San Francisco, CA
S U M M A R Y
DIARY: April 3, 2008 09:00 AM Thursday;
Millie meeting UCSF evaluate 2nd cycle clinical trial IBC 4th relapse.
2...Agenda Meeting Next Cycle Clinical Trial Cetuximab Carboplatin
3...IBC 4th Relapse Examination Shows Stable to Improved Condition
4...Carboplatin Chemotherapy Well Tolerated Energy Exercise Increase
5...Energy Exercise Increase Carboplatin Chemotherapy Well Tolerated
6...Exercise Energy Rise Emotional Trauma Stress Anxiety Subside
7...Emotional Trauma Stress Anxiety Subside with Exercise Increasing
8...Lab Results Timely Doctor Patient Partnership Expedites Health Care
9...Blood Counts Requires Neupogen Exercise Cannot Maintain Immune System
10...Exercise Cannot Maintain Immune System Blood Counts Requires Neupogen
11...Immune System Exercise Cannot Maintain Blood Counts Requires Neupogen
12...Approved Treatment Chemotherapy Blood Counts Slightly Low
13...Chemotherapy Approved Blood Counts Slightly Low Neupogen Prescribed
14...Neupogen Prescribed Within 3 Days After Chemo NEUTS Blood Counts Low
15...Coordination Referral Communication Delay Frustrating People Give Up
16...Communication People Give Up Referral Coordination Delay Frustrating
17...Referral Coordination Difficult People Giving Up on Communication
18...Knowledge Management Exposure Changes Attitudes Improve Communication
19...Exposure Aids Transformation from Information to Culture of Knowledge
20...Experience Grows Confidence in Coordination Referral Communication
21...Referral Coordination Prescribe Medication Doctor Patient Partnership
22...Neupogen Prescribed Increase Blood Counts Maintain Treatment Protocol
23...Cost Effective Care 1 Treatment then Assess Need to Increase Dose
24...Magnesium Missing from Blood Test Lab Report UCSF Investigating
25...CT Test Coordinated by UCSF
26...Prozac Not Needed Emotional Stress Subsides Improvement in Work
27...FLUOXETINE 20 MG CAPSULES Prozac to Treat Stress Depression
28...Prozac Prescribe Cope Emotional Trauma IBC Relapse Cellulitis Relapse
29...Emotional Coping Difficult IBC Relapse Severe Fall Cellulitis Relapse
30...Disability Status Report Progress Processing Insurance Report
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Meeting Examination Doctor Review Strategy Work Plan 2nd Cycle 1st T
0803 - ..
0804 - Summary/Objective
080501 - Follow up ref SDS 69 0000. ref SDS 66 0000.
080503 - Examination shows stable to improved IBC conditions from getting just
080504 - one of three prescribed treatments this past cycle with Carboplatin
080505 - added to cetuximab. ref SDS 0 SA5J So far, Carboplatin has been well
080506 - tolerated, with rising energy allowing exercise to increase despite
080507 - adding chemotherapy. ref SDS 0 VU7P Favorable results from treatment
080508 - have reduced previous emotional trauma, relieving stress, worry, and
080509 - doubt about the future. Prozac treatments are not needed. ref SDS 0
080510 - 336H Millie was further grateful today that the doctor approved
080511 - treatment with Carboplatin chemotherapy despite slightly low blood
080512 - counts. Neupogen was prescribed to increase blood counts that
080513 - maintain the immune system for safe treatment next week. ref SDS 0
080514 - XV4G Case management for health care improved today with UCSF
080515 - applying doctor patient partnership for communication with Kaiser on
080516 - referral coordination ordering Neupogen. ref SDS 0 4U9O Magnesium was
080517 - missing again from the blood test; UCSF investigating. ref SDS 0 XQ6L
080518 - UCSF ordered another CT test to measure response to treatment next
080519 - cycle in 4 weeks. ref SDS 0 669L UCSF investigating progress on
080520 - processing documentation for medical disability requested by Millie's
080521 - employer and insurance company. ref SDS 0 I33H
080523 - [...in another record today, Millie submits report to Kaiser
080524 - and UCSF on results of examination, ref SDS 83 IW5I, and
080525 - coordinates with Kaiser to order Neupogen medication prescribed
080526 - by UCSF, ref SDS 83 TS7T; requests cost effective medication
080527 - order at Kaiser. ref SDS 83 TS8Y
080529 - ..
080530 - [On 080404 UCSF reported Magnesium was added to the blood test
080531 - for today, and results show counts are too low, ref SDS 84
080532 - O059, doctor prescribes Magnesium replacement treatment.
080533 - ref SDS 84 OP6U
080542 - ..
0808 - Progress
080901 - Agenda Meeting Next Cycle Clinical Trial Cetuximab Carboplatin
080903 - Follow up ref SDS 69 QY5I.
080905 - Millie met today with the medical team to start another cycle of
080906 - treatment.
080908 - ..
080909 - Begin 15th cycle on clinical study with cetuximab, and start 2nd cycle
080910 - of 2nd arm of the study that includes both cetuximab and Carboplatin.
080911 - Today is the 1st treatment of the 16th cycle, and for the 1st cycle
080912 - with cetuximab and Carboplatin together. Today, Millie gets only the
080913 - 2nd treatment wtih Carboplatin, because there was only 1 treatment in
080914 - the 1st cycle of the 2nd arm, which began on 080306, ref SDS 69 NW3N,
080915 - and was given on 080313. ref SDS 73 TZ8I The first treatment on the
080916 - clinical study began on 070201. ref SDS 23 G68I
080918 - ..
080919 - Millie went initially this morning to the Infusion Clinic on the 5th
080920 - floor for a blood test, specified by the clincial trial protocol.
080921 - ref SDS 82 FW5N This took about 15 minutes, afterwhich Millie came
080922 - down to the 2nd floor and checked in at the counter in the Breast Care
080923 - clinic for the meeting at 0830.
