CONTACTS 

SUBJECTS
Cellulitis Left Arm Lymphedema Swelling Moderate to Severe Red Rash

1603 -
1603 -    ..
1604 - Summary/Objective
1605 -
160501 - Follow up ref SDS 16 0000. ref SDS 15 0000.
160502 -
160503 - Millie suffered another recurrence today of Cellulitis.  This time
160504 - seems a little worse than previously in December, ref SDS 0 V45J;
160505 - however, now, as then, there is no elevated temperature today,
160506 - ref SDS 0 0P96, so it was not necessary to go to the ER for immediate
160507 - treatment.  Additionally, Millie has not been feeling well, possibly
160508 - reflecting continuing low blood counts. ref SDS 0 0P44  Her right arm
160509 - is still sore from a fall about 6 weeks ago. ref SDS 0 H05L  Began
160510 - treatment for Cellulitis with Keflext on hand from prior prescription.
160511 - ref SDS 0 106G  Treatment and ice seems to be effective. ref SDS 0
160512 - 010G Notified medical team. ref SDS 0 AP5J  UCSF recommended
160513 - examination today by a doctor. ref SDS 0 6S7I  Kaiser scheduled
160514 - examination for tomorrow. ref SDS 0 UZ89
160516 -         ..
160517 -        [On 080305 Kaiser primary care physician performs examination
160518 -        of Cellulitis. ref SDS 23 QY5I and, ref SDS 23 RM6J
160520 -         ..
160521 -        [On 080307 Millie reports to medical team that Cellulitis
160522 -        has responded to treatment with Keflex. ref SDS 26 HS6W
160524 -         ..
160525 -        [On 080312 report to medical team Kaiser and UCSF that
160526 -        Cellulitis seems completely subsided. ref SDS 27 RU4Q
160528 -         ..
160529 -        [On 080313 Millie completed 10-day treatment with Keflex for
160530 -        Cellulitis; no visible inflammation or swelling that signal
160531 -        Cellulitis and lymphedema. ref SDS 28 MQ4I
160533 -         ..
160534 -        [On 080314 possible Cellulitis recurrence with sudden increased
160535 -        inflammation on upper left arm, ref SDS 29 V45J; Mil had no
160536 -        temperature which often occurs with Cetuximab, but went ahead
160537 -        and took another Keflex pill, ref SDS 29 JK6G; decided the next
160538 -        day based on inflammation subsiding that this was a reaction to
160539 -        cetuximab, and so stopped taking Keflex; therefore, the
160540 -        standard 10-day treatment was successful. ref SDS 29 XS82
160542 -         ..
160543 -        [On 080409 Cellulitis another recurrence, temperature 101.9,
160544 -        ref SDS 30 V45J, Millie treated in Kaiser ER, ref SDS 30 0R4H,
160545 -        and released after 8 hours of care. ref SDS 30 F194
160546 -
160547 -
160548 -
160550 -  ..
1606 -
1607 -
1608 - Progress
1609 -
160901 - Cellulitis Recurrence Moderate to Severe Swelling Inflammation
160902 - Delayed Reaction Fall 080125 Aligns Prior Cellulitis on 061027
160903 -
160904 - Millie was getting ready to go to the gym this morning.  While
160905 - dressing she noticed her left arm has swelled again with inflammation
160906 - that shows recurrence of Cellulitis, similar to experience on 071214.
160907 - ref SDS 13 V45J
160908 -
160909 -     [On 080305 examination at Kaiesr shows Cellulitis and swelling
160910 -     from lymphedema has substantially subsided. ref SDS 23 RM6J
160912 -      ..
160913 -     [On 080306 examination at UCSF shows Cellulitis and swelling from
160914 -     lymphadema are nearly gone. ref SDS 24 NV42
160916 -  ..
160917 - Rash reported as "mild" on 071214 seems more severe today, enveloping
160918 - the entire left arm.
160920 -  ..
160921 - Prior Cellulitis and lymphedema attacks are shown in case study on
160922 - 061203. ref SDS 7 YT4M
160924 -  ..
160925 - Patient history shows Millie treated at Kaiser ER for Cellulitis when
160926 - temperature rises above 100.5, e.g., on 041202. ref SDS 2 IX9N  On
160927 - 070607 Millie was treated with intravenous drugs at UCSF because
160928 - temparature increased above 102. ref SDS 9 8J37
160929 -
160930 -     [On 080313 Millie completed 10-day treatment with Keflex for
160931 -     Cellulitis; no visible inflammation or swelling that signal
160932 -     Cellulitis and lymphedema. ref SDS 28 MQ4I
160934 -      ..
160935 -     [On 080314 possible Cellulitis relapse; difficult to
160936 -     distinguish from normal inflammation caused by cetuximab
160937 -     treatments for cancer; Millie begins another 10 day treatment.
160938 -     ref SDS 29 XS82
160940 -      ..
160941 -     [On 080409 Millie suffered recurrence of Cellulitis severe, and
160942 -     moderate swelling of lymphedema, temperature 101.9, ref SDS 30
160943 -     0001; treated in Kaiser Emergency department, and released same
160944 -     day for 14-day home treatment with Keflex. ref SDS 30 F142
160945 -
160946 -
160947 -
160948 -
160949 -
1610 -

