CONTACTS 

SUBJECTS
Meeting Examination Doctor Review Strategy Work Plan 2nd Cycle 1st T

0803 -
0803 -    ..
0804 - Summary/Objective
0805 -
080501 - Follow up ref SDS 69 0000. ref SDS 66 0000.
080502 -
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
080522 -
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
080534 -
080535 -
080536 -
080537 -
080538 -
080539 -
080540 -
080542 -  ..
0806 -
0807 -
0808 - Progress
0809 -
080901 - Agenda Meeting Next Cycle Clinical Trial Cetuximab Carboplatin
080902 -
080903 - Follow up ref SDS 69 QY5I.
080904 -
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.
080931 -
080932 -
080933 -
0810 -

SUBJECTS
IBC Examination Stable to Improved Condition After 1 of 3 Prescribed

2803 -
280401 -  ..
280402 - IBC 4th Relapse Examination Shows Stable to Improved Condition
280403 -
280404 - Follow up ref SDS 69 NW3N.
280405 -
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
280453 -
280455 -  ..
280456 - Carboplatin Chemotherapy Well Tolerated Energy Exercise Increase
280457 - Energy Exercise Increase Carboplatin Chemotherapy Well Tolerated
280458 -
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
280466 -
280468 -  ..
280469 - Exercise Energy Rise Emotional Trauma Stress Anxiety Subside
280470 - Emotional Trauma Stress Anxiety Subside with Exercise Increasing
280471 -
280472 - Follow up ref SDS 81 Q25V.
280473 -
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
280489 -
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
280496 -
280497 -
280498 -
280499 -
280500 -
280501 -
2806 -

SUBJECTS
Labs Blood Counts NEUTS 1.34 Below Safe Chemotherapy Treatment Requi

4403 -
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
440406 -
440407 - Follow up ref SDS 69 JT3L.
440408 -
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.
440457 -
440458 -
440459 -
4405 -

SUBJECTS
Treatment Chemotherapy Carboplatin Approved Blood Counts Slightly Lo

6503 -
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
650405 -
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.
650419 -
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
650443 -
650444 -
650445 -
650446 -
650447 -
6505 -

SUBJECTS
Coordination Referral Communication Delay Frustrating People Give Up

AW03 -
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
AW0405 -
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.
AW0410 -
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
AW0454 -
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
AW0594 -
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
AW0603 -
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
AW0610 -
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
AW0683 -
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)
AW0722 -
AW0723 -
AW08 -

SUBJECTS
Neupogen Current Medications Prescription UCSF Cost Effective Care 1

BM03 -
BM0401 -  ..
BM0402 - Neupogen Prescribed Increase Blood Counts Maintain Treatment Protocol
BM0403 -
BM0404 - Follow up ref SDS 69 033B, ref SDS 79 TZ8I.
BM0405 -
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
BM0416 -
BM0418 -  ..
BM0419 - Cost Effective Care 1 Treatment then Assess Need to Increase Dose
BM0420 -
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...
BM0464 -
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
BM0471 -
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
BM0481 -
BM0482 -
BM0483 -
BM0484 -
BM05 -

SUBJECTS
Magnesium Missing Blood Test Lab Report Medical Mistake Conflicts Ch

C703 -
C70401 -  ..
C70402 - Magnesium Missing from Blood Test Lab Report UCSF Investigating
C70403 -
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
C70407 -
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
C70430 -
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
C70435 -
C70436 -
C70437 -
C705 -

SUBJECTS
CT Test Coordinated UCSF Schedule with Kaiser Monitor Response to Tr

CH03 -
CH0401 -  ..
CH0402 - CT Test Coordinated by UCSF
CH0403 -
CH0404 - Follow up ref SDS 64 6V5I.
CH0405 -
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.
CH0418 -
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
CH0461 -
CH0462 -
CH05 -

SUBJECTS
Prozac Fluoxetine 20 MG Capsules Prescribed Current Medication Not T

CX03 -
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
CX0406 -
CX0407 - Follow up ref SDS 72 RT8Y, ref SDS 68 KT4J.
CX0408 -
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
CX0436 -
CX0437 -
CX0438 -
CX05 -

SUBJECTS
Disability Status Benefits Entitlement Documentation Employer Nixon

DB03 -
DB0401 -  ..
DB0402 - Disability Status Report Progress Processing Insurance Report
DB0403 -
DB0404 - Follow up ref SDS 69 QQ3I.
DB0405 -
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
DB0411 -
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
DB0420 -
DB0421 -
DB0422 -
DB0423 -
DB0424 -
DB0425 -
DB0426 -
DB05 -