CONTACTS
SUBJECTS
Meeting Doctor Examine Recovery from Mastectomy Surgery Response to
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 99 0000. ref SDS 88 0000.
040502 -
040503 - CA 15-3 rose from 28 to 34; this is still well below the critical
040504 - benchmark of 39, ref SDS 0 GJ5M, however, report of new, swelling
040505 - under the left arm (axillary) raises concern of cancer relapse.
040506 - Initial diagnosis is lymphedema, ref SDS 0 MW8J, which is a severe
040507 - condition, though not immediately life threatening, like cancer.
040508 - ref SDS 0 RV3J PET scan test scheduled to assess relapse, and will
040509 - also provide diagnostic support on the new lump under the left arm.
040510 - ref SDS 0 NL4N Breast examination indicates surgical wound healing
040511 - normally. ref SDS 0 025H Patient status still NED; remains on
040512 - treatment holiday until next meeting on 060217, ref SDS 0 4Y9N, when
040513 - PET scan test results are reviewed. ref SDS 0 AW5G
040514 -
040515 - [On 060126 received report on PET scan test performed on 060120,
040516 - ref SDS A5 NL4N; found no evidence of disease, patient NED; mild
040517 - FDG requires study, ref SDS A5 MW6K; evidence of esophagitis
040518 - requires investigation. ref SDS A5 DH4O Failure to find prior PET
040519 - scan test o 051005 prevented comparision study. ref SDS A5 XF3K
040521 - ..
040522 - [On 060217 blood tests are all normal for 1st time in 4 years,
040523 - supporting finding that patient history shows NED and stable.
040524 - ref SDS A6 DQ6L
040526 - ..
040527 - [On 060217 examination showed significantly reduced swelling of
040528 - left axillary, and PET scan test on 060120 made no findings; CA
040529 - 15-3 fell slightly, ref SDS A6 MW8J; therefore doctor deferred
040530 - work up and treatment for lymphedema until further examination in
040531 - April 2006, ref SDS A6 SG3O; doctor describes swelling left axilla
040532 - as post op localized edema. ref SDS A6 T56K
040534 - ..
040535 - [On 060306 examination at lyphedema clinic showed worsening
040536 - condition; follow up meeting for personalized treatment scheduled.
040537 - ref SDS A7 Q05H
040539 - ..
040540 - [On 060308 lymphedema symptoms increase, report at work.
040541 - ref SDS A8 0001
040543 - ..
040544 - [On 060314 physical therapy treatment and new guidance for
040545 - lymphedema; begin regimin of personal massage treatments to reduce
040546 - swelling left arm. ref SDS A9 Q05H
040547 -
040548 -
040549 -
040550 -
040552 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Agenda for Work Plan After Switching to Taxotere and Capecitabine
040902 -
040903 - Follow up ref SDS 99 SM6M, ref SDS 88 SM6M.
040904 -
040905 - The reception area seemed nearly empty. There were three attendants
040906 - to process patients, but there was no line to check in.
040908 - ..
040909 - The doctor was busy today. We were admitted to the examination room
040910 - about 1415. The doctor opened the door about 1445, and interrupted a
040911 - cell phone call to say he would be in shortly. About 1500 the
040912 - examination began. The doctor seemed tired, and said there is a lot
040913 - going on today.
040915 - ..
040916 - This is the 2nd review meeting with primary care physician following
040917 - surgery on 051021, ref SDS 93 0001, and following examination by the
040918 - surgeon on 051027, when Millie's status was reported "no evidence of
040919 - disease (NED)". ref SDS 97 M58G
040921 - ..
040922 - Millie listed an agenda on the marking board in the examination room
040923 - to guide discussions...
040924 -
040925 - 1. CA 15-3 cancer marker report............... ref SDS 0 GJ5M
040926 - 2. PET test for relapse schedule.............. ref SDS 0 NL4N
040927 - 3. Lump under left arm........................ ref SDS 0 MW8J
040928 - 4. Breast exam recovering IBC................. ref SDS 0 025H
040929 - 5. Port flush................................. ref SDS 0 SH5N
040930 - 6. Surgeon's pre-op patient history........... ref SDS 0 355G
040931 - 7. Treatment plan............................. ref SDS 0 AW5G
040932 - 8. Status change treatment options............ ref SDS 0 ZR6J
040934 - ..
040935 - Scheduled next meeting in six weeks on 060217.
040936 -
040937 -
040938 -
040939 -
040940 -
040941 -
0410 -
SUBJECTS
CA 15-3 34 and 5 Points Below Normal 39 and 6 Point Rise from 28 abo
1403 -
140401 - ..
140402 - CA 15-3 Cancer Marker 34 Rises from 28 the Past 3 Weeks
140403 -
140404 - Follow up ref SDS 99 087J, ref SDS 88 087J.
140405 -
140406 - The most recent blood test on 051223 shows CA 15-3 rose to 34, after
140407 - dropping to an all time low of 28 on 051202 as shown in a report
140408 - submitted by the doctor today...
140410 - ..
