THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: April 4, 2008 02:40 PM Friday; Rod Welch

Brigid called and advised that Millie needs Magnesium replacement.

1...Summary/Objective
2...Magnesium 1.5 Low Millie Treated with Magnesium Replacement
.................magnesium replacement
3...Referral Coordination UCSF Resists Notifying Kaiser Medication Change
4...Collaboration Coordination UCSF Notify Kaiser Prescription Magnesium
5...Accuracy Give Up Not Enough Time Writing Verify Conversation
6...Literacy Declines Reliance on Conversation without Authentication
7...Writing Feedback Loops Resisted for Accuracy Medical Prescriptions
8...Patient Performs Case Management Referral Coordination Magnesium


..............
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CONTACTS 

SUBJECTS
Magnesium Replacement Treatment Ordered Blood Counts Magnesium 1.5 B

1603 -
1603 -    ..
1604 - Summary/Objective
1605 -
160501 - Follow up ref SDS 69 0000. ref SDS 67 0000.
160502 -
160503 -
160504 -
160506 -  ..
1606 -
1607 -
1608 - Progress
1609 -
160901 - Brigid received the copy of Millie's letter yesterday to Kaiser,
160902 - ref SDS 70 TR5O, confirming understandings about getting treatment
160903 - with Neupogen for low blood counts. ref SDS 70 TS5U
160904 -
160906 -  ..
160907 - Magnesium 1.5 Low Millie Treated with Magnesium Replacement
160908 -
160909 - Follow up ref SDS 68 XQ6L, ref SDS 48 4F9G,.
160910 -
160911 - Brigid advised that Jackie added magnisum to the blood test yesterday.
160912 - Results reported today show Magnesium 1.5, which is blow the target
160913 - range of 1.8. ref SDS 69 CP6J
160915 -  ..
160916 - This corrects the problem reported yesterday that Magnesium was
160917 - missing from the blood test report, ref SDS 68 XQ6L, which occurred
160918 - previously on 080110, ref SDS 45 JH6F, and was then corrected, as
160919 - reported a week later on 080117. ref SDS 48 4F9G  Protocol for
160920 - cetuximab and Carboplatin clinical trial specifies blood tests for
160921 - Magnesium every 4 weeks, shown on 080313. ref SDS 65 2N6N
160923 -  ..
160924 - The doctor wants Millie to get...
160925 -
160926 -                 magnesium replacement
160927 -
160928 - ...medication in addition to Neupogen prescribed yesterday during the
160929 - meeting at UCSF, ref SDS 68 XV4G, and reported to Kaiser by Millie's
160930 - letter latter in the afternoon. ref SDS 70 TS5U  This can be an oral
160931 - or an IV treatment at Millie's preference.  Brigid indicated in the
160932 - call that "magnesium replacement" is the full extent of the
160933 - prescription.
160935 -         ..
160936 -        [On 080405 Pharmacist discloses Kaiser does not sell products
160937 -        for Magnesium Replacement; customers must buy Calcium and
160938 -        Magnesium dietary supplement tablets taken 3 times a day for
160939 -        multiple days. ref SDS 71 J23S
160941 -         ..
160942 -        [On 080409 notify primary care physician of discrepancies
160943 -        in the work performed by Kaiser pharmacy. ref SDS 72 OP4O
160945 -         ..
160946 -        [On 080410 blood test shows Magnesium 1.9 which is within
160947 -        the target range, and indicates effective treatment ordered
160948 -        by UCSF on 080404. ref SDS 75 RW6F
160949 -
160950 -
160951 -
160952 -
1610 -

SUBJECTS
Referral Coordination Failure UCSF Resists Notify Kaiser Medication

4503 -
450401 -  ..
450402 - Referral Coordination UCSF Resists Notifying Kaiser Medication Change
450403 - Collaboration Coordination UCSF Notify Kaiser Prescription Magnesium
450404 -
450405 - Discussed Brigid contacting Arlette at Kaiser to coordinate additional
450406 - treatment, as Jackie did for the CT test ordered yesterday at UCSF,
450407 - ref SDS 68 669L, shown by Millie's letter confirming understandings,
450408 - also, reported yesterday. ref SDS 70 TS4Q
450410 -  ..