080925 - ..
080926 - Millie was called into the clinic examination area at about 0900, as
080927 - scheduled. The first step is a nurse taking vitals on blood pressure,
080928 - pules, temperature, and oxygen blood content, which are entered in the
080929 - medical chart as initial diagnostics for the doctor evaluate patient
080930 - status.
IBC Examination Stable to Improved Condition After 1 of 3 Prescribed
280401 - ..
280402 - IBC 4th Relapse Examination Shows Stable to Improved Condition
280404 - Follow up ref SDS 69 NW3N.
280406 - Brigid made the examination today, following discusison in the hallway
280407 - with the doctor, per below. ref SDS 0 XU6H
280409 - ..
280410 - Examination shows full recovery of bruising on the right arm and eye
280411 - area from the fall on 080125. ref SDS 54 N65K Brigid advised that
280412 - UCSF received Kaiser's report on the xray of the right arm taken on
280413 - 080305 and showing no fracture or sprain, which was submitted in
280414 - Millie's letter on 080312. ref SDS 72 RT6S Millie reported today that
280415 - lifting the right arm no longer presents discomfort, cited in the
280416 - meeting at Kaiser on 080305, ref SDS 68 5M39, and in the letter to the
280417 - medical team on 080312. ref SDS 72 RU3S
280419 - ..
280420 - Examination today further shows stable IBC condition with no evident
280421 - increase in disease. Palpation of right and left axilla, and
280422 - supraclavicular identified no findings of concern.
280424 - ..
280425 - There was discussion of possible improvement after just 1 treatment
280426 - with Carboplatin on 080313, as reported in Millie's letter on 080315.
280427 - ref SDS 77 KF5L However, assessment of response to treatment is only
280428 - speculative without comparing measurements from photographs of the
280429 - starting condition taken on 080306, ref SDS 69 814N, with measurements
280430 - from new photographs of the condition today.
280432 - ..
280433 - For some reason, no photographs were taken today. Photographs to
280434 - evaluate response to treatment was planned in the meeting on 070201.
280435 - ref SDS 23 6T6M
280437 - ..
280438 - Millie reported in a letter to UCSF on 080219 that IBC seemed to be
280439 - subsiding. ref SDS 65 1K9W Weeks later the letter on 080312 reported
280440 - continued improvement treating IBC with cetuximab alone prior to
280441 - adding Carboplatin. ref SDS 72 RU4U This aligns with improving cancer
280442 - marker CA 15-3 59 tested on 080306, ref SDS 70 A16M, dropping from 63
280443 - reported for the test 4 weeks earlier on 080207. ref SDS 58 A16M
280445 - ..
280446 - This past treatment cycle Millie had only 1 of 3 prescribed treatments
280447 - with Carboplatin added to cetuximab. This was given on 080313.
280448 - ref SDS 73 TZ8I She elected to skip treatment on 080306. ref SDS 69
280449 - M18J A week later on 080320 Millie's blood counts were too low for
280450 - treatment with Carboplatin. ref SDS 79 TZ8I Last week on 080327 was
280451 - the normal bye week when chemotherapy is skipped in the 4-week cycle.
280452 - ref SDS 80 TZ8I
280455 - ..
280456 - Carboplatin Chemotherapy Well Tolerated Energy Exercise Increase
280457 - Energy Exercise Increase Carboplatin Chemotherapy Well Tolerated
280459 - Millie's letter on 080314 reported being energetic the day after
280460 - treatment with chemotherapy Carboplatin on 080313, and so went hiking.
280461 - ref SDS 75 KO6Y Millie later reported on 080320 there is a definite
280462 - loss of energy from adding chemotherapy Carboplatin to cetuximab.
280463 - ref SDS 78 PN8M Yesterday, on 080402 Millie reported exeriencing a
280464 - burst of energy the past 2 weeks increasing exercise perhaps more than
280465 - in 3 4 years. ref SDS 81 Q25V
280468 - ..
280469 - Exercise Energy Rise Emotional Trauma Stress Anxiety Subside
280470 - Emotional Trauma Stress Anxiety Subside with Exercise Increasing
280472 - Follow up ref SDS 81 Q25V.
280474 - Experiencing continued high energy for exercise and normal activity
280475 - after chemotherapy treatment aligns with Jackie's report on 080306
280476 - that patients tolerate Carboplatin well. ref SDS 69 7V6M Experience
280477 - getting favorable results helps relieve worry, stress, and depression
280478 - that made transition adding Carboplatin emotionally hard to accept,
280479 - reported on 080219, ref SDS 66 I35G, and evident during the meeting at
280480 - Kaiser 080305, ref SDS 68 WE58, citing concern about loss of energy
280481 - that reduces exercise needed to maintain blood counts that are reduced
280482 - by chemotherapy, ref SDS 68 PC6M, also noted in Millie's letter on
280483 - 080219 citing low blood counts for 4 months, ref SDS 65 1K4P, similiar
280484 - to prior experience with capecitabine in 2005, ref SDS 65 CA4N
280485 - Millie's letter to Kaiser on 080307 expressed worry about getting
280486 - treatment with low blood counts. ref SDS 71 HS6R Prior worries were
280487 - addressed by the primary care physician prescribing Prozac medication
280488 - during the meeting at Kaiser on 080305. ref SDS 68 5L5M
280490 - [On 080409 Millie reports to Kaiser being thrilled by
280491 - improvement recovering from IBC disease, and that energy and
280492 - exercise have increased despite adding Carboplatin chemotherapy
280493 - to cetuximab for the clinical trial regimen; causing reduced
280494 - emotional trauma from stress, anxeity, doubt, and worry about
280495 - the future. ref SDS 87 W14P
Labs Blood Counts NEUTS 1.34 Below Safe Chemotherapy Treatment Requi
440401 - ..