140411 - Test Date Date Received
140412 - 051223......... 34............... 060106, ref SDS 0 087JL
140413 - 051202......... 28............... 060106, ref SDS 0 087JL
140414 - 051116......... 31............... 051121, ref SDS 99 087JL
140415 - 051109......... 30............... 051121, ref SDS 99 087JL
140416 - 051102......... 34............... 051121, ref SDS 99 087JL
140417 - 050909......... 45 H............. 051007, ref SDS 88 087JL
140418 - 050826......... 45 H............. 050913, ref SDS 75 087JL
140419 - 050819......... 45 H............. 050913, ref SDS 75 087JL
140420 - 050812......... 39 .............. 050819, ref SDS 68 3K6L
140421 - 050729......... 45 H............. 050819, ref SDS 68 EA5G
140422 - 050708......... 46 H............. 050729, ref SDS 66 087J
140423 - 050701......... 37 .............. 050708, ref SDS 63 2N5J
140424 - 050617......... 45 H............. 050729, ref SDS 66 087J
140425 - 050527......... 56 H............. 050610, ref SDS 62 087J
140426 - 050512......... 67 H............. 050520, ref SDS 61 087J
140427 - 050506......... 80 H............. 050520, ref SDS 61 087J
140428 - 050415.........105 H............. 050422, ref SDS 59 087J
140429 - 050325.........100 H............. 050329, ref SDS 57 087J
140430 - 050318.........101 H............. 050325, ref SDS 56 2N5J
140431 - 050304......... 88 H............. 050311, ref SDS 54 087J
140432 - 050225......... 95 H............. 050308, ref SDS 53 0001
140433 - 050211......... 78 H............. 050214, ref SDS 52 02BB
140434 - 050128......... 67 H............. 050204, ref SDS 51 087J
140435 - 041228......... 56 H............. 041230, ref SDS 50 087J
140436 - 041204......... 43 H............. 041210, ref SDS 49 087J
140437 - 041007......... 39............... 041104, ref SDS 44 087J
140438 - 040923......... 49 H............. 041005, ref SDS 43 087J
140439 - 040908......... 44 H............. 040909, ref SDS 42 087J
140440 - 040825......... 47 H............. 040812, ref SDS 42 087J
140441 - 040811......... 42 H............. 040812, ref SDS 41 087J
140442 - 040728......... 43 H............. 040729, ref SDS 39 2N5J
140443 - 040712......... 47 H............. 040713, ref SDS 38 087J
140444 - 040614......... 55 H............. 040615, ref SDS 37 PX6X
140445 - 040517......... 78 H............. 040601, ref SDS 35 2N5J
140446 - 040311......... 70 H............. 040318, ref SDS 29 SM6M
140447 - 040205......... 60 H............. 040211, ref SDS 27 SM6M
140448 - 031201......... 62 H............. 031205, ref SDS 26 SM6M
140449 - 030912......... 66 H............. 030915, ref SDS 25 SM6M
140450 - 030708......... 68 H............. 030710, ref SDS 24 SM6M
140451 - 030503......... 54 H............. 030508, ref SDS 23 SM6M
140452 - 030403......... 45 H............. 030508, ref SDS 23 SM6M
140453 - 030215......... 46 H............. 030220, ref SDS 22 5E6L
140454 - 030106......... 37 H............. 030109, ref SDS 21 SM6M
140455 - 021202......... 41 H?............ 021204, ref SDS 20 SP5G
140456 - 021111......... 36 H?............ 021113, ref SDS 19 Y65I
140457 - 021023......... 33 H?............ 021023, ref SDS 18 SQ5I
140458 - 020930......... 33 H?..29........ 021002, ref SDS 17 SQ5I
140459 - 020917......... 36 H?............ 020924, ref SDS 16 SQ5I
140460 - 020717......... 59 H?............ 020726, ref SDS 14 YN5K
140461 - 020629......... 75 H ............ 020705, ref SDS 13 UX6I
140462 - 020608........ 67 H ............ 020614, ref SDS 12 0001
140463 - 020603........ 108 H ............ 020607, ref SDS 11 X67F
140464 - 020511........ 117 H ............ 020603, ref SDS 10 PJ4J
140465 - 020419......... 81 H ............ 020430, ref SDS 8 7N5H
140466 - 020321......... 85 H ............ 020405, ref SDS 6 6T8K
140467 -
140468 -
140470 - ..
1405 -
1406 -
1407 - Analysis
1408 -
140801 - CA 15-3 34 Cancer Marker Rises Still Significantly Below Target Level
140802 -
140803 - Follow up ref SDS 99 GJ5M, ref SDS 88 GJ5M.
140804 -
140805 - The doctor was pleased with CA 15-3 dropping into the 20s, and that
140806 - the most recent test which rose from 28 to 34 still remains
140807 - significantly below the danger level of 39. The doctor characterized
140808 - this result as "stable."
140810 - ..
140811 - [...below, new lump under left arm may be lymphedema, or could
140812 - signal cancer relapse, based on patient history. ref SDS 0 MW8J
140814 - ..
140815 - The doctor scheduled a standing order for additional monthly CA 15-3
140816 - tests, which will expire in a year, on 070331. ref SDS 0 0303 This
140817 - schedule aligns with planning during the meeting on 051121.
140818 - ref SDS 99 FV6L
140819 -
140820 - [On 060126 Millie had a CA 15-3 test on 060109, and the report
140821 - received on 060125 shows stable condition at 34. ref SDS A5 GJ5M
140823 - ..
140824 - [On 060217 CA 15-3 test on 060210 dropped slightly to 33, further
140825 - indicating stable condition. ref SDS A6 GJ5M
140826 -
140827 -
140828 -
140829 -
1409 -
SUBJECTS
Blood Tests Scheduled to Monitor Relapse Status Meeting Doctor Johns
1603 -
160401 - ..
160402 - Blood Tests Scheduled to Monitor Relapse Status
160403 -
160404 - Additional blood tests include...
160405 -
160406 - [On 060126 received results of blood tests showing everything
160407 - normal for 1st time in 4 years. ref SDS A5 YZ3N
160409 - ..
160410 - [On 060217 reviewed favorable blood tests with doctor. ref SDS A6
160411 - SZ9L
160413 - ..
160414 - Future Orders Class
160415 -
160416 - CBC+DIFF (REG LAB) [211998] 31880070 OP
160417 -
160418 - Expires........070331
160419 - Expected by....
160421 - ..
160422 - ALAKALINE PHOSPHATASE [84075B] 31880071 OP
160423 -
160424 - Expires........070331
160425 - Expected by....
160427 - ..
160428 - AST, SERUM [84450B] 31880072 OP
160429 -
160430 - Expires........070331
160431 - Expected by....
160433 - ..
160434 - BILIRUBIN, TOTAL, SERUM [82247F] 31880073 OP
160435 -
160436 - Expires........070331
160437 - Expected by....
160438 -
160440 - ..
160441 - Standing Orders
160442 -
160443 - CA 15-3 [86300A] 31879993 OP
160444 -
160445 -
160446 -
160447 -
160448 -
160449 -
1605 -
SUBJECTS
PET Scan Test Scheduled After Examination on 060106 Evaluate Lump Le
2503 -
250401 - ..
250402 - PET Scan Test Scheduled Evaluate Relapse and New Swelling Left Axilla
250403 -
250404 - Follow up ref SDS 99 NL4N, ref SDS 88 NL4N.
250406 - ..
250407 - The doctor scheduled PET scan test in 3 - 5 weeks, to follow up the
250408 - test on 051005, that was received on 051007. ref SDS 88 WJ6G This
250409 - implements planning on 051121 to vigorously test for relapse.
250410 - ref SDS 99 NL4N Results should be available for review during the
250411 - next meeting on 060217. ref SDS 0 4Y9N
250413 - ..
250414 - This new test can evaluate new swelling in the left axilla.
250415 - ref SDS 0 MW8J
250416 -
250417 - [...research indicates work up on lymphedema, ref SDS 0 S28I, and
250418 - timely treatment helps prevent disease from cascading out of
250419 - control. ref SDS 0 PG5J
250421 - ..
250422 - [On 060126 received report on PET scan test performed on 060120,
250423 - ref SDS A5 NL4N; found no evidence of disease, patient NED; mild
250424 - FDG requires study, ref SDS A5 MW6K; evidence of esophagitis
250425 - requires investigation. ref SDS A5 DH4O Failure to find prior PET
250426 - scan test on 051005 prevented comparision study. ref SDS A5 XF3K
250427 -
250428 -
250429 -
250430 -
250431 -
250432 -
2505 -
SUBJECTS
Left Axillary Lump Under Arm Diagnosis Lymphedema Not Cancer Right L
3503 -
350401 - ..
350402 - Left Axillary Lump Under Arm Diagnosis Lymphedema Not Cancer
350403 - Lymphedema Left Axillary Not Cancer Lump Under Arm Diagnosis
350404 - Right Left Axillary Examination No Evidence Lumps Lymphedema
350405 -
350406 - Follow up ref SDS 99 MW8J, ref SDS 88 MW8J.
350407 -
350408 - Millie reported swelling under the left arm pit, above the surgical
350409 - incision.