450411 - Previously on 071213, Brigid coordinated with Catherine to prescribe
450412 - adding Magnesium treatment at UCSF in the Infusion Clinic. ref SDS 37
450413 - S24K   Brigid advised today, that she does not want to coordinate the
450414 - work because referral coordination with Kaiser takes more time than
450415 - internal coordination at UCSF.
450417 -  ..
450418 - Brigid explained that she does not know Arlette, and has no experience
450419 - working with Kaiser.  Brigid does not want to contact Jackie to
450420 - coordinate with Arlette, and she does want to coordinate with Jackie
450421 - to get Arlette's telephone number, nor does she want Arlette's
450422 - telephone number from the patient.  Brigid does not want
450423 - responsibility for contacting Kaiser, because this takes a lot of
450424 - time.  She said that for many patients she can call the pharmacy
450425 - directly for a referring agency, like Kaiser in this case, and order
450426 - treatments, but Kaiser does not provide this level of customer
450427 - support.
450429 -             ..
450430 -            [...below in this record today on 080404 1440 Brigid notes
450431 -            coordination is difficult for comprehensive medical care,
450432 -            and is even harder for complex case management between
450433 -            hospitals treating referral patients. ref SDS 0 SE5L
450435 -  ..
450436 - Brigid's report today that coordinating referral work with Kaiser to
450437 - order Magnesium medication for Millie from Kaiser takes too much time
450438 - aligns with Doctor Rugo discussing difficulties yesterday on 080403
450439 - ordering Neupogen from Kaiser. ref SDS 68 IM87  This record conflicts
450440 - with the report from Kaiser on 070710 that communication with UCSF on
450441 - Millie's referral treatment was effective. ref SDS 26 OG7F
450443 -             ..
450444 -            [On 080410 UCSF refused to respond to written request for
450445 -            medical status to disability entitlement; proposed patient
450446 -            use telephone for conversation to perform case management,
450447 -            ref SDS 74 PT4M, contrary to UCSF report on 080403 that
450448 -            reliance on conversation using the telephone phone tag does
450449 -            not support effective case management. ref SDS 68 IM87
450451 -  ..
450452 - Brigid advised the best solution to recover from the blood test
450453 - mistake is for Millie to go to UCSF and get supplemental IV treatment
450454 - for Magnesium Replacement in the Infusion Clinic for clincial trial
450455 - standard of care, as occurred previously on 071213. ref SDS 38 HH5I
450456 - This is effective, because she can write a prescription in a few
450457 - seconds someone; she can call the Infusion Clinic and can coordinate
450458 - the work in seconds, rather than minutes and hours.  It is fast and
450459 - easy, requiring essentially zero cognitive overhead, explained in NWO.
450460 - ref OF 15 LH6K
450462 -  ..
450463 - Of course this solution that takes the health care professional
450464 - seconds and zero diligence, may take 3 - 6 hours for the patient to
450465 - drive to San Francisco, get the treatment, and return to Concord in
450466 - the middle of commute traffic, with attendant frustrations and risks.
450468 -  ..
450469 - Brigid suggested that since Millie needs Neupogen, possibly Kaiser can
450470 - give both Neupogen, and the Megnesium replacement at the same time.
450471 - This would save time, since accurate work by a professional only takes
450472 - a few seconds.  She asked that since Millie coordinated with Kaiser on
450473 - prescribing Neupogen, as requested by Doctor Rugo yesterday,
450474 - ref SDS 68 SG7I, the patient can perform additional referral
450475 - coordination with Kaiser today to add Magnesium treatments.
450476 -
450477 -     [...below Arlette at Kaiser coordinating with the doctor to
450478 -     schedule IV treatment at the Kaiser Infusion Clinic for Neupogen
450479 -     and Magneseum medications prescribed by UCSF. ref SDS 0 JV97
450481 -      ..
