaging exam results are also sent to the archive server and other systems.
A radiologist reviews images and dictates a report with the imaging exam identifier on the dictation system.
The radiologist signs off on the imaging exam report with any modifications.
The archive database is updated with any changes and the exam gets “signed off”.
A transcriptionist retrieves the dictation and types the report into the RIS.
The RIS sends the report.
Radiologists may query previous reports from reading workstations.
Referring physicians may query previous reports from review workstations.

The patient’s physician reviews the Radiologist’s interpretation and impression and refers the patient to a
neurosurgeon. If the Neurosurgeon is associated with the hospital clinic system, the referral may be done through an
integrated electronic health record system.

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The IT workflow associated with this surgery is similar to that associated with an appendectomy as previously
described. Surgery is scheduled to take place in the OR (operating room). Pre-operative evaluation, administration of
anesthesia, and surgery occur followed by post-operative observation. Procedure notes, progress notes, and a
discharge note regarding these are prepared and stored. All of these steps may be done using a single HIS or using
multiple systems. There may be an AIS (Anesthesia Information System) for anesthesia and a surgical system for
surgery. A patient tracker system may also be utilized. Systems optionally receive and send information to other
systems based on configuration. Systems may be configured differently based on the business rules of a hospital’s
operations.

A follow-up visit note is recorded and stored in the Neurosurgeon’s office or clinic EHR (electronic health record)
system. The Neurosurgeon may also order other procedures using CPOE based on medical need.

Associated IT: the Nervous System

It is almost impossible for a single system to provide all the functions that a healthcare organization needs. Hence,
there is a need for a standard protocol help systems “talk” to each other. HL7 (Health Level 7) fulfills this need. HL7
provides a platform to exchange information in a specific format. It is mainly used to integrate heterogeneous
healthcare information systems. HL7 provides universal platform to allow information to be shared across the world.
The information is sent or received in a specific format called messages. There are different types of messages e.g.
ADT messages are for admission, discharge, and transfers. ORU messages are for results. MFN messages are for
master files such as providers. A sample ADT messages is shown below.

MSH|^~\&|ADT|Sending-System|InterfaceEngine|OrgName|20111122114739||ADT^A08|10|T|2.3|||NS
EVN|A08|20111122114739|||97133
PID|1||5580|5580|JOSEPH^Test||20110101|F||B^Black or African American|11 PARK
ROL|1||1|1001001^TEST^JOSEPH^R|20111122||||GENERAL|EXTERNAL|370 OAK STREET^SUITE

HL7 messages are broken into segments. A segment consists of fields and a field may consist of subfields. A field or
segment may have single or multiple occurrences. Some fields or segments may be optional and some may be
required or have single occurrence only. This is all defined in the HL7 specifications.

In the current market, there are many systems/applications that provide a platform to integrate applications in a 1-to-1
or 1-to-many architecture. These can receive messages from one system, optionally make changes to implement the
business logic of the receiving system(s), and send the messages to the receiving system(s). These changes can be
applied at various stages e.g. before receiving or before sending. The receiving systems may optionally send an
acknowledgement messages or error message saying that a message has been received, processed or an error was
detected at the receiving system side. A sample acknowledgement message is below.

MSA|AA|234242|Message Received Successfully|

Other healthcare standards and data formats include X12, XML, DICOM, EDI, NCPDP, CSV, CCD, CDA, and CCR.
Protocols utilized by integration engines could be TCP/IP, HTTP, Files, Database, S/FTP, Email, Web Services, PDF,

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RTF, or custom protocols. Cloverleaf, Mirth, Ensemble, Corepoint, JCAPS, eGate, Epic, Cerner, and Rhapsody are
interface engines or vendors in the current market.

A screen capture of an interface engine and monitor is shown below. The interface engine not only integrates the
systems, but can also provide additional functions such as monitoring, reporting, temporary or permanent storage,
and the capability to resend messages.

This following screen capture shows the dash board of an interface engine.

The following diagram shows the connectivity among registration, order, results, radiology, and pacs (picture archiving
and communication system) systems.