350411 - ..
350412 - Examination showed a "big" lump under the left arm. The right arm has
350413 - a slight lump. The doctor pressed his fingers on the left lump, and
350414 - commented that the feel is not like cancer. Similar examination on
350415 - the right axillary showed a lump about 20% the size of the left bulge.
350416 - The doctor said both lumps feel similar, very soft and mushy, common
350417 - for senior people.
350419 - ..
350420 - Preliminarily, the doctor diagnosed lymphedema.
350421 -
350422 - [On 060217 examination showed significantly reduced swelling of
350423 - left axillary, and PET scan test on 060120 made no findings; CA
350424 - 15-3 fell slightly, ref SDS A6 MW8J; therefore doctor deferred
350425 - work up and treatment for lymphedema until further examination in
350426 - April 2006, ref SDS A6 SG3O; doctor describes swelling left axilla
350427 - as post op localized edema. ref SDS A6 T56K
350429 - ..
350430 - [On 060417 therapyst finds decreased swelling, marked improvement
350431 - compared to examination on 060314; explains that removal of lymph
350432 - nodes during surgery on 051021 may have triggered increased
350433 - symptoms of lymphedema. ref SDS B1 2Z9M
350435 - ..
350436 - Research today indicates that lymphedema is a serious affliction
350437 - caused by surgical removal of lymph nodes, often for breast cancer,
350438 - which fits Millie's patient profile. ref SDS 0 NT6G, and was
350439 - considered previously on 040517. ref SDS 35 V768 Lymph nodes were
350440 - originally removed with surgery on 020312. ref SDS 5 7V61 There has
350441 - been no diagnosis of lymphedema the past four (4) years. In this
350442 - case, the external appearance of the skin does not seem to fit
350443 - criteria for lymphedema. ref SDS 0 S264
350444 -
350445 - [...research indicates work up on lymphedema, ref SDS 0 S28I, and
350446 - timely treatment helps prevent disease from cascading out of
350447 - control. ref SDS 0 PG5J
350449 - ..
350450 - [On 060320 letter to primary care physician reports research
350451 - showing bandage should be worn during exercise; lymphedema may
350452 - have accelerated because exercise was performed without bandage
350453 - during exercise for several months prior to notice. ref SDS B0
350454 - X96V
350456 - ..
350457 - On 041007 research seemed to indicate people live relatively okay with
350458 - lymphedema. ref SDS 45 JI4Y and further, ref SDS 45 8U5L,
350460 - ..
350461 - On 051027 the surgeon advised that recommendations on 050907 to avoid
350462 - lymphadenopathy by removing additional lymph nodes with mastectomy
350463 - surgery, ref SDS 71 JS4H, were not performed on 051021 in order to
350464 - reduce the risk of lymphedema. ref SDS 98 LI3K
350466 - ..
350467 - Case study on lumps under left arm is listed on 040517. ref SDS 35
350468 - SU7G Patient history shows repeated swelling under the left arm, and
350469 - reduction of swelling with chemotherapy treatment. e.g., on 040318,
350470 - ref SDS 35 V14V, and later on 040517 swelling recedes. ref SDS 35 EO56
350471 - and later on 040909. ref SDS 35 H29Q Similar sequence occurred during
350472 - relapse in 2005 -- compare 041210, ref SDS 35 E894, with recovery
350473 - later in the year, cited in later study on 050812. ref SDS 68 M863
350475 - ..
350476 - This record of patient history, together with rising CA 15-3 reported
350477 - today, per above, ref SDS 0 087J, requires thorough, timely testing
350478 - and diagnosis.
350480 - ..
350481 - The doctor indicated that the PET test ordered today, ref SDS 0 NL4N,
350482 - will evaluate the new lump.
350483 -
350484 - [...research indicates work up on lymphedema, ref SDS 0 S28I, and
350485 - timely treatment helps prevent disease from cascading out of
350486 - control. ref SDS 0 PG5J
350488 - ..
350489 - [On 060217 PET scan test showed swelling not cancer; left axillary
350490 - shows no lymphadenopathy, ref SDS A6 MW8J; examination showed
350491 - reduced swelling of lymphedema. ref SDS A6 T56K
350493 - ..
350494 - [On 060306 examination at lymphedema clinic showed worsening
350495 - condition; follow up meeting for personalized treatment scheduled.
350496 - ref SDS A7 Q05H
350497 -
350498 -
350499 -
350500 -
350501 -
3506 -
SUBJECTS
Lymphedema Research Serious Debilitating No Cure Caused by Failure L
3703 -
370401 - ..
370402 - Lymphedema Research Serious Debilitating No Cure
370403 -
370404 - Research on the Internet shows analysis dated 051025 and presented by
370405 - Medicine...
370406 -
370407 - http://www.emedicine.com/med/topic2722.htm
370409 - ..
370410 - Lymphedema is a notoriously debilitating progressive condition
370411 - with no known cure. The unfortunate patient faces a lifelong
370412 - struggle of medical, and sometimes surgical, treatment fraught
370413 - with potentially lethal complications.
370415 - ..
370416 - Pam later found another Internet resource on lymphedema...
370417 -
370418 - http://www.breastcancer.org/lymphedema_avoid.html
370420 - ..
370421 - On 041007 research seemed to indicate people live relatively okay with
370422 - lymphedema, ref SDS 45 JI4Y and further, ref SDS 45 8U5L, which seems
370423 - conflicting with research today.
370425 - ..
370426 - Research continues...
370427 -
370428 - Frequency:
370429 -
370430 - In the United States, the highest incidence of lymphedema is
370431 - observed following breast cancer surgery, particularly among
370432 - those who undergo radiation therapy following axillary
370433 - lymphadenectomy. Among this population, 10-40% develop some
370434 - degree of ipsilateral upper extremity lymphedema.
370436 - ..
370437 - Millie had radiation, beginning on 020708, ref SDS 15 TV4I, which
370438 - followed up prior work performing a left axillary lymphadenoctomy on
370439 - 020312. ref SDS 5 7V61
370441 - ..
370442 - Research continues...
370443 -
370444 - Worldwide, 140-250 million cases of lymphedema are estimated
370445 - to exist, with filariasis being the most common cause.
370447 - ..
370448 - The underlying problem is lymphatic dysfunction, resulting in
370449 - an abnormal accumulation of interstitial fluid containing high
370450 - molecular weight proteins. This condition underscores the
370451 - tremendous importance of a normally functioning lymphatic
370452 - system, which returns proteins, lipids, and accompanying water
370453 - from the interstitium to the venous circulation near the
370454 - subclavian vein-internal jugular vein junction, bilaterally.
370456 - ..
370457 - Accumulation of interstitial fluid leads to massive dilatation
370458 - of the remaining outflow tracts and valvular incompetence that
370459 - causes reversal of flow from subcutaneous tissues into the
370460 - dermal plexus. The lymphatic walls undergo fibrosis, and
370461 - fibrinoid thrombi accumulate within the lumen, obliterating
370462 - much of the remaining lymph channels. Spontaneous lymphovenous
370463 - shunts may form. Lymph nodes harden and shrink, losing their
370464 - normal architecture.