450482 -     [...below Arlette reports doctor ordered Neupogen treatment; wants
450483 -     Millie to get the medication from the Kaiser Pharmacy at Park
450484 -     Shadelands. ref SDS 0 JW6J
450486 -      ..
450487 -     [On 080423 UCSF applies doctor patient partnership again
450488 -     requests scope of blood draw from patient that is prescribed in
450489 -     the Chemotherapy Orders issued by the doctor. ref SDS 76 1P6M
450491 -  ..
450492 - The patient agreed to support referral coordination, and needs the
450493 - exact prescription UCSF orders in order to accurately perform the
450494 - work.
450495 -
450497 -  ..
450498 - Accuracy Give Up Not Enough Time Writing Verify Conversation
450499 - Literacy Declines Reliance on Conversation without Authentication
450500 - Writing Feedback Loops Resisted for Accuracy Medical Prescriptions
450501 -
450502 - Follow up ref SDS 68 4U9O.
450503 -
450504 - Requested that Brigid respond to the letter yesterday coordinating
450505 - Neupogen, ref SDS 70 TS5U, and confirm the explanation in this telecon
450506 - that the doctor at UCSF has ordered further treatment for "Magnesium
450507 - replacement." She can clarify any details of the prescription Millie
450508 - needs so there is less chance for misunderstanding by Kaiser that
450509 - occurs in verbal conversation.
450511 -  ..
450512 - Brigid feels feedback loops writing a letter for comprehensive care to
450513 - confirm discussion conveying prescriptions written in the medical
450514 - chart for medications takes extra time that is unnecessary
450515 - duplication, since she writes down the record of this telecon in the
450516 - UCSF medical chart to make sure everything is understood correctly.
450517 - She noted that relying on assumptions from memory of conversation in
450518 - meetings and calls is effective for other patients in her practice at
450519 - UCSF.  Brigid asked why invest time writing a prescription for
450520 - patients to take to the pharmacy, when talking in meetings and on the
450521 - telephone, like today, seems so fast and easy?
450522 -
450523 -        [On 080405 Kaiser pharmacy has no products for "Magnesium
450524 -        Replacement; Kaiser sells the patient Calcium Magnesium
450525 -        supplement pills. ref SDS 71 J24F
450527 -  ..
450528 - The patient needs precisely what is written in the medical chart in
450529 - order to avoid mistakes coordinating verbal guidance ordering
450530 - medications.  Traceability to original sources is an ISO industry
450531 - standard for accuracy to reduce mistakes by authenticating verbal
450532 - communications, reported on 950721. ref SDS 3 1740
450534 -  ..
450535 - Written communication was requested yesterday on 080403 by Doctor Rugo
450536 - at UCSF, and in order to verify accuracy of coordinating work with
450537 - Kaiser. ref SDS 68 4U9O  For the same reason, the patient needs
450538 - written confirmation of new instructions today that expand prior
450539 - understandings.
450540 -
450541 -        [On 080410 UCSF wants patient to call so that someone can
450542 -        document a call rather than respond to documentation submitted
450543 -        by the patient. ref SDS 74 U59F
450545 -  ..
450546 - Verbal communication causes errors when not confirmed in writing due
450547 - to variables in biology of speaking and hearing, commonly called the
450548 - "telephone game," cited in NWO. ref OF 11 XF5H  UCSF explains
450549 - treatments in meetings, then writes a prescription, rather than rely
450550 - on people to remember what was said, shown by the record on 080313.
450551 - ref SDS 65 4E9N  The report on 990912 shows communication is the
450552 - biggest cause of medical mistakes. ref SDS 6 0001  Andy Grove at Intel
450553 - notes mental maps are awfully forgiving of ambiguity, reviewed on
450554 - 980307. ref SDS 4 3668  People pay a price for relying on assumptions
450555 - to fill in the gaps from ambiguity in conversation that is not
450556 - authenticated by writing to verify accuracy, shown by research on
450557 - 900303. ref SDS 1 F999
450559 -  ..
450560 - An example is the communication snafu at UCSF on 080306 that delayed
450561 - treatment delivering the order to the wrong place, reported by Jackie.
