CONTACTS 
0201 - Kaiser Permanente                                                                                                                                                  O-00000652 0203
020101 - Dr. Vincent E. Yamamoto, M.D.; Orthopedic Surgon
020102 - Orthopedic Department                                                                                                                                            O-00000652 0203
0202 - Kaiser Medical Center                                                                                                                                              O-00000258 0702
020201 - Dr. Kory Zipperstein; 415 202 2207 (advice)                                                                                                                      O-00000258 0702
020202 - Injury/Office Surgery Appointments 415 202 2957; appts. 2291                                                                                                     O-00000258 0702
0203 - Kaiser Permanente - Shadelands                                                                                                                                     O-00000718 0403
020301 - Walnut Creek, CA                                                                                                                                                 O-00000718 0403
020302 - Ms. Jeanne Bradley; Coordinator
020304 - Administration Department                                                                                                                                        O-00000718 0403
0204 - Kaiser Permanente - Shadelands                                                                                                                                     O-00000718 0309
020401 - Walnut Creek                                                                                                                                                     O-00000718 0309
020402 - Dr. Elia Racah; Primary Care Physician
020404 - Primary Care

SUBJECTS
Partnership
Team Care

0504 -
0504 -    ..
0505 - Summary/Objective
0506 -
050601 - Follow up ref SDS 47 0001, ref SDS 44 0863.
050602 -
050603 - Implemented Jeanne's suggestion on assigning a Primary Care physician,
050604 - interviewed Doctor Racah who indicated willingness to give the Welch
050605 - system a try.  Got advice on new medical issues.  Visited briefly with
050606 - Jeanne and reported progress on her schedule of tasks to solve pending
050607 - issues.
050609 -  ..
050610 - Submitted ref DIT 1 0001 to Elia linked to this record for background
050611 - and to demonstrate the communication we have in mind.
050613 -  ..
050614 - Included reminder to update Kaiser's records on Primary Care
050615 - physician.
050616 -
050617 -     [On 000208 received letter from Doctor Racah. ref SDS 48 0001]
050618 -
050619 -
050621 -  ..
0507 -
0508 -
0509 - Progress
051001 -  ..
051002 - Team Care Needs Support for Medical Management
051003 -
051004 - Follow up ref SDS 47 0004.
051005 -
051006 - Met Jeanne in her office and gave her the letter to Vincent for the
051007 - meeting on 000124. ref SDS 45 0001  She will send it to him through
051008 - Kaiser's internal mail.
051010 -  ..
051011 - Advised of having sent her a letter, ref DIP 12 0001 yesterday,
051012 - ref SDS 47 0004, transmitting letters to Doctors Yamamoto and
051013 - Zipperstein, and responding to Jeanne's letter, ref DRP 8 0001,
051014 - received on 000121. ref SDS 44 0863
051016 -  ..
051017 - Jeanne asked about progress on actions in her letter?
051019 -  ..
051020 - I explained things are proceeding according to her schedule, per
051021 - below. ref SDS 0 0788
051022 - ..
051023 - We reviewed the need to help doctors perform competent medical
051024 - management, since they are scheduled out to see patients every 15
051025 - minutes, per Michelle below. ref SDS 0 0788  This does not leave time
051026 - for analysis and coordination that Jeanne accomplished in her letter.
051027 - ref DRP 8 0001
051029 -  ..
051030 - We also reviewed the problem of multiple medical charts, reported in
051031 - the meeting with Vincent on 000124. ref SDS 45 2065
051033 -  ..
051034 - I thanked Jeanne for her help.
051035 - ..
051036 - She demonstrated ability to access links in SDS.  This worked
051037 - well, evidently solving the problem reported on 990706. ref SDS 6 7410
051038 -
051039 -
051040 -
051041 -
051042 -
051043 -
0511 -

SUBJECTS
15 Minutes Doctors Scheduled to Meet Patients Not Enough Time for Do
Personality Patient Impact Health
Personality Impacts Willingness Doctors to Perform
Exam 000207 Primary Care Physcian, Hiatic Hernia, Feet
Primary Care Physician
15 Minutes Doctors Scheduled to Meet Patients Not Enough Time for Do