370466 - ..
370467 - The overlying skin becomes thickened and displays the typical
370468 - peau d'orange (orange skin) appearance of congested dermal
370469 - lymphatics. The epidermis forms thick scaly deposits of
370470 - keratinized debris and may display a warty verrucosis. Cracks
370471 - and furrows often develop and accommodate debris and bacteria,
370472 - leading to lymphorrhea, the leakage of lymph onto the surface
370473 - of the skin.
370475 - ..
370476 - Clinical: Patients present with varying degrees of severity,
370477 - from mild swelling to severe disabling enlargement with
370478 - potentially life-threatening complications. This disease is
370479 - often first noticed by the patient as an asymmetry or increased
370480 - circumference of an extremity. As swelling slowly progresses,
370481 - patients may have difficulty fitting into clothing. Once well
370482 - established, lymphedema may cause fatigue related to the size
370483 - and weight of the extremity, embarrassment in public, and
370484 - severe impairment of daily activities. Recurrent bacterial or
370485 - fungal infections are also common.
370487 - ..
370488 - Diagnosis lymphedema seems to require major work up...
370489 -
370490 - The diagnosis is usually made with a thorough history and
370491 - physical examination. Other causes of edema, such as edema
370492 - secondary to congestive heart failure, renal insufficiency,
370493 - hepatic insufficiency, or venous stasis disease, must be
370494 - excluded. Malignancy must always be considered, particularly
370495 - when patients report sudden onset, rapid progression, or
370496 - associated pain. These symptoms may indicate direct tumor
370497 - growth or metastatic disease in the regional lymph node basin.
370499 - ..
370500 - The doctor seemed to indicate today that the first step in diagnosis
370501 - in this case will be the PET scan test. ref SDS 0 NL4N
370503 - ..
370504 - [On 060217 examination showed significantly reduced swelling of
370505 - left axillary, and PET scan test on 060120 made no findings; CA
370506 - 15-3 fell slightly, ref SDS A6 MW8J; therefore doctor deferred
370507 - work up and treatment for lymphedema until further examination
370508 - in April 2006. ref SDS A6 SG3O
370510 - ..
370511 - [On 060306 examination at lyphedema clinic showed worsening
370512 - condition; follow up meeting for personalized treatment
370513 - scheduled. ref SDS A7 Q05H
370515 - ..
370516 - [On 060308 lymphedema symptoms increase, report at work.
370517 - ref SDS A8 0001
370519 - ..
370520 - [On 060314 physical therapy treatment and new guidance for
370521 - lymphedema; begin regimin of personal massage treatments to reduce
370522 - swelling left arm. ref SDS A9 Q05H
370523 -
370524 -
370525 -
370526 -
3706 -
SUBJECTS
Imaging Studies Lmphoscintgraphy Current Practice
3903 -
390401 - ..
390402 - Research continues...
390403 -
390405 - ..
390406 - Imaging Studies Lmphoscintgraphy Current Practice
390407 -
390408 - Although infrequently required to establish the diagnosis,
390409 - certain tests may be useful to confirm the diagnosis in
390410 - complex cases, to determine residual lymphatic function, to
390411 - establish treatment preferences, and to evaluate therapy.
390413 - ..
390414 - Lymphoscintigraphy has replaced lymphangiography.
390415 -
390416 - It does not promote further damage to the delicate lymphatic
390417 - channels.
390419 - ..
390420 - This test can be used to define anatomy and patency,
390421 - evaluate dynamics of flow and reversal of flow, and
390422 - determine the severity of obstruction.
390424 - ..
390425 - The doctor prescribes PET scan tests today for evaluating lumps.
390426 - ref SDS 0 CN4I
390428 - ..
390429 - Research continues...
390430 -
390431 - Computed tomography (CT) scans and magnetic resonance imaging
390432 - (MRI) have been advocated by some authors.
390433 -
390434 - These tests can delineate nodal architecture at a greatly
390435 - increased cost, but they have very few advantages over
390436 - lymphoscintigraphy.
390438 - ..
390439 - An indication for CT scan or MRI is suspicion of malignancy,
390440 - for which these tests offer the most information.
390442 - ..
390443 - Doppler ultrasonography is also used by some to evaluate flow
390444 - in the lymphatic and venous systems.
390445 -
390446 - The presence of a deep vein thrombosis is in the
390447 - differential diagnosis of unilateral extremity swelling, and
390448 - it may also occur concomitantly with lymphedema.
390450 - ..
390451 - This is a very cost-effective test in the appropriate
390452 - clinical situation.
390453 -
390454 -
390455 -
390456 -
3905 -
SUBJECTS
Treatment Lymphedema Surgery Palliative No Cure
4103 -
410401 - ..
410402 - Treatment Lymphedema Surgery Palliative No Cure
410403 -
410404 - Surgical treatment is palliative, not curative, and it does not
410405 - obviate the need for continued medical therapy. Moreover, it
410406 - is rarely indicated as the primary treatment modality. Rather,
410407 - reserve surgical treatment for those who do not improve with
410408 - conservative measures or in cases where the extremity is so
410409 - large that it impairs daily activities and prevents successful
410410 - conservative management.
410411 -
410412 -
410413 -
410414 -
4105 -
SUBJECTS
Fibrosclerotic Evolution Avoid with Early Treatment
4303 -
430401 - ..
430402 - Fibrosclerotic Evolution Avoid with Early Treatment
430403 - Weight Reduce Avoid Constrictive Clothing
430404 - Meticulous Hygiene Remove Keratinaceous Debris Bacteria
430405 - Therapy Treatments Uncomfortable Time Consuming Essential
430406 -
430407 - The goal of conservative therapy is to eliminate protein
430408 - stagnation and restore normal lymphatic circulation. Initiate
430409 - therapy as early as possible before extensive irreversible
430410 - fibrosclerotic changes occur in the interstitium. These
430411 - techniques are often cumbersome, uncomfortable, inconvenient,
430412 - and time-consuming. Strict compliance is essential, and
430413 - treatment lasts throughout the lifetime of the individual. The
430414 - majority of compliant patients can be treated successfully with
430415 - conservative measures.
430417 - ..
430418 - Meticulous hygiene is necessary to remove keratinaceous debris
430419 - and bacteria. Cleanse the skin regularly and dry thoroughly.
430420 - Regular inspection is necessary to identify any open wounds or
430421 - developing cellulitis. Bland skin moisturizers applied
430422 - conservatively may ameliorate cracking and furrowing. Even
430423 - with excellent skin care, chronic cellulitis may occur. At the
430424 - earliest signs of infection, institute topical or systemic
430425 - antifungal or antimicrobial therapy to prevent sepsis from
430426 - developing. Long-term prophylactic antimicrobial treatment
430427 - with agents such as penicillin, cephalexin, or erythromycin may
430428 - be required in 15-25% of patients experiencing recurrent
430429 - lymphangitis or cellulitis. Although relatively uncommon in
430430 - this country, filariasis is treated with diethylcarbamazine.
430432 - ..