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The Immune System

The Immune System

The immune system is composed of a network of cells, tissues, and organs that work together to protect the body
against bacteria, viruses, and other parasites. Phagocytes are immune cells that protect the body by ingesting
(phagocytosing) harmful foreign particles, bacteria, and dead or dying cells. A lymphocyte is any of three subtypes of
white blood cell that originates in the bone marrow and later migrates to parts of the lymphatic system such as the
lymph nodes, spleen, and thymus. Lymphocytes include natural killer cells (NK cells) (which function in cell-mediated,
cytotoxic innate immunity), T cells (for cell-mediated, cytotoxic adaptive immunity), and B cells (for humoral, antibody-
driven adaptive immunity) (Nobelprize.org, n.d.).

The immune system is divided into two categories–innate and adaptive. Innate immune system, the defense system
with which you were born, is non-specific. It is the first line of defense and involves barriers that keep harmful
materials from entering the body. Examples of innate immunity include cough reflex, enzymes in tears and skin oils,
mucus, which traps bacteria and small particles, skin, stomach acid, and inflammation, which occurs when tissues are
injured by bacteria, trauma, toxins, heat or any other cause (MedlinePlus, 2014). Ninety-nine percent of the animal
kingdom finds that the innate immune response together with epithelial cell barriers is more than enough to handle
their defense needs for a lifetime. However the innate immune system is not very good at handling viruses because
viruses are continuously evolving and a general defense mechanism is not enough.

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The adaptive immune system, also known as the acquired immune system, is composed of highly specialized,
systemic cells and processes that eliminate or prevent pathogen growth. There are two types of adaptive immune
responses, antibody-based responses and cell-based responses that cooperate together and with the innate system
to not only handle viruses but also generate a “memory” (Wikipedia, 2015). This memory is the basis of vaccination.
When Dr. Edward Jenner immunized patients with cowpox, he was preparing the body to respond to an infection it
had never seen before – smallpox!

For more details on the immune system, refer to the NIH's immune system research page.

Immune system cells.

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Organs of the immune system.

Case Study: the Immune System

A 37 year old male with a history of type 1 diabetes mellitus presented to the emergency department after being found
“sleeping” in his chair at work and being difficult to “wake up.” The patient has a 22 year history of type 1 diabetes
mellitus and is treated with insulin. Over the last week, the patient has been working on an “important” project for his
boss. The project has not been going well. The patient has been working much longer hours than normal and may
have slept on the floor of his office a couple of nights this week. The patient’s wife arrives at the emergency room and
reports that the patient did not take his insulin to work.

On examination, the patient is awake, but not answering questions coherently. A “fruity” smell is noted on examination.
The patient’s blood pressure drops significantly and his heart rate increases when standing as opposed to lying down.

Among other laboratory results, the patient’s serum glucose is three to four times of the normal levels and his serum
bicarbonate is low.

The patient was diagnosed with diabetic ketoacidosis and was admitted to the hospital. Among other treatments, the
patient was treated with intravenous fluid and insulin.

The patient responded well to treatment and was eventually discharged.

The patient was seen by his physician at a follow-up visit and reported no complaints or problems.

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IT Workflow: the Immune System

IT workflow for emergency department evaluation and hospital admission would be similar to that previously
described. Laboratory tests are ordered in the HIS/CPOE system. The HIS/CPOE system sends the orders to the Lab
system. Laboratory test results are stored in a Lab system that may be part of HIS, which is an enterprise application.
The lab system sends test results to another “downstream” system or systems. Downstream systems may include the
patient’s physician’s office system. Upon discharge, the attending physician may prescribe medications for the patient
to use after hospital discharge using a prescription system. Also, the attending physician prepares a discharge
summary in the HIS.

The discharge summary is electronically or manually sent to the patient’s primary care physician’s office. The
physician’s office may also order other procedures based on medical need. Visit notes from follow-up visits at the
physician’s office may be recorded in an office EMR system.

The information systems used at physician’s offices are often smaller scale EMR (electronic medical
record)/EHR(electronic health record) systems. At hospitals, these may be big enterprise applications or a
combination of multiple enterprise applications based on the hospital’s operational needs. One HIS may have better
subsystems than another HIS or may not have a sub-system at all for a particular hospital department. If there is more
than one system at a hospital, they usually are connected to each other via a central connecting system or a p2p
(peer-to-peer) connectivity mechanism.