SUBJECTS
Temperature High Last Night Normal This Morning When Cellulitis Lymp

2403 -
240401 -  ..
240402 - Temperature Normal So Far
240403 -
240404 - Earlier this morning about 0630 when Millie got up, she reported
240405 - feelings of having a temperature last night.  Took her temperature at
240406 - 0630 and got a reading of 99.4f.  We took it again and got 98.7, and
240407 - so concluded there was no temperature.  At that time, there was no
240408 - awareness of Cellulitis.  Forehead seemed somewhat warm, but not
240409 - conclusive on a temperature.
240410 -
240411 -
240412 -
2405 -

SUBJECTS
Blood Counts Low Cellulitis May Relate Recurrence Weak Immunity Fall

3403 -
340401 -  ..
340402 - Low Blood Counts Weak Immunity May Relate Recurrence Cellulitis??
340403 - Fall Injuring Right Arm and Head Injury Cellulitis Delayed Reaction??
340404 - General Ill Feeling Past Week Low Blood Counts Delayed Reaction Fall
340405 -
340406 - At dinner last night about 1800, Millie said she has not felt well the
340407 - past few days.  She has seemed tired and sluggish for a week or so.
340408 - In years past, "feeling bad" has accompanied low blood counts, which
340409 - Millie has experienced again the past few months, reported on 080207.
340410 - ref SDS 19 IU3F  On 071214 Millie was not feeling well prior to minor
340411 - outbreak of Cellulitis, ref SDS 13 SR6L, but this could be a symptom,
340412 - rather than a cause of disease.
340414 -  ..
340415 - Her right arm still hurts from the fall on 080125, ref SDS 17 N65K,
340416 - though the bruise has almost entirely subsided.  If the arm still
340417 - aches when we meet with the primary care physician at Kaiser on
340418 - 080316, Mil plans to ask about an xray to assess possible fracture.
340420 -  ..
340421 - Millie plans to report general aching feeling, during the meeting at
340422 - UCSF on Thursday, 080306.
340424 -  ..
340425 - There has been no evident trauma to the left arm, such as a fall, or
340426 - heavy lifting, which have caused recurrence of Cellulitis previously.
340427 - Yesterday, she took BART to visit a friend in Berkeley.  They went
340428 - shopping and took a short walk along the beach or a marina.
340430 -  ..
340431 - Cellulitis today may be delayed reaction to injuring the right arm on
340432 - 080125.  Examination at Kaiser on 080204 yielded no findings of
340433 - injury, other than bruising. ref SDS 18 JQ8N  Previously, a fall on
340434 - 060914 at the BART station in Concord was later ascribed, by the
340435 - doctor at Kaiser ER, as likely cause of Cellulitis weeks later on
340436 - 061027. ref SDS 3 V759
340437 -
340438 -        [On 080305 primary care physician at Kaiser orders xray to
340439 -        evaluate trauma to right arm. ref SDS 23 5M39
340440 -
340441 -
340442 -
340443 -
3405 -

SUBJECTS
Keflex Treatment Cellulitis 10 Day Protocol Ice Arm Reduce Swelling

4203 -
420401 -  ..
420402 - Treatment Keflex 10 Day Supply Ice Arm Reduce Swelling Inflammation
420403 -
420404 - Millie has Keflex for a 10 day regimen previously prescribed on 070720
420405 - and received on 070725, ref SDS 10 FC5M, for medication in case
420406 - Cellulitis and lymphedema swelling would have occurred while traveling
420407 - on vacation in Europe during September.  Since Cellulitis has occurred
420408 - today, per above, ref SDS 0 V45J, this treatment can be started
420409 - immediately.
420411 -  ..
420412 - The prescription calls for 4 pills a day, i.e., every 6 hours, and for
420413 - 10 days. ref SDS 10 IZ71
420415 -  ..
420416 - Starting Keflex with the last bottle of pills, suggests we need an
420417 - other prescription for 2 more bottles to care for future episodes.
420418 -
420419 -     [On 080312 report to medical team Kaiser and UCSF that Cellulitis
420420 -     seems completely subsided. ref SDS 27 AR5K
420421 -
420422 -
420424 -  ..
4205 -
4206 -
4207 - 0815
4208 -
420801 - Mil took a Keflex pill.  Also wrapped her arm with an ice pack, which
420802 - was done with prior Cellulitis on 071214, citing ER practice.
420803 - ref SDS 13 V46Y
420804 -
420805 -        [...below, inflammation and swelling subside. ref SDS 0 6R5S
420806 -        after icing paused, inflammation increased, ref SDS 0 03E4,
420807 -        with continued icing and Keflex, rash and swelling again
420808 -        subside. ref SDS 0 9B9G
420810 -         ..
420811 -        [On 080305 examination by primary care physician finds
420812 -        Cellulitis and lymphedema recovering, and approves course of
420813 -        treatment with Keflex and icing. ref SDS 23 RM6J
420815 -         ..
420816 -        [On 080313 Millie completed 10-day treatment with Keflex for
420817 -        Cellulitis; no visible inflammation or swelling that signal
420818 -        Cellulitis and lymphedema. ref SDS 28 MQ4I
420820 -         ..
420821 -        [On 080314 possible Cellulitis relapse; difficult to
420822 -        distinguish from normal inflammation caused by cetuximab
420823 -        treatments for cancer; Millie begins another 10 day treatment.
420824 -        ref SDS 29 XS82
420826 -  ..
420827 - She is sitting up in bed watching television.  Quite a bit
420828 - discouraged.
420830 -  ..
420831 - Next pill in 6 hours due at 1415 (0215p).
420832 -
420833 -        [...below, Millie took another pill at 1400. ref SDS 0 UX4H
420834 -
420835 -
420836 -
4209 -