1408 -
140901 -  ..
140902 - Primary Care Physician Obtain List Available for Assignment
140903 -
140904 - Follow up ref SDS 44 0788.
140905 -
140906 - Called Michelle Kitts at 925 906 2320 for list of physicians with open
140907 - panels, per Jeanne's instruction, ref DRP 8 2408, received on 000121.
140908 - ref SDS 44 0282
140910 -  ..
140911 - Michelle said doctors see patients every 15 minutes by appointment.
140912 -
140913 -    Michelle's report aligns with Sylvia's comments on 990625 that
140914 -    doctors do not have enough time to comply with requirements in
140915 -    Kaiser's Healthwise Handbook to review the record for verifying
140916 -    accuracy of communication with patients. ref SDS 5 1978
140917 -
140918 -        [On 050311 doctors have difficulty with communication and
140919 -        collaboration among themselves preparing timely reports,
140920 -        distribution, review, and feedback. ref SDS 52 PB8N
140922 -     ..
140923 -    15 minutes is barely enough time to say hello, and speculate about
140924 -    a few symptoms.  Being bombarded by a different personality and new
140925 -    information streams every 15 minutes, plus interacting with staff
140926 -    on administrative matters, taking personal calls, etc., is not
140927 -    enough time for analysis to think carefully about diagnosis and
140928 -    treatment options, nor to verify accuracy of communication, called
140929 -    out in Kaiser's requirements, reported on 990625. ref SDS 5 3190
140931 -     ..
140932 -    15 minutes allocated to examine a patient helps explain why
140933 -    doctor's handwriting degrades, causing errors that impact care,
140934 -    reported on 990912. ref SDS 8 0900
140936 -  ..
140937 - Michelle advised that the only way for a patient to interview a doctor
140938 - is to schedule a meeting and pay $10.
140940 -  ..
140941 - We reviewed the objective to work with a primary care physician who is
140942 - willing to try to follow Kaiser's Healthwise Handbook on communication
140943 - by using the Internet in order to solve the time problem that Michelle
140944 - discloses today, per above. ref SDS 0 VM4V
140946 -  ..
140947 - Michelle said that...
140948 -
140949 -                          Elia Racha, MD
140950 -                          Family Practice
140951 -
140952 - ...is a good family practice doctor, who, she understands, is open to
140953 - using email in his practice.  She suggested visiting with Doctor Racha
140954 - about this opportunity.
140956 -  ..
140957 - Michelle advised that doctors schedule patient visits for every 15
140958 - minutes, and that Doctor Racah has some time today at 1530 and 1630.
140959 - Since I am in town today for the meeting with Doctor Edwards tomorrow,
140960 - decided to shoot for 1530.
140962 -  ..
140963 - Michelle set a meeting for today at 1530...
140964 -
140965 -                          Group AB
140966 -                          Sequoia Building
140967 -
140968 -        [On 000208 Doctor Racah found that SDS enables amazing records
140969 -        with accuracy comparable to tape recordings. ref SDS 48 0001
140970 -
140971 -
140972 -
140973 -
140975 -  ..
1410 -
1411 -
1412 - 1530 met with Doctor Elia Racah, MD
1413 -
141301 - Doctor Racah To Try Primary Care Assignment
141302 - Implement Kaiser Procedures using Communication Metrics
141303 -
141304 - This is the meeting to discuss changing the primary care physician,
141305 - per above. ref SDS 0 0788, and called out by Kaiser's Healthwise
141306 - Handbook reviewed on 990625. ref SDS 5 TD4S
141308 -  ..
141309 - While waiting in the examination room, I opened the office copy of the
141310 - Healthwise Handbook to the section on doctor/patient partnership,
141311 - reviewed previously at Kaiser on 990625. ref SDS 5 4185  Prepared to
141312 - discuss with the doctor guidelines on communication, ref OF 1 3430,
141313 - also reviewed previously on 990625. ref SDS 5 0806
141315 -  ..
141316 - Also marked the next page on "ping pong" communication procedures of
141317 - continual feedback. ref OF 1 1395
141319 -  ..
141320 - Doctor Racah noticed, upon entering the examination room, and
141321 - commented that the Kaiser Healthwise Handbook manual was open.
141323 -  ..
141324 - I asked about the large graphic on the wall showing a panorama of
141325 - major peaks, with elevations, in the Himalaya mountains.  Doctor Racah
141326 - indicated he has not climbed Everest, but has climbed in the area.  I
141327 - mentioned my brother Robby's report on 000107 that his son, Erik, has
141328 - recently climbed peaks in Nepal. ref SDS 38 3038
141330 -  ..
141331 - We discussed the agenda for today to interview primary care doctors,
141332 - put forward in Jeanne's letter on 000121, ref SDS 44 0282, in order to
141333 - support Kaiser's Team Care, as reviewed on 990625. ref SDS 5 2784
141335 -  ..
141336 - Doctor Racah asked why Jeanne was involved in communication with the
141337 - patient?
141339 -  ..
141340 - We briefly reviewed medical problems set out in the record on 991008,
141341 - ref SDS 11 9055, which needed assistance in moving forward, reported on
141342 - 000118. ref SDS 41 3248  Experience the past 7 months, reported on
141343 - 000121, shows doctors do not have time to perform medical management.
141344 - ref SDS 44 0863  Michelle's report above that doctors see patients
141345 - every 15 minutes, ref SDS 0 0788, illustrates that doctors do not have
141346 - time to perform medical management.  Kaiser's Healthwise Handbook also
141347 - cites the 15 minute patient schedule intervals. ref OF 1 3430
141349 -  ..
141350 - We reviewed the objective to develop a doctor/patient partnership
141351 - using SDS to enhance conventional email and voice mail which Kaiser is
141352 - currently using.  Better partnership hopefully will enhance care and
141353 - reduce mistakes with less burden on the doctor, based on Kaiser's
141354 - Healthwise Handbook communication Model of partnership, reviewed at
141355 - Kaiser on 990625, ref SDS 5 4185, and subsequent analysis in a letter,
141356 - ref DIP 5 0001, issued 990924 addressing steps for reducing the high
141357 - cost of medical mistakes. ref SDS 9 3922
141359 -  ..
141360 - Doctor Racah asked if this has been tried working with doctors?
141362 -  ..
141363 - The meeting with Doctor Yamamoto at Kaiser on 000124 is a recent
141364 - example. ref SDS 45 0001  Doctor Boulris applied the SDS methodology