430433 - Encourage patients to lose weight, avoid even minor trauma, and
430434 - avoid constrictive clothing that might have a tourniquet
430435 - effect. Encourage elevation of the affected extremity whenever
430436 - possible, particularly at night. For lower extremity
430437 - lymphedema, this may be accomplished by elevating the foot of
430438 - the bed to an appropriate level.
430440 - ..
430441 - Patients should use compression garments continuously during
430442 - the day. They may be removed at night when the extremity is
430443 - elevated in bed, but they should be replaced promptly each
430444 - morning. To encourage compliance, the elastic compression
430445 - garments must fit appropriately. Garments should be custom fit
430446 - when the extremity is decompressed, they should be comfortable,
430447 - and they should not have a tourniquet effect. They should also
430448 - have graduated compression, increasing from distal to proximal,
430449 - on the affected extremity.
430451 - ..
430452 - Intermittent pneumatic pump compression therapy may also be
430453 - instituted on an outpatient basis or in the home. These manual
430454 - lymphatic devices are most appropriate prior to fibrosclerotic
430455 - evolution, and they assist in preventing fibrosclerotic
430456 - evolution of the condition. These devices provide sequential
430457 - active compression from distal to proximal, effectively milking
430458 - the lymph from the extremity. In Europe, the best available
430459 - nonsurgical therapy is manual lymphatic drainage according to
430460 - the Vodder and/or Leduc techniques. Compression garments are
430461 - essential between treatments. Contraindications to this
430462 - therapy include congestive heart failure, deep vein thrombosis,
430463 - and active infection. Similarly, other authors advocate manual
430464 - massage of the affected extremity to recruit collateral vessels
430465 - so that the accumulated lymph can be drained into neighboring
430466 - regions with normally functioning lymphatics.
430468 - ..
430469 - Diuretics have no role in the treatment of lymphedema.
430471 - ..
430472 - Benzopyrenes, including flavonoids and coumarin, have become a
430473 - useful adjuvant in other countries but are currently not
430474 - available for clinical use in the United States. These drugs
430475 - bind to accumulated interstitial proteins, inducing macrophage
430476 - phagocytosis and proteolysis. The resulting protein fragments
430477 - pass more readily into the venous capillaries and are removed
430478 - by the vascular system.
430480 - ..
430481 - Surgical therapy: Surgical treatment is palliative, not
430482 - curative, and it does not obviate the need for continued
430483 - medical therapy. Moreover, it is rarely indicated as the
430484 - primary treatment modality. Rather, reserve surgical treatment
430485 - for those who do not improve with conservative measures or in
430486 - cases where the extremity is so large that it impairs daily
430487 - activities and prevents successful conservative management.
430488 - The goals of surgical therapy are volume reduction to improve
430489 - function, facilitation of conservative therapy, and prevention
430490 - of complications. A myriad of surgical procedures have been
430491 - advocated, reflecting a lack of clear superiority of one
430492 - procedure over the others. In general, surgical procedures are
430493 - classified as physiologic or excisional.
430495 - ..
430496 - Physiologic procedures attempt to improve lymphatic drainage.
430497 - Multiple techniques have been described, including omental
430498 - transposition, buried dermal flaps, enteromesenteric bridging,
430499 - lymphangioplasty, and microvascular lympholymphatic or
430500 - lymphovenous anastomoses. None of these techniques has clearly
430501 - documented favorable long-term results. Further evaluation is
430502 - necessary. Moreover, many of theses physiologic techniques
430503 - also include an excisional component, making it difficult to
430504 - distinguish the two approaches.
430506 - ..
430507 - Excisional techniques remove the affected tissues, thus
430508 - reducing the lymphedema load. Some authors advocate
430509 - suction-assisted removal of subcutaneous tissues, but this
430510 - technique is difficult because of the extensive subcutaneous
430511 - fibrosis that is present. Additionally, this approach does not
430512 - reduce the skin envelope, and the lymphedema often rapidly
430513 - recurs. Suction-assisted removal of subcutaneous tissue
430514 - followed by excision of the excess skin envelope has no clear
430515 - advantage over direct excisional techniques alone.
430517 - ..
430518 - The Charles procedure is another quite radical excisional
430519 - technique. This procedure involves the total excision of all
430520 - skin and subcutaneous tissue from the affected extremity. The
430521 - underlying fascia is then grafted, using the skin that has been
430522 - excised. This technique is extreme and is reserved for only
430523 - the most severe cases. Complications include ulceration,
430524 - hyperkeratosis, keloid formation, hyperpigmentation, weeping
430525 - dermatitis, and severe cosmetic deformity.
430527 - ..
430528 - Staged excision has become the option of choice for many
430529 - authors and is described in greater detail. This procedure
430530 - involves removing only a portion of skin and subcutaneous
430531 - tissue, followed by primary closure. After approximately 3
430532 - months, the procedure is repeated on a different area of the
430533 - extremity. This procedure is safe, reliable, and demonstrates
430534 - the most consistent improvement with the lowest incidence of
430535 - complications.
430537 - ..
430538 - Preoperative details: Prior to surgery, appropriate
430539 - documentation is necessary to evaluate the outcome of
430540 - treatment. This includes photographic documentation as well as
430541 - extremity measurements. Ideally, these measurements are of
430542 - limb volume by water displacement, although some rely on
430543 - circumferential measurements alone. Obtain measurements and
430544 - photographs at the same time of day each time, document both
430545 - affected and contralateral extremities, and preferably conduct
430546 - documentation in the morning after extremity elevation in bed
430547 - overnight.
430549 - ..
430550 - Institute strict elevation and pneumatic compression, if
430551 - available, 24-72 hours prior to surgery. This allows maximum
430552 - excision to be performed. The extremity must also be free of
430553 - infection at the time of surgery, and a single dose of
430554 - preoperative intravenous antibiotic is administered
430555 -
430556 -
430557 -
430558 -
4306 -
SUBJECTS
Complications Chronic Lymphedema 10 Years Risk Cancer
4503 -
450401 - ..
450402 - Complications Chronic Lymphedema 10 Years Risk Cancer
450403 - Cellulitus Lymphangitis Complications Chronic Lymphedema
450404 -
450405 - Patients with chronic lymphedema for 10 years have a 10% risk
450406 - of developing lymphangiosarcoma, the most dreaded complication
450407 - of this disease. Patients with this tumor commonly present
450408 - with a reddish purple discoloration or nodule that tends to
450409 - form satellite lesions. It may be confused with Kaposi sarcoma
450410 - or traumatic ecchymosis. This tumor is highly aggressive,
450411 - requires radical amputation of the involved extremity, and has
450412 - a very poor prognosis. The 5-year survival rate is less than
450413 - 10%, and average survival following diagnosis is 19 months.
450414 - This malignant degeneration is most commonly observed in
450415 - patients with postmastectomy lymphedema (Stewart-Treves
450416 - syndrome), where incidence is estimated to be 0.5%.
450418 - ..