SUBJECTS
Temperature High Last Night Normal This Morning When Cellulitis Lymp

5003 -
5004 - 0909
500501 -  ..
500502 - Temperature Monitor Patient Progress
500503 -
500504 - Temperature 97.8
500505 -
500507 -  ..
5006 -
5007 -
5008 - 1045
5009 -
500901 - Millie dressed and left to visit Kaiser Park Shadelands to see the
500902 - eye doctor, previously scheduled.
500904 -  ..
500905 - Her left arm now seems somewhat less inflammed and swelled, as a
500906 - result of treatment with Keflex, and icing, started OA 0815.
500907 - ref SDS 0 010G
500908 -
500910 -  ..
5010 -
5011 -
5012 - 1223
5013 -
501301 - Mil arrived home from Kaiser.  Her forehead seems slightly warm.
501302 -
501303 - Tempeature:  97.7
501305 -  ..
501306 - Examined left arm; seems slightly worse, since there was noticable
501307 - improvement at 1045 earlier this morning. ref SDS 0 0R4H
501308 -
501310 -  ..
5014 -
5015 -
5016 - 1400
5017 -
501701 - Mil took another Keflex pill, per prescription, shown above.
501702 - ref SDS 0 J06M
501703 -
501705 -  ..
5018 -
5019 -
5020 - 1512
5021 -
502101 - Changed ice pack.
502102 -
502103 - Temperature.................. 97.7F
502105 -  ..
502106 - Swelling and inflammation have subsided somewhat again.
502107 -
502109 -  ..
5022 -
5023 -
5024 - 1733
5025 -
502501 - Dinner.
502502 -
502503 - Inflammation on left arm seems about the same, but swelling seems to
502504 - be increased, almost like a baked potatoe.
502506 -  ..
502507 - Continue ice pack treatment.
502508 -
502510 -  ..
5026 -
5027 -
5028 - 2000
5029 -
502901 - Millie took third Keflex pill.  Next due at 0200.
502902 -
502903 - Temperature............ 97.3.
502905 -  ..
502906 - Removed ice for about 30 minutes while Millie has ice cream.
502908 -  ..
502909 - Inflammation - red rash - seems stable, no appreciable improvement,
502910 - but swelling has noticably subsided compared to 1733.  The upper arm
502911 - now looks much more normal, rather than like a baked potatoe.
502912 -
502914 -  ..
5030 -
5031 -
5032 - 2045
5033 -
503301 - Resume ice treatment to control swelling.
503302 -
503303 -
503305 -  ..
5034 -
5035 -
5036 - 0200 -- next day
5037 -
503701 - Keflex 4th pill scheduled.
503702 -
503703 -
503704 -
5038 -

