THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: January 6, 2006 02:00 PM Friday;
Rod Welch
Millie meeting at Kaiser on recovery from surgery for secondary IBC
1...Summary/Objective
2...Agenda for Work Plan After Switching to Taxotere and Capecitabine
3...CA 15-3 Cancer Marker 34 Rises from 28 the Past 3 Weeks
4...CA 15-3 34 Cancer Marker Rises Still Significantly Below Target Level
5...Blood Tests Scheduled to Monitor Relapse Status
........Future Orders Class
........Standing Orders
6...PET Scan Test Scheduled Evaluate Relapse and New Swelling Left Axilla
7...Left Axillary Lump Under Arm Diagnosis Lymphedema Not Cancer
8...Lymphedema Left Axillary Not Cancer Lump Under Arm Diagnosis
9...Right Left Axillary Examination No Evidence Lumps Lymphedema
10...Lymphedema Research Serious Debilitating No Cure
........Imaging Studies Lmphoscintgraphy Current Practice
........Treatment Lymphedema Surgery Palliative No Cure
........Fibrosclerotic Evolution Avoid with Early Treatment
........Weight Reduce Avoid Constrictive Clothing
........Meticulous Hygiene Remove Keratinaceous Debris Bacteria
........Therapy Treatments Uncomfortable Time Consuming Essential
........Complications Chronic Lymphedema 10 Years Risk Cancer
........Cellulitus Lymphangitis Complications Chronic Lymphedema
11...Prognosis Stage IV Metastatic Disease Currently in Remission
12...Palliation Mastectomy Surgery for Future Relapse Stage IV Cancer
13...Lumps in Neck Reported 040309 Establish Stage IV Metastatic Cancer
14...No Evidence of Disease NED Patient Recovering Mastectomy Surgery
15...Examination Left Breast Surgical Wound Mastectomy Incision Healing
16...Healing Surgical Wound Mastectomy Incision Examination Left Breast
17...Discomfort Below Right Breast Likely Muscle Pull
18...Treatment Plan Testing for Relapse Patient NED Metastatic Cancer
19...Holiday Treatment Patient NED Test for Relapse Metastatic Cancer
20...Port Catheter Flush Performed at Kaiser to Maintain Chemo Treatment
21...Status Change Retest Biopsy 040419 Treatment Options
22...Treatment Options Status Change Retest Biopsy 040419
23...Disability Recovery from Cancer Millie Returning to Work
24...Work Plan Doctor Submits Doctor/Patient Partnership Communications
25...Communications Doctor Submits Work Plan Doctor/Patient Partnership
26...Doctor/Patient Partnership Communications Doctor Submits Work Plan
..............
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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 -
AL0662 -
AL0663 -
AL0664 -
AL0665 -
AL0666 -
AL0667 -
AL07 -