450419 - Other complications of lymphedema include recurrent bouts of
450420 - cellulitis and/or lymphangitis, deep venous thrombosis, severe
450421 - functional impairment, cosmetic embarrassment, and necessary
450422 - amputation. Complications following surgery are common and
450423 - include partial wound separation, seroma, hematoma, skin
450424 - necrosis, and exacerbation of foot or hand edema.
450425 -
450426 -
450427 -
450428 -
4505 -
SUBJECTS
Lumps in Neck Reported 040309 Currently Resolved Establish Stage IV
6003 -
600401 - ..
600402 - Prognosis Stage IV Metastatic Disease Currently in Remission
600403 - Palliation Mastectomy Surgery for Future Relapse Stage IV Cancer
600404 - Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
600405 -
600406 - Follow up ref SDS 99 8R6M, ref SDS 88 8R6M.
600407 -
600408 - There was no examination of the neck today.
600409 -
600410 -
600411 -
600412 -
600413 -
6005 -
SUBJECTS
Examination Finds No Evidence of Disease NED Patient Recovering Mast
7003 -
700401 - ..
700402 - No Evidence of Disease NED Patient Recovering Mastectomy Surgery
700403 - Examination Left Breast Surgical Wound Mastectomy Incision Healing
700404 - Healing Surgical Wound Mastectomy Incision Examination Left Breast
700405 -
700406 - Follow up ref SDS 99 025H, ref SDS 88 025H.
700408 - ..
700409 - There has been no recurrence of evidence indicating possible seepage
700410 - from the surgical wound, following examination by the surgeon on
700411 - 051202. ref SDS A3 025H
700413 - ..
700414 - There has been some periodic and general discomfort all along the left
700415 - side, including ear ache.
700417 - ..
700418 - The doctor described this as somewhat psychosomatic symptoms of the
700419 - brain being traumatized by recognizing major loss of body tissue.
700421 - ..
700422 - The doctor used a stethoscope to examine lung and heart function. He
700423 - seemed satisfied with these conditions.
700425 - ..
700426 - The doctor examined the incision wound from mastectomy surgery on
700427 - 051021, ref SDS 94 YG4R, and indicated the wound is still healing
700428 - normally without complications, which extends findings by the surgeon
700429 - on 051027, ref SDS 97 RI6I, and more recently on 051202. ref SDS A3
700430 - 025H
700432 - ..
700433 - Kaiser has still been unable to find the surgeon's pre-op patient
700434 - history, which was missing from the record prior to surgery on 051021,
700435 - ref SDS 94 DG6J, and then discussed with the surgeon a week later on
700436 - 051027. ref SDS 98 PO5J
700438 - ..
700439 - At this time, patient status is NED and stable, based on history and
700440 - analysis reported on 051121. ref SDS 99 GV6K
700441 -
700442 - [On 060217 blood tests are all normal for 1st time in 4 years,
700443 - supporting finding that patient history shows NED and stable.
700444 - ref SDS A6 DQ6L
700446 - ..
700447 - Rise of CA 15-3 and swelled left axillary are new worries. ref SDS 0
700448 - MW8J
700449 -
700450 - [On 060217 CA 15-3 test on 060210 dropped slightly to 33, further
700451 - indicating stable condition. ref SDS A6 GJ5M
700453 - ..
700454 - While checking the computer, and entering results of the current
700455 - meeting, the doctor smiled and remarked that Millie has a big birthday
700456 - coming up in a few weeks. Millie asked how the doctor knew about
700457 - this, and he mentioned something about Kaiser having a good computer
700458 - system. After the examination, the doctor hugged Millie and wished
700459 - her happy birthday. His assistant, Arlette, also, hugged and kissed
700460 - Millie, indicating a lot of good feelings in the department for Mil.
700466 - ..
700467 - Doctor scheduled follow up examination on 060106, per below.
700468 - ref SDS 99 PXXQ
700469 -
700470 -
700471 -
700472 -
700473 -
700474 -
7005 -
SUBJECTS
Stomach Muscle Pull Likely Discomfort New Below Right Breast No Trea
7303 -
730401 - ..
730402 - Discomfort Below Right Breast Likely Muscle Pull
730403 -
730404 - Follow up ref SDS 99 6R6G, ref SDS 88 6R6G.
730405 -
730406 - There was no discussion of this today.
730407 -
730408 -
730409 -
730410 -
730411 -
7305 -
SUBJECTS
Treatment Plan Testing for Relapse Patient NED Metastatic Cancer Tre
9703 -
970401 - ..
970402 - Treatment Plan Testing for Relapse Patient NED Metastatic Cancer
970403 - Holiday Treatment Patient NED Test for Relapse Metastatic Cancer
970404 -
970405 - Follow up ref SDS 99 AW5G, ref SDS 88 AW5G.
970406 -
970407 - Treatment holiday continues.
970409 - ..
970410 - Testing for relapse based on prognosis of metastatic cancer, most
970411 - recently on 051121, ref SDS 99 8R6M, is primary treatment concern
970412 - going forward. Implementation with CA 15-3 and PET scan testing is
970413 - reported above. ref SDS 0 SZ9H and ref SDS 0 NL4N
970414 -
970415 -
970416 -
970417 -
970418 -
9705 -
SUBJECTS
Port Catheter Flush Performed at Kaiser to Maintain Chemo Treatment
9903 -
990401 - ..
990402 - Port Catheter Flush Performed at Kaiser to Maintain Chemo Treatment
990403 -
990404 - Follow up ref SDS 99 SH5N, ref SDS 94 QW3M.
990405 -
990406 - While we waited in the reception area to be called for meeting with
990407 - the doctor, Laurie, a nurse in the Chemotherapy Clinic asked Millie to
990408 - go with her to have the port flush procedure performed. So, this was
990409 - accomplished today, per planning on 051121. ref SDS 99 SH5N
990411 - ..
990412 - Port will flushed again in 4 weeks, with the next examination.
990413 -
990414 -
990415 -
990416 -
9905 -
SUBJECTS
Status Test for Change ER PR HER2/neu from Negative to Positive Trea
A103 -
A10401 - ..
A10402 - Status Change Retest Biopsy 040419 Treatment Options
A10403 - Treatment Options Status Change Retest Biopsy 040419
A10404 -
A10405 - Follow up ref SDS 99 ZR6J, ref SDS 88 ZR6J.
A10406 -
A10407 - The doctor did not report further findings on testing for status
A10408 - change ordered and followed up during the prior meeting on 051121.
A10409 - ref SDS 99 ZP5F
A10411 - ..
A10412 - There was no clarification today of the call on 051123 that seemed to
A10413 - indicate favorable results, but also seemed to have been a mistake.
A10414 - ref SDS 98 XL70
A10415 -
A10416 -
A10417 -
A10418 -
A10419 -
A10420 -
A10421 -
A10422 -
A105 -
SUBJECTS
Disability Patient No Evidence of Disease Return to Work Meeting Doc
A503 -
A50401 - ..
A50402 - Disability Recovery from Cancer Millie Returning to Work
A50403 -
A50404 - Follow up ref SDS 99 J29L, ref SDS 88 J29L.