SUBJECTS
Notified Medical Team UCSF Kaiser  Cllulitis Lymphedema Recurrence L

6003 -
6004 - 1118
600501 -  ..
600502 - Notify Medical Team of Cellulitis Request Guidance
600503 -
600504 - Follow up ref SDS 13 NF4G.
600505 -
600506 - Submitted ref DIT 1 0001 to the medical team, including Brigid and
600507 - Arlette, notifying of Cellulitis recurrence, per above, ref SDS 13
600508 - V45J, and saying...
600509 -
600510 -    1.  Millie suffered another recurrence of Cellulitis on left arm;
600511 -        seems more serious than prior episode on 071214, but no
600512 -        elevated temperature so far.
600514 -         ..
600515 -    2.  Background and treatment are reported in the record today.
600516 -        ref SDS 0 V45J
600518 -         ..
600519 -    3.  Please note plans to discuss possible injury to right arm from
600520 -        fall on 080125.
600522 -         ..
600523 -    4.  Since Mil has started on the last 10-day supply of Keflex, we
600524 -        need prescription refilled for two bottles to have for future
600525 -        care.  She has just left to visit Kaiser in Park Shadelands,
600526 -        and will check with Pharmacy to see if the prescription for
600527 -        Keflex is available, otherwise we can get it later.
600528 -
600529 -            [On 080305 the doctor prescribed Keflex for 2 treatments,
600530 -            as requested today. ref SDS 23 5M3F
600532 -         ..
600533 -    5.  We may need contingency plans for chemo treatment, if
600534 -        temperature rises and Millie requires treatment in ER on or
600535 -        before Thursday.
600537 -         ..
600538 -    6.  By copy to Jackie, reminding to order CA 15-3 and INR for blood
600539 -        tests to start next cycle on Thursday, 080306.
600540 -
600541 -            [On 080306 Stephanie reported the order for the blood test
600542 -            was not submitted by the doctor. ref SDS 25 NK4G
600543 -
600544 -            [On 808306 Jackie advised that an order for the blood test
600545 -            was prepared, but wad delivered to the wrong place due
600546 -            communication snafu; she prepared a new order to correct
600547 -            the problem. ref SDS 24 JT4F
600549 -             ..
600550 -            [On 080312 Millie's letter to Jackie coordinates scope of
600551 -            blood testing required to begin treatment with Carboplatin
600552 -            added to cetuximab. ref SDS 27 EX5H
600554 -         ..
600555 -    7.  Millie has adjusted to the idea that adding carboplatin seems
600556 -        necessary.  It is an emotional jolt.  Millie is grateful for
600557 -        the manner this change has been handled by Doctor Rugo and the
600558 -        team, reported on 080219. ref SDS 22 I33K
600560 -         ..
600561 -    8.  By copy, alerting Brigid and Arlette, in case the doctors are
600562 -        out of town, or otherwise tied up today.
600563 -
600564 -
600565 -
600566 -
6006 -