440402 - Lab Results Timely Doctor Patient Partnership Expedites Health Care
440403 - Blood Counts Requires Neupogen Exercise Cannot Maintain Immune System
440404 - Exercise Cannot Maintain Immune System Blood Counts Requires Neupogen
440405 - Immune System Exercise Cannot Maintain Blood Counts Requires Neupogen
440407 - Follow up ref SDS 69 JT3L.
440409 - While the nurse was getting vitals in the hallway, Doctor Rugo walked
440410 - down the hall and visited briefly with Millie in advance of meeting
440411 - with the medical team.
440413 - ..
440414 - The doctor advised that results from the lab test on the 5th floor
440415 - this morning at about 0805 are already posted on UCSF's computer.
440417 - ..
440418 - That seems remarkably fast, taking only about 20 minutes. ref SDS 82
440419 - FW5N Timely reporting of lab results expedites work by the doctor
440420 - that helps keep meetings on schedule. Timely lab reports are in turn
440421 - expedited by the patient getting to the hospital early for blood draws
440422 - so that Millie's blood work is the first assignment in the lab.
440423 - Synergy between timely work by the patient enabling early work by the
440424 - lab that aids assessment by the physician reflects effective doctor
440425 - patient partnership proposed in the Kaiser Healthwise Handbook
440426 - reviewed on 990625. ref SDS 2 4185
440428 - ..
440429 - Millie's letter on 080219 cited problems the past 3 - 4 months
440430 - maintaining blood counts while getting treatment with only cetuximab,
440431 - ref SDS 65 1K4P During the meeting at UCSF on 080207, Doctor Rugo
440432 - disucssed plans for treatment to increase blood counts for safe
440433 - treatment with chemotherapy using Carboplatin added to cetuximab,
440434 - since blood counts dropped consistently despite reports that treatment
440435 - with cetuximab alone has no effect on blood counts. ref SDS 57 E14H
440437 - ..
440438 - There was hope last month on 080306 that sudden rise of blood counts
440439 - NEUTS 2.75 without treatment signaled that prior difficulties were
440440 - resolved. ref SDS 69 033B This favorable turn was reported to Kaiser
440441 - in a letter on 080307. ref SDS 71 HS6R
440443 - ..
440444 - The doctor advised this morning that test results show blood counts
440445 - for NEUTS 1.34, slightly below 1.5 needed for safe chemotherapy, and
440446 - significantly lower than NEUTS 2.30 tested last week on 080327.
440447 - ref SDS 80 QY6H This dramatic fall in blood counts changes planning
440448 - in Millie's letter yesterday on 080402 to use exercise rather drugs
440449 - (Neupogen) to maintain blood counts at safe levels for chemotherapy.
440450 - ref SDS 81 Q26R Millie reported yesterday having a "burst of energy"
440451 - that increased her exercise more than in the past 4 years. ref SDS 81
440452 - Q25V Since patient history in this case shows close correlation
440453 - between low blood counts and loss of energy, Millie was hopeful that
440454 - rising energy signaled good blood counts. Failure to maintain blood
440455 - counts therefore implies that exercise will not be sufficient without
440456 - adding Neupogen treatment.
Treatment Chemotherapy Carboplatin Approved Blood Counts Slightly Lo
650401 - ..
650402 - Approved Treatment Chemotherapy Blood Counts Slightly Low
650403 - Chemotherapy Approved Blood Counts Slightly Low Neupogen Prescribed
650404 - Neupogen Prescribed Within 3 Days After Chemo NEUTS Blood Counts Low
650406 - Millie was pleased that, despite low blood counts, Doctor Rugo
650407 - approved chemotherapy today, adding Carboplatin to cetuximab, as
650408 - called out by the new protocol for the 2nd arm of the clinical study,
650409 - reported on 080306, ref SDS 69 NW7K, and which Millie started a week
650410 - later on 080313. ref SDS 73 TZ8I
650412 - ..
650413 - The doctor further prescribed 1 treatment with Neupogen to increase
650414 - blood counts for treatment next week. She wants Millie to self-inject
650415 - Neupogen 2 - 3 days after treatment today so that blood counts will
650416 - rise enough to get treatment again next week. The doctor said that
650417 - since Sunday is the 3rd day after treatment today, Millie can get the
650418 - treatment at Kaiser on the next business day, which is Monday.
650420 - [...below, Brigid explains UCSF strategy for cost effective
650421 - care, ref SDS 0 I33G; she confirms timing Neupogen treatment at
650422 - Kaiser within 3 days of chemotherapy at UCSF today, ref SDS 0
650423 - SN4J, and prepares a handwritten prescription for Kaiser to
650424 - order Neupogen medication. ref SDS 0 SF4M
650426 - ..
650427 - [On 080405 Pharmacist discloses patient must pay for Neupogen
650428 - medication and cannot get IV injection treatment as previously
650429 - provided because the Infusion Clinic in the hospital is closed
650430 - on Saturday, ref SDS 85 XQ7U; Neupogen not pre-configured in
650431 - disposable syrenge, ref SDS 85 158O, 20 minute transaction
650432 - takes over 2 hours. ref SDS 85 J23F
650434 - ..
650435 - [On 080417 Millie asks UCSF about Neupogen treatments needed
650436 - when blood counts fall to lowest level ever. ref SDS 90 4W8Q
650438 - ..
650439 - [On 080417 Brigid says Neupogen treatment not needed this week,
650440 - because no Carboplatin chemothearpy next week for 4th treatment
650441 - in the cycle; discusses new treatment plan lowering dose of
650442 - Carboplatin to achieve consistent treatments. ref SDS 89 MR3L
Coordination Referral Communication Delay Frustrating People Give Up
AW0401 - ..