A50405 -
A50406 - Millie returned to work in the first week of December, last month,
A50407 - based on the doctor finding no evidence of disease. ref SDS 99 J29L
A50408 - On 051202 surgeon signed authorization for patient return to work.
A50409 - ref SDS A3 LY99
A50410 -
A50411 -
A50412 -
A50413 -
A50414 -
A505 -
SUBJECTS
Work Plan Doctor Submits Doctor/Patient Partnership Communications I
AL03 -
AL0401 - ..
AL0402 - Work Plan Doctor Submits Doctor/Patient Partnership Communications
AL0403 - Communications Doctor Submits Work Plan Doctor/Patient Partnership
AL0404 - Doctor/Patient Partnership Communications Doctor Submits Work Plan
AL0405 -
AL0406 - Follow up ref SDS 99 FE4I, ref SDS 88 OH9L.
AL0407 -
AL0408 - Kaiser made more progress today toward working intelligently, as set
AL0409 - out in POIMS. ref OF 3 1X6G At the end of the meeting, the doctor
AL0410 - submitted a partial report on what transpired, including a work plan.
AL0411 - This begins correction of past practices on 020403 when Kaiser would
AL0412 - not review the record to prepare feedback that verifies accuracy of
AL0413 - communications. ref SDS 7 V168 On 041130 the doctor objected to
AL0414 - preparing a work plan to analyse complex treatment scenarios and
AL0415 - confirm discussion on changing the course of treatment to address
AL0416 - major change in patient profile, ref SDS 49 YR8F, and further charged
AL0417 - that a written plan is unnecessary overkill because Millie's case is
AL0418 - too simple. ref SDS 49 763L On 041230 progress began with
AL0419 - presentation of a verbal plan, and the doctor commented on benefits of
AL0420 - "having a plan." ref SDS 51 LU6K On 050520 the doctor began capturing
AL0421 - a legible record of patient history on Kaiser's computer. ref SDS 62
AL0422 - HX6J
AL0424 - ..
AL0425 - Recently, on 051121 the doctor reported Kaiser has a new business
AL0426 - system for efficient, timely electronic communication to support the
AL0427 - doctor/patient partnership. ref SDS 99 FE4I This aligns with Kaiser's
AL0428 - Healthwise Handbook calling for effective communications, reviewed on
AL0429 - 990625. ref SDS 2 4185
AL0431 - ..
AL0432 - Kaiser's effort to apply computers for efficient case management is
AL0433 - correct in every respect. This makes progress on reducing the high
AL0434 - cost of medical mistakes, reviewed on 990912, ref SDS 3 0001, stating
AL0435 - that most mistakes begin with errors in commuication. ref SDS 3 0960
AL0436 - On 020221 patients and loved ones who complain about malpractice,
AL0437 - reported on 020221, ref SDS 4 255G, can be encouraged by Kaiser's
AL0438 - proactive efforts to improve care through technology that makes
AL0439 - communication effective, rather than the biggest risk in enterprise.
AL0441 - ..
AL0442 - Electronic data entry in the medical chart can improve timeliness,
AL0443 - accuracy, and uniform access to patient history. Getting things done
AL0444 - faster and more accurately, with broader collaboration integrates team
AL0445 - care among practice groups that strengthens the doctor/patient
AL0446 - partnership. Better communication enables comprehensive health care,
AL0447 - e.g., surgery, internal, emergency, resperatory, pediatrics,
AL0448 - orthopedics, cardio/pulmonary, oncology, etc., and the various labs
AL0449 - and testing departments. Implementation necessarily takes time to
AL0450 - experiment for discoverying and refining effectiveness.
AL0452 - ..
AL0453 - At this time, Kaiser's online Internet electronic messaging system for
AL0454 - patients to communicate with doctors is extremely inefficient,
AL0455 - requiring extra time and effort that discourages clear, concise,
AL0456 - complete communication that degrades productivity, causing poor
AL0457 - decisions and outcomes, as listed below. ref SDS 0 MT9I This
AL0458 - conflicts with the Healthwise Handbook calling for effective doctor
AL0459 - patient partnership, ref SDS 2 4185, through timely, comprehensive,
AL0460 - accurate communication. ref SDS 2 TD6Q Poor support for communication
AL0461 - conflics with HHS sub-group the Agency for Healthcare Research and
AL0462 - Quality (AHRQ) Publication No 00-PO38 reviewed on 041125, that says
AL0463 - the single most important way to prevent medical mistakes is for
AL0464 - patients to be an active member of the health care team; taking part
AL0465 - in every decision gets better results. ref SDS 48 2R4O
AL0467 - ..
AL0468 - [On 060428 doctor begins making electronic distribution of
AL0469 - computer medical chart for collaboration with the patient.
AL0470 - ref SDS B2 FE4I
AL0472 - ..
AL0473 - [On 070115 Kaiser submitted issues with email productivity
AL0474 - to technical and management teams. ref SDS B4 OX5J
AL0476 - ..
AL0477 - [On 070223 Kaiser changed email system to display
AL0478 - connections in internal fixed window, rather than use
AL0479 - browser that fits the display to requirements of the work.
AL0480 - ref SDS B6 OH9H
AL0482 - ..
AL0483 - [On 070315 complex communication that delays work causes
AL0484 - emotional stress, similar to swings in assessment of cancer
AL0485 - treatments. ref SDS B9 ER6F
AL0487 - ..
AL0488 - [On 140825 0700 tried sending this letter using Sutter
AL0489 - Medical Center electronic medical record system called
AL0490 - Myhealth Online, got error saying the letter was over
AL0491 - the limit by about 1534 characters set for patients to
AL0492 - communicate with doctors. ref SDS C1 XK9H Therefore,
AL0493 - sent message requesting email address for the doctor to
AL0494 - enable clear, concise, complete communication that
AL0495 - supports doctor/patient partnership. ref SDS C1 TO4F
AL0497 - ..
AL0498 - Problems with Kaiser's email include...
AL0499 -
AL0500 - 1. Correspondence cannot be distributed with Kaiser's email system
AL0501 - to the medical team either internally at Kaiser nor to extended
AL0502 - support, e.g., at UCSF, Stanford, MD Anderson, family and
AL0503 - friends who may be contributing. This paralyzes productivity
AL0504 - for coordination and collaboration to leverage medical assets,
AL0505 - and requires sick, tired, customers in poor health to waste
AL0506 - precious time duplicating communications in order to work
AL0507 - intelligently, as defined in POIMS. ref OF 3 1X6G
AL0508 -
AL0509 - [On 070307 examples of collaboration problems arising from
AL0510 - difficulty cross-communicating between Kaiser and UCSF for
AL0511 - treatment on referral. ref SDS B7 Q65K
AL0513 - ..
AL0514 - [On 070309 coordinator at Kaiser reports Doctor wants
AL0515 - patient to double efforts coordinating between Kaiser and
AL0516 - UCSF because Kaiser's communications systems for
AL0517 - doctor/patient partnership does not support efficient
AL0518 - distribution. ref SDS B8 VP73
AL0520 - ..