SUBJECTS
UCSF Recommends Examination Doctor Kaiser Oncology Today for Acute M

7303 -
7304 - 1213
730501 -  ..
730502 - UCSF Recommends Examination by Doctor Today for Acute Cellulitis
730503 -
730504 - Brigid called.
730505 -
730506 - She has reviewed the record submitted with the letter to the medical
730507 - team, per above. ref SDS 0 AP5J
730509 -  ..
730510 - Brigid advised that UCSF recommeds Millie's condition requires
730511 - examination by a doctor today, rather than wait for the meeting at
730512 - UCSF on Thursday.
730513 -
730514 -            [...below, UCSF's letter does not specify same day
730515 -            examination. ref SDS 0 B18J
730517 -             ..
730518 -            [On 080409 Millie suffers Cellulitis recurrence;
730519 -            temperature 101.9, she gets treatment at Kaiser Emergency.
730520 -            ref SDS 30 0R4H
730522 -             ..
730523 -            [On 080520 Millie suffers Cellulitis recurrence, no
730524 -            temperature; letter to Kaiser and UCSF proposes no medical
730525 -            examination required, ref SDS 31 O26H; Kaiser and UCSF
730526 -            concur. ref SDS 31 1K7H
730528 -  ..
730529 - We reviewed the record on 071214.  At that time, neither UCSF nor
730530 - Kaiser recommended examination based on Millie treating herself with
730531 - Keflex, and no temperature. ref SDS 13 NF4G  This issue was resovled
730532 - favorably 3 days later on 071217 without examination at the hospital.
730533 - ref SDS 16 V45J
730535 -  ..
730536 - Brigid noted that while Millie again has no temperature, so far, the
730537 - record shows the condition today is more severe than on 071214, per
730538 - above. ref SDS 0 5P8L  As a result, she feels Mil should be seen by a
730539 - doctor today.
730541 -  ..
730542 - Explained that swelling and inflammation subsided by 1045 when Millie
730543 - left the house to visit Kaiser in Park Shadelands, per above.
730544 - ref SDS 0 0R4H
730546 -  ..
730547 - Brigid feels examination by a doctor today is required for Cellulitis
730548 - because this is an acute condition, and that examination cannot wait
730549 - until Thursday when Millie is scheduled to visit Brigid and Doctor
730550 - Rugo at UCSF.
730551 -
730552 -            [...below, letter to medical team at Kaiser and UCSF
730553 -            confirm understandings that UCSF telephone call recommends
730554 -            same day examination of Cellulitis. ref SDS 0 NQ5V
730556 -             ..
730557 -            [...below, UCSF's letter does not specify same day
730558 -            examination. ref SDS 0 B18J
730560 -             ..
730561 -            [On 080305 Kaiser primary care physician performs
730562 -            examination of Cellulitis. ref SDS 23 QY5I and ref SDS 23
730563 -            RM6J
730565 -  ..
730566 - Urgency may be increased by persistent low blood counts the past 6
730567 - months, noted by Doctor Rugo during the meeting at UCSF on 080207.
730568 - ref SDS 19 IU3F  Low blood counts most evident by NEUTS (ANC at
730569 - Kaiser), still well below target levels a week later on 080214,
730570 - ref SDS 20 UL4N, weaken the immune system, presenting risks of
730571 - infection cascading out of control without prompt treatment prescribed
730572 - by the doctor.
730573 -
730574 -            [...below, Kaiser schedules meeting for next day 080305
730575 -            1200. ref SDS 0 UZ89
730577 -             ..
730578 -            [On 080307 patient commends Kaiser for making time to
730579 -            perform exigent examination of Cellulitis on short notice
730580 -            recommended by UCSF. ref SDS 26 GZ4H
730582 -  ..
730583 - Requested a letter to coordinate with everyone, and to assist Millie
730584 - in appreciating urgency of seeing a doctor today.
730586 -  ..
730587 - Brigid explained UCSF policy to rely on telephone calls to guide
730588 - conduct of the work in this case.
730590 -  ..
730591 - People feel telephone calls can be intrepreted in many ways, explained
730592 - in POIMS. ref OF 4 3943
730593 -
730594 -            [...below, UCSF's letter conflicts with understanding from
730595 -            conversation in telephone call; does not specify same day
730596 -            examination. ref SDS 0 B18J
730598 -  ..
730599 - Written records distributed to everyone on the medical team reduce
730600 - mistakes from forgetting what was said, and further avoids errors of
730601 - meaning drift, illustrated by the "telephone game," explained in the
730602 - record on 971229. ref SDS 1 1526  Writing reduces confusion by
730603 - checking the record.  Writings improve coordination by fast, efficient
730604 - distribution so that collateral support complements rather than
730605 - conflicts with multi-discipline action in complex cases like Millie's,
730606 - as explained in NWO. ref OF 11 4077
730608 -  ..
730609 - Brigid will submit a letter confirming UCSF recommendations, with
730610 - copies to the team, so everyone is on the same page.  This will
730611 - facilitate coordination.
730612 -
730613 -        [...below, Brigid's letter could not be accessed due to
730614 -        password conflicts. ref SDS 0 0T8F
730616 -         ..
730617 -        [On 080305 Kaiser primary care physician performs examination
730618 -        of Cellulitis. ref SDS 23 QY5I and, ref SDS 23 RM6J
730620 -         ..
730621 -        [On 080305 primary care physician at Kaiser had difficulty
730622 -        using new email procedures at UCSF. ref SDS 23 US6I
730624 -         ..
730625 -        [On 080306 during the meeting at UCSF, the medical team
730626 -        disclosed that UCSF management has mandated using a UCSF email
730627 -        channel for secure communication, rather than provide timely,
730628 -        accurate communication requested by the patient. ref SDS 24
730629 -        JT66
730631 -  ..
730632 - Advised that Millie just arrived from visiting Kaiser at Park
730633 - Shadelands.  Will present UCSF recommendations.
730635 -  ..
730636 - Thanked Brigid for timely, thorough response.
730637 -
730639 -  ..
7307 -
7308 -
7309 - 1223
7310 -
731001 - Millie arrived home, per above. ref SDS 0 6S52
731002 -
731003 - She feels strongly about not going to the doctor.  She related
731004 - experience having to wait for a long time to see anyone, and makes the
731005 - point that her arm needs to be iced.
731007 -  ..
731008 - We discussed going to ER where she might be able to be seen with less
731009 - delay, although that was not true on 061027 when Cellulitis and
731010 - temperature were much worse than today - registered at 1728,
731011 - ref SDS 3 Q265, doctor made examination and began treatment 3 hours
731012 - later at 2010. ref SDS 3 ZP8I
731014 -  ..
731015 - Investigated Brigid's recommendation for examination at Kaiser.
731016 -
731017 -
731018 -
7311 -