450562 - ref SDS 63 EX4I
450564 -  ..
450565 - Writing things down increases accuracy by orders of magnitude that
450566 - makes people "superhuman," compared to reliance on assumption from
450567 - memory, reported on 010622. ref SDS 8 N668  Standards for medical
450568 - practice require writing things down rather than rely on memory, shown
450569 - by Kaiser's Healthwise Handbook, reviedwed on 990625. ref SDS 5 3960
450571 -  ..
450572 - Drucker notes people have given up on improving management because
450573 - communication is too complex, reported on 931130. ref SDS 2 3851
450575 -  ..
450576 - Review on 991108 shows cultural pressures that cause reliance on
450577 - literacy to decline on the job. ref SDS 7 1092   Knowledge Management
450578 - professionals and educators object to accuracy because avoiding
450579 - mistakes takes extra time that slows conversation, reported on 020820.
450580 - ref SDS 10 V66I  Similarly, NASA reported on 030826 that loss of the
450581 - Columbia Space Shuttle costing billions of dollars reflects skills of
450582 - engineering professionals interpret good management practices to
450583 - verify accuracy as suggestions that take extra time, rather than
450584 - requirements for investing time to save lives, time, and money.
450585 - ref SDS 11 8K4G  Case study on 020504 show people feel enormous
450586 - pressure to ignore requirements for good management in law,
450587 - regulations, contracts, and professional standards. ref SDS 9 NS6F
450589 -         ..
450590 -        [On 080409 UCSF reliance on verbal communication for treatment
450591 -        medication prescriptions aligns with Kaiser practices in the
450592 -        Emergency Room, because doctor does know how to use computer to
450593 -        write things down. ref SDS 73 F194
450595 -         ..
450596 -        [On 080410 UCSF wants patient to call so that someone can
450597 -        document a call rather than respond to documentation submitted
450598 -        by the patient. ref SDS 74 U59F
450600 -  ..
450601 - Of course in an emergency time is compressed.  People are forced to
450602 - work by conversation.  Telling someone to turn down the heat when the
450603 - pot boils over is effective because timely action is needed and
450604 - context is clear.  For more complex activity, like ordering
450605 - medication, especially for the first time, as here ordering Magnesium
450606 - for oral treatment, ref SDS 0 O142, introduces ambiguity about what
450607 - precisely should be done, not for the experienced, expert health care
450608 - professional, but for the patient who is nervous about past mistakes.
450610 -  ..
450611 - The oral treatment option seems to have a great many variables.  How
450612 - many milligrams in a pill?  How many pills to take in day, how often,
450613 - for how long?  What precisely does the over-the-counter box say?
450614 - Will anything with "Magnesium" on the box be okay?
450616 -  ..
450617 - Accordingly, if there is enough time, submitting written confirmation
450618 - by email, as Brigid did for the Cellulitis matter last month on
450619 - 080304, ref SDS 62 B18J, is the best prescription for effective case
450620 - management.
450622 -  ..
450623 - The challenge is to avoid the slippery slope of sloppy work relying
450624 - solely on conversation that seems fast and easy, like fools gold, even
450625 - when there is time for good management.  Since the consequences of
450626 - poor communciation are usually delayed, people get accustom to working
450627 - by converstation, and soon nothing is verified.  Requests for good
450628 - practice cause anger and resentment as intrusive, unncessary overkill,
450629 - duplicating what everybody knows.  An example is the record on 041130
450630 - asking the doctor for a written explanation of treatments available to
450631 - care for Millie. ref SDS 13 YR8F
450633 -  ..
450634 - This challenge can be met with good will through the doctor-patient
450635 - partnership that saves time for the medical professional while
450636 - creating a written record that increases accuracy to reduce mistakes.
450638 -  ..
450639 - Brigid feels that coordination is difficult for comprehensive care,
450640 - and that coordinating medical care for referral patients increases
450641 - complexities of case management.  She said that sometimes things "slip
450642 - through the cracks" due to a hectic schedule, like today, because
450643 - there is not enough time to very accuracy, per above. ref SDS 0 O166
450645 -  ..