AW0402 - Coordination Referral Communication Delay Frustrating People Give Up
AW0403 - Communication People Give Up Referral Coordination Delay Frustrating
AW0404 - Referral Coordination Difficult People Giving Up on Communication
AW0406 - This decision requires getting the primary care physician to place an
AW0407 - order with the Kaiser Pharmacy to fill the UCSF prescription for
AW0408 - Neupogen - patient care requires timely, effective referral
AW0409 - coordination between UCSF and Kaiser.
AW0411 - [...below, Brigid writes the order for Neupogen at Kaiser.
AW0412 - ref SDS 0 I33G
AW0414 - ..
AW0415 - Since UCSF is treating Millie on referral from Kaiser, and since the
AW0416 - referral agreement requires Kaiser to provide medications prescribed
AW0417 - by UCSF, reported on 061230, ref SDS 17 3X6K, and since prescriptions
AW0418 - are entered by doctors on computers, and since further Kaiser and UCSF
AW0419 - computers are not integrated, then direct communication is required to
AW0420 - coordinate health care responsibilities, as planned in the meeting at
AW0421 - UCSF on 070222. ref SDS 24 VK5N Somehow the doctor at UCSF must
AW0422 - convey to the doctor at Kaiser what is required, so that the doctor at
AW0423 - Kaiser can type up an order in the Kaiser computer that will be
AW0424 - executed by the Kaiser pharmacy to provide drugs specified by UCSF for
AW0425 - treating Millie.
AW0427 - ..
AW0428 - Doctor Rugo asked Millie to coordinate with Kaiser on implementing the
AW0429 - UCSF prescription today for Neupogen medication.
AW0431 - ..
AW0432 - Doctor Rugo explained that calling Kaiser to coordinate work with UCSF
AW0433 - on caring for patients takes a lot of time and is very frustrating and
AW0434 - stressful.
AW0436 - ..
AW0437 - No one at UCSF has authority to direct work at Kaiser, and Kaiser
AW0438 - cannot direct work at UCSF. Nobody has authority to direct the work
AW0439 - for coordinating solutions that require complementary action to care
AW0440 - for the patient. Kaiser and UCSF are working in partnership with a
AW0441 - matrix management model that lacks authority to meet responsibilities.
AW0442 - Responsibility without authority is frustrating, because no one can
AW0443 - determine priority.
AW0445 - ..
AW0446 - Second, there is no precision access (see NWO, ref OF 13 PX6J). It
AW0447 - takes a long time on hold, guessing which buttons to press, using
AW0448 - advanced technology for "skill-based" routing intended to improve
AW0449 - productivity, but which causes endless delays for busy people,
AW0450 - reported on 000304. ref SDS 4 UT9I Accordingly, the report today on
AW0451 - failed communications conflicts with the report from Kaiser on 070710
AW0452 - that communication with UCSF on Millie's referral treatment was
AW0453 - effective. ref SDS 26 OG7F
AW0455 - [...in another record today, Millie coordinates with Kaiser to
AW0456 - order Neupogen medication prescribed by UCSF, ref SDS 83 TS7T,
AW0457 - requests cost effective medication order at Kaiser. ref SDS 83
AW0458 - TS8Y
AW0460 - ..
AW0461 - [On 080404 UCSF asks patient to coordinate additional treatment
AW0462 - with Magnesium Replacement. ref SDS 84 O152
AW0464 - ..
AW0465 - [On 080404 fixing mistake in UCSF blood test too frustrating;
AW0466 - UCSF asks patient to coordinate with Kaiser on medication for
AW0467 - Magnesium treatment, ref SDS 84 N23L; patient submits letter to
AW0468 - Kaiser coordinating order for Magnesium prescribed by UCSF.
AW0469 - ref SDS 84 6H9N
AW0471 - ..
AW0472 - [On 080404 Brigid feels referral coordination with Kaiser takes
AW0473 - too much time, ref SDS 84 OP69; asks patient to perform case
AW0474 - management coordinating to order Magnesium treatment.
AW0475 - ref SDS 84 YO68; Millie coordinates the work without written
AW0476 - guidance from UCSF. ref SDS 84 6H9N
AW0478 - ..
AW0479 - [On 080405 Millie encounters problems getting Neupogen
AW0480 - treatment at Kaiser Pharmacy ordered by primary care physician
AW0481 - with referral coordination on UCSF prescription. ref SDS 85
AW0482 - 7E5L
AW0484 - ..
AW0485 - [On 080410 UCSF refused to respond to written request for
AW0486 - medical status to disability entitlement; proposed patient use
AW0487 - telephone for conversation to perform case management,
AW0488 - ref SDS 88 PT4M, contrary to UCSF report on 080403 that
AW0489 - reliance on conversation using the telephone phone tag does not
AW0490 - support effective case management. ref SDS 0 IM87
AW0492 - ..
AW0493 - [On 080423 UCSF says lowering dose of Carboplatin when blood
AW0494 - counts are low, prevents getting full dose when blood counts
AW0495 - are good; patient requests continue full dose, and use Neupogen
AW0496 - to increase blood counts. ref SDS 91 TY6Y
AW0498 - ..
AW0499 - [On 080501 during the meeting with the medical team to start
AW0500 - the next cycle, Millie confirmed that she wants to get the full
AW0501 - dose of Carboplatin chemotherapy; UCSF revised the treatment
AW0502 - plan to prevent skipping Carboplatin by maintaining blood
AW0503 - counts with 1 weekly Neupogen treatment. ref SDS 97 CZ3N
AW0505 - ..
AW0506 - [On 080502 another Neupogen prescription Kaiser advises "Black
AW0507 - Box" transaction uncertain results. ref SDS 99 NM3M
AW0509 - ..
AW0510 - [On 080529 review of Chemotherapy Orders, ref SDS 90 MM9I, for
AW0511 - 080501, received from UCSF on 080515, ref SDS 91 E43I;
AW0512 - discovered UCSF evidently reduced the dose of Carboplatin and
AW0513 - prescribed 2 weekly Neupogen treatments, ref SDS 92 PVUQ,
AW0514 - contrary to understandings with the medical team today, 080501,
AW0515 - that Millie would get full dose of Carboplatin with 1 weekly
AW0516 - Neupogen tratment this cycle. ref SDS 97 CZ3N
AW0518 - ..