Physicians’ offices and a hospital may not be connected and sharing information. Physicians’ offices and a hospital
may also be connected, but sharing limited information depending on need. In addition, it is possible for the system
used at a physician’s office to be part of the same integrated system used by a hospital.

The Challenge of Chronic Disease

“The growing prevalence of chronic disease is the greatest single cause of the rise in healthcare spending in the
United States” (Kumar and Nigmagulin, 2010). As shown in the below figure on federal healthcare spending, medicare
is the main driver of the future increase in healthcare cost. In the simplest way, medical problems can be grouped into
two categories, acute and chronic medical problems.

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Acute medical problems, such as many viral infections, are curable or self-limited. The U.S. National Center for Health
Statistics defines a chronic disease as one lasting 3 months or more. They are generally incurable conditions that
require ongoing medical attention. The goal is to control and optimally manage to avoid complications that can lead to
serious issues, including death (Braunstein, 2014). As of 2005, 87.9% of Americans of age 65-74 have at least one
chronic health condition (the below left figure). The following figure to the right shows that many chronic conditions are
on the rise among medical beneficiaries over 65 years of age. More than half of Americans over 50 years of age have
more than one chronic condition and 11 million of them live with five or more chronic conditions (AARP, n.d.). The
management of chronic diseases should be on a continuous basis, which requires patients’ involvement from home.

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Patient-Facing Software

The more complex a patient’s condition, the more difficult the care coordination is. Often patients have to coordinate
their own care, and it can be a daunting task when paper records are used (Trotter and Uhlman, 2011). Two
technologies, the Nation Wide Health Information Network which will be covered CS581 and CS781 and patient-
facing health records, will make the care coordination an easier process. Most people refer to patient-facing
healthcare software as personal health record (PHR).

AHIMA e-HIM Personal Health Record Work Group defined the PHR as “an electronic, lifelong resource of health
information needed by individuals to make health decisions. Individuals own and manage the information in the PHR,
which comes from healthcare providers and the individual. The PHR is maintained in a secure and private
environment, with the individual determining rights of access. The PHR does not replace the legal record of any
provider”. The group also suggested the following functionality of PHR (AHIMA e-HIM Personal Health Record Work
Group, 2005):

Aids the transition from paper to electronic record-keeping

Allows the individual to refill prescriptions electronically
Addresses the major issues of health literacy skills (reading and writing) in the context of culture and language
Allows selective retrieval and formatting of information by individuals or agents
Is portable (remains with the individual)
Helps the individual organize personal health information
Educates the individual about personal health information

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Assists the individual with decision making and health management and wellness (e.g., reminders of health
activities, health risk assessments, and public health and patient safety alerts)
Is flexible and expandable to support evolving health needs of the individual and family

The Markle Foundation’s Personal Health Working Group defined PHR as an Internet-based set of tools that allows
people to access and coordinate their lifelong health information and make appropriate parts of it available to those
who need it. PHRs offer an integrated and comprehensive view of health information, including information people
generate themselves such as symptoms and medication use, information from doctors such as diagnoses and test
results, and information from their pharmacies and insurance companies (Markle Foundation, 2003). The Markle
group suggested the following key attributes of a PHR, which share some commonality with the AHIMA group
suggestions, but not exactly the same (Markle Foundation, 2003):

Gives each person control of his or her own PHR

Allows individuals to decide which parts of their PHR can be accessed, by whom, and for how long
Contains information from the patient’s entire lifetime
Contains information from all healthcare providers
Is accessible at any place at any time
Is private and secure
Is “transplant” – individuals can see who entered each piece of data, where it was transferred from, and who
has viewed it
Permits easy exchange of information with other health information systems and health professionals

Microsoft HealthVault and Indivo X are the two dominant PHR platforms. Google health used to be a dominant
platform. In mid-2011 Google announced the retirement of Google Health on January 1, 2012. The data was available
for download through January 1, 2013. The Dossia Consortium, a not-for-profit organization dedicated to develop an
open-source, personally controlled, and comprehensive PHR platform, was founded in 2006.