SUBJECTS
Email UCSF Secure Mailbox Misuse HIPAA Productivity Falls Health Car

9103 -
9104 - 1233
910501 -  ..
910502 - Email UCSF Productivity Falls Secure Channel Extra Steps Delays Work
910503 -
910504 - Received ref DRT 1 0001 letter from Brigid with copies to the medical
910505 - team for coordination. ref DRT 1 00W3
910512 -  ..
910513 - It is a "picture" from UCSF without any text, and with security that
910514 - requires a password in order to access something.  Was unable to see
910515 - what Brigid said because our password policy conflicts with UCSF
910516 - procedures.  Assume Brigid confirmed understandings from the call, per
910517 - above, ref SDS 0 6S7I, since that is what she has done effectively
910518 - many times this past year, e.g., most recently providing good guidance
910519 - on Millie getting dental work done on 080214. ref SDS 21 LS6F
910520 -
910521 -        [On 080305 primary care physician at Kaiser had difficulty
910522 -        using new email procedures at UCSF. ref SDS 23 US6I
910524 -         ..
910525 -        [On 080306 during the meeting at UCSF, the medical team
910526 -        disclosed that UCSF management has mandated using a UCSF email
910527 -        channel for secure communication, rather than provide timely,
910528 -        accurate communication requested by the patient for effective
910529 -        health care. ref SDS 24 JT66
910531 -         ..
910532 -        [On 081103 Millie received "secure email" correspondence from
910533 -        Kaiser, ref SDS 32 XO8J, alleged to be sent by the primary care
910534 -        physician, but which could not be accessed, and which the
910535 -        doctor indicated not having actually sent the letters.
910536 -        ref SDS 32 E59N
910538 -         ..
910539 -        [On 090205 1318 primary care physician at Kaiser requests using
910540 -        the Kaiser closed, proprietary email system that has more
910541 -        limitations than the UCSF system, and for the purpose of
910542 -        increasing productivity by preveinting details from falling
910543 -        through the cracks. ref SDS 33 278T
910545 -         ..
910546 -        [On 100107 1327 Millie received a letter from Doctor Johnson at
910547 -        Kaiser using "secure email" which prevented access, similar to
910548 -        Doctor Johnson being unable to open "secure email" sent to him
910549 -        by UCSF. ref SDS 34 CX9G
910551 -         ..
910552 -        [On 100108 0852 Millie notifies medical team that Kaiser's
910553 -        "secure email" presented same problems preventing access by the
910554 -        patient that previously prevented Doctor Johnson from opening a
910555 -        secure email which UCSF submitted to Doctor Johnson at Kaiser.
910556 -        ref SDS 35 MW4P
910558 -  ..
910559 - After the crisis subsided an attempt was made to open Brigid's letter.
910560 - This effort took over 10 minutes, and then timed out, i.e., failed.
910562 -  ..
910563 - Tried this again, and again it timed out.
910565 -  ..
910566 - UCSF furnishes a screen that says in part...
910567 -
910568 -    UCSF Secure Mailbox
910569 -
910570 -    COMPLETE ACCOUNT INFORMATION
910571 -
910572 -    To ensure security, the sender of this message requires all
910573 -    recipients to have a validated UCSF Secure Messenger account.
910574 -    Please complete this one-time account setup to receive your
910575 -    message.
910577 -     ..
910578 -    First Name:
910579 -    Last Name:
910580 -    New Password
910581 -
910582 -        Password requires a minimum of 8 character(s) with at least 1
910583 -        digit(s) and at least 1 alphabetical character(s).
910585 -     ..
910586 -    Re-enter New Password
910587 -    Password Hint Phrase
910589 -     ..
910590 -    UCSF staff, employees and students, please contact your local UCSF
910591 -    IT Support services if you need assistance. Non-UCSF customers,
910592 -    please direct your questions to the sender.
910594 -  ..
910595 - Further experimenting shows UCSF mail system requires customers to
910596 - increase risk of access attacks by using Microsoft Activex Control
910597 - tools that give others control of the local computer.  Approving
910598 - Activex processing allowed the sign-in process to advance.
910599 -
910612 -  ..
910613 - Elevating Privacy Above Accuracy Entropy Degrades Productivity to Zero
910614 -
910615 - This new mail system will be a significant challenge to collaboration
910616 - in the referral coordination plan, listed on 070222, ref SDS 8 KL5G,
910617 - for Millie's care at UCSF.  Up until now, email has been effective.
910618 - Requiring busy people to remember access details for UCSF and with
910619 - Kaiser communication requirements could degrade communication to
910620 - conversation on the telephone, with attendant loss of accuracy, and
910621 - rise of mistakes due to meaning drift, as related in POIMS.
910622 - ref OF 4 V8P1  The call from UCSF this morning illustrates pressures
910623 - that make conversation seem attractive. ref SDS 0 6T41
910625 -         ..
910626 -        [On 080306 during the meeting at UCSF, the medical team
910627 -        disclosed that UCSF management has mandated using a UCSF email
910628 -        channel for secure communication, rather than provide timely,
910629 -        accurate communication requested by the patient. ref SDS 24
910630 -        JT66
910631 -
910632 -
9107 -