AW0519 - [On 080529 Chemotherapy Orders for Carboplatin show same dose
AW0520 - 175 mg as today, ref SDS A1 PVUQ, there is a handwritten mark
AW0521 - that says "error," dated 080529 with initials mg. ref SDS A1
AW0522 - F55F
AW0524 - ..
AW0525 - [On 080609 more frustrating problems ordering Neupogen; Kaiser
AW0526 - corrects the problem, Kaiser cannot correct $2,000 payment
AW0527 - mistake because nobody understands how to use the computer.
AW0528 - ref SDS A2 K273
AW0530 - ..
AW0531 - [On 080627 primary care physician at Kaiser annoyed getting
AW0532 - referral coordination through the patient on UCSF request for
AW0533 - certification that is not common medical documentation at
AW0534 - Kaiser; notifies surgeon to submit certification on suitability
AW0535 - for use of Power Port. ref SDS A3 GT6O
AW0537 - ..
AW0538 - [On 080708 surgeon annoyed by coordination requirements between
AW0539 - Kaiser and UCSF on documentation to establish Power Port was
AW0540 - correctly implanted and certified for use. ref SDS A4 O65F
AW0542 - ..
AW0543 - [On 080708 Kaiser submitted a letter stating the Power Port was
AW0544 - tested successfully, and signed by the surgeon. ref SDS A4 O14F
AW0546 - ..
AW0547 - [On 080710 Millie submitted the doctor's letter to UCSF,
AW0548 - ref SDS A5 EE4O, the nurse advised that UCSF actually needs the
AW0549 - report on the xray performed showing placement of the Power
AW0550 - Port, ref SDS A4 UY3I; UCSF management called Kaiser; the
AW0551 - Surgery department coordinated submission of the xray report to
AW0552 - the Infusion Clinic at UCSF. ref SDS A5 TM5J
AW0554 - ..
AW0555 - [On 080718 stress communicating with so many people to get
AW0556 - things done with coordination illustrated by problems with CT
AW0557 - test failure, and then trying to fix the problems. ref SDS A6
AW0558 - Y38M
AW0560 - ..
AW0561 - [On 081210 example difficulties UCSF attempting to coordinate
AW0562 - blood tests and Neupogen treatments at Kaiser, ref SDS A8 6S9M;
AW0563 - Glenna, the treatment coordinator asks Millie to coordinate
AW0564 - with Kaiser. ref SDS A8 6131
AW0566 - ..
AW0567 - [On 090106 Glenna asked for assistance coordinating with Kaiser
AW0568 - to get medical test records for patient care. ref SDS A9 N77H
AW0570 - ..
AW0571 - Lack of precision access for direct communication through conversation
AW0572 - between organizations, discussed today, also causes resistance to
AW0573 - using links in correspondence for verifying accuracy and understanding
AW0574 - context, cited on 020820. ref SDS 7 6P8K
AW0576 - ..
AW0577 - Communication is further complicated by talking to intermediaries,
AW0578 - leaving messages with voice mail, and often having to call back
AW0579 - several times (i.e., "playing phone tag"), and eventually
AW0580 - communicating requirements to someone who can take responsibility and
AW0581 - has authority to perform the work. Compared to taking immediate
AW0582 - action by simply typing a prescription into the computer and having it
AW0583 - executed by the pharmacy, calling a doctor to get the same result is
AW0584 - unbearably frustrating, because it is impossible to call the doctor
AW0585 - and have a discussion to make clarifications that ensure correct
AW0586 - understanding that avoids mistakes entering the prescription, and then
AW0587 - hang up and continue treating other patients.
AW0589 - ..
AW0590 - Delay due to lack of precision access causes emotional stress,
AW0591 - anxiety, and depression because human biology drives people to take
AW0592 - immediate action relying on assumptions from experience rather than
AW0593 - invest time for cognitive overhead, explained in NWO. ref OF 15 LH6K
AW0595 - [On 080502 "Black Box" uncertain results frustrates doctor using
AW0596 - computer to order prescribed medications for patient treatment at
AW0597 - Kaiser. ref SDS 99 NM3M
AW0599 - ..
AW0600 - Peter Drucker notes that people have given up trying to improve
AW0601 - management because communication is too complex, reviewed on 931130.
AW0602 - ref SDS 1 3851
AW0605 - ..
AW0606 - Knowledge Management Exposure Changes Attitudes Improve Communication
AW0607 - Exposure Aids Transformation from Information to Culture of Knowledge
AW0608 - Experience Grows Confidence in Coordination Referral Communication
AW0609 - Referral Coordination Prescribe Medication Doctor Patient Partnership
AW0611 - The doctor asked Millie to send a letter to the primary care physician
AW0612 - at Kaiser, presenting UCSF requirements for Neupogen, and with a copy
AW0613 - to UCSF, so that she can see from this feedback that coordination was
AW0614 - accomplished, and can verify that medication prescribed by Kaiser
AW0615 - correctly reflects the UCSF treatment plan.
AW0617 - ..
AW0618 - Doctor Rugo cited Millie's letter yesterday on 080402 using electronic
AW0619 - mail (email) to plan the meeting today, including blood test work, and
AW0620 - report coordination between Kaiser and UCSF with links to relevant
AW0621 - background for context and to verify accuracy, as the model she wants
AW0622 - applied in this case. ref SDS 81 KB9J The doctor explained that
AW0623 - doctor patient partnership helps relieve stress and frustration
AW0624 - communicating to coordinate work between UCSF and Kaiser cultures,
AW0625 - discussed above. ref SDS 0 SG7I
AW0627 - ..