141365 - on 991018. ref SDS 13 0001  Doctor Zipperstein also commented
141366 - favorably on saving time for treating patients using SDS records,
141367 - reported 940728. ref SDS 2 0001
141369 -  ..
141370 - Doctor Racah asked how it works?
141372 -  ..
141373 - I explained the process of capturing the record of medical history and
141374 - making it available to the doctor via a link through email.
141375 -
141376 -     [On 000208 Doctor Racah found that SDS enables amazing records
141377 -     with accuracy comparable to tape recordings. ref SDS 48 0001
141378 -
141379 -     [On 041202 Doctor Parsley used email for timely, accurate
141380 -     coordination between patient, primary care physician and surgeon
141381 -     on follow up for emergency treatment that found biopsy wound that
141382 -     failed to heal over 8 months. ref SDS 51 426W
141384 -  ..
141385 - The process connects events, like the examination we are doing today,
141386 - with related sources and history, so it is quick and easy to get
141387 - accurate answers to questions, for example, why Jeanne communicated
141388 - with a patient, shown on 000118, ref SDS 41 3248, medical history on a
141389 - knee problem, shown on 990625, ref SDS 5 5152, Team Care procedures,
141390 - and so on.
141392 -  ..
141393 - It probably is helpful to have a program of doctor/patient training in
141394 - communication, called out to solve the high cost of medical mistakes,
141395 - ref DIP 5 2601  Initially, we want to test Communication Metrics
141396 - without express training.  Testing requires a doctor willing to try
141397 - new methods in order to assess effectiveness and provide feedback on
141398 - improvements.  For example Jeanne reported problems on 000118.
141399 - ref SDS 41 3128  We do not have a perfect system, but we have a good
141400 - one, as reported by the U.S. Army Corps of Engineers, ref DRP 6 6172,
141401 - and we have to use it to discover improvements.
141403 -  ..
141404 - Doctor Racah indicated this sounds helpful.  He said he is not a
141405 - computer expert, and asked how much he has to learn?
141407 -  ..
141408 - Doctor Racah noted that Doctor Tom Connolly is an expert computer user
141409 - who has developed strong technology capabilities to support medical
141410 - practice, reflecting the meeting with Sylvia on 990625. ref SDS 5 2541
141412 -  ..
141413 - Doctor Racah said he does not have Tom's expertise.
141415 -  ..
141416 - We reviewed the process of clicking on a link in an email to open a
141417 - web mail letter.  The letter summarizes understandings, as with
141418 - conventional correspondence, and has links to detailed history, most
141419 - often to a record like this one, that has context on actions taken,
141420 - why, planned results, and follow up.  These links can in turn be
141421 - opened by clicking.  Typically, subsidiary links only provide
141422 - supplemental context that need not be fully reviewed.  After reading a
141423 - paragraph or so, use the "back" button to return to the prior level,
141424 - i.e., the main letter, and continue reading.  The environment emulates
141425 - the web of connections in human thought, so they essentially go on
141426 - forever.  Sometimes people get lost, as when we lose a train of
141427 - thought and have to start over in a conversation.  It is frustrating,
141428 - but in the Welch environment, simply keep clicking back to the primary
141429 - letter in order to regain orientation.
141431 -  ..
141432 - The only skills needed are to click forward on links to get more
141433 - information, and click back to return to the original letter.  As with
141434 - any communication, if you get stuck, call the author and ask for help.
141436 -  ..
141437 - Doctor Racah repeated the process...
141438 -
141439 -             1.  Click to get information.
141440 -             2.  Click the "back" button to go back.
141441 -
141442 - ...that does not sound difficult."
141443 -
141444 -     [On 000208 Doctor Racah reported success navigating SDS
141445 -     intelligence support for medical practice, and found that SDS
141446 -     enables amazing records with accuracy comparable to tape
141447 -     recordings. ref SDS 48 0001
141449 -  ..
141450 - We reviewed the record that some doctors decline to use this procedure
141451 - for very valid reasons of not wanting to adversely impact their time,
141452 - as reported on 990802, ref SDS 7 9108, and on 991006, ref SDS 10 0896
141453 - Other doctors have objected, but then supported the effort, as
141454 - occurred with Doctor Boulris on 991018. ref SDS 13 0001
141456 -  ..
141457 - As noted, Doctor Zipperstein reported on 940728 that this procedure
141458 - helped him and it saved time. ref SDS 2 0001
141460 -  ..
141461 - The aim is to find a doctor willing to experiment toward developing a
141462 - stronger doctor/patient partnership to implement Kaiser's guidelines
141463 - on communication, reviewed on 990625. ref SDS 5 5740
141465 -  ..
141466 - Doctor Racah glanced through Kaiser's requirements and noted that he
141467 - was not familiar with these procedures, reflecting common practice for
141468 - doctors to focus on treatment and not medical management.
141470 -  ..
141471 - We reviewed the report on 990625 that doctors do not have time to
141472 - analyse the record. ref SDS 5 1978  We want to see if patients can
141473 - help within the meaning of partnership.  Patients have relatively more
141474 - time and strong self-interest to support medical work on themselves,
141475 - with accurate communications.  Doctors need merely submit corrections
141476 - and additions, if necessary.  This does not eliminate the need for
141477 - doctors to report on patient progress, from time to time, but it
141478 - reduces the burden, and provides a resource that aids the doctor.
141480 -  ..
141481 - Doctor Racah said he would like to try this method, and advised that
141482 - he has access to the Internet.
141484 -  ..
141485 - He gave his email address to send him the record of this meeting
141487 -  ..
141488 - Request help if you get stuck.  Don't waste a lot of time trying to
141489 - figure things out.  Right now nothing in the record requires immediate
141490 - action.  So, review it as time permits, and call for help if needed.
141491 - (415 781 5700)
141492 -
141493 -     [On 000208 letter from Doctor Racah says the record of the meeting
141494 -     today was accurate. ref SDS 48 0001]
141495 -
141496 -
141497 -
141498 -
1415 -