SUBJECTS
UCSF Recommends Examination Doctor Kaiser Oncology Today for Acute M

A403 -
A40401 -  ..
A40402 - UCSF Confirms Guidance Examination of Cellulitis But Not Today
A40403 - Documentation Conflicts with Conversation Telephone Call
A40404 -
A40405 - Accessing Brigid's letter shows...
A40406 -
A40407 -    1.  As per our conversation on the phone, Millie should be seen and
A40408 -        evaluated in person for this cellulitis by either us or your MD
A40409 -        that is closer to you. ref DRT 1 T46I
A40411 -         ..
A40412 -    2.  thanks.
A40414 -  ..
A40415 - This letter calling for evaluation by a doctor without specifying a
A40416 - date... today, tomorrow, Thursday, conflicts with understandings from
A40417 - the call this morning that strongly recommended examination today, per
A40418 - above. ref SDS 0 5U8I  Millie has a meeting previously scheduled at
A40419 - UCSF in 2 days on Thursday at 0830.  Does this meet requirements in
A40420 - UCSF's letter?
A40421 -
A40422 -            [On 080305 Kaiser primary care physician performs
A40423 -            examination of Cellulitis. ref SDS 23 QY5I and, ref SDS 23
A40424 -            RM6J
A40426 -             ..
A40427 -            [On 080307 Millie reports to medical team that Cellulitis
A40428 -            has responded to treatment with Keflex. ref SDS 26 HS6W
A40430 -             ..
A40431 -            [On 080312 report to medical team Kaiser and UCSF that
A40432 -            Cellulitis seems completely subsided. ref SDS 27 AR5K
A40434 -             ..
A40435 -            [On 080409 Cellulitis another recurrence, temperature
A40436 -            101.9, ref SDS 30 V45J, Millie treated in Kaiser ER,
A40437 -            ref SDS 30 0R4H, and released after 8 hours of care.
A40438 -            ref SDS 30 F194
A40440 -  ..
A40441 - Brigid seemed to convey during her call this morning that UCSF
A40442 - recommends examination today, per above. ref SDS 0 6S7I  Does the
A40443 - letter clarify that examination can wait until tomorrow?  How about
A40444 - Thursday?  Does failure to specify examination today in the UCSF
A40445 - letter support Kaiser's decision to defer examination until the next
A40446 - day, per below? ref SDS 0 UZ89  If examination can be delayed for 1
A40447 - day, can it be delayed for another?
A40449 -  ..
A40450 - Since a copy of the UCSF letter was sent to Kaiser, is Kaiser's
A40451 - subsequent decision to defer examination until the next day,
A40452 - ref SDS 0 UZ89, despite notice from the patient that UCSF recommends
A40453 - same day examination, ref SDS 0 UZ47, result from omission in the UCSF
A40454 - letter specifying examination today?  Did Kaiser rely on UCSF deciding
A40455 - to ignore notice from the patient that presented conflicting evidence
A40456 - of urgency? ref SDS 0 NQ6X
A40457 -
A40458 -        [On 080305 primary care physician at Kaiser had difficulty
A40459 -        using new email procedures at UCSF. ref SDS 23 US6I
A40461 -         ..
A40462 -        [On 080306 during the meeting at UCSF, the medical team
A40463 -        disclosed that UCSF management has mandated using a UCSF email
A40464 -        channel for secure communication, rather than provide timely,
A40465 -        accurate communication requested by the patient. ref SDS 24
A40466 -        JT66
A40467 -
A40468 -
A405 -

SUBJECTS
Kaiser Schedules Examination Cellulitis Recurrence 080305 1200 Rathe

AL03 -
AL04 - 1252
AL0501 -  ..
AL0502 - Kaiser Contacted to Schedule Examination Today
AL0503 -
AL0504 - Called Arlette.
AL0505 -
AL0506 - Used the number that contacted Arlette on 070607. ref SDS 9 GY41
AL0508 -  ..
AL0509 - Got an answering machine reporting that everybody is at lunch until
AL0510 - 1330.
AL0512 -  ..
AL0513 - Left message following up UCSF recommendation for doctor to examine
AL0514 - Millie today, ref SDS 0 AP35, for acute condition of Cellulitis, per
AL0515 - Brigid above. ref SDS 0 V45J
AL0519 -
AL0521 -  ..
AL06 -
AL07 -
AL08 - 1317
AL09 -
AL0901 - Submitted ref DIT 2 0001 response to Brigid with copy to medical team,
AL0902 - and advising of action taken on recommendation to meet with the
AL0903 - doctor.
AL0904 -
AL0905 -    1.  Thanks very much for timely response to notice this morning of
AL0906 -        subject matter. ref SDS 0 6S7I, ref DIT 2 0001
AL0908 -         ..
AL0909 -    2.  As I mentioned, Millie just returned from Kaiser Park
AL0910 -        Shadelands. ref SDS 0 6S52, ref DIT 2 F56H
AL0912 -         ..
AL0913 -    3.  I related your advice for her to be examined today by a doctor.
AL0914 -        ref DIT 2 Y56K
AL0916 -         ..
AL0917 -    4.  She does not want to do that, but I am working the issue.  My
AL0918 -        feeling is that Cellulitis is slightly worse now than when she
AL0919 -        left an hour or so ago to visit Kaiser on another matter, but
AL0920 -        is still less severe than initially presented at 0800 this
AL0921 -        morning. ref SDS 0 6S52, ref DIT 2 BO6L
AL0923 -         ..
AL0924 -    5.  Accordingly, seeing a doctor seems like a good idea.
AL0925 -        ref DIT 2 567J
AL0927 -         ..
AL0928 -    6.  We took her temperature and got 97.7. ref DIT 2 E67M
AL0930 -         ..
AL0931 -    7.  I called Kaiser.  Everyone is at lunch until 1330.  Left a
AL0932 -        message for Arlette citing the letter sent to the doctor this
AL0933 -        morning, and your recommendation for examination by a doctor
AL0934 -        today. ref SDS 0 PT8Q, ref DIT 2 BO7M
AL0935 -
AL0936 -            [...above letter from UCSF with copy to Kaiser does not
AL0937 -            specify urgency for examination today. ref SDS 0 KV5H
AL0939 -         ..
AL0940 -    8.  We could go to ER, as we have done in the past when Mil's
AL0941 -        temperature gets above 100.5. ref DIT 2 BO8I
AL0943 -         ..
AL0944 -    9.  Will wait another hour to see if Kaiser responds, and the
AL0945 -        direction of Cellulitis. ref DIT 2 BO8N
AL0947 -         ..
AL0948 -   10.  Please let us know if you feel this is an ER issue. ref DIT 2
AL0949 -        979I
AL0951 -         ..
AL0952 -   11.  Thanks again for being there with good advice. ref DIT 2 C79L
AL0953 -
AL0954 -
AL0955 -
AL0956 -
AL10 -