AW0628 - [On 080423 UCSF applies doctor patient partnership again
AW0629 - requests scope of blood draw from patient that is prescribed in
AW0630 - the Chemotherapy Orders issued by the doctor. ref SDS 92 P45J
AW0632 - ..
AW0633 - [On 081017 doctor thanks Millie for coordinating work plan with
AW0634 - Kaiser changing treatment to Sunitinib clinical study, when 5th
AW0635 - relapse of IBC occurs from progression of disease, ref SDS A7
AW0636 - RI6I, cites challenge of complexity high volume information,
AW0637 - and difficulty using handheld Treo computer like
AW0638 - Palmpilot/Blackberry technology. ref SDS A7 6I6J
AW0640 - ..
AW0641 - [On 090121 Glenna asked for help from the SDS "well ordered
AW0642 - record" of patient history to expedite finding treatments which
AW0643 - Doctor Rugo has proposed after sunitinib, ref SDS B0 Y67L;
AW0644 - listed the report today that UCSF is starting another study,
AW0645 - and that UCSF has other non-study options for Millie.
AW0646 - ref SDS B0 EV53
AW0648 - ..
AW0649 - [On 090206 0747 Doctor Stritter credits Millie's medical
AW0650 - team for controlling clinical, logistical and financial
AW0651 - complexities caring for very aggressive cancer much longer
AW0652 - than normally expected. ref SDS A0 7Q7J
AW0654 - ..
AW0655 - [On 090213 1140 primary care physician at Kaiser credits
AW0656 - command and control of the record enables case management
AW0657 - to extend Millie's longevity surviving cancer much longer
AW0658 - than expected for disease trajectory. ref SDS A1 NY7L
AW0660 - ..
AW0661 - [On 090514 0830 doctor cites hectic schedule with many
AW0662 - patients who need emergency care; so, there is not enough
AW0663 - time for comprehensive communication to avoid mistakes.
AW0664 - ref SDS B3 LS6I
AW0666 - ..
AW0667 - [On 090529 1109 tried summarizing complexity of relevant
AW0668 - patient history for Doctor Rugo, and submitting analysis
AW0669 - for comprehensive care to the medical team. ref SDS B4 448K
AW0671 - ..
AW0672 - [On 100104 0930 Doctor Sandhu reported that SDS records
AW0673 - improved case management coordinating patient care between the
AW0674 - VA Medical Center in San Francisco and the VA Clinic in
AW0675 - Martinez. ref SDS B5 PP8W
AW0677 - ..
AW0678 - This procedure can be described as Knowledge Management, explained in
AW0679 - POIMS. ref OF 4 J26O It fits "doctor patient partnerhsip" goals for
AW0680 - optimizing efficiency through synergy expediting communication,
AW0681 - planned in Kaiser's Healthwise Handbook, reviewed on 990625.
AW0682 - ref SDS 2 4185
AW0684 - [...in another record today, Millie coordinates with Kaiser to
AW0685 - order Neupogen medication prescribed by UCSF, ref SDS 83 TS7T,
AW0686 - requests cost effective medication order at Kaiser. ref SDS 83
AW0687 - TS8Y
AW0689 - ..
AW0690 - [On 080404 UCSF referral coordination with Kaiser takes too
AW0691 - much time, ref SDS 84 OP69; patient asked to perform case
AW0692 - management coordinating to order Magnesium treatment.
AW0693 - ref SDS 84 O152 and ref SDS 84 O174; Millie coordinates the
AW0694 - work without written guidance from UCSF, ref SDS 84 6H9N;
AW0695 - doctor orders Neupgoen prescribed by UCSF to increase blood
AW0696 - counts for safe chemotherapy treatments. ref SDS 84 JW6J
AW0698 - ..
AW0699 - [On 080405 Millie encounters problems getting Neupogen
AW0700 - treatment at Kaiser Pharmacy ordered by primary care physician
AW0701 - with referral coordination on UCSF prescription. ref SDS 85
AW0702 - 7E5L
AW0704 - ..
AW0705 - [On 080417 blood counts very low; Millie coordinates medical
AW0706 - team on Neupogen treatment again. ref SDS 90 P45J
AW0708 - ..
AW0709 - There was no discussion today of why coordination by email between the
AW0710 - two doctors to make the referral assignment on 061230 cannot similarly
AW0711 - expedite communication today ordering medication. One reason may be
AW0712 - that UCSF is going through a management audit that now forces using a
AW0713 - dedicated UCSF email system, which is separate from conventional email
AW0714 - service, and in order to increase security of patient health records,
AW0715 - as reported during the meeting at UCSF last month on 080306.
AW0716 - ref SDS 69 JT66 This change increases the work load on everybody, and
AW0717 - makes uniform distribution to affected parties difficult. The
AW0718 - doctor's request for the patient to perform case management
AW0719 - coordinating work with Kaiser may reflect aversion to cognitive
AW0720 - overhead that takes time, causing stress, frustration, anxiety, and
AW0721 - depression on the medical staff. (see NWO, ref OF 15 1L8N)
Neupogen Current Medications Prescription UCSF Cost Effective Care 1
BM0401 - ..
BM0402 - Neupogen Prescribed Increase Blood Counts Maintain Treatment Protocol
BM0404 - Follow up ref SDS 69 033B, ref SDS 79 TZ8I.
BM0406 - During the meeting with the medical team, Brigid showed results of the
BM0407 - blood test this morning discussed moments earlier by the doctor.
BM0408 - Brigid displayed on the computer screen in the Examination room the
BM0409 - complete list of tests performed by the lab, ref SDS 82 075H, and
BM0410 - which showed NEUTS 1.34. ref SDS 82 QY6H She then changed the screen
BM0411 - to display recent history on NEUTS alone. This view of the record
BM0412 - shows continued difficulty maintaining blood counts at safe levels for
BM0413 - chemotherapy, as set out in Millie letter to Kaiser on 080219,
BM0414 - ref SDS 65 1K4P, and discussed at UCSF on 080207 considering
BM0415 - challenges moving the 2nd arm of the clinical study. ref SDS 57 E14H
BM0418 - ..