HealthVault has successfully implemented an app platform and includes extensive libraries for embedded
applications. Microsoft created a Software Development Kit so that its software can be easily embedded directly into
computer and devices that gather healthcare data as long as they are running either a Microsoft operating system or
are near a Microsoft computer. The HealthVault API (Application Programming Interface) is platform agnostic. Making
use of the API, the American Heart Association (AHA) developed Heart360 app and the American Diabetes
Association (ADA) created Diabetes 24/7 app for patients to manage their health data (Trotter and Uhlman, 2011).

The Direct Project is one of the major initiatives of the Nationwide Health Information Network (NHIN). It is a secure e-
mail system for physicians, their colleagues, and their patients. It defines a specification for the use of a set of existing
Internet standards and protocols to allow secure exchange of healthcare data. It will be covered in depth in later
health informatics courses. HealthVault team was active in the project from the beginning and created an open source
.NET implementation of Direct that, alongside the Java implementation, enabled the first proof of concept of the Direct
networks. HealthVault is the first PHR system that offers Direct address to its registered users (Trotter and Uhlman,
2011).

Besides PHR platforms, there are other patient-facing software applications including health apps, health websites,
patient portals, and so on. With more than 1.5 billion smart phones and 200 million tablets around the world, mobile
health (mHealth) has undergone exponential growth in the past few years. A patient portal is a webpage that facilitates

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communication between patients and their health providers. Web-based patient portals are in wide use and provide
functions such as secure email, making appointments, and viewing test results.

The American Recovery and Reinvestment Act of 2009 (ARRA), also known as “the Stimulus Bill, set aside more than
$20 billion for incentives to encourage healthcare providers to employ information technologies, such as EHRs, in
specific and accountable ways that are denoted by the term meaningful use. Meaningful use will be covered in depth
in CS581. There are several stages of term meaningful use requirements related to PHRs. PHRs could send patient
reminders and preventative care notices through the Direct network. There are also meaningful use requirements to
provide a complete copy of electronic health information upon request. To achieve comprehensive certification, most
EHR systems will have simple tethered PHR options. One of the major challenges for any patient-facing system is
whether and how to allow data sharing between its users. Meaningful use will eventually require EHR systems to
accept patient-generated data. The data will be manually or automatically uploaded into a PHR and then accepted
into the EHR system (Trotter and Uhlman, 2011).

References

AARP (n.d.) Chronic care: a call to action for health reform. Chronic conditions among older Americans. Retrieved
8/20/2015 from http://assets.aarp.org/rgcenter/health/beyond_50_hcr_conditions.pdf.

AHIMA e-HIM Personal Health Record Work Group (2005) "Defining the Personal Health Record." Journal of AHIMA
76, no.6, 24-25.

Braunstein M (2014). Contemporary health informatics. Chapter 1 The US Healthcare System.

Braunstein M (2014a). Contemporary health informatics. Chapter 7 Empowering the Patient.

Kumar S. and Nigmatulin A. (2010) Exploring the impact of management of chronic illnesses through prevention on
the U.S. healthcare delivery system: A closed loop system’s modeling study.

Information Knowledge Systems Management 9: 127-152.

Markle Foundation (2003) The Personal Health Working Group Final Report. Retrieved 8/20/2015 from
http://www.markle.org/sites/default/files/final_phwg_report1.pdf.

MedlinePlus (2014) Immune system structures. Retrieved 8/20/2015 from

https://www.nlm.nih.gov/medlineplus/ency/imagepages/8932.htm.

NIAID (2015) Immune system. Retrieved 8/20/2015 from

http://www.niaid.nih.gov/topics/immunesystem/Pages/default.aspx.

Nobelprize.org (n.d.) The Immune System - in More Detail. Retrieved 8/20/2015 from
http://www.nobelprize.org/educational/medicine/immunity/immune-detail.html.

Trotter F and Uhlman D (2011). Hacking healthcare: A guide to standards, workflows, and meaningful use. Chapter 6
Patient-facing software.

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Wikipedia (2015) Adaptive immune system. Retrieved 8/20/2015 from

https://en.wikipedia.org/wiki/Adaptive_immune_system.

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