450646 - Previously on 070517, Brigid cited difficulties coordinating between
450647 - hospitals for accurate test reports. ref SDS 24 CV6K
450649 -  ..
450650 - Today, Brigid proposed that instead of UCSF writing a letter to Millie
450651 - with accurate presentation of complex verbal instructions, which she
450652 - has written in the UCSF medical chart, per above, ref SDS 0 BH6G,
450653 - Millie can write a letter to UCSF with recollections from memory of
450654 - what has been said in the call is written in the medical chart.  This
450655 - will save time for Brigid, and if there is a mistake in the letter,
450656 - Brigid will submit clarifications to correct the record, following the
450657 - procedure requested by Doctor Rugo at UCSF yesterday. ref SDS 68 4U9O
450659 -  ..
450660 - Explained the patient is pleased to support UCSF case management by
450661 - writing a letter to Kaiser.  Would like to get precisely what is being
450662 - prescribed for inclusion in the letter to Kaiser.
450664 -  ..
450665 - Brigid feels there is not enough time to support the patient with a
450666 - letter showing what is proposed.
450667 -
450668 -
450669 -
4507 -

SUBJECTS
Magnesium Replacement Treatment Prescribed  b UCSF Ordered from Kais

6303 -
6304 - 1447
630501 -  ..
630502 - Patient Performs Case Management Referral Coordination Magnesium
630503 -
630504 - Millie submitted ref DIT 1 0001 to the primary care physician at
630505 - Kaiser with copy to Arlette, and to the medical team at UCSF...
630506 -
630507 -    1.  Brigid called this afternoon and advised that after my
630508 -        treatment yesterday at UCSF, Magnesium was added to the scope
630509 -        of the blood test.  Results today show Magnesium 1.5, which is
630510 -        below the 1.8 target range, ref SDS 0 O059, as shown in the
630511 -        revised test report. ref SDS 69 CP6J, ref DIT 1 0001
630513 -         ..
630514 -    2.  Doctor Rugo has ordered "Magnesium Replacement" to increase my
630515 -        blood counts. ref SDS 0 OP6U, ref DIT 1 US6G
630517 -         ..
630518 -    3.  This supplements the order yesterday for Neupogen. ref SDS 70
630519 -        TS5U, ref DIT 1 OL6J
630521 -         ..
630522 -    4.  Can you please arrange for me to come in later today, tomorrow,
630523 -        or at the latest on Monday to get both Neupogen and Magnesium
630524 -        Replacement treatments. ref DIT 1 US6M
630526 -         ..
630527 -    5.  Arlette called this morning, and indicated she would coordinate
630528 -        the Neupogen matter.  I will call and follow up to incorporate
630529 -        magnesium. ref DIT 1 US7I
630530 -
630531 -            [...below, Arlette calls back with instructions
630532 -            implementing doctor's orders on Neupogen treatment in the
630533 -            Infusion Clinic. ref SDS 0 JW6J
630534 -  ..
630535 - Millie's letter to Kaiser continues...
630536 -
630537 -    6.  Thanks to Brigid for timely notice.  Please correct or clarify
630538 -        these understandings as needed. ref DIT 1 US7N
630540 -         ..
630541 -    7.  Just a heads up -- I was able to go hiking 3+ miles today,
630542 -        which is the steroids working from yesterday.  Hoping to go to
630543 -        the gym tomorrow, but we'll see. ref DIT 1 US7S
630544 -
630545 -
630546 -
630548 -  ..
6306 -
6307 -
6308 - 1555
6309 -
630901 - Called Arlette, per planning in Millie's letter to Kaiser, earlier
630902 - today for Millie to get treatment in the Infusion Clinic for Neupogen
630903 - and Magnesium, per above. ref SDS 0 V39U
630905 -  ..
630906 - Explained new request from UCSF today for treatment with Magnesium
630907 - Replacement, per above. ref SDS 0 O059, in addition to Neupogen
630908 - prescribed yesterday by UCSF.
630910 -  ..