BM0419 - Cost Effective Care 1 Treatment then Assess Need to Increase Dose
BM0421 - Brigid confirmed that the doctor has prescribed just one treatment
BM0422 - with Neupogen this week, per above, ref SDS 0 6Y9K She presented the
BM0423 - doctor's strategy to minimize excessive treatment and cost. Rather
BM0424 - than begin with 5 treatments for the entire week prescribed previously
BM0425 - at Kaiser on 020520, ref SDS 6 RF4M, UCSF will start with just one (1)
BM0426 - treatment for the week. If blood counts do not rise sufficiently,
BM0427 - then Neupogen will be increased with additional IV infusions on
BM0428 - subsequent weeks until NEUTS rises to a safe level for treatment,
BM0429 - above 1.5.
BM0431 - ..
BM0432 - [...in another record today, Millie coordinates with
BM0433 - Kaiser to order Neupogen medication prescribed by UCSF,
BM0434 - ref SDS 83 TS7T, requests cost effective medication
BM0435 - order at Kaiser. ref SDS 83 TS8Y
BM0437 - ..
BM0438 - [On 080417 Millie asks UCSF about Neupogen treatments
BM0439 - needed when blood counts fall to lowest level ever.
BM0440 - ref SDS 90 4W8Q
BM0442 - ..
BM0443 - Brigid explained worry about complex communication procedures at UCSF
BM0444 - that make timely coordination ordering Neupogen IV treatments for
BM0445 - Millie at Kaiser hard to accomplish by UCSF.
BM0447 - ..
BM0448 - Millie related the doctor's request before the meeting for support
BM0449 - coordinating with Kaiser under the doctor patient partnership, per
BM0450 - above. ref SDS 0 SG7I
BM0452 - ..
BM0453 - Brigid advised that Neupogen should be taken within 3 days of getting
BM0454 - chemotherapy treatment today, which would be at the latest on Sunday.
BM0455 - Since the 3rd in this case occurs on a weekend, the doctor approved
BM0456 - Millie can wait until Monday, per above, ref SDS 0 6Y9K, to go to
BM0457 - Kaiser for a Neupogen IV injection in the Infusion Clinic. Millie
BM0458 - could come into UCSF for the IV injection tomorrow, but this requires
BM0459 - driving 60 miles round trip to San Francisco. Brigid wrote an order
BM0460 - for getting Neupogen at Kaiser...
BM0462 - ..
BM0463 - The order reads in part...
BM0465 - 1) ANC = 1.34; Day 2 Neupogen 480 meg SQ x T
BM0467 - ..
BM0468 - This is a handwritten order, so transcription is problematic, reported
BM0469 - as causing high cost of medical mistakes in the study on 990912.
BM0470 - ref SDS 3 0900
BM0472 - [...in another record today, Millie coordinates with
BM0473 - Kaiser to order Neupogen medication prescribed by UCSF,
BM0474 - and asks Brigid to clarify transcription of her
BM0475 - handwritten prescription, ref SDS 83 TS7T, requests cost
BM0476 - effective medication order at Kaiser. ref SDS 83 TS8Y
BM0478 - ..
BM0479 - [On 080404 primary care physician at Kaiser orders
BM0480 - Neupogen treatment. ref SDS 84 JW6J
Magnesium Missing Blood Test Lab Report Medical Mistake Conflicts Ch
C70401 - ..
C70402 - Magnesium Missing from Blood Test Lab Report UCSF Investigating
C70404 - Millie asked Brigid about the test for Magnesium missing from the lab
C70405 - report displayed on the UCSF computer screen, per above. ref SDS 0
C70406 - I33G
C70408 - Brigid asked why Magnesium should be investigated?
C70410 - ..
C70411 - Millie recalled that failure to test Magnesium was a problem reported
C70412 - on 080110. ref SDS 50 JH6F UCSF corrected the problem a few days
C70413 - later by adding Magnesium to the test for blood drawn on 080110, as
C70414 - shown in an updated report received from UCSF on 080117. ref SDS 52
C70415 - 4F9G The correction was needed to evaluate treatment for low
C70416 - Magnesium prescribed a month before on 071213? ref SDS 48 HH5I
C70417 - Research at that time indicated low Magnesium contributes to anxiety,
C70418 - insomia, and fatigue. ref SDS 48 SF62
C70420 - ..
C70421 - Brigid advised that Magnesium is not listed in the report for the
C70422 - blood test today, evident from the the computer screen per above,
C70423 - ref SDS 0 I33G, because Magnesium is not required for every blood
C70424 - test, cited previously on 080110. ref SDS 50 S24K
C70426 - ..
C70427 - Millie proposed reviewing the chemotherapy order on 080306 that seems
C70428 - to specify testing Magnesium every 4 weeks, reported in the record on
C70429 - 080313. ref SDS 73 2N6N
C70431 - [On 080404 UCSF reported Magnesium was added to the blood test
C70432 - for today, and results show blood counts are too low,
C70433 - ref SDS 84 O059, doctor prescribes Magnesium replacement
C70434 - treatment. ref SDS 84 OP6U
CT Test Coordinated UCSF Schedule with Kaiser Monitor Response to Tr
CH0401 - ..
CH0402 - CT Test Coordinated by UCSF
CH0404 - Follow up ref SDS 64 6V5I.
CH0406 - Jackie advised that UCSF will coordinate with Kaiser for another CT
CH0407 - test to evaluate response to treatment by looking for progression of
CH0408 - disease, called out by the clinical trial protocol, shown on 070116,
CH0409 - ref SDS 19 SE8M, and planned with the doctor on 070130. ref SDS 22
CH0410 - 436J
CH0412 - ..