SUBJECTS
Hiatic Hernia

1503 -
150401 -  ..
150402 - Hiatic Hernia, Heart Burn, Solution Incline Sleeping Position
150403 -
150404 - Doctor Racah asked if there are any specific medical problems he might
150405 - address today.
150406 -
150407 - I mentioned that over the past 5 years or so a problem has developed
150408 - in sleeping face down.  Liquid backs up into the throat, and causes
150409 - choking.  There is also chest pain of varying severity, but this is
150410 - less frequent, probably a heart burn thing that can be controlled by
150411 - eating different foods, maybe more exercise.  The liquid backflow
150412 - problem seems more troubling.
150414 -  ..
150415 - Doctor Racah indicated this problem can be caused by a "Hiatic" (sp
150416 - ??) valve that becomes weakened with age.  It permits fluid from the
150417 - stomach to flow back up the throat, which normally does not occur.
150419 -  ..
150420 - We reviewed efforts to mitigate the problem using pillows to maintain
150421 - an elevated posture during sleep.
150423 -  ..
150424 - Doctor Racah suggested purchasing a wedge pillow that provides a more
150425 - stable and constant posture than pillows.
150427 -  ..
150428 - He said the only cure is to operate, and that is not recommended,
150429 - except in the most severe cases, because it is a very "messy"
150430 - procedure.
150431 -
150432 -
150433 -
150434 -
150435 -
1505 -