SUBJECTS
Kaiser Schedules Examination Cellulitis Recurrence 080305 1200 Rathe

B203 -
B204 - 1418
B20501 -  ..
B20502 - Kaiser Schedules Examination Wednesday 1200 for Cellulitis Recurrence
B20503 -
B20504 - Becky called, responding to the message left at Kaiser, per above.
B20505 - ref SDS 0 PT8Q  She works with the primary care physician at Kaiser.
B20507 -  ..
B20508 - Becky said the doctor has scheduled to see Millie tomorrow, 080305
B20509 - 1200.
B20510 -
B20511 -            [On 080305 Kaiser primary care physician performs
B20512 -            examination of Cellulitis. ref SDS 23 QY5I and, ref SDS 23
B20513 -            RM6J
B20515 -  ..
B20516 - Becky indicated she has not seen the record in this case, and does not
B20517 - know if the doctor has had time to review it. ref SDS 0 V45J  She told
B20518 - the doctor about the voice mail reporting Cellulitis recurrence,
B20519 - ref SDS 0 PT8Q, and that it seems more severe today than the prior
B20520 - episode last December when home care using Keflex resolved the
B20521 - problem, but that in this case UCSF recommends examination today.
B20522 - ref SDS 0 AP35
B20523 -
B20524 -            [...above letter from UCSF with copy to Kaiser does not
B20525 -            specify urgency for examination today. ref SDS 0 KV5H
B20527 -             ..
B20528 -            [On 080305 primary care physician reports problems
B20529 -            accessing UCSF correspondence system, indicating Kaiser was
B20530 -            only aware of patient notice relating understanding,
B20531 -            possibly incorrect, but none-the-less that UCSF recommends
B20532 -            same day examination. ref SDS 23 7V4M
B20534 -             ..
B20535 -            [On 080307 patient commends Kaiser for making time to
B20536 -            perform exigent examination of Cellulitis on short notice
B20537 -            recommended by UCSF. ref SDS 26 GZ4H
B20539 -  ..
B20540 - Asked to talk to Arlette, who has been effective coordinating work at
B20541 - Kaiser with UCSF referral in Millie's case.
B20543 -  ..
B20544 - Becky explained that Arlette cannot take the call because she is tied
B20545 - up working with technicians to resolve a computer problem of some
B20546 - kind.
B20547 -
B20548 -            [On 080305 primary care physician reports problems using
B20549 -            UCSF secure electronic mail system, which prevented timely
B20550 -            communication for referral coordination on Millie's care;
B20551 -            possibly Arlette was tied up helping the doctor work out
B20552 -            these problems. ref SDS 23 US6I
B20554 -  ..
B20555 - Thanked Becky for assisting Millie with timely examination at Kaiser,
B20556 - implementing UCSF recommendation and addressing possible increased
B20557 - risks from low blood counts, per above. ref SDS 0 AP35
B20558 -
B20560 -  ..
B206 -
B207 -
B208 - 1556
B209 -
B20901 - Notify Medical Team of Planning for Kaiser Review of Cellulitis
B20902 -
B20903 - Submitted ref DIT 3 0001 to medical team confirming planning with
B20904 - Becky for meeting at Kaiser tomorrow...
B20905 -
B20906 -    1.  Per UCSF recommendation, this confirms planning today for
B20907 -        examination of Cellulitis recurrence.  Millie will meet with
B20908 -        [primary care physician at Kaiser] tomorrow at 1200 (noon).
B20909 -        ref SDS 0 UZ89, ref DIT 3 0001
B20910 -
B20911 -            [On 080307 patient commends Kaiser for making time to
B20912 -            perform exigent examination of Cellulitis on short notice
B20913 -            recommended by UCSF. ref SDS 26 GZ4H
B20915 -         ..
B20916 -    2.  Millie seems to be stable with Keflex.  Ice has held down
B20917 -        inflammation and swelling.  Temperature remains normal.
B20918 -        ref SDS 0 0R4H, ref DIT 3 KT6J
B20920 -         ..
B20921 -    3.  See you tomorrow, and Doctor Rugo on Thursday. ref DIT 3 T87I
B20922 -
B20923 -
B20924 -
B20925 -
B20926 -
B20927 -
B20928 -
B210 -