CH0413 - The last CT test on 080212, ref SDS 61 FP5H, was expedited from the
CH0414 - 12-week schedule in order to assess evident rising adenopathy reported
CH0415 - in the test on 071210, reported during the meeting on 080207.
CH0416 - ref SDS 57 GH5M Ordering the test today, seems to return to the
CH0417 - 12-week CT test schedule in time to start the next cycle on 080501.
CH0419 - [...in another record Millie confirms Jackie coordinate schedule
CH0420 - CT test at Kaiser on 080426. ref SDS 83 TS4Q
CH0422 - ..
CH0423 - [On 080425 CT test performed, ref SDS 93 9W9I; Millie suffered a
CH0424 - lot of pain and technicians experienced frustration, anxiety, and
CH0425 - stress, because they could not find a vein in the right arm for
CH0426 - making CT test contrast medium injection. ref SDS 93 FP6F
CH0428 - ..
CH0429 - [On 080428 CT test results show stable and minor conditions of
CH0430 - lymphadenopathy, no evident progression of IBC disease, and no
CH0431 - findings of distant metastasis. ref SDS 94 EO8F
CH0433 - ..
CH0434 - [On 080428 Millie reported problems to primary care physician
CH0435 - at Kaiser, and requested investigation to upgrade the port
CH0436 - catheter to handle CT test contrast medium injections.
CH0437 - ref SDS 94 1H6Y
CH0439 - ..
CH0440 - [On 080429 Kaiser checking on switching to a "Huber" needle
CH0441 - to avoid problems making injections of contrast medium for
CH0442 - CT tests. ref SDS 95 1H6Y
CH0444 - ..
CH0445 - [On 080430 letter to UCSF requests report on experience using this
CH0446 - method to relieve problems from excessive needle penetrations for
CH0447 - injecting contrast medium to perform CT tests. ref SDS 96 W65Q
CH0449 - ..
CH0450 - [On 080501 CT test on 080425 was discussed with the medical team
CH0451 - at UCSF to start the next cycle of treatment on the 2nd arm of the
CH0452 - clinical study drug trial, and indicated response to treatment
CH0453 - with no evident rise of adenopathy, ref SDS 97 YF5K; seems to
CH0454 - align with review of the test report on 080428. ref SDS 94 EO8F
CH0456 - ..
CH0457 - [On 080501 Brigid explained that CT test injections of contrast
CH0458 - medium cause higher pressures that can cause port catheter
CH0459 - mechanisms to fail, and so UCSF began installing only Power Ports
CH0460 - designed for higher pressures. ref SDS 97 TQ6F
Prozac Fluoxetine 20 MG Capsules Prescribed Current Medication Not T
CX0401 - ..
CX0402 - Prozac Not Needed Emotional Stress Subsides Improvement in Work
CX0403 - FLUOXETINE 20 MG CAPSULES Prozac to Treat Stress Depression
CX0404 - Prozac Prescribe Cope Emotional Trauma IBC Relapse Cellulitis Relapse
CX0405 - Emotional Coping Difficult IBC Relapse Severe Fall Cellulitis Relapse
CX0407 - Follow up ref SDS 72 RT8Y, ref SDS 68 KT4J.
CX0409 - Proactive planning coordinating referral with Kaiser, per above,
CX0410 - ref SDS 0 4U9O, together with favorable examination today showing
CX0411 - stable to subsiding IBC disease, ref SDS 0 SA5J, despite getting only
CX0412 - a third of prescribed treatments with Carboplatin, ref SDS 0 5N6L, and
CX0413 - also increased energy, reviewed above, ref SDS 0 VU7P, have helped
CX0414 - relieve anxiety, stress, and worry about the future. Millie confirmed
CX0415 - during the meeting today her letter to the medical team on 080312,
CX0416 - that improved prospects have relieved emotional trauma sufficiently,
CX0417 - ref SDS 72 RT4W, without taking Prozac medication prescribed by the
CX0418 - primary care physician at Kaiser on 080305, ref SDS 68 5L5M, and
CX0419 - disclosed to UCSF in a meeting the next day on 080306. ref SDS 69 NV5F
CX0421 - ..
CX0422 - Today, Millie confirmed she is not taking Prozac, answering the
CX0423 - primary care physician's letter at Kaiser on 080313. ref SDS 74 UE5N
CX0425 - ..
CX0426 - [...in another record today, Millie submitted a letter to
CX0427 - Kaiser transmitting this record of meeting today at UCSF on
CX0428 - 080403 and confirmed that she is not taking Prozac.
CX0429 - ref SDS 83 TS5W
CX0431 - ..
CX0432 - [On 080502 Millie during meeting at Kaiser notified the
CX0433 - primary care physician that she is not taking Prozac because
CX0434 - issues causing former emotional stress have subsided, and
CX0435 - exercise helps relieve routine stress. ref SDS 99 HH4I
Disability Status Benefits Entitlement Documentation Employer Nixon
DB0401 - ..
DB0402 - Disability Status Report Progress Processing Insurance Report
DB0404 - Follow up ref SDS 69 QQ3I.
DB0406 - Millie reported receiving a call from the office yesterday asking
DB0407 - about status for returning to work. Brigid advised that the UCSF
DB0408 - medical team plans to check with the department that responds to
DB0409 - disability documentation for the employer, which was submitted several
DB0410 - weeks ago on 080306 for processing by UCSF. ref SDS 69 QQ3I
DB0412 - [On 080403 Millie confirmed in a letter to Kaiser with a copy to
DB0413 - UCSF that UCSF is preparing the documentation. ref SDS 83 TS6V
DB0415 - ..
DB0416 - [On 080409 Millie submitted letter to UCSF asking about
DB0417 - progress preparing documentation requested by N&P and Unum
DB0418 - Insurance company on Millie's entitlement to medical disability
DB0419 - benefits. ref SDS 86 OX3S