SUBJECTS
Feet Fungus
Lamisil Fungus Treatment
Fungus on Feet, 000207

1805 -
180601 -  ..
180602 - Feet Fungus Treated with Lamisil
180603 -
180604 - Explained recent problem of both feet becoming excessively dry and
180605 - callused.
180606 -
180607 - Doctor Racah examined my feet.  He prescribed Lamisil, which can be
180608 - purchased from the Kaiser pharmacy.
180609 -
180611 -  ..
1807 -
1808 -
1809 - 1608
1810 -
181001 - After the meeting, visited the Kaiser pharmacy and purchased two
181002 - units of Lamisil for $33 or so.
181004 -  ..
181005 - The product is described as...
181006 -
181007 -
181008 -                     Terbinafine Hydrochloride Cream
181009 -
181011 -  ..
181012 - It treats an infection of the outer layer of skin caused by fungus.
181014 -  ..
181015 - This is a one to two week treatment.
181017 -  ..
181018 - Treatment requires...
181019 -
181020 -      •  Washing the infected area (feet) with soap and
181021 -         water, and dry.
181022 -
181023 -      •  Do not cover treated area with bandages.
181025 -          ..
181026 -      •  Apply Lamisil to infected area twice a day for two weeks.
181028 -  ..
181029 - For technical support call...
181030 -
181031 -                     800 570 9611  0900 - 1700 Eastern time
181032 -
181033 - ..
181034 - When I returned from Kaiser, I began treatment by applying the
181035 - cream to the bottom and slightly up the sides of each foot, and
181036 - between and around the toes.
181037 -
181038 -     [On 000209 reported worsening condition. ref SDS 49 0001]
181039 -
181040 -     [On 000308 reported progress. ref SDS 50 0047]
181041 -
181042 -
181043 -
1811 -

SUBJECTS
Colonoscopy Test
Exam 000208 Colonoscopy

2004 -
200501 -  ..
200502 - Sigmoidoscopy (also Conoloscopy) Scheduled for 000208
200503 -
200504 - Follow up ref SDS 44 1681.
200505 -
200506 - Called Doctor Edwards at the Park Shadelands facility.
200507 -
200508 -                     925 295 4080
200510 -  ..
200511 - Talked to Caroline.
200513 -  ..
200514 - Advised that we are meeting tomorrow with Doctor Edwards, and
200515 - understand from Millie, that there are supplemental instructions to
200516 - prepare for the examination.
200518 -  ..
200519 - Caroline confirmed we should have received specific instructions.
200521 -  ..
200522 - Since we did not get the instructions, Caroline can fax them or read
200523 - them over the phone.  I asked about sending by email.  Caroline said
200524 - they don't have email yet in her department.
200526 -  ..
200527 - She read the instructions.
200529 -  ..
200530 - Beginning on the day before the meeting, do not eat food with seeds.
200532 -  ..
200533 - Drink lots of liquids.
200535 -  ..
200536 - Tomorrow use clear liquid diet until after the exam.
200538 -  ..
200539 - Two hours before meeting, perform two "fleet" enimas, water based.
200540 -
200541 -    10 minuets apart.  Take two tap water enimas by filling little
200542 -    bottle with water and continue until it is clear.
200543 -
200544 -    Fleet enimas can be obtained at the drug store, and at the Kaiser
200545 -    Pharmacy.
200546 -
200547 -
200549 -  ..
2006 -
2007 -
2008 - 1608
2009 -
200901 - After meeting with Doctor Racha, visited the pharmacy and purchased
200902 - two emina applications.  The pharmacist said Fleet emimas are no
200903 - longer available.  She directed attention to a new product that is
200904 - used in place of the prescribed item.
200906 -  ..
200907 - Bought two of them.
200908 -
200909 -
200910 -
200911 -
2010 -