AL0521 - 2. 1000 character limit for customers is overwhelmed by unlimited
AL0522 - characters provided to Kaiser doctors and staff. Imbalance
AL0523 - distorts accountability and supresses feedback, essential for
AL0524 - accurate, timely, comprehensive patient care that saves lives,
AL0525 - time, and money. Customers waste valuable time writing to an
AL0526 - artificial limit that reduces time to construct chronology,
AL0527 - context, and connections for clear, concise, complete
AL0528 - communication NWO. ref OF 14 JZ5N This frustrates Kaiser's
AL0529 - Healthwise Handbook requirements for collaboration to support
AL0530 - the doctor patient partnership model, reviewed on 990625.
AL0531 - ref SDS 2 4185
AL0533 - ..
AL0534 - 3. Precision access is prevented by Kaiser's fixed page width for
AL0535 - customers writing email to doctors. Arbritary limitations
AL0536 - split links that extend beyond Kaiser's page width, causing
AL0537 - anger and frustration wasting valuable time when doctors are
AL0538 - denied timely knowledge of critical details. Links with
AL0539 - precision access, defined in NWO, ref OF 13 PX6J, increase
AL0540 - accuracy with traceability to original sources, called out in
AL0541 - ISO management stantards, reviewed on 950721. ref SDS 1 1740
AL0542 - Better accuracy reduces medical mistakes, which is a big
AL0543 - problem in health care, reported on 990912. ref SDS 3 0001
AL0544 - Precision access leverages doctor's time and talent with
AL0545 - connections that yield the power of knowledge to control the
AL0546 - future under the locality principle, presented in NWO,
AL0547 - ref OF 12 I38N, and reviewed on 040312. ref SDS 30 YH4G This
AL0548 - can be achieved by providing flexible page width for customers.
AL0549 -
AL0550 - [On 061227 webmaster letter demonstrates sufficient page
AL0551 - width for effective links; need patient email for doctor to
AL0552 - conform with webmaster page width. ref SDS B3 UK5L
AL0554 - ..
AL0555 - [On 070115 Kaiser submitted issues with email productivity
AL0556 - to technical and management teams. ref SDS B4 OX5J
AL0558 - ..
AL0559 - [On 070116 Millie received a letter from Manny advising
AL0560 - that Kaiser is reviewing the issue. ref SDS B5 455M
AL0562 - ..
AL0563 - [On 070116 Millie notified Kaiser on scope of 5 problems to
AL0564 - address. ref SDS B5 4Q3Y
AL0566 - ..
AL0567 - [On 070116 Kaiser assigns case 78351027 to issues Millie
AL0568 - presents. ref SDS B5 EF7L
AL0570 - ..
AL0571 - [On 070116 Millie's letter dated 070116 clarifies that
AL0572 - resolution of technology systems initially requires
AL0573 - technical engineering solution, rarther than doctor
AL0574 - training and local system configuration. ref SDS B5 Y27I
AL0576 - ..
AL0577 - [On 070223 Kaiser may have fixed this problem, though no
AL0578 - notice was submitted to customers explaining improvements.
AL0579 - ref SDS B6 EN6H
AL0581 - ..
AL0582 - 4. Communication, coordination, collaboration fails for team care
AL0583 - because Kaiser changed the email design to open connections
AL0584 - within fixed limits of the Kaiser email window, rather than use
AL0585 - the operating system to open another session of the browser
AL0586 - that adjusts the window screen to fit content requirements. As
AL0587 - a result, doctors and patients wast time shifting the screen to
AL0588 - read every line of text. This increases cognitive overhead
AL0589 - exponentially, and so discourages diligence for analysis to
AL0590 - save lives, time, and money, explained in NWO. ref OF 12 JZ7O
AL0591 -
AL0592 - [On 070223 Kaiser changed email system to display
AL0593 - connections in internal fixed window, rather than use
AL0594 - browser that fits the display to requirements of the work.
AL0595 - ref SDS B6 OH9H
AL0597 - ..
AL0598 - 5. Customers waste time turning "cookies" on and off to open a
AL0599 - dedicated email account with a user ID and password, which
AL0600 - increases cognitive overhead for information management, rather
AL0601 - than use a single email program for comprehensive management
AL0602 - and priority of all correspondence streams.
AL0604 - ..
AL0605 - 6. Editing has none of SDS features for efficent usability to
AL0606 - enhance command and control of the work. ref OF 6 6M5H
AL0608 - ..
AL0609 - 7. Kaiser's email system suddenly and without warning shifts
AL0610 - screens and displays a message asking if the customer wants to
AL0611 - continue writing a letter? Clicking "yes" restores the email
AL0612 - screen, but it is blank. The customer's work product, time,
AL0613 - and effort are destroyed, requiring a continual loop of rework
AL0614 - that evicerates productivity.
AL0616 - ..
AL0617 - This is actually part of the 1000 character limit problem, per
AL0618 - above. ref SDS 0 5U7I Investing time for clear, concise,
AL0619 - complete communication to avoid mistakes requires a lot of
AL0620 - editing to present complex issues in 1000 characters. Editing
AL0621 - to arbitrary character limitations causes Kaiser's email system
AL0622 - to time out, requiring the customer to start over constructing
AL0623 - communications from scratch. Hurrying to avoid timing out,
AL0624 - causes mistakes, reported on 990912 citing chronic errors in
AL0625 - medical practice. ref SDS 3 QP3N
AL0627 - ..
AL0628 - 8. Cut and paste in customer email system for communicating with
AL0629 - doctors was changed OA 070223, when evidently Kaiser fixed the
AL0630 - screen width problem so that precision access is supported,
AL0631 - addressing problem #3, per above. ref SDS 0 5U8L The screen
AL0632 - colors are changed, and the process of capturing a particular
AL0633 - body of text is nebulous. Additionally, for some reason the
AL0634 - Subject field cannot be captured with cut and paste for working
AL0635 - efficiently.
AL0636 -
AL0637 - [On 070223 discovered cut and paste was changed in
AL0638 - Kaiser's email system. ref SDS B6 NQ4L
AL0640 - ..
AL0641 - 9. Reply in context seems to have been eliminated after a year or
AL0642 - so of support. Without context, correspondence takes much
AL0643 - longer to construct and increases errors, time, and cost of
AL0644 - rework.
AL0645 -
AL0646 - [On 070328 notified Kaiser about loss of support for reply
AL0647 - in context. ref SDS C0 3L7K
AL0649 - ..
AL0650 - The doctor's effort today handing the patient a written work plan is a
AL0651 - big step for Kaiser to meet the challenge of the new world order. As
AL0652 - greater use occurs of electronic communications, and inefficient
AL0653 - limitations are eliminated, Kaiser will improve care for more patients
AL0654 - at less cost, hopefully in time to meet skyrocketing demand for the
AL0655 - Baby Boom generation coming through the system in the next 10 years.
AL0656 -
AL0657 - [On 060217 doctor experiencing transition challenges moving from
AL0658 - printed to electronic communication for saving lives, time, and
AL0659 - money with better speed and accuracy. ref SDS A6 PG9I
AL0660 -
AL0661 -
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AL0663 -
AL0664 -
AL0665 -
AL0666 -
AL0667 -
AL07 -