630911 - Arlette let the doctor know that UCSF has prescribed Neupogen and
630912 - Magnesium Replacement, per above. ref SDS 0 O152
630913 -
630914 -
630916 -  ..
6310 -
6311 -
6312 - 1733
6313 -
631301 - Called Arlette back.
631302 -
631303 - No one answers the telephone to coordinate the work.  Got a message
631304 - everyone has gone home.
631305 -
631307 -  ..
6314 -
6315 -
6316 - 1807
6317 -
631701 - Arlette called.
631702 -
631703 - The doctor has ordered a single Neupogen treatment, as prescribed by
631704 - UCSF yesterday.  Arlette said the doctor wants Millie to get Neupogen
631705 - at the Park Shadelands Pharmacy tomorrow, and go to the Infusion
631706 - Clinic.  A nurse will do the treatment injection, as discussed by
631707 - Brigid in her call from UCSF this morning, per above, ref SDS 0 O152,
631708 - and further related in Millie's letter to Kaiser, also above.
631709 - ref SDS 0 V39U
631710 -
631711 -        [On 080607 UCSF provides Neupogen treatments to patients in the
631712 -        Infusion Clinic that avoids confusion, problems, and mistakes.
631713 -        ref SDS 77 4154
631715 -  ..
631716 - Arlette's work plan seems to address issues presented in the letter to
631717 - Kaiser yesterday on 080403. ref SDS 70 TS8Y  On 061031 there was no
631718 - charge for Neupogen treatment in the hospital. ref SDS 15 9U65
631719 - Arelette advises today the doctor has ordered Neupogen at the Pharmacy
631720 - for Millie to take to the Infusion Clinic across the hall, and get
631721 - injection in the hospital by professionals, as Kaiser did on 061031.
631722 - ref SDS 15 9U65  This should solve problems getting Neupogen at Kaiser
631723 - on 061101. ref SDS 16 JS4U
631725 -         ..
631726 -        [On 080405 Park Shadelands Kaiser Pharmacy closed; Millie gets
631727 -        Neupogen from Kaiser Pharmacy in Walnut Creek, after 2 hours
631728 -        long, complex transaction, ref SDS 71 H656, charged $12 for 1
631729 -        self-injection treatment, because Infusion Clinic was closed,
631730 -        ref SDS 71 XQ6O; Millie finally takes medication prescribed by
631731 -        UCSF in order to get chemotherapy treatment next Thursday.
631732 -        ref SDS 71 RU6I
631733 -
631734 -
631736 -  ..
631737 - Arlette explained that Magnesium replacement is an over-the-counter
631738 - oral treatment that requires Millie to take pills for a number of
631739 - days.  Millie may be able to get this at the Park Shadelands Pharmacy.
631740 - Arletted seemed to say look for anything that says...
631741 -
631742 -                              "Magnesium"
631744 -  ..
631745 - Alternatively, Mil can go to any drug store, e.g., Longs Drugs, and
631746 - ask for "Magnesium" tablets.
631748 -  ..
631749 - This seems potentially problematic.  Typically, instructions say to
631750 - take a specific number of pills (e.g., 1, 1.5, 2), containing a
631751 - specific amount of agent, so many times a day and for a specified
631752 - number of days.  If treatment was with an IV some specific amount of
631753 - agent would be given.  Why no similar instructions for oral treatment?
631755 -         ..
631756 -        [On 080405 Pharmacist discloses Kaiser does not sell products
631757 -        for Magnesium Replacement; customers must buy Calcium and
631758 -        Magnesium dietary supplement tablets. ref SDS 71 J23S
631760 -         ..
631761 -        [On 080409 notify primary care physician of confusion and
631762 -        problems getting Neupogen treatments from Kaiser. ref SDS 72
631763 -        OP4O
631765 -         ..
631766 -        [On 080409 commend Arlette for good coordination in letter to
631767 -        Kaiser primary care physician. ref SDS 72 OP4O
631768 -
631769 -
631770 -
631771 -
631772 -
631773 -
631774 -
631775 -
631776 -
631777 -
631778 